EuroMEdLab 2013 - SCIENTIFIC SESSIoNS
20th IFCC-EFLM European Congress of Clinical Chemistry and Laboratory
Medicine (EuroMedLab)
45th Congress of the Italian Society of Clinical Biochemistry and Clinical
Molecular Biology (SIBioC)
Milan, 19-23 May 2013
Abstracts of Scientific Sessions
Abstract code
Session type
•OL1
Opening Lecture
•PL1 - PL4
Plenary Lectures
•SY01 - SY72
Symposia
•OC01 - OC34
Selected Oral Communications
•EW001 - EW112
Educational Workshops
biochimica clinica, 2013, vol. 37, SS
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EuroMEdLab 2013 - sciEntific sEssions
OL1
PATHOPHYSIOLOGICAL ROLES OF THE PROTEASOME
IN VERTERBRATE
K. Tanaka
Metropolitan Institute of Medical Science, Tokyo, Japan
The proteasome in collaboration with ubiquitin, whose
covalent modification of target proteins marks them for
degradation, rapidly and selectively degrades unnecessary
proteins that must be eliminated from the cells, such as shortlived regulatory proteins as well as proteins with aberrant
structures caused by various stresses. Over the past 30 years,
our research work has focused on elucidating the basic
mechanisms of eukaryotic proteasomes. The 26S
holoproteasome is a 2.5-MDa multisubunit complex that
contains a catalytic core particle (CP) and two regulatory
particles (RP). The CP consists of four heptameric rings (two
outer α-rings and two inner β-rings), which are made up of
seven structurally related, but not identical, α and β subunits
(i.e., α1-7β1-7β1-7α1-7). The CP contains catalytic threonine
residues (β1, β2, and β5 with caspase-like, trypsin-like, and
chymotrypsin-like activities, respectively) on the surface of a
chamber formed by two abutting β-rings. The RP comprises 6
ATPase and 13 non-ATPase non-identical subunits, which
recognize polyubiquitylated substrate proteins and then unfold
and translocate these proteins into the interior of the CP for
degradation. It is longstanding question how the complex
structures of the 26S proteasome are organized with high
fidelity. Recently, we found that the assembly of the 26S
proteasome requires multiple proteasome-dedicated
assembling chaperones. Intriguingly, previously we discovered
the "immunoproteasome" whose β1, β2, and β5 subunits are
replaced by the structurally related and interferon-γ-induced
β1i, β2i, and β5 respectively, which emphasized their
specialized functions in cell-mediated immunity (i.e.,
collectively functioning as a professional antigen processing
enzyme). Lately, we also identified another unique
"thymoproteasome", which contains a novel catalytic subunit,
designated β5t, which is expressed exclusively in the thymus,
specifically in cortical thymic epithelial cells and proposed a
key role for the thymoproteasome in the development of the
MHC class I-restricted CD8+T cell repertoire during thymic
positive selection. The discovery of these two types of
vertebrate-specific immuno-type proteasomes highlights the
significance and impact of our biological studies on the
proteasome.
PL1
IRON METABOLISM AND PATHOPHYSIOLOGY
T. Ganz
Departments of Medicine and Pathology, David Geffen
School of Medicine, University of California, Los Angeles,
USA
Extracellular concentrations of iron are regulated by the
peptide hormone hepcidin. Hepcidin controls the transfer of
iron from cells to plasma by regulating the cell membrane
concentration of the sole known iron exporter, ferroportin.
Hepcidin binding to ferroportin causes their endocytosis and
proteolysis, trapping iron inside cells that normally transport
iron to plasma: duodenal enterocytes, macrophages recycling
erythrocyte iron, and hepatocytes that store iron. Iron
consumption, mainly for hemoglobin synthesis, then depletes
plasma of iron causing hypoferremia and limiting iron delivery
to tissues. Hepcidin production is transcriptionally induced by
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biochimica clinica, 2013, vol. 37, SS
iron-transferrin through a complex pathway centered on the
bone morphogenetic protein (BMP) receptor, interacting
directly or indirectly with iron sensors transferrin receptors 1
and 2, and associated modulators HFE, hemojuvelin,
TMPRSS6 /matriptase 2, BMP-6, and others. Another
unknown pathway regulates hepcidin in response to
intracellular iron concentrations in the liver, partly by
modulating the secretion of BMP-6. As a mediator of innate
immunity, hepcidin is greatly increased by inflammation,
predominantly through IL-6. Finally, hepcidin is suppressed
during stress erythropoiesis, induced by endogenous or
exogenous erythropoietin. Hepcidin suppression with resulting
iron overload is a pathological manifestation of ineffective
erythropoiesis, e.g.
in thalassemias. Hereditary
hemochromatosis is an iron overload syndrome commonly
caused by hepcidin deficiency leading to hyperabsorption of
dietary iron. Hepcidin is deficient because of mutations in one
of its regulators or rarely the hepcidin gene itself. Iron-loading
anemias result from the suppression of hepcidin production
by hyperactive but ineffective erythropoiesis. Erythrocyte
transfusions partially relieve the erythropoietic suppression of
hepcidin but cause severe iron loading because of their high
content of iron. Iron-restrictive anemias result from excessive
hepcidin production due to inflammation or mutations in
matriptase 2/TMPRSS6, causing hypoferremia that limits iron
delivery to hemoglobin synthesis. Understanding of these
regulatory pathways is leading to improvements in diagnosis
and treatment of disorders of iron homeostasis.
PL2
SICK MOLECULES AND AMYLOIDOSIS
G. Merlini
Amyloidosis Research and Treatment Centre, and Clinical
Chemistry Laboratories,
Scientific Institute Policlinico San Matteo, Department of
Molecular Medicine, University of Pavia, Italy
An increasing number of diseases are recognized to arise from
the failure of proteins to adopt functional conformational states.
These pathologic conditions are generally referred to as protein
misfolding (or protein conformational) diseases. These proteins
behave like “sick molecules”, a term coined by Jan
Waldenström, since they display a pathological conformation
prone to aggregate and become toxic for cells and tissues,
producing devastating damage. The largest group of misfolding
diseases is associated with the conversion of peptides or
proteins from their soluble functional states into highly
organized fibrillar aggregates showing a cross-beta supersecondary structure termed “amyloid.” It is becoming
increasingly apparent that amyloid-forming proteins exist in a
complex dynamic equilibrium between soluble monomeric or
oligomeric states and various insoluble states of higher-order
aggregation. The formation of these aggregates depends on
the protein concentration, complex interactions with other
molecules and the specific cellular environment. Several lines
of evidence support a role for extracellular chaperones in the
in vivo clearance of aggregation-prone proteins. To date, at
least 28 different proteins have been identified as causative
agents of amyloid diseases, ranging from localized cerebral
amyloidosis in neurodegenerative conditions, to systemic
amyloidoses such as immunoglobulin monoclonal light chain
amyloidosis and transthyretin amyloidosis. The process of
amyloid formation results in cellular injury, tissue damage, and
organ dysfunction through mechanisms that are incompletely
understood. The simple explanation of a physical, mechanical
replacement of parenchymal tissue by amyloid deposits seems
to be insufficient. A growing body of literature has implicated
prefibrillar oligomers, rather than the fibrillar form, as the
EuroMEdLab 2013 - sciEntific sEssions
primary pathologic species. Direct cytotoxicity of amyloidogenic
immunoglobulin light chains to cardiac cells has also been
demonstrated. The clinical chemist plays a central role in the
diagnosis and management of these complex diseases.
Advances in biomarker studies have enabled detection of
amyloid pathology in vivo in presymptomatic stage, before
irreversible organ damage has occurred, providing the basis
for early intervention trials. The accurate typing of the amyloid
deposits is the prerequisite for designing the appropriate
therapeutic strategy and involves the precise identification of
the amyloid protein by mass spectrometry-based technologies.
The assessment of the organ damage by novel biomarkers
allows monitoring the efficacy of treatment. Advances in
deciphering the molecular mechanisms underlying the amyloid
process are leading to the development of novel therapeutic
resources and strategies.
PL3
MOLECULAR BASIS AND CLONAL EVOLUTION OF
MYELOPROLIFERATIVE NEOPLASMS
R. Kralovics
CeMM Research Center for Molecular Medicine of the
Austrian Academy of Sciences, Vienna, Austria; Department
of Internal Medicine I, Division of Hematology and Blood
Coagulation, Medical University of Vienna, Vienna, Austria
Excessive production of terminally differentiated myeloid cells
is the hallmark of myeloproliferative neoplasms (MPN).
Current classification of MPN by the World Health
Organization includes nine disease entities, however, only the
classical BCR-ABL negative MPN are the subject of this
overview. The classical MPN include polycythemia vera (PV),
essential thrombocythemia (ET), and primary myelofibrosis
(PMF). The discovery of a gain of function mutations of the
JAK2 kinase facilitated the molecular diagnosis of MPN and
also offered a target for therapeutic intervention. Although the
majority of MPN patients are positive for the JAK2 exon 14
mutation (V617F), one third of patients with MPN are negative
for JAK2 mutations. The MPN phenotype of JAK2-V617F
negative patients has been in some cases associated with
exon 12 JAK2 mutations or mutations in the thrombopoietin
receptor gene MPL but they are present only in 1-5% of the
cases. Therefore, considerable effort has been exerted to
identify other disease associated mutations. This review will
be providing an overview of these findings and discuss the
role of other genes in the pathogenesis of MPN.
PL4
ACUTE CORONARY SYNDROMES – THE PRESENT AND
FUTURE ROLE OF BIOMARKERS
B. Lindahl
Uppsala Clinical Research center and department of
medical sciences, Uppsala University, Sweden
Over the past two decades there have been dramatic changes
in the diagnosis, treatment and prognosis of acute coronary
syndromes (ACS). Several new treatment modalities have
been added. The prognosis after acute myocardial infarction
(AMI) has improved, e.g. the 30 day mortality has been more
than halved the last decade. Biomarkers have crucial roles in
the management of ACS: for diagnosis as well as for
prognosis and selection of treatment. At present, cardiac
troponin (cTn) is the biomarker of choice for diagnosis of AMI.
Currently, there are no other biomarkers, especially after the
introduction of the high sensitivity assays, which can compete,
neither regarding specificity nor regarding early sensitivity.
However, there is still a clinical need of a biomarker able to
reliably rule-in or rule-out AMI, immediately on admission.
Secondly, a marker able of separating type I from type II
infarctions would be clinically very useful. Thirdly, for the
diagnosis of unstable angina a biomarker of cardiac ischemia
is needed. MicroRNAs seem to be the most promising new
candidates for diagnostic purposes. The optimal combination
of biomarkers and new imaging techniques is another
important area for research. The list of biomarkers associated
with an adverse prognosis in ACS is long. However, for most
of them it has been very difficult to prove an added clinical
value. Only cTn, and to some degree also B-type natriuretic
peptides, is widely used in clinical practice for risk assessment.
Among new markers, growth differentiation factor 15 and the
mid-regional part of the prohormone of adrenomedullin, have
shown some promising results. The importance of moderate
decrease in renal function for the prognosis has been much
overlooked in the past. And since the renal function must be
assessed anyway, i.e. for correct dosing of many drugs, it
seems logical to utilize also the prognostic capacity of markers
of the renal function. Cardiac troponin has been proven useful
for selection of antithrombotic, antiplatelet and invasive
treatment. Besides cTn, no other markers have consistently
been shown to be useful for selection of specific treatments.
However, in the predicted future era of “personalized medicin”,
new biomarkers for selection of treatments are much needed.
SY01
BEYOND CREATININE STANDARDIZATION
J. Delanghe
Ghent University Hospital, Ghent, Belgium
Background: Recent global restandardization has enabled
clinicians to use eGFR values. National implementation
programs have promoted the use of eGFR, which is an
important tool to detect chronic kidney disease at population
level. However, some problems remain after standardisation.
Results: eGFR formulas (e.g. MDRD, CKD-EPI) show
limitations (e.g. age, ethnicity). In clinical practice, laboratories
and clinicians often do not take these limitations into account.
Expanding the formula to normal range results in remarkable
findings: e.g. increased hazard ratio of death among patients
with an eGFR >90 mL/min per 1.73m2. This finding may be
due to inadequacies of eGFR formulas at low serum creatinine
levels. In children, where serum creatinine values are low,
uncertainty remains a problem. Cystatin C determination might
offer an interesting alternative for GFR estimation. The recent
availability of the IFCC cystatin C standard will contribute to
the popularization of cystatin C as a renal function marker.
As the lion share of literature dealing with drug dosage in renal
insufficiency is based upon older (often poorly characterized)
creatinine methods, the effects of creatinine standardization
on drug doses calculation are important. Pharmacokinetic
studies based on nonstandardized methods obtained results
that were method dependent. Recommended drug dosages
were inconsistently translated into clinical practice due to
methodological variability. It is impossible to re-express all
current drug-dosing recommendations for use with
standardized creatinine values. For the majority of patients
and for most drugs, there is little difference in the calculated
dose according to the equation used. However, if using eGFR
in very large or very small patients, reported eGFR should be
multiplied by the body surface area to obtain eGFR. Assessing
kidney function using alternative methods (e.g. measured CrCl
or measured GFR using exogenous markers) should be
considered for drugs with narrow therapeutic indices, or for
individuals in whom eGFR and eCrCl provide different
estimates, or for patients in whom estimates based on
creatinine are likely to be inaccurate.
biochimica clinica, 2013, vol. 37, SS
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Conclusion: vigilance is required to tackle the side effects of
creatinine restandardization.
SY02
SPECIFIC PROTEINS AS RENAL FUNCTION MARKERS
A. Grubb
Department of Clinical Chemistry, Laboratory Medicine,
University Hospital, Lund, Sweden
The plasma levels of all proteins freely filtered through the
glomerular membrane can be used as markers of glomerular
filtration rate (GFR). Examples of such proteins are: cystatin C,
free protein HC (alias alpha-1-microglobulin), beta-2microglobulin, retinol-binding protein (RBP), complement
factor D, beta-trace protein (BTP) and free kappa- and
lambda-chains. The diagnostic performance of the plasma
levels as GFR-markers is mainly decided by the degree of
variation in the production of the marker proteins. A constant
production of a protein in all body tissues, uninfluenced by
normal and pathophysiological variations, strongly favours its
use as a GFR-marker.
So far, the cystatin C level has been shown to be the best
protein marker for GFR. GFR-prediction equations based
upon cystatin C alone generally have better diagnostic
performances than GFR-prediction equations based upon
creatinine alone. Only by addition of biologically ill-defined and
ethically questionable additional parameters like race/ethnicity,
can creatinine-based prediction equations reach the
diagnostic performance of cystatin C-based prediction
equations. The best way to estimate GFR is to use both a
cystatin C-based and a creatinine-based GFR-prediction
equation and to produce two estimates and use the mean of
these estimates as the best GFR-estimate. This way is
superior to other ways of combining cystatin C- and creatininelevels to estimate GFR, since it allows detection of
non-GFR-factors influencing either, or both, levels of creatinine
and cystatin C. By specifying maximal limits for the
discordance between the two estimates, a higher total
diagnostic performance of the GFR-estimation will result.
The urinary levels of all proteins freely filtered through the
glomerular membrane are good markers for the function of
and/or damage to the renal tubular system, since all these
proteins are completely, or nearly completely, reabsorbed by
the proximal tubules. Their urinary concentration will thus
increase markedly and rapidly at malfunctions of the renal
tubular system. The urinary level of free protein HC (alpha-1microglobulin) displays the best diagnostic performance, due
to its stability and high level in urine from healthy persons.
SY03
MARKERS OF ACUTE KIDNEY INJURY
M. Haase
Dept. of Nephrology and Hypertension, Otto-von-Guericke
University Magdeburg, Germany
Acute kidney injury (AKI) is a frequent complication in
hospitalized patients and associated with substantially
increased morbidity and mortality. There is a delay in the
diagnosis of AKI, at least in part, resulting from currently used
diagnosis parameters basing on renal function such as serum
creatinine and urine output. Such delay contributes to the fact
that to date, no effective intervention to prevent or successfully
treat AKI has been found. At the time of diagnosis of
established AKI, irreversible organ damage may already have
occurred. Currently, several acute tubular damage markers
have been introduced, including neutrophil gelatinaseassociated lipocalin (NGAL), interleukin-18, liver-type fatty
acid-binding protein and kidney injury molecule 1. Exemplary
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biochimica clinica, 2013, vol. 37, SS
for other acute tubular damage markers, in the following the
presentation will focus on NGAL given the most
comprehensive experimental and clinical data available in the
literature. NGAL is a protease-resistant polypeptide with a
molecular weight of 25 kDa, which is released from the distal
nephron in response to ischemic, toxic, or inflammatory insult
to the kidney or from other organs. NGAL is a transcellular
transporter of iron in specific conformation. As a siderophoreiron complexing molecule, NGAL is involved in renal tubular
cell differentiation and growth. Within a few hours after renal
insult NGAL and other tubular damage markers are detected
in urine and plasma which is 24 to 72 hours prior to renal
function marker-based AKI diagnosis, which is the goldstandard in current clinical practice. Available data from
experimental and clinical studies suggests NGAL to be a
reliable ‘real-time’ biomarker for AKI of diverse etiology. NGAL
may also be helpful in distinguishing volume depletion from
oliguria in the setting of AKI. Novel renal biomarkers indicating
cellular damage in real-time might soon guide patient-tailored
earlier initiation of nephroprotection, improved fluid
management or withdrawal of nephrotoxins directed at
improvement of outcomes in patients developing AKI. Since,
the recent‚ Acute Dialysis Quality Initiative’ Consensus
Conference has now recommended the use of tubular
damage markers for AKI diagnosis complementary to renal
function markers.
OC01
MALDI IMAGING MASS SPECTROMETRY: A POWERFUL
TOOL TO SUPPORT RENAL DISEASES DIAGNOSIS
V. Mainini(1), F. Pagni(2), C. Chinello(1), G. Bovo(2), G.
Cattoretti(2), F. Ferrario(2), F. Magni(1)
1
Dept. of Health Science, University of Milano-Bicocca,
Monza, Italy
2
Dept. of Surgical Pathology and Nephropathology, Azienda
Ospedaliera San Gerardo, Monza, Italy
Background: Renal biopsies represent the standard choice to
diagnose renal diseases (e.g. glomerulonephritis).
Immunofluorescence and electron microscopy, long
established techniques, are still non-redundant diagnostic tools
in most cases. MALDI Imaging mass spectrometry (IMS) is a
powerful new technology to assess the spatial distribution of
biomolecules in tissue sections, providing hundreds of different
molecular images from a single scan.
We explored the ability of the MALDI-IMS as a companion
diagnostic tool for membranous (MG) and minimal change
(MCG) glomerulonephritis, two morphologically different
glomerular alterations in which the changes involve every
glomerulus.
Methods: Serial sections were cut from the very same fresh
frozen biopsy used for diagnosis. Protein profiles were obtained
from four MG, two MCG and two controls. Data analysis was
performed by ClinProTools 2.2, protein spatial distribution by
FlexImaging 2.1, with a pathologist’s supervision.
Results: MALDI-IMS allowed to detect many protein changes
between tubules and glomeruli in normal samples versus MCG
and MG, even when indistinguishable by histology. Several
differentially expressed peptides, able to discriminate between
the 3 classes under study, were detected when comparing
protein profiles obtained from glomeruli and tubules structures.
Ten and four peptides were differentially expressed in glomeruli
of MCG and of MG compared to the normal structures. When
comparing areas of morphologically normal tubules, eight
peptides were detected at significantly higher and three at
lower intensity in patients compared to control. Images of the
spatial distribution of these peptides confirm their different
expression in the pathological areas of the biopsies.
Conclusions: MALDI-IMS is a powerful and promising
EuroMEdLab 2013 - sciEntific sEssions
technique to classify renal biopsies, reading beyond the
traditional histopathology. Differentially expressed proteins
detected through MALDI-IMS represent powerful classifiers of
nosologic groups and may help subclassify each disease
according to glomerular cellular composition, interstitial
damage or systemic co-factors. Moreover, this approach may
detect early changes in the tubules or the surrounding tissue,
possibly of prognostic value for the outcome of the pathologic
process.
OC02
CYS327CYS POLYMORPHISMS OF THE PAPP-A GENE
(PREGNANCY ASSOCIATED PLASMA PROTEIN A) IS
RELATED TO MORTALITY OF LONG TERM
HEMODIALYSIS PATIENTS
M. Kalousova(1), M. Jachymova(1), A. Muravska(1), A.A.
Kubena(1), V. Tesar(2), T. Zima(1)
1
Institute of Medical Biochemistry and Laboratory
Diagnostics, First Faculty of Medicine, Charles University
and General University, Prague, Czech Republic
2
Department of Nephrology, First Faculty of Medicine,
Charles University and General University, Prague, Czech
Republic
Background: PAPP-A is an independent mortality predictor of
long term hemodialysis patients and a prognostic marker of
acute coronary syndrome in general population. Cys327Cys
PAPP-A polymorphism(SNP) (rs12375498, exon 2) was found
to be of significance in preeclampsia and the C allele of the
PAPP-A C/G SNP (rs13290387, intron 6) was defined as an
independent risk factor for acute myocardial infarction. The aim
of the study was to test the role of these two PAPP-A SNPs in
long term hemodialysis patients.
Methods: The studied group consisted of 464 subjects – 319
long term hemodialysis patients (183 men and 136 women,
mean age 62±14 years) and 145 controls (65 men and 80
women, mean age 49±14 years). A subgroup of 211
hemodialysis patients (118 men and 93 women, mean age
63±13 years) was prospectively followed up for 4.5 years.
During the follow up, 111 patients died, 51 of them due to
cardiovascular events. PAPP-A SNPs were analysed by DNA
sequencing and serum PAPP-A was measured by TRACE
(time resolved amplified cryptate emission).
Results: Both SNPs were in Hardy-Weinberg equilibrium. Allelic
and genotype frequencies did not differ between patients and
controls and were not related to serum PAPP-A concentrations.
Cys327Cys SNP was significant for patients´ survival while C/G
SNP was not. Presence of the mutated allele was significant
both for overall and cardiovascular mortality (HR(95%CI):
1,616 (1,110-2,353), P=0.012; 1,757 (1,018-3,030), P=0.043,
respectively).
Conclusions: Our study shows for the first time the significance
of Cys327Cys PAPP-A SNP (rs12375498) for overall and
cardiovascular mortality of long term hemodialysis patients.
SY04
ENSURING POCT QUALITY IN THE COMMUNITY
S. Sandberg
Norwegian Quality Improvement of Primary Care
Laboratories (NOKLUS), Bergen, Norway
POC instruments are increasingly used throughout the
community. Instruments are used at GPs offices, pharmacies,
nursing homes, departments in the hospitals and in the hands
of patients. How can the quality of these instruments be
ensured? There are relatively more errors of POC instruments
in the analytical phase compared to central laboratory
instruments. But, of course, errors in the pre-analytical and
post-analytical phase are also frequent. First of all, politically it
has to be decided that quality of POC instruments is the
responsibility of the laboratory profession. It should be a goal
for laboratory medicine to ensure the quality of equipment of
POC instruments wherever they are situated. Most clinicians
and patients do not know that POC results can be misleading
and prone to errors. Therefore an important aspect will be
education of the users of the instruments, both in pre-analytical
errors, in how to choose the right instrument for their use and
how to run it and of course the post-analytical aspects e.g. how
to report the results. As a laboratory profession we have
critically to judge if – and how to - use traditional internal quality
control. External quality control for POC instruments have to
be improved securing that we can get information on both
participant performance as well as method performance. To be
able to do this, improved quality control material has to be used
and/or methods to improve the “commutability of the EQA
schemes” have to be developed.
SY05
ENSURING POCT QUALITY IN THE HOSPITAL
ENVIRONMENT
R. Slingerland
Clinical Chemistry Laboratory, Isala Clinics, Zwolle, The
Netherlands
The quality of point-of-care tests (POCT) within different
segments and between different parts of the health-care chain
is currently insufficiently harmonised. Status of guidelines
regarding the different segments of POC glucose
measurements as one of the most profound used POC test will
be presented.
Connecting all POCT instruments in and outside a hospital to
central databases is an essential step in improving the
continuity of data in the health-care chain. This lecture will
address the involved necessary and standardised
requirements from a laboratory point-of-view.
Patients privacy is at stake with increasing digital
communication. The White House in the US has launched an
intiative in 2010 to improve the privacy of patients and others
in this market. The increasing use of wifi and other digital
applications in and outside hospitals makes this initiative even
more relevant. The clinical chemistry society needs to be more
involved in solutions in this area invented for telecom and
finance market because these solutions will in the end or do
already enter the medical POC-market. Currently, telemedicine
based on remote POCT is increasing rapidly. However, telemedicine can be a dangerous exercise if it is based on patient
identification only. Patient authentication is an essential
improvement for the near future. An example how to perform
safe digital authentication with minimal patient credentials
involved will be presented.
This lecture will show some validation topics to ensure the
quality of POCT in the hospital which may be useable in the
whole health care chain. The challenges in the critical care
setting will be described regarding e.g. continuous glucose
monitoring vs. point-to-point glucose comparison studies,
statistic parameters involved and power of these statistic
parameters.
Differences between glucose measurements in a hospital
vs.home-use setting and consequences for the quality of the
glucose measurement will be presented.
biochimica clinica, 2013, vol. 37, SS
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SY06
AS A PATIENT, HOW GOOD DO I WANT POCT TO BE?
I. Watson
University Hospital Aintree Dept Clinical Chemistry Lower
Lane Liverpool, UK
Patients’ views of laboratory testing are they will “have some
bloods done” determining either their diagnosis, treatment
changes or that monitoring is effective. The lack of
understanding of how tests are done does not mean that
patients do not understand the need for the quality.
Patients are also familiar with testing for themselves e.g.
pregnancy tests or blood glucose checking for diabetics; either
through OTC devices, Point of Care Testing (POCT) in
pharmacies or through the internet; for a POCT service patients
make the assumption it is as good as the bloods that are sent
for “testing”. As a patient I expect my results to be guaranteed
as being from me, accurate and done immediately; I want the
result without an anxious wait; I may not understand the
concept of error, to me a mistake; nor do I understand
probability, I assume the result is absolute! This is a rather
simplistic view: there is a spectrum, some patients with
knowledge and experience in other fields understand that there
may be variation, that there may be mistakes (errors); however
a value is assumed to be correct: many have no such insight.
We know about the many errors in the sample-result pathway
for central laboratories, surprisingly such work is unavailable
for POCT; excepting the proximity of analysis and return of
result element all the others are the same as the central
laboratory pathway: there are the same requirements for
quality. Patients are aware of quality, they may see company
vehicles with an ISO 9001 a demonstrable quality standard, so
there will be a standard for my test and it will be done to the
required standard: this implies professionalism.
Hence, I want my POCT test to be convenient, something I can
trust, supervised by professionals so that I can have confidence
in getting the quality investigations I need to ensure quality
outcomes for my disease processes: it is up to you, as the
healthcare professionals who understand these things, to make
sure my expectations are met!
OC03
A SURVEY OF LABORATORY ANALYSES PERFORMED
IN PRIMARY HEALTH CARE IN SWEDEN
L. Norlund(1), P. Norlund(2), G. Nordin(3), M. Rotzen Östlund(4),
H. Hansson(5), S. Nilsson(6), P. Karlsson(7), C. Krook
Persson(3), K. Skov-Poulsen(8), H. Liljenbring(9)
1
Norrbottens läns landsting, 2University of Colorado Boulder
Equalis, 4Karolinska Universitetssjukhuset, 5Vårdcentralen
Aleris Medilab , 6Vårdcentralen Vikbolandet , 7Ryhovs
sjukhus, 8Växjö sjukhus, 9Unilabs, Mälarsjukhuset
3
In Sweden, in primary health care, there is a lack of basic
information on the different types of laboratory test performed
and at what quality. There is not even accurate statistics on the
number of primary health care centers within the country.
EQUALIS (the provider of external quality assessment for
clinical laboratory investigation in Sweden) initiated a study to
gather this valuable data by creating a survey. The purpose of
the survey was to understand the analyses done in Sweden by
primary health care providers and occupational health service,
how they are done, and at what level of quality. This has
included not only the tests performed, but also the types of
personnel involved in proving the testing (doctors, nurses, or
laboratory technicians). The main objectives were to learn
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biochimica clinica, 2013, vol. 37, SS
whether the number of doctors (a necessity for providing
certain tests) and distance to the closest hospitals from the
primary health care center. Can the number of doctors and the
distance to hospitals explain the number of analyses performed
at the primary health care centers? Furthermore, since this
study includes the entire nation of Sweden, one important
research objective is whether there were regional differences
present within Sweden? Since no actual estimate of the
number of primary health care centers is available in Sweden,
study purchased 700 addresses to complement those that
were already members of EQUALIS. The survey results
covered roughly 22 percent of the Swedish population.
Statistical analysis, including generalized linear models
(Poisson GLM) , geographic information science (GIScience),
and cluster analyses were performed. Results of the study
show that distance to hospitals has no bearing on the number
of tests performed or on whether a laboratory was quality
assured. Furthermore, doctors showed a negative association
with quality assurance. Statistics on individual tests were also
gathered, including frequency of a test and at what quality it
was done. Finally, there were strong regional differences
discovered in the frequency of tests analyzed in various regions
of Sweden.
OC04
ERRORS IN BLOOD GAS POCT: A METHOD TO QUALIFY
NONCONFORMITIES AND ADDRESS EFFECTIVE
TRAINING FOR POCT OPERATORS
L. Varraso(1), F. Stea(2), R. Lovero(1), E. Mascolo(1), F. Di
Serio(1)
1
Department of Clinical Pathology, University Hospital of Bari,
Italy
2
Department of Accident and Emergency, University Hospital
of Bari, Italy
Background: 22 blood gas analyzers (Instrumentation
Laboratory; n. 10 Gem 4000, 12 Gem 3500) have been placed
and used since 2010, as Point-of-Care testing (POCT), at the
University Hospital of Bari. Laboratory’s staff supervise all
processes through Gem Web Plus system. Intelligent Quality
Management (IQM) and External Quality Assessment (EQA)
programs, ensure blood gas analysis quality assurance. GEM
4000 analyzers were interfaced with Laboratory Information
System (LIS). All operators have been formally trained for the
process management and the operating procedures. To
tracking pre-analytical errors, major nonconformities (NC) we
evaluated along 12 months.
Method and materials: Thanks to LIS and Gem Web Plus, we
have identified two classes of NC: Management NC (MNC),
strictly linked to the registration –phase (typing patient
demographic into LIS and bar-code generation) and Process
NC (PNC) strictly linked to the inadequate sample handling;
corrective actions have been taken to specific operating unit,
accordingly.
Results: Three MNC categories caused failed data transmission to LIS: planned analysis but not run in LIS mode
(MNC1); analysis with wrong sample ID (MNC2); analysis with
re-used sample ID (MNC3). Three PNC categories caused the
analysis abortion: non detected sample (PNC1); insufficient
sample (PNC2); air bubble into the sample (PNC3). NC
incidence was as follows: MNC=5% (n.422/9250 test);
MNC1=67%,
MNC2=7%,
MNC3=26%.
PNC=8%
(n.2448/29298 test); PNC1=58%, PNC2=33%, PNC3=8%. NC
showed a decrease across the year which was significant for
MNC (6% vs 3%) but not for PNC (7% vs 6%). In the
Emergency Room (E.R) was found the highest incidence in
PNC (42%). Following a certified training session, where all
EuroMEdLab 2013 - sciEntific sEssions
operators were undergone to an interactive and self-evaluation
session thanks to the Gem Web Plus, after a three-months
period, NCP in the E.R. were decreased to 23%.
Conclusions: A systematic method for identifying management
and process Non conformities supports the lab to better
manage blood gas POC testing. In a critical setting such as
E.R., is essential to constantly monitor the operator’s skills and
enforce corrective actions to reduce the clinical risk caused
by errors in the "total POCT blood gas process".
SY07
ANALYTICAL TOXICOLOGY OF EMERGING DRUGS OF
ABUSE
F.T. Peters
Institute of Forensic Medicine, Jena University Hospital,
Germany
Background: In recent years an ever increasing number of
novel psychoactive substances has emerged on the
recreational drug market. They belong to various drug classes
and may have psych stimulant, hallucinogenic or cannabis-like
properties. At the time they first appear on the market, these
emerging drugs are generally not scheduled as controlled
substances and therefore sold as “legal highs” and in part
labelled as e.g. incense, research chemicals, or bath salts.
Methods: To the analytical toxicologist the emerging drugs are
an on-going challenge. At the time they first appear, often not
even their chemical structures are known. Once these have
been elucidated and reference substances have become
(commercially) available, laboratories working in the field of
clinical and forensic toxicology must either update existing
methods or develop new ones to cover these novel
psychoactive drugs. This presentation will provide an overview
on the chemical structures of different classes of emerging
drugs (e.g. cathinones, synthetic cannabinoids) and on
analytical procedures for their analysis in biomatrices most
relevant to clinical and forensic toxicology (blood, urine, oral
fluid, hair). Different analytical strategies (targeted vs
untargeted analysis) and techniques (immunoassays, gas
chromatography-mass spectrometry [GC-MS], liquid
chromatograghy-mass spectrometry [LC-MS(/MS)]) will be
discussed. This will include aspects of sample workup, analyte
separation, and detection modes.
Results: The majority of the emerging drugs are not sufficiently
detectable by commercial immunoassays for conventional
drugs of abuse testing, but amenable to analysis by
hyphenated chromatographic-mass spectrometric techniques.
While the respective equipment is available in most forensic
and clinical toxicology laboratories, analysis of emerging drugs
generally requires modification of established or development
of new analytical methods.
Conclusion: The occurrence of ever new psychoactive
compounds on the drug market calls for regular updates of
analytical methods in clinical and forensic toxicology
laboratories.
SY08
BIOMARKERS OF ETHANOL CONSUMPTION
L. Morini
Department of Public Health, Neuroscience, Experimental
and Forensic Medicine, Legal Medicine and Forensic
Science 'A. Fornari' Unit, University of Pavia, Italy
A clinician should evaluate not only a recent/acute alcohol
abuse, but also a long-term ethanol consumption. The choice
of a proper biological matrix as well as the right biomarker is
crucial for this purpose. For example, the evaluation of “Driving
under the influence of alcohol” is carried out through the
determination of Breath Alcohol concentration (BrAC) or
through the determination of Blood Alcohol Concentration
(BAC). BAC is the analytical procedure that guarantee a result
with the highest diagnostic sensitivity and specificity. The
determination of alcohol in urine is performed whether a recent
alcohol intake diagnosis is required. Also direct phase II
metabolites of ethanol, ethyl glucuronide (EtG) and ethyl sulfate
(EtS) are also frequently used as potential markers of alcohol
intake. They can be detected in all the biological fluids for
several hours (up to 80 h in urine). Another biomarker for recent
alcohol abuse is 5-hydroxytryptophol (5-HTOL) that is a minor
metabolite of serotonine, produced in higher amount when
acetaldehyde (the main metabolite of ethanol) affect the
transformation of serotonin. For several years liver enzymes
such as serum gamma-glutamyltransferase (GGT), aspartate
aminotransferase (AST), alanine aminotransferase (ALT) have
been used as state biomarkers for chronic alcohol abuse.
These enzyme reflect the activity of the liver; however they
showed low sensitivity and specificity. So far, the most used
biomarker for ethanol dependence is a version of the
glycoprotein transferrin, the carbohydrate deficient transferrin
(CDT). Despite a relative high rate of false negative CDT is a
well-characterized biomarker for chronic alcohol abuse.
Another promising biomarker is blood phosphatidylethanol
(PEth). This is an abnormal phospholipid produced only in the
presence of ethanol consumption by the phospholipase D.
Recently EtG and fatty acid ethyl esters (FAEE) detected in
hair showed a very high diagnostic sensitivity and specificity
for chronic excessive alcohol consumption as well; the Society
of Hair Testing (SoHT) edited an International Consensus on
the use of these compounds for forensic purposes, indicating
the cut-off and analytical procedures for their determination in
the keratin matrices.
SY09
ORAL FLUID DRUG TESTING
S.M. Wille
NICC, Brussel
Background: Over the last decades, knowledge concerning
oral fluid (OF) and its possibilities for monitoring the presence
of drugs of abuse (DOA) for clinical and forensic purposes has
increased enormously. Especially in the domain of testing
drivers under influence of DOA (DUID), OF testing has gained
popularity due to its non-invasive collected directly on-site
without hampering privacy. Several on-site immunosorbent
assays (OIA) were developed and evaluated over the years.
For confirmatory toxicological analysis, the use of OF has been
hampered by the influence of the salivary composition on the
final drug concentrations. The OF collection protocol, the
degree of stimulation of salivary flow, the physicochemical
properties of DOA, and the type of drug administration are
some of the parameters that influence the OF drug
concentrations. In addition, OF influences the analytical
procedure through matrix effects and recovery issues. For the
final result, the analyst will also have to pay attention to the
collected volume, the dilution factor of the collection device and
to the stability of the sample. As a result, toxicological analysis
of OF samples and the final interpretation is not always
straightforward.
Material and methods: Laboratory studies and samples
obtained from DUID will be use to evaluate OIA (e.g. Drugwipe
and DrugTest) and quantitative methods using OF collection
devices such as StatSure® (StatSure Diagnostic Systems Inc),
Quantisal® (Immunalysis) and Certus® (Concateno) in
biochimica clinica, 2013, vol. 37, SS
S13
EuroMEdLab 2013 - sciEntific sEssions
combination with UPLC-MS/MS.
Results: Sensitivity of OIA seem to increase and more
knowledge concerning OF as toxicological matrix is obtained.
Stability and adsorption of several DOA in the OF collectors
as well as practical considerations for method developers to
tackle matrix effects and limitations due to small sample
volumes will be discussed. Furthermore, we will address
quality control as required by ISO 17025 and the current
problems. All these considerations will be implicated to DUID
legislations
Conclusion: OF has its limitations as a toxicological matrix.
However, in situations were ‘recent’ drug use in combination
with analytical cut-offs for interpretations are used, OF
combines an easy collection of samples with a quick analysis
of large batches.
OC05
EMERGING TRENDS IN DRUG USE AMONG YOUNG
PEOPLE
S. Pichini, E. Marchei, M.C. Rotolo, M. Pellegrini, R. Pacifici
Istituto Superiore di Sanità, Rome, Italy
Background: User surveys show that there have been
significant changes over the last years in the recreational drugs
being used by young people and available through
conventional and new telematic sources. Whereas cannabis
and cocaine remain the most used drugs of abuse new
designer drugs, psychoactive medicaments, dietary
supplements, alcohol mixed to energy-drinks, anabolic steroids
are emerging trends in youth consumption.
Methods: Forums, social media, online shops, websites and
other internet sources have been extensively and regularly
monitored in cooperation with the Italian anti-adulteration and
safety bureau (NAS) for emerging trends of novel drugs among
young people. Different products sold via internet or through
illegal venue were seized, listed, photographed and analysed
by systematic toxicological analysis using GC-MS and/or LCMS/MS methodologies.
Results: Products seized using “purchase by false identity” in
websites or inn illegal venues by NAS contained e.g. psilocin
found in “magic truffles”, 1,3 - dimethylamylamine and sildenafil
in dietary supplements, steroids not declared in the label or in
different amount in counterfeit preparations, methylpirovalerone
in salt baths, synthetic cannabinoids in perfumed incenses and
butylone sold as plant food.
Discussion: These emerging trends in drug use among young
people are certainly a niche phenomenon in drugs market and
present some peculiarities, which differentiate from “classical”
drugs of abuse. These substances are available via the Internet
with no contact with the dealer, no possibility to reach the
ultimate user and marked “not for human use”, or “plant
material for collection”, so the dealers are not legally
responsible if the products are consumed in a different way
from that indicated in the labels. Moreover, they are legal for the
period of time when they are sold but when they are included
in the specific banning laws, new products (structurally similar
to the previous one) are sold in place of the previous ones.
Conclusions: Although the use of these new drugs is
increasing, no toxicity studies in animal or human models and
no analytical assays are available so that side effects, long term
adverse effects and eventual forms of intoxications are
unknown, so is the way to treat them.
OC06
AN ELEVATED CARBOHYDRATE-DEFICIENT
TRANSFERRIN (CDT) LEVEL DUE TO
PHOSPHOMANNOSE ISOMERASE DEFICIENCY IN AN
ASYMPTOMATIC ADULT WOMAN WITH CONGENITAL
DISORDER OF GLYCOSYLATION OF THE MPI-CDG
SUBTYPE
A. Helander(1), J. Jaeken(2), G. Matthijs(3), G. Eggertsen(1)
1
Department of Laboratory Medicine, Karolinska Institutet,
Stockholm, Sweden
2
Center for Metabolic Disease, University Hospital
Gasthuisberg, Leuven, Belgium
3
Center for Human Genetics, University Hospital
Gasthuisberg, Leuven, Belgium
Background: In connection with a routine company health
check-up, a 32-year old woman showed a markedly elevated
level of carbohydrate-deficient transferrin (CDT) in serum, a
biomarker for long-term heavy alcohol consumption. Because
there were no other signs of excessive drinking, this study
aimed to disclose the cause of her elevated CDT value.
Methods: Serum CDT (% disialotransferrin) was determined by
an HPLC candidate reference method and phosphatidylethanol
(PEth) in whole blood, another long-term alcohol biomarker, by
an LC-MS method. Analysis of enzymes causing defective
transferrin glycosylation in congenital disorders of glycosylation
(CDG), a family of rare complex metabolic disorders, was
performed in cultured skin fibroblasts. The fibroblasts were also
used for DNA sequencing analysis.
Results: The CDT level remained very high with 17%
disialotransferrin (reference <2) and 3% asialotransferrin
(reference 0) on two separate occasions, despite a negative
PEth test. This confirmed that the elevated CDT level was not
related to heavy alcohol consumption. The HPLC analysis
showed a “type1” transferrin pattern (i.e., elevated asialo- and
disialotransferrin) pointing to a defect in N-glycan assembly.
The phosphomannomutase activity in fibroblasts was within
normal limits but the phosphomannose isomerase (MPI)
activity was very low (0.64 mU/mg protein; reference 2.3–6.9)
indicating CDG of the MPI-CDG subtype (formerly called CDGIb). Mutation analysis of MPI revealed that the woman is
homozygous for the c.656G>A mutation causing replacement
of arginine by glutamine (p.R219Q). The women has not
reported any of the clinical manifestations typically associated
with MPI-CDG, and has thus never been treated by mannose.
Conclusions: CDT is considered a specific alcohol biomarker
with little risk for generating false positive identifications of
alcohol abuse. In this case report, a markedly elevated CDT
level in an adult woman obtained in connection with a routine
company health check-up was demonstrated not to be caused
by heavy alcohol consumption but by MPI deficiency due to a
homozygous mutation in MPI. The woman thus seems to be an
asymptomatic MPI-CDG adult. Only one other similar case has
been reported.
SY10
EPIGENETIC BIOMARKERS IN SOLID TUMOR
DETECTION, PROGNOSIS AND MANAGEMENT
K. Heichman
ARUP Laboratories, Inc., USA
Background: Cellular DNA undergoes profound changes in
methylation
during
cancer
development,
with
hypermethylation occurring in specific gene promoters, amidst
a backdrop of generalized hypomethylation. DNA methylation
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biochimica clinica, 2013, vol. 37, SS
EuroMEdLab 2013 - sciEntific sEssions
in cancer often causes the silencing of tumor suppressors and
other genes important for cellular growth, regulation and
differentiation. Thousands of publications describe the
methylation status of hundreds of genes in cancer, however
only a relatively small number of methylated genes are specific
for an individual cancer type. Further, even fewer have been
utilized as cancer biomarkers in the clinical laboratory.
Methods and results: The Septin9 gene was first described by
Lofton-Day in 2008 to be differentially hypermethylated in
colorectal cancer (CRC) tissue, and this hypermethylation was
shown to be detected in the blood of CRC patients of all clinical
stages using a sensitive molecular method. A more recently
improved sensitivity method to detect methylated Septin9 has
been demonstrated to detect 90% of CRCs with 88%
specificity. Septin9 hypermethylation can be detected in the
blood of patients with cancers arising from all regions of the
large intestine, including the right side of the colon which is
often difficult to reach in colonoscopy and which is challenging
to detect using stool-based screening methods. The Septin9
test may have additional clinical applications as well as its
established role in CRC screening and early detection.
Individuals with inflammatory bowel disease, such as Crohn’s
and Ulcerative Colitis, have an increased lifetime risk of
developing CRC; studies are currently underway to determine
if Septin9 testing may be useful in detecting cancer or even
dysplasia in these patients who otherwise are subjected to
frequent surveillance colonoscopies involving multiple biopsies
at each procedure. Interesting, Septin9, and like other genes
differentially hypermethylated in cancer, has been shown to
be highly methylated in the blood pregnant women.
Conclusions: Septin 9 may represent the first example of a
blood-based, DNA methylation test based a new class of
oncofetal biomarker, akin to other well-known biomarkers such
as CEA (carcinoembryonic antigen), AFP (alpha-fetoprotein)
and CA-125.CA 19-9 and CA 15-3.
SY11
EPIGENETIC BIOMARKERS FOR EARLY DETECTION OF
AERODIGESTIVE TRACT CANCERS IN BIOLOGICAL
FLUIDS
T. Liloglou
Department of Molecular and Clinical Cancer Medicine,
University of Liverpool, UK
Cancers of the respiratory tract (lung and head and neck)
contribute to more than 25% of human cancer-related mortality
worldwide. Tumours along the respiratory tract share common
aetiologies, risk factors and molecular characteristics. Major
clinical challenges in reducing mortality from these cancers
include the detection of early lesions, timely discovery of
relapse and patient stratification into more efficient therapeutic
regimens. Epigenetic reprogramming is one of the hallmarks
of human cancer. DNA methylation is currently the best-studied
epigenetic modification pointing to a large number of genes
being silenced by hypermethylation. These genes are now
looked as potential biomarkers for clinical management of
cancer. DNA methylation possesses many characteristics,
which make it advantageous in biomarker development. The
biological function of DNA methylation, its covalent chemical
nature, the stability during fixation and the durability of DNA is
clinical specimens are some of such characteristics. The
application of molecular biomarkers in biological fluids and
specimens acquired in common clinical practice has been a
long term demand. To date, there is significant literature on the
applicability of DNA methylation biomarkers in a variety of
specimens including bronchial washings, sputum, buccal
swabs, saliva, plasma and serum. However, while the feasibility
has been demonstrated, the diversity of methods and study
designs makes comparison particularly complicated. In
addition, lack of statistical power is a frequent problem. Last
but not least, is the lack of a continuum in DNA methylation
biomarker studies thus very few groups move into proper
clinical validation. This underlines the need of large consortia
contributing clinical samples and information as well as the use
of a consensus on the use of robust, high precision assays.
Clinical validation of DNA methylation biomarkers is very
important, especially when running along computed
tomography (CT) trials, where it may be able to assist in the
management of indeterminate nodules.
SY12
DNA HYPOMETHYLATION IN CANCER
M. Fernandez Fraga
Cancer Epigenetics Laboratory, Instituto Universitario de
Oncología del Principado de Asturias (IUOPA), HUCA,
Universidad de Oviedo, Spain and Department of
Immunology and Oncology, National Center for
Biotechnology, CNB-CSIC, Cantoblanco, Madrid, Spain
DNA methylation plays a central role in growth and
development. Alteration of DNA methylation is a hallmark of
cancer. Tumors present sites specific DNA hypermethylation
and a global DNA hypomethylation. This overall loss of DNA
methylation can be a relevant biomarker for cancer and other
diseases. Thus, in recent years it has become apparent that
there is a need to develop methods for the analysis of DNA
methylation using different approaches: global, locus-specific,
or genome-wide.
OC07
IDENTIFICATION AND ENUMERATION OF TUMOR
SPHERES CULTURED FROM CIRCULATING
EPITHELIAL TUMOR CELLS IN PATIENTS WITH SOLID
CANCERS
M. Pizon(1), D. Zimon(1), U. Pachmann(2), K. Pachmann(2)
1
SIMFO Spezielle Immunologie Forschung, and Entwicklung
GmbH, Bayreuth, Germany
2
Transfusion Centre Bayreuth, Bayreuth, Germany
Background: The main cause of mortality of cancer patients is
the formation of metastasis. A subpopulation of circulating
tumor cells with stem-like properties is responsible for tumor
initiation, invasive growth and metastasis formation. This
population is termed cancer stem cells (CSCs). CSCs can be
identified by different approaches one of them is assessment
of their ability to grow as floating spheres.
Methods: We enrolled 60 patients into the study suffering from
breast (40), colorectal (10) and prostate (10) cancer in which
circulating tumor cells (CETCs) were detected. CETCs were
determined using the maintrac® method and viable CETCs
were plated in suspension culture system allowed for tumor
sphere formation. Cell viability and surface marker expression
was evaluated by laser scanning cytometer.
Results: Sphere formation was observed in 78% of patients
with breast, colorectal and prostate cancer. The number of
tumor spheres was dependent on the type of tumor and varied
from 0 to 122 in breast cancer; from 0 to 30 in colorectal cancer
and from 0 to 7 in prostate cancer per 1ml of blood.
Furthermore, we found a highly significant correlation between
the number of CETCs and the number of tumor spheres after
biochimica clinica, 2013, vol. 37, SS
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EuroMEdLab 2013 - sciEntific sEssions
21 days of culture in breast cancer patients (r=0,867; P
<0,005). The number of tumor spheres was always higher in
patients with metastatic disease as compared to patients with
non metastatic disease. There was no sphere formation in 10
healthy donors.
Conclusion: This study demonstrates that tumor stem cells are
present in peripheral blood from metastatic and non-metastatic
tumor patients. They represent a small subpopulation of
circulating epithelial tumor cells with the ability to growth as
tumor spheres.
OC08
MODULATION OF EXPRESSION OF CYTOKERATIN -19
FRAGMENTS (CYFRA 21-1) BY IRON AND RISK OF
LUNG CANCER IN SOME WELDERS
O. Ige(2), O. Olorunsogo(3), B. Banjoko(1)
1
Department of Chemical Pathology, College of Health
Sciences Obafemi Awolowo University, Ile-Ife, Nigeria
2
Department of Medicine, College of Medicine, University of
Ibadan, Nigeria
3
Department of Biochemistry, College of Medicine,
University of Ibadan, Nigeria
Background: The wielding process is classified as probably
carcinogenic and welders may be at risk of developing lung
cancer. Limited evidence in humans and inadequate evidence
in experimental animals of carcinogenicity of welding fumes
and gases were therefore the underpinnings of this study.
Materials and Methods: Sixty (60) welders and fifty (50) healthy
volunteers were recruited as controls. Interviewer styled
questionnaire was administered to all participants for
demographic, medical history and occupational features. Urine
samples were obtained from all subjects for estimation of
welding related heavy metals including iron, manganese, lead,
chromium, zinc, nickel and cadmium using flame atomic
absorption spectrophotometer. Blood obtained from
venepuncture was used for the estimation of plasma iron,
ferritin, transferrin, total iron binding capacity, transferrin
saturation and Cytokeratin- 19 fragments (Cyfra 21-1).
Statistical analyses were performed using Student T-test, Mann
– Whitney U, Kruskaal Wallis and Pearson correlation.
Results Mean ages (yrs) of the welders and control were 42.97
±8.75, 40.36±7.56 (P=0.100) respectively. There were
statistically significant differences in the values of urinary iron,
lead, zinc, nickel, manganese and chromium P <0.05 but not
in cadmium. Levels of plasma iron, transferrin, ferritin, TIBC,
transferrin saturation and Cytokeratin -19 fragments were also
significantly different (P <0.05). Furthermore, markers of iron
metabolism positively correlated with Cytokeratin-19 fragments
expression
Conclusion: These findings suggest that the welders studied
were at risk of developing lung cancer as evidenced by
significant expression of Cytokeratin-19 fragments in their
plasma which was most likely mediated by iron. Therefore,
periodic biomonitoring of markers of exposure and effect would
be beneficial to this group.
SY13
THE IMPORTANCE OF AUTOANTIBODY TESTING IN
AUTOIMMUNE RHEUMATIC DISEASE
P.L. Meroni
University of Milan, Istituto Auxologico Italiano, Milan, Italy
Autoantibodies are diagnostic tools for most of the rheumatic
diseases and in some cases they also are formal classification
S16
biochimica clinica, 2013, vol. 37, SS
criteria. Moreover autoantibody profile is useful for identifying
subgroups of patients in a given disease and in some cases
are prognostic factors for co-morbidities or for peculiar clinical
manifestations. In this regard autoantibody testing is not only
useful but also essential for a correct management of
autoimmune rheumatic diseases. There is evidence that an
early diagnosis may allow a prompt treatment. Such a strategy
has been found to be successful since an early and – in some
cases – aggressive treatment may induce stable remission or
allow the use of maintenance therapy at lower dosages with
reduced side effects. Reliable results in autoantibody testing
are mandatory for such treatment in the daily practice.
False negative results may delay the diagnosis with a
consequent increased risk for complications or disease
progression. At the same time, false positive results may
require re-testing or un-necessary second step diagnostic
assays. Altogether these processes may increase the direct
and the indirect costs for the management of rheumatic
autoimmune diseases. All these considerations explain the
need for the best standardization of the available diagnostic
test for the autoimmune rheumatic diseases.
SY14
ROLE OF ANTI-NEUTROPHIL CYTOPLASMIC
ANTIBODIES
C. Kallenberg
Dept. of Rheumatology & Clinical Immunology, University
Medical Center Groningen, Groningen, The Netherlands
Anti-neutrophil cytoplasmic antibodies (ANCA) are
autoantibodies mainly directed to proteinase 3 (PR3) and
myeloperoxidase (MPO). By indirect immunofluorescence (IIF)
on ethanol-fixed neutrophils (PMN) PR3-ANCA produce a
cytoplasmic staining pattern (c-ANCA) and MPO-ANCA a
perinuclear pattern (p-ANCA). The large majority of c-ANCA
corresponds to PR3-ANCA but this is not the case for p-ANCA
in relation to MPO-ANCA. So, a positive IIF-test should be
followed by an antigen-specific test (mostly ELISA/ELIA). PR3ANCA are very sensitive and specific for granulomatosis with
polyangiitis (GPA, formerly Wegener’s) and MPO-ANCA for
microscopic polyangiitis (MPA) and for Churg-Strauss
syndrome with a vasculitic phenotype. Levels of ANCA follow
disease activity to some extent, but a rise of ANCA titer is not
highly sensitive nor specific for an ensuing relapse. A primary
pathogenic role for ANCA in the associated small-vessel
vasculitides is suggested by the observation that they appear
before the clinical onset of GPA/MPA, the development of MPA
in a newborn child from a mother with MPO-ANCA, and the
associations of PR3-ANCA and MPO-ANCA with different
MHC-class II antigens (being stronger than with the associated
diseases themselves). Also in vitro and in vivo experimental
data strongly suggest a pathogenic role for ANCA. In vitro,
ANCA are able to activate primed PMN to full activation with the
release of reactive oxygen species and lytic enzymes resulting
in damage to endothelial cells, a process in which the
alternative pathway of complement plays a reinforcing role. In
vivo, induction of MPO-ANCA in mice and rats results in
necrotizing glomerulonephritis and vasculitis also in the lungs.
This is less clear for PR3-ANCA associated GPA in which
granulomatous inflammation is present, particularly in the
airways, in addition to vasculitis. Here, Th-17 mediated cellular
immunity is involved as well.
In conclusion, ANCA are important diagnostic markers for
small-vessel vasculitis with, supposedly, pathogenic
significance.
EuroMEdLab 2013 - sciEntific sEssions
SY15
ANTI-CYCLIC CITRULLINATED PEPTIDE ANTIBODIES IN
AUTOIMMUNITY
G. Pruijn
Department of Biomolecular Chemistry, Institute for Molecules
and Materials, and Nijmegen Center for Molecular Life
Sciences, Radboud University, Nijmegen, the Netherlands
Rheumatoid arthritis (RA) is an autoimmune disease
characterized by autoantibodies against citrullinated antigens.
The importance of citrulline for the epitopes bound by these
autoantibodies, referred to as ACPA (anti-citrullinated
peptide/protein antibodies), was first described in 1998. In
addition to citrullinated proteins, cyclic citrullinated peptides
(CCP) can be used as test substrates for detecting ACPA,
which are only rarely found in diseases other than RA. The
standard test for these antibodies is the second-generation
CCP (CCP2) test, which is one of the best in terms of sensitivity
and specificity. The generation of ACPA is an early event in the
disease course, and is dependent on the presence of certain
MHC class II alleles. ACPA in the inflamed synovium have been
shown to associate with citrullinated antigens to form immune
complexes, resulting in progression of the inflammatory
process. The involvement of ACPA in the chronicity of RA is
probably the reason why ACPA-positive patients have a more
erosive disease course than ACPA-negative patients. The
presence of ACPA has been included in the 2010 RA
classification criteria. Thus, it is important to further standardize
ACPA testing, for example by including an internal serum
standard, which may lead to a better distinction between low
and high ACPA levels. Recent data tend to indicate that ACPApositive RA patients develop erosions earlier and the erosions
become more widespread than in patients that are consistently
ACPA-negative. The therapeutic window of opportunity to
prevent the progression from early inflammatory synovitis to
the chronic joint destructive phase of RA is narrow, and hence,
early diagnosis and early therapy with disease-modifying
agents under tight disease control is mandatory. Although
citrulline is a common and essential feature of ACPA epitopes,
ACPA represent a diverse set of antibodies that target distinct
citrullinated epitopes. Multiplex ACPA assays are currently
being developed to measure ACPA profiles and to investigate
whether these have additional value for the early diagnosis and
prognosis of RA patients.
SY16
HARMONIZATION OF AUTOANTIBODY MEASUREMENTS
J. Sheldon
St. George's Hospital, UK
The detection and quantification of IgG autoantibodies against
normal components of tissue remain important tests in the
diagnosis and management of patients with autoimmune
diseases. The nature of the analysis and the lack of any robust
reference materials have generated a group of tests that show
astonishing variability. A sample known to be from a “normal”
donor can show numerical values that vary 10 fold across the
various methods, even though they are reporting results in the
same units! This represents a very dangerous situation for
patients that will be accentuated as labs consolidate and
introduce more automation. There are many factors
contributing to the variability of autoantibody measurements.
However, to understand the causes and to address them, we
need to begin the process of harmonisation. Many of the
factors are outside our direct control but as a scientific
community, we are able to produce materials that can be
evaluated and if appropriate, introduced as common calibration
solutions for widespread use in assays. The IFCC is supporting
the Harmonisation of Autoantibody Testing Working Group
which has been working with the IRMM on evaluating and
producing candidate materials for selected autoantibody tests.
Our aims were to produce materials for the harmonisation of 5
clinically significant autoantibodies. An important component
of the production of these materials was to generate the first
robust definition of the process for making calibration materials
for autoimmune serology. This is to ensure the long term
availability of reference material but also to define the process
sufficiently well to allow more analytes to added to the
repertoire as necessary. The preliminary investigations of one
material are complete and the development of the second
material is progressing well. A plan to produce materials for
further analytes will be developed. Reagent manufacturers in
the field of autoimmune serology have been very supportive of
this initiative but will want to see tangible benefits of using new,
common materials. We are planning a project to investigate
changes in between assay (method) variability that result from
the introduction of these materials.
SY17
PROFESSIONAL MOBILITY ACROSS EUROPEAN
BORDERS
G. Wieringa
Laboratory Medicine, Bolton NHS Foundation Trust, UK
For the 60% of specialists in laboratory medicine who are
pharmacists and scientists professional mobility across
European borders has long been hindered by barriers to mutual
recognition of qualifications. Such mobility is important in
supporting individual choice and encouraging a more equitable
distribution of human resources and expertise across Europe
at a time when demand for highly qualified professionals is
increasing and the labour force is declining. The passage
through the EU parliament of the Directive on recognition of
professional qualifications brings with it a responsibility on
fellow professionals to ensure that patient safety is not
compromised through discordant practice across European
borders. In this regard, EFLM/EC4’s building blocks for
common training frameworks that identify the skills, knowledge
and competencies to practice at specialist level are
acknowledged as an exemplar of good practice. This talk will
focus on the need to support free professional movement, the
responsibilities on the individual in meeting the skills,
knowledge and competence of specialist European practice,
and the need for the professions to speak with one voice in
ensuring mutual recognition.
SY18
THE EU DIRECTIVE ON RECOGNITION OF
PROFESSIONAL QUALIFICATIONS – IMPLICATIONS FOR
THE PROFESSIONS
S. Zerah
Laboratoire Zerah/Taar/Pfeffer, Bagnolet, France
Introduction: The (anticipated) publication early 2013 of the
revised Directive (2005/36/EC) on the Recognition of
Professional Qualifications in the Official Journal of the
European Union represents an opportunity for Specialists in
Laboratory Medicine to prepare free movement across
European borders.
Methods: We will give a quick overview of the history to enable
biochimica clinica, 2013, vol. 37, SS
S17
EuroMEdLab 2013 - sciEntific sEssions
understanding where we are now, after active participation and
strong involvement in the numerous meetings and
questionnaires, propositions of amendments to the final draft
proposed by the European Commission to the European
Parliament . We will present and explain the main points of the
revised directive, and stress the importance for the future of
our profession: Professional cards, «Common training
frameworks» replacing the common-platforms, back to
harmonization instead of identifying differences for
compensation measures, CPD, Partial access, rules on
language skills. High quality practice working to an equivalence
of standards across the European Union is the key guarantor
for patient safety. In this regard, the European professional
associations are taking the lead in devising “common training
frameworks” for harmonisation and the EC4 Register of
Specialists in Laboratory Medicine identifies individuals able to
reach such equivalence at high level of education.
Results and conclusion : 9 EU countries where professionals
and the Member States agree on the program of harmonisation
according to the “common training frameworks”, are needed to
make propositions the European Commission. If accepted the
frameworks will be transposed into national legislation. We will
report at what point we will be in May 2013.
SY19
THE COMMON TRAINING PROGRAMME FOR
SPECIALISTS IN LABORATORY MEDICINE
R. Jansen
EFLM/EC4 SKML, Radboud University, Nijmegen,
Netherlands
The Directive on Recognition of Professional Qualifications is
there to facilitate professionals in moving from one EU member
state to another, and to practice in the host member state in
the same way as in the member state of origin. In the directive
seven professions are regulated specifically among which
medical doctors. The rest of the professions fall under the so
called General System. In Annex VII of the directive the medical
specialisms are named. Although the list suggests equivalence
of names and equivalence of standards in education and
training in practice this is not the case in Europe. A cardiologist
in one member state may well have enjoyed a different training
than a cardiologist in another state. In the same way an
urologist is not an urologist. Harmonization of training is of the
utmost importance for patient safety. Patients must know
whether a specialist coming from another country is equivalent,
and also whether specialists in his or hers country are
equivalent to those in other member states. For specialists in
laboratory medicine even two specialties are mentioned,
clinical biology and biological chemistry. In the revision of the
directive the system of Common Training is introduced. The
EFLM Profession Commission focusses on the Common
Training System to get our profession recognized for specialists
in laboratory medicine for all educational groups, medical,
pharmaceutical and scientific. The European Register for
Specialists in Laboratory Medicine should serve as a basis. The
criteria to be registered in this register are discussed.
SY20
THE EC4 REGISTER OF SPECIALISTS IN LABORATORY
MEDICINE
J.P. Brochet
EXALAB, France
To be able to obtain an adequate level of quality of the
profession and practice in healthcare within the European
S18
biochimica clinica, 2013, vol. 37, SS
Union, it is vital to have an up-to-date, efficient and operational
level of skills required to be a Specialist in Laboratory Medicine
(SLM).This is based on two pillars : common training and code
of conduct. The EC4 committee plays a central role in the
coordination of the recognition of equivalence of standards for
application to the EC4 Register. Today, more than 3200
Specialists in Laboratory Medicine are members of the register.
The Netherlands and the UK have successfully implemented
an automatic registration procedure. In France this procedure
is ongoing and it will be the next country. Now it is time to
modernize the website and make it easier to use, this will make
it possible to increase the number of registrations and reregistrations in the future.
SY21
MOLECULAR GENETIC APPROACHES TO THE
DIAGNOSIS OF THYROID CANCER
Y. Nikiforov
School of Medicine, Department of Pathology, Division of
Molecular Anatomic Pathology, University of Pittsburgh, PA
Thyroid cancer is the most common type of endocrine
malignancy and its incidence has been steadily increasing in
many regions of the world. Papillary and follicular thyroid
carcinomas are the two most common types of thyroid cancer.
Initiation and progression of thyroid cancer involves multiple
genetic and epigenetic alterations, of which mutations leading
to the activation of the MAPK and PI3K/AKT signaling
pathways are crucial. Non-overlapping genetic alterations,
including BRAF and RAS point mutations and RET/PTC and
PAX8/PPARg rearrangements, are found in more than 70% of
papillary and follicular thyroid cancers. They represent the most
common genetic alterations in thyroid cancer, as well as
molecular markers of diagnostic and prognostic significance.
These mutational markers are being introduced into clinical
practice, assisting the diagnosis of malignancy in fine-needle
aspirates from thyroid nodules, and are particularly helpful for
those nodules that have indeterminate cytologic diagnosis.
Moreover, some of these markers, such as BRAF, provide
additional prognostic information, which may facilitate more
individualized operative and post-operative management of
patients with thyroid cancer. New emerging laboratory
technologies, such as next generation sequencing, will allow
to significantly expand the extent and precision of molecular
testing for thyroid cancer in the near future.
SY22
SUBCLINICAL THYROID DISEASE: IS IT CLINICALLY
IMPORTANT?
B. Velkeniers
Department of Internal Medicine, Free University of
Brussels, Belgium
The introduction of ultrasensitive immunoassays for TSH and
free thyroid hormones has changed the diagnosis of clinical
thyroid disease and enables us to detect early mild failure or
hyper function of the thyroid. The estimated prevalence of
subclinical hyper- and hypothyroidism (defined as a TSH
outside of reference range, with normal thyroid hormones) in
the general population is higher than overt dysfunction and
varies from 1.5% to 5.9%, and 2.9% to 16%, respectively.
Clinicians should consider the limitations of diagnostic
classification according to a single sample. Spontaneous
individual variations of thyroid tests may occur over time and
results may return to normal on follow-up. (Meyerovitch et al.,
EuroMEdLab 2013 - sciEntific sEssions
2007). Today it is much debated whether these abnormalities
should be treated. The precise threshold at which excess or
failure of the thyroid makes the clinical difference will ultimately
be guided by the results of well-designed prospective cohort
and intervention studies. There is consensus on the need to
treat subclinical hypothyroidism (SHypo) of any magnitude in
pregnant women and women who are contemplating
pregnancy, to decrease the risk of pregnancy complications. In
non-pregnant adult patients SHypo with a TSH > 10 mIU/L, has
been associated with a higher incidence of ischemic
cardiovascular events and heart failure.(Rodondi et al., 2010;
Gencer et al., 2012). Three recent meta-analyses provide
evidence that subclinical hyperthyroidism (SHyper) may
increase CV mortality in patients with undetectable serum TSH.
The increased CV risk may be linked to the risk of atrial
arrhythmias, especially atrial fibrillation, and heart failure.( Yang
et al.,2012;Collet et al.,2012; Gencer et al, 2012). Although
SHyper has been associated with lower bone density, data on
fracture risk are limited and contradictory.
Most of the data linking adverse CV outcomes of subclinical
thyroid dysfunction are derived from observational data. No
appropriately powered randomized controlled trials have
evaluated the effects of treatment to improve CV endpoints in
SHypo and SHyper . Today, inference on the potential benefits
from the treatment of the condition remains hazardous. Finally
the risk benefit ratio of such an intervention needs to be
addressed prospectively.
SY23
QUALITY AND STANDARDISATION ISSUES IN THYROID
FUNCTION TESTING
G. Beastall
University of Glasgow, UK
The diagnosis, treatment and monitoring of thyroid disease
relies on accurate thyroid function testing. The volume of
thyroid function testing in most laboratories is high and
increasing, with reliance on a high capacity immunoassay
analysers from the major diagnostics manufacturers. External
quality assessment schemes reveal an unacceptable level of
between method variability for the most commonly performed
thyroid function tests – thyroid stimulating hormone (TSH); free
thyroxine (FT4); and free tri-iodothyronine (FT3). This between
method variability has significant implications for patients,
especially for those being monitored during and after
treatment. This variability limits the applicability and
effectiveness of clinical practice guidelines and has caused a
loss of confidence in thyroid function testing amongst patients
with thyroid disease. In order to address the issue IFCC
established a Working Group (now a Committee) for the
Standardisation of Thyroid Function Tests (C-STFT) under the
direction of Prof Linda Thienpont. C-STFT has established a
reference measurement procedure (RMP) based on
equilibrium dialysis isotope dilution mass spectrometry which
has been validated for the measurement of FT4 and FT3. The
RMP has been applied to the measurement of FT4 and FT3
in a panel of sera from normal subjects and from patients with
thyroid disease. The same sera were used by the
manufacturers to measure FT4 and FT3 using their
commercial assay systems. TSH was measured in the same
sera but in the absence of a RMP results were compared to
the all method mean. The FT4 and FT3 results varied
significantly across the methods tested. None of the
commercial methods showed close agreement with the
respective RMP. Careful analysis of the data demonstrated
that recalibration of each method would dramatically reduce
between method variability. Similar, though less dramatic
results were found from analysis of the TSH data. These data
have shown the potential for reducing between method
variability for FT4, FT3 and TSH methods. The data is being
assessed by manufacturers in terms of assay calibration and
the impact on reference intervals. Coordinated implementation
of recalibration would be of maximum benefit to patient safety.
OC09
DIAGNOSTIC VALUE OF THYROGLOBULIN
MEASUREMENT IN FINE-NEEDLE ASPIRATE WASHOUTS OF LYMPH NODES METASTASES OF PAPILLARY
THYROID CARCINOMA.
C. Carrozza(1), M. Raffaelli(2), G. Canu(1), D. Maccora(2), G.
Fadda(3), R. Bellantone(2), C. Zuppi(1)
1
Laboratory of Clinical Biochemistry, Catholic University,
School of Medicine, Rome, Italy
2
Division of Endocrine and Metabolic Surgery, Catholic
University, School of Medicine, Rome, Italy
3
Division of Anatomic Pathology and Histology, Catholic
University, School of Medicine, Rome, Italy
Background. Ultrasound-guided fine-needle aspiration biopsy
cytology (FNAB-C) is the most common procedure for
diagnosing lymph node metastases from papillary thyroid
carcinoma (PTC). The thyroglobulin measurement in the washout of the fine-needle (FNAB-Tg) has been proposed to
improve its accuracy. However, there is disagreement on the
FNAB-Tg cut-off value. The aim of this study was to determine
the FNAB-Tg cut-off on samples obtained from patients
undergoing ultrasound-guided fine-needle aspiration of
suspected lymph nodes metastases of PTC.
Methods. FNAB-C was performed on 73 lymph nodes in 60
patients with PTC before initial surgery or during postthyroidectomy follow up. After obtaining a FNAB-C specimen,
the needle was washed with 1 mL of saline solution. The
FNAB-Tg
was
performed
by
chemiluminescence
immunoassay method on the Beckman Coulter DXI800
(functional sensitivity: 0.1 ng/mL at 20 CV%). ROC curve was
produced calculating the best FNAB-Tg cut-off to discriminate
true-positive from true-negative subjects. Moreover ROC curve
was created for FNAB-C; sensitivity and specificity were
calculated according to the area under curve (AUC) for FNABTg and FNAB-C. FNAB-Tg/serum-Tg ratio >1 in
non-thyroidectomized patients were considered positive.
Results. Overall, lymph node metastases were found at final
histological examination in 47 cases (64.4%). ROC curve
analysis for FNAB-Tg and FNAB-C showed an AUC=94% e
83% respectively (P <0.001); on the basis of this curve, the
best FNAB-Tg cut-off was 1.2 ng/ml leading to 92% sensitivity
and 81 % specificity. Overall accuracy, positive and negative
predictive values were 92%, 100% and 81% respectively for
FNAB-Tg and 82%, 100% and 67% respectively for FNAB-C.
The integration of both methods resulted in 95% overall
accuracy, 100% positive predictive value and 87% negative
predictive value. Two out six patients with false negative FNABTg result were correctly diagnosed by FNAB-C. Thirteen out of
fourteen non-diagnostic FNAB-C were correctly classified by
FNAB-Tg.
Conclusions. Integration of FNAB-Tg and FNAB-C, significantly
improves the diagnostic accuracy in the evaluation of lymph
nodes site of metastases of PTC, particularly in presence of
non-diagnostic FNAB-C.
biochimica clinica, 2013, vol. 37, SS
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OC10
LOW T3 SYNDROME IS ASSOCIATED WITH GREATER
MYOCARDIAL DAMAGE AND MORTALITY IN PATIENTS
WITH ST-ELEVATION MYOCARDIAL INFARCTION
E. Galli(3), N. Botto(1), U. Paradossi(1), S. Cardullo(1), M.S.
Parri(1), S. Storti(1), A. Taddei(2), G. Iervasi(2), S. Berti(1), A.
Clerico(3)
1Fondazione Toscana Gabriele Monasterio, Ospedale del
Cuore, Massa, Italy
2CNR, Institute of Clinical Physiology, Pisa, Italy
3Scuola Superiore S. Anna, Pisa, Italy
Background. An altered thyroid hormone (TH) metabolism
known as Low T3 syndrome (LT3S) is a frequent finding in
patients with severe illness, including patient with acute
myocardial infarction. Aim of this study is to evaluate the
relationship between LT3S, myocardial damage, mortality and
major adverse cardiac events (MACEs) in patients with STelevation myocardial infarction (STEMI).
Methods. 1007 patients (male: 74%; mean age: 66.1±12.5
years) admitted for STEMI and subjected to early reperfusion
therapy were included in this study. TH levels were determined
in all patients at admission. Myocardial injury was assessed by
peak troponin I (TnI) levels. Brain natriuretic peptide (BNP) and
echocardiographic left ventricular ejection fraction (LVEF) were
used to describe myocardial dysfunction. An 18±13 months
follow-up was performed and cardiac mortality, all cause
mortality and MACEs (cardiac death, re-hospitalization for
acute coronary syndrome and elective revascularization for
angina) were reported.
Results. A LT3S (fT3<1.7 ng/L) at admission was observed in
242 patients (24%). Subjects with LT3S had higher peak TnI
(86.9±98.0 vs 72.9±79.7 ng/mL, P=0.02), basal BNP
(515.4±1018.9 vs 242.9±449.6 ng/mL P <0.0001), peak BNP
(890.6±1494 vs 470.5±659.7 ng/mL P <0.0001), and had a
lower ejection fraction (42.4±10 vs 45.5±9%, P <0.0001). A
significant increase in all cause mortality (Log-Rank 13.7;
P=0.0002) and MACEs (Log-Rank 9.1; P=0.003) were also
observed in patients with LT3S.
Conclusions. Patients with LT3S have a greater degree of
myocardial damage and myocardial dysfunction after STEMI
and an increase in all cause mortality and MACE at follow-up.
Further investigations are needed to clarify the potential role
of a TH replacement therapy in this group of patients.
SY24
ADVANCES IN THE PATHOGENESIS AND DIAGNOSIS
OF ALZHEIMER’S DISEASE
R. Quirion
McGill University, Montréal, Canada
Recent progress have been made on the pathogenesis on
Alzheimer’s Disease (AD) including the identification of
biomarkers facilitating an earlier diagnosis. However, if we
consider the huge investments made over the past few
decades by the public and private sectors, progress has been
rather limited and translation of research findings into effective
clinical treatments has been extremely limited—the current
drug arsenal is mostly similar to that of the early eighties! We
will review here recent progress on genes possibly associated
with AD, and their association with lifestyle events with a
particular focus on the early features of the disease process.
Recent findings in animal models will also be presented and
discussed in term of relevance to some of the earliest features
of AD. Supported by Canadian Institutes of Health Research
(Canada).
S20
biochimica clinica, 2013, vol. 37, SS
SY25
CEREBROSPINAL FLUID BIOMARKERS FOR
ALZHEIMER’S DISEASE
M. Blankenstein
Department of Clinical Chemistry, VU University Medical
Center, Amsterdam, The Netherlands
Amyloidb (Aβ), Tau and phosphorylated Tau (pTau) in
cerebrospinal fluid (CSF) are established biomarkers for
Alzheimer’s Disease (AD). Their main application is the
differentiation of patients with AD from patients with other
memory complaints. Combined in a logistic model, these
biomarkers can distinguish patients with AD from patients with
subjective memory complaints with 93.5% sensitivity and
82.7% specificity.
Different centres have reported different levels of the CSF
biomarkers in the various disease states and multi-center
combination of data sets showed a larger variation than
datasets from individual research centers. Hence an initiative
was launched for international quality control. Initially the
variation of Aβ between laboratories was reduced significantly,
i.e. from 30 to 17%. Currently, over 65 laboratories participate
in the world wide QC program of the Alzheimer Association.
Continuous surveillance of the performance of the CSF
biomarker tests is imperative. Lot-to-lot differences have been
observed that influence patient results and, therefore, reference
values. Despite the absolute differences in results, the clinical
value of different assays for CSF biomarkers appears to be
comparable. This observation complicates comparison of
datasets between research centers as well as multi-center
investigations.
A serious drawback of the CSF markers is the fact that the
sample can only obtained invasively. Establishing a blood test
would be of paramount importance and might have a major
impact on early diagnosis, as well as monitoring the course of
disease or the effect of treatment. Apart from the search for
blood based markers, proteomic studies are in progress to
identify possible new markers, that overcome the
disadvantages of the current markers.
Based on serial measurements CSF Aβ, Tau and pTau are
considered not to be of prognostic value in patients with
established AD. They have, however, been implicated in
differential diagnosis of dementia and the progression of
patients with mild cognitive impairment (MCI) to AD. Our
findings implicate a different role for biomarkers in diagnosis
and prognosis of MCI-AD. While amyloid markers can be used
to identify MCI-AD, injury markers like Tau and pTau may
predict rapid progression to dementia.
SY26
MOLECULAR IMAGING TECHNIQUES IN
NEURODEGENERATIVE DISEASES
A. Nordberg
Karolinska Institutet, Stockholm, Sweden
Modern molecular imaging has provided new exciting tool to
investigate the brain and understand functional disturbances
as well the time course of different pathological changes.
Several neurodegenerative brain disorders are characterized
by proteinpathies. Some similarity seem to exist for some
diseases as Parkinson’s disease, Lewy body disease and
Alzheimer’s Disease (AD) showing a continuum and similarity
in pathology. AD is the most common neurodegenerative
disorder when the first symptoms of subtle episodic memory
disturbances the disease has most probably been on-going
for several even decades. The current predominant hypothesis
EuroMEdLab 2013 - sciEntific sEssions
for the cause of AD is related to dysfunction in brain of
processing, deposition and clearance of amyloid-β (Aβ)
proteins. The introduction of amyloid PET imaging with the
radiotracer 11C-PIB ten years ago has provided new and
valuable insight into the dynamic processes and time course
of deposition of fibrillar Aβ in brain from preclinical to clinical
stages of AD. Different amyloid PET tracers have been tested
and one, florobetapir, has been recently approved for clinical
use in US and Europe. PET studies have shown that the
deposition of Aβ in brain precedes decline in regional cerebral
glucose metabolism (18F-FDG PET), followed by impairment
of neurotransmitter function and cognitive decline. Brain
structural changes appears a quite late phenomena. By
combining amyloid deposition with biomarkers for brain injury
estimation of risk can be made of progression from mild
cognitive impairment (MCI) to AD. Neurodegenerative
processes are coupled to neuro-inflammatory reactions
fundamental for defending the brain against injury. In a multitracer PET concept (11C-deuterium-L-deprenyl, DED has
been used to measure reactive astrocytes. Elevated
astrocytosis has been observed in MCI patients compared to
AD and controls. High astrocytosis have also been observed
in non-symptomatic mutation carriers from early-onset familial
AD (eoFAD. Increased DED binding is measured by PET at
detectable levels before significant deposition of fibrillar Aß in
subjects with high risk of developing AD which may indicate
that some type of reactive astrocytes play a crucial role in early
preclinical stages of AD.
OC11
APPLICATION OF QUANTITATIVE CLINICAL CHEMISTRY
PROTEOMICS (QCCP) TO AMYLOID PEPTIDES, TAU
PROTEIN, AND APOLIPOPROTEIN E IN HUMAN
CEREBROSPINAL FLUID FOR ALZHEIMER’S DISEASE
DIAGNOSIS
S. Lehmann, J. Vialaret, L. Tiers, C. Delaby, J. Touchon, A.
Gabelle, C. Hirtz
CHU Montpellier, Université, France
Background: Recent improvements in mass spectrometry (MS)
allow this technology to quantify with clinical grade analytical
sensitivity and specificity, peptides and proteins in biological
fluids. We believe that in some cases MS will represent a
valuable alternative to traditional methods of immunochemical
quantification of proteins. We followed this path for the
quantitation of biomarkers in Alzheimer disease (AD) which
represents major cause of dementia. AD is associated with
specific apolipoprotein E (ApoE) isoforms, and with alteration
of cerebrospinal fluid (CSF) biomarkers. As a matter of fact,
the decrease of amyloid peptides (Aβ) and the increase of Tau
proteins in CSF are currently use for AD diagnosis. Many
isoforms of these molecules exist and MS represent an
interesting tool to quantify the diversity of the isoforms, and
therefore, to improve AD diagnosis and follow-up.
Methods: For this purpose, quantitative targeted mass
spectrometry was developed using a nano-LC triple quadripole
Agilent 6490. Sample prefractionation (Solid Phase Extraction),
trypsic digestion and sample clean-up were realised using an
automated liquid handling robot (Agilent Bravo Assay Map
plateform). Quantotypic peptides (Aβ1-40, Aβ1-42, tau, ApoE..)
were synthetized in light and heavy (13C and 15N) versions
(Eurogentec) and used in calibration curve to evaluate the Limit
Of Detection (LOD) and Quantification (LOQ). Experiments
were run on series of biological samples from control and AD
patients.
Results: Optimal Multiple Reaction Monitoring methods for the
different analytes were developed. Detection of specific Apo E
peptides resulted in a rapid method for e2/e3/e4 phenotyping.
Different isoforms of Aβ and Tau proteins were detected with
sensibility compatible with pathophysiological variations.
Correlation with immuno-detection methods and validation of
the clinical relevance of the results are on-going.
Conclusions: The mass spectrometry detection of several
isoforms of amyloid peptides, Tau protein, and apolipoprotein
E in human cerebrospinal fluid represents an important
achievement that opens new avenue for quantitative Clinical
Chemistry Proteomics (qCCP). The perspective is exploit these
results to improve phenotyping, diagnosis and follow-up of
dementia.
OC12
REDUCED MITOCHONDRIAL COMPLEX I+III ACTIVITY
RELATED TO THE RED BLOOD CELL FOLATE LEVELS
IN PATIENTS WITH ALZHEIMER’S DISEASE
H. Erdogan(2), M. Gultepe(1), A. Cosar(3); O. Ozcan(1), T.
Muftuoglu(1), O. M. Ipcioglu(1)
1
GATA Haydarpasa Training Hospital, Department of
Biochemistry, Istanbul, Turkey
2
Gumussuyu Military Hospital, Istanbul, Turkey
3
Kıbrıs, Military Hospital
Background: Folic acid-mediated one-carbon metabolism is
essential in all cells, and mitochondria play a critical role in
these pathways. This is reflected in human diseases
associated with folate and homocysteine metabolism. Since
mitochondrial dysfunction is accepted as a central role in the
progression of neurodegenerative disorders like Parkinson’s
Disease (PD) and Alzheimer’s Disease (AD). In this study we
aimed to show the dysfunctions in mitochondrial energy
metabolism and one-carbon metabolism and to investigate the
relationships between them in neurodegenerative disorders.
Methods: Thirty eight AD, 14 PD and 25 healthy individuals as
a control group were included to the study. Mitochondrial
complex activities in the platelets, plasma folate, vitamin B12,
total homocysteine (tHcy), urine methylmalonic acid (uMMA)
and serum amino acids were measured in all groups.
Results: AD patients had significantly lower platelet Complex
IV activity (with a mean reduction of 41%), Complex I+III
activity (with a mean reduction of 47%) and Complex II+III
activity (with a mean reduction of 56%). Also AD patients had
declines in Complex II activity. Similarly, in comparison with
the healthy controls, PD patients had significantly lower
Complex I+III activity (with a mean reduction of 70%) and no
significant differences were found between the other complex
activities. In AD and PD groups folate and RBC folate levels
were significantly lower and tHcy levels were significantly
higher than in controls. Among serum amino acids, alanine,
glycine, glutamate , glutamine, histidine, cystine, ornitine and
proline were significantly higher in AD group whereas none of
the amino acids were different in PD group compared with
controls. In AD group there was a positive correlation between
complex I+III activity and RBC folate concentrations whereas
no correlation was found between reduced complex I+III
activity and any parameter related to one carbon metabolism
in PD group.
Conclusions: Mitochondrial dysfunction in AD might be as a
consequence of impairment in folate mediated one carbon
metabolism or vice versa.
biochimica clinica, 2013, vol. 37, SS
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SY27
LC-MS/MS FOR ENDOCRINE AND METABOLITE
TESTING IN CLINICAL LABORATORIES
M. Vogeser
Institut für Laboratoriumsmedizin Klinikum der Universität
München (LMU)
LC-MS/MS offers highly attractive features regarding
endocrine and metabolic testing. This includes high specificity
of detection, capability of multi-analyte profiling, compensation
of matrix effects by isotope dilution internal standardisation,
no impact of anti-reagent antibodies, standardisation
independent from reagent lots, and thus consistency of results
over time and space with assay independent reference
ranges. In the field of metabolic testing, neonatal screening
for inherited metabolic diseases by flow-injection MS/MS is
now standard in many countries; by simultaneous
determination of a large number of analytes in one minute,
very reliable identification of phenylketonuria but also
detection of many less frequent, treatable diseases is
achieved. Furthermore quantification of methylmalonic acid as
the most reliable marker of cobalamin deficiency by LCMS/MS is widely used now. Metabolomics, the concept of a
comprehensive description of the small molecule patterns of
sample materials might contribute to laboratory medicine with
the introduction of new sets of markers which can be
addressed by LC-MS/MS. In endocrinology, quantification of
25-hydroxyvitamin D is performed using LC-MS/MS in a
continuously growing number of laboratories worldwide.
Quantification of cortisol and androgens (testosterone, 17hydroxyprogesterone, androstendione) and of metanephrins
in plasma is also implemented in a relevant number of
laboratories now. Quantification of analytes such as
oestrogens and aldosterone which are present in very low
concentrations in serum is so far realized only in few
institutions. Besides the low concentration range of analytes,
the presence of isomers represents a particular challenge for
LC-MS/MS in endocrinology. The quantification of proteo- and
peptide hormones by LC-MS/MS is even far more demanding
compared to the quantification of small molecule hormones,
however, first candidate reference methods have been
described (e.g., for insulin and ghrelin). At present the
application of LC-MS/MS in laboratory medicine is still
restricted to rather specialized laboratories; however, complete
automation finally leading to industrialized availability of highly
convenient MS/MS-based routine analysers seems feasible
today.
SY28
“TRICK OR TREAT” FOR DETERMINATION OF
IMMUNOSUPPRESSIVE DRUGS BY LC-MSMS
P. Wallemacq
Cliniques Universitaires St Luc, Clinical Chemistry
Department, Brussels, Belgium
Therapeutic drug monitoring (TDM) of immunosuppressive
drugs (ID) (tacrolimus, cyclosporine, sirolimus, everolimus),
significantly improves patient outcome, and is now considered
as an essential prerequisite. The need for accurate, precise,
and standardized measurement of ID presents a major
challenge for clinical laboratories and diagnostic industry. A
plethora of different techniques have been developed to meet
these requirements, with various performances and bias. The
routine ID measurements are still dominated by
immunoassays, but the number of laboratories using liquid
chromatography tandem mass spectrometry (LC-MSMS) is
S22
biochimica clinica, 2013, vol. 37, SS
increasing over the past decade to reach about 30%. It should
be clear that LC-MSMS can by no means be, by definition, a
reference measurement procedure. Similarly to any other
analytical technique, LC-MSMS procedures can be graded
from inadequate to gold standard depending upon the efforts
given during the development and validation steps.
ID TDM may be characterized by a few specific points: the
drugs are distributed into the red blood cells and the presence
of dozens of metabolites structurally-related. Most mass
spectrometry methods are “home-brew”. Therefore, steps to
validate an LC-MSMS method for clinical use have to be
rigorously followed: sensitivity, specificity, accuracy,
repeatability, stability, absence of ion suppression effect. The
use of deuterated internal standards should contribute reducing
this last effect. To improve standardization and inter-centre
imprecision, a number of manufacturers have recently and
successfully commercialized LC-MSMS IVD kits. However, an
optimal standardization should include identical and well
validated pretreatment protocol to extract the drug out of the
erythrocytes. The lack of automation and connectivity to the
Laboratory Information System (LIS) may result to manual
handling and encoding, with corresponding risks of errors. The
current instruments available on the market could be run
routinely by “standard” laboratory technicians. However, the full
process supervision needs a higher qualification level
(engineer, PhD).
Finally, the positive role of international proficiency testing
schemes should be stressed in both the validation and the
routine use of an ID LC-MSMS method.
SY29
TRUENESS OF RESULTS REMAINS AN ISSUE IN
CLINICAL USE OF LC-MS/MS SYSTEMS
C. Seger
Division of Mass Spectrometry and Chromatography,
Institute of Medical and Chemical Laboratory Diagnostics
(ZIMCL), University Hospital Innsbruck
In the past decades, the metrological concept of traceability
has been successfully introduced to different fields of laboratory
medicine including endocrinology and clinical enzymology. To
meet standardization needs, reference measurement systems
(RMS) have been put into order, leading to routine laboratory
results embedded into a network of reference laboratories,
methods, and materials. Since mass spectrometry is often
serving as the technological basis of reference methods, it was
soon recognized to be a “gold standard” technique in the
clinical laboratory. In the past few years however, it became
clear from different prominent application fields that both
precision and accuracy of LC-MS/MS derived results can be
questioned beyond clinical acceptance thresholds, if this
complex technology is not operated properly. This talk will give
an overview about the most important error sources of LCMS/MS encountered in clinical routine setups. It will be shown,
that even for “gold standard” LC-MS/MS methods reference
materials and methods have to be provided to allow of routine
mass spectrometry operations with acceptable low interlaboratory variability. Recent progress the production of new
reference materials and the generation of novel reference
methods in drug monitoring and endocrinology will be
discussed.
EuroMEdLab 2013 - sciEntific sEssions
OC13
ISOTOPE DILUTION MASS SPECTROMETRY (IDMS)
BASED DETERMINATION OF GROWTH HORMONE FOR
RE-CALIBRATION OF IMMUNOASSAY IDS-ISYS
C. Arsene1, J. Kratzsch2, A. Henrion1
1
Department of Bioorganic Analysis, PhysikalischTechnische Bundesanstalt (PTB), Braunschweig, Germany
2
Institute of Laboratory Medicine, Clinical Chemistry and
Molecular Diagnostics, University of Leipzig, Germany
Background: A growth hormone (GH) peak-level of less than 10
ng/mL in response to two different stimulation tests is
biochemically defining growth hormone deficiency (GHD) in
children. Variability of test results is partly attributed to the use
of different commercially available GH assays. As a
consequence, for many patients diagnosis of GHD is assaydependent.
Methods: A recently developed mass spectrometry (MS) based
method is offering an option to SI-traceable re-calibration of the
commercial antibody-based assays linking them to the
metrologically primary level. To this end, a representative set of
patient sera was analyzed using both, isotope-dilution mass
spectrometry and the IDS-iSYS immunoassay. A particular
advantage associated with the MS approach is the capability of
specifically quantifying the main (22 kDa) isoform by using an
appropriate tryptic cleavage product (T6) next to measuring
“whole GH” which is represented by a cleavage product
common to all major isoforms (T12)
Results: Data obtained using the IDS-iSYS assay are in good
correlation with both, MS results for “whole GH” as well as 22
kDa GH as expressed by regression equations y=1.086x 0.747 (x: T12 based “whole GH”; R2 = 0.89) and y=1.228x +
0.506 (x: T6 based 22 kDa GH; R2 =0.92). This indicates an
average bias of 9 percent of the iSYS assay with respect to
“whole GH” as measurand, whereas 22 kDa GH is
overestimated by iSYS by about 23 percent. The data fit
significantly is improved by inclusion of growth hormone
binding protein (GHBP) concentration as regression parameter,
which is proof of susceptibility to GHBP levels of the iSYS
antibody-assay.
Conclusion: It has been demonstrated here for the first time
that, owing to close correlation of results, SI-traceable recalibration of antibody-based GH assays is a promising way
forward to increase reliability and comparability of clinical
testing results. Basically, other commercial assays can be
expected to be amenable to similar calibration.
OC14
ON LINE TLC-MALDI FOR THE CHARACTERIZATION OF
NEUTRAL AND ACIDIC GLYCOSPHINGOLIPIDS:
QUALITATIVE AND QUANTITATIVE ANALYSIS
E. Torretta1, M. Vasso2, C. Fania1, S. Bergante1, M. Piccoli3,
L. Anastasia1, C. Gelfi1
1
Department of Biomedical Sciences for Health, University
of Milan, Segrate, Milan, Italy
2
Institute of Molecular Bioimaging and Physiology (IBFM),
CNR, Cefalù (Palermo) - Segrate, Milan, Italy
3
Laboratory of Stem Cells for Tissue Engineering, IRCCS
Policlinico San Donato, Milan, Italy
Background: Glycosphingolipids are a wide class of ubiquitous
lipids, characterized by a great structural and functional variety.
Importantly, altered levels of these lipids have been correlated
with different diseases, as lipid storage disorders or cancer,
suggesting their crucial role in health as potential diagnostic
markers. To date, characterization and quantification are mainly
based on often unspecific antigen-antibody reactions or by
cumbersome radioactive labelling followed by thin layer
chromatography and retention factor comparison with known
standards. Unfortunately these approaches do not allow to fully
identify the molecular structure of these lipids, especially in
terms of differences in fatty acid chains.
Herein we set up an online analytical methodology which
combines the ease of separation of HPTLC chromatography
and the high resolving power and mass accuracy of MALDIMS, directly performed on the HTPLC plate.
Methods: Total lipids from wild-type and overexpressing NEU3
sialidase C2C12 murine myoblasts were extracted with 20:10:1
(v/v/v) chloroform/methanol/water. The aqueous and organic
phases were analysed by HPTLC, followed by MALDI-TOF and
results compared to [3H]sphingolipids radiolabeled HPTLC. In
order to set up the best conditions for matrix delivery to improve
GSLs detection, different matrices solutions were tested.
Quantitative analyses were conducted with serial dilutions of
Gb3 and GM3 standards.
Results: Analysis by HTPLC-MALDI gave comparable
sphingolipid profiles to those obtained by [3H]sphingosine
radiolabeling. However, MS resolution allowed to identify
several species with similar retention factor on the HTPLC
plate, and that could not be resolved with the radiolabelling.
Several sphingolipids that differed for their fatty acid chains
could be distinguished. In particular, neutral GSLs (SM, Gb3,
LacCer, GlcCer) and gangliosides (GM1, GM2, GM3, Gd1a)
were identified as C16:0, C22:0, C24:1 and C24:0 chains.
Quantitative analysis showed a linear trend comparable to
radioactive measurements.
Conclusions: On line TLC-MALDI is an easy and highthroughput analysis for the qualitative and quantitative
characterization of GSLs suggesting its use for their profiling
with high specificity and sensitivity.
SY30
MICRORNAS IN THE SPOTLIGHT: UNDERSTANDING
CANCER GENE DEPENDENCY
C. Croce
Department of Molecular Virology, Immunology and Medical
Genetics The Ohio State University Medical Center, USA
Since the discovery of miR-15a and miR-16-1 deletions in
CLL15, many laboratories around the world have shown
miRNA dysregulation in all tumors studied, including the most
common, such as lung, breast, prostate and gastrointestinal
cancers. Such dysregulation, like the dysregulation of
oncogenes and tumor suppressor genes, can be caused by
multiple mechanisms, such as deletion, amplification, mutation,
transcriptional dysregulation and epigenetic changes. As
miRNAs have multiple targets, their function in tumorigenesis
could be due to their regulation of a few specific targets,
possibly even one, or many targets. A future challenge will be
to identify all of the targets of the miRNAs involved in cancer
and establish their contribution to malignant transformation. An
additional challenge will be the identification of all of the
miRNAs that are dysregulated by pathways that are
consistently dysregulated in various types of human cancers.
This point is of particular importance, as instead of focusing on
specific alterations in protein-coding oncogenes or tumour
suppressor genes — which may be difficult to treat — we could
focus on their downstream miRNA targets. If these miRNA
targets are crucial for the expression of the malignant
phenotype and the cancer cells depend on their dysregulation
for proliferation and survival, we can expect that the use of
miRNAs or anti-miRNAs will result in tumor regression.
Genomic analyses for alteration in miRNA genes or for copy
biochimica clinica, 2013, vol. 37, SS
S23
EuroMEdLab 2013 - sciEntific sEssions
number alterations in various human tumors by deep
sequencing is in progress but has not been completed. These
studies could provide additional information concerning the
involvements of miRNAs in cancer and in many other diseases.
Over the past few years, we have observed a shift from
conventional chemotherapy to targeted therapies, and miRNAs
and anti-miRNAs will contribute extensively to the latter.
SY31
THE ROLE OF NON-CODING RNAs IN METASTASES:
NOVEL DISCOVERIES AND FUTURE CHALLENGES
G. Calin
Md Anderson Cancer Center, USA
The newly discovered differential expression in numerous
tissues, key cellular processes and multiple diseases for
several families of long and short non-codingRNAs (ncRNAs,
RNAs that do not codify for proteins but for RNAs with
regulatory functions), including the already famous class of
microRNAs (miRNAs) strongly suggest that the scientific and
medical communities have significantly underestimated the
spectrum of ncRNAs whose altered expression has significant
consequences in diseases. MicroRNA and other short or long
non-codingRNAs alterations are involved in the initiation,
progression and metastases of human cancer. The main
molecular alterations are represented by variations in gene
expression, usually mild and with consequences for a vast
number of target protein coding genes. The causes of the
widespread differential expression of non-codingRNAs in
malignant compared with normal cells can be explained by the
location of these genes in cancer-associated genomic regions,
by epigenetic mechanisms and by alterations in the processing
machinery. MicroRNA and other short or long non-codingRNAs
expression profiling of human tumors has identified signatures
associated with diagnosis, staging, progression, prognosis and
response to treatment. In addition, profiling has been exploited
to identify non-codingRNAs that may represent downstream
targets of activated oncogenic pathways or that are targeting
protein coding genes involved in cancer. Recent studies proved
that miRNAs and non-coding ultraconserved genes are main
candidates for the elusive class of cancer predisposing genes
and that other types of non-codingRNAs participate in the
genetic puzzle giving rise to the malignant phenotype. Last, but
not least, the shown expression correlations of these new
ncRNAs with cancer metastatic potential and overall survival
rates suggest that at least some member of these novel
classes of molecules could potentially find use as biomarkers
or novel therapeutics in cancers and other diseases.
SY32
MicroRNAS AS PROMISING NOVEL TUMOR
BIOMARKERS IN THE CLINICAL LABORATORY
E. Lianidou
Analysis of Circulating Tumor Cells lab, Laboratory of
Analytical Chemistry, Department of Chemistry, University of
Athens, Greece
Changes in miRNA expression levels have been detected in
many human tumor types, and recent studies have
demonstrated the critical roles of miRNAs in cancer
pathogenesis. MicroRNA profiling in most types of tumors has
shown significant different miRNA profiles when compared to
normal cells from the same tissues. Nowadays, there is
increasing evidence that altered microRNA expression is
associated with tumor progression and survival in many types
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biochimica clinica, 2013, vol. 37, SS
of cancer. Very recently detection of cell-free miRNAs,
circulating in plasma and serum has been shown in several
studies. Altered expressions of miRNAs in plasma would
provide potential blood-based biomarkers for the clinical
laboratory. Circulating miRNA profiles have now been
associated with a range of different tumor types, diseases such
as stroke and heart disease as well as altered physiological
states such as pregnancy. According to recent findings plasma
miRNAs expression patterns could correctly discriminate
between normal and cancer patient samples. Plasma levels of
specific miRNAs were associated with short disease-free
survival and overall survival, and are associated with poor
outcome. In conclusion, circulating miRNAs obtained by
noninvasive methods have a high potential to serve as highly
specific and sensitive circulating tumor biomarkers in the
clinical laboratory. However there is still a lot of work to be done
before the establishment of circulating miRNAs as biomarkers
in the clinical laboratory, especially towards the standardization
of analytical methodologies used, the inclusion of internal and
external controls in each assay, and the consensus towards
normalization of these results.
OC15
AN ASSOCIATION BETWEEN MicroRNA-155 AND THE
HP GENOTYPE IN PATIENTS WITH SICKLE CELL
ANEMIA
M. Santos1, R. Ferreira2, D. Albuquerque2, R. Oliveira2, M.
Bezerra3, C. Lanaro2, T. Zaccariotto1, A. Araujo3, F. Costa2,
M. Blotta1, M. Sonati1
1
Department of Clinical Pathology, School of Medical
Sciences, UNICAMP, SP-Brazil
2
Hematology and Hemotherapy Center of
Campinas,UNICAMP, SP-Brazil
3
Hematology and Hemotherapy Center of Pernambuco, PEBrazil
Background: Sickle cell anemia (SCA) is characterized by
chronic inflammation with a variable immune response that
depends on multiple genetic and environmental factors.
Haptoglobin (Hp) is an acute-phase protein with
immunomodulatory and antioxidant properties whose main
function is to bind to free hemoglobin in the plasma and protect
blood vessels from its oxidative effects. Two codominant alleles
(HP1 and HP2) result in three main genotypes/phenotypes
(Hp1-1, Hp2-1, Hp2-2), which correspond to proteins with
distinct physical, chemical and functional characteristics.
MicroRNAs (miRs) are post-transcriptional modulators of gene
expression and their role in infection, inflammation and cell
differentiation, proliferation and apoptosis has been
investigated. miR-155 is involved in red blood cell differentiation
and also plays an important role in inflammation and immunity;
however, there is a dearth of information in the literature about
the expression of these molecules in SCA. The aim of this
study was to investigate the expression profile of miR-155 in
granulocytes in SCA patients classified according to Hp
genotype.
Methods: 12 patients of each Hp genotype (determined by
allele-specific PCR), in steady state, were selected for the
study. miR-155 expression profile was determined by q-PCR.
Results: The miR-155 expression rate in granulocytes from
patients with the Hp1-1 genotype was greater than the
expression rate in Hp2-1 patients, which in turn was greater
than that in Hp2-2 patients. The difference between the
expression rates for Hp1-1 and Hp2-2 patients was statistically
significant (P=0.002).
Conclusion: miR-155 is considered important for inflammatory
activation of human myeloid cells and, when overexpressed in
EuroMEdLab 2013 - sciEntific sEssions
CD14+ cells in peripheral blood, can lead to down-regulation of
SHIP-1, an inhibitor of inflammation, and an increase in
production of pro-inflammatory cytokines such as IL-6 and
TNF-α. In agreement with this, our results suggest that miR155 may be related to Hp genotype and may play a role in the
inflammatory response in SCA patients. Financial support:
FAPESP/CNPq/CAPES.
SY33
THE INTRODUCTION OF A NOVEL BIOMARKER FOR
PULMONARY EMBOLISM - A PARABLE
OC16
GENE MUTATION IN MicroRNA TARGET SITES OF CFTR
GENE: A NOVEL PATHOGENETIC MECHANISM IN
CYSTIC FIBROSIS?
The unraveling of the human genome and the expansion of
genomics, proteomics and metabolomics have fuelled the
development of novel biomarkers. New in-vitro diagnostics
other forms of medical testing and can improve health care,
bringing us closer to stratified and personalized medicine. At
the same time, society is concerned about the never-ending
increase in health care expenditure while other groups lament
a creeping medicalization through the use of novel forms of
testing. Increasingly, decision-makers, physicians and other
users request more information than technical and analytical
performance and diagnostic accuracy. Health care
policymakers have long called on manufacturers to shift from
a narrow technical or biomedical perspective to a wider one,
one that considers whether the diagnostic technology
improves final outcomes in typical patient populations. Before
recommending the use of diagnostic tests and markers, and
before deciding on their reimbursement, decision-makers and
users now want to see evidence that testing actually improves
outcomes in relevant patient populations, or that it enhances
patient outcome, health care quality, efficiency and costeffectiveness. Using the introduction and dissemination of a
new test to detect pulmonary embolism as an example, we
will illustrate how the landscape for the evaluation of medical
tests is changing. Our presentation will be structured as a
parable, a short a allegorical story designed to illustrate or
teach some truth.
F. Amato1, M. Seia2, S. Giordano1, A. Elce1, F. Zarrilli3, G.
Castaldo1, R. Tomaiuolo1
1
CEINGE-Biotecnologie Avanzate scarl, Dipartimento di
Biochimica e Biotecnologie Mediche, Università di Napoli
Federico II, Naples, Italy
2
Laboratorio di Genetica Medica, Fondazione IRCCS
Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena,
Milan, Italy
3
Dipartimento di Bioscienze e Territorio, Università del
Molise, Isernia, Italy
Background: Cystic fibrosis (CF) is the most frequent lethal
genetic disorder among Caucasians with one child in every
3000 newborns affected by disease. It depends on alterations
of a chloride channel expressed by most epithelial cells and
encoded by CFTR gene. Also using scanning techniques to
analyze the whole coding regions of CFTR, mutations are not
identified in up to 10% of CF alleles, and such figure increases
in CFTR-Related Disorders (CFTR-RD). This suggests that
other gene regions, i.e. 3’Untranslated region (3’UTR) of CFTR
gene, may be the site of causing-disease mutations.
Methods: We set up a multistep analysis: 1) Analysis of 1500
bp of CFTR 3’UTR region to search for genetic variants in
either CF patients with the F508del homozygous genotype and
different clinical expression (n=20), CF (n=32) and CFTR-RD
(n=43) patients with one or none mutation after CFTR scanning
and in controls (n=50). 2) Identification of miRNA binding sites
within the CFTR 3’UTR using software, i.e. TargetScan,
miRBase, PITA. 3) Cloning of the 3'UTR of CFTR into pGL3Control vector for luciferase assay to validate the activity of
putative miRNA, using both miRNA mimic or Lentiviral particle
pre-miRNA expressing. 4) Western Blot analysis to verify the
CFTR protein level in cell transient transfected with miRNA
mimics.
Results: We identified three SNPs, one of which located in a
region predicted to bind miR-433 and miR-509-3p. Western
blot analysis revealed that the miRNAs are able to down
regulate the CFTR protein expression and the Luciferase assay
that this down regulation is due to the interaction of miRNA with
the 3’UTR of CFTR gene. Further, this variant was peculiar of
a CFTR-RD patient and the expression analysis demonstrated
that such SNP increases the affinity for miR-509-3p and slightly
decreases that for the miR-433.
Conclusion: These data show that at least two new miRNAs
are able to regulate the expression of CFTR protein. But, more
importantly, demonstrate that the presence of a SNP in the
3’UTR region can affect the binding of miRNAs likely leading to
a pathological effect.
Acknowledgements: Grants from Regione Campania (DGRC
1901/09 and L. 548/93, 2005, 2006 and 2007) are gratefully
acknowledged
P.M. Bossuyt
Dept. Clinical Epidemiology, Biostatistics & Bioinformatics;
Academic Medical Center; University of Amsterdam
SY34
MANUFACTURER’S AND REGULATORY
PERSPECTIVES
P. S. Zammaretti
Roche Diagnostics International Ltd, Switzerland
New in-vitro diagnostics tests are one of the keys to
personalized medicine and improved patient care. Widespread
implementation of a novel biomarker usually depends on
availability of a commercial product. In this presentation, we
look beyond the scientific development of a novel biomarker, to
discuss the steps involved in placing an in vitro diagnostic
product on the market. Development and commercialization of
such devices are heavily controlled by regulators worldwide.
Regulations aim to ensure that the technical performance and
biomarker science will translate into a safe, reliable, costeffective and clinically useful product. Using the introduction of
a new test to detect pulmonary embolism as an example, we
will illustrate how development, manufacture, registration and
commercialization are impacted by the regulations. Specifically,
we will introduce the concept of design control and cover basic
registration pathways for the US and EU. Furthermore, we
would like to give you an overview of some recent trends and
upcoming changes in regulatory requirements surrounding
clinical utility, which will translate into increased emphasis and
scrutiny on clinical performance.
biochimica clinica, 2013, vol. 37, SS
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EuroMEdLab 2013 - sciEntific sEssions
SY35
CLINICAL AND LABORATORY PERSPECTIVES
A.R. Horvath
On behalf of the Test Evaluation Working Group of the
European Federation of Clinical Chemistry and Laboratory
Medicine; SEALS Department of Clinical Chemistry, Prince of
Wales Hospital and School of Medical Sciences, University of
New South Wales; Screening and Test Evaluation Program,
School of Public Health, University of Sydney, Australia
The ability of novel medical tests to improve patient outcomes
is becoming more central in decisions about their market entry,
clinical use, reimbursement and coverage. These
considerations and new regulatory requirements affect the
way novel medical tests are developed and evaluated. The
evaluation of medical tests is more difficult and differs in many
ways from the evaluation of therapeutics. One of the most
important differences is that medical testing rarely improves
health outcomes directly; biomarkers used for several different
purposes (diagnosis, monitoring, prognosis, etc.) are often part
of a more complex intervention; and most clinical outcomes
follow from subsequent clinical management decisions guided
by the test results. New biomarkers should be developed in
response to unmet clinical needs. After identifying a link
between the clinical condition and the biomarker, the
subsequent essential components of medical test evaluation
are: analytical performance, clinical performance, clinical
effectiveness, cost-effectiveness and the broader impact of
testing. The Test Evaluation Working Group of the European
Federation of Clinical Chemistry and Laboratory Medicine has
defined and tightly integrated these components into a
dynamic evidence-based framework which clarifies the link
and sequence between the various stages of test evaluation
and describes the journey of a new biomarker in becoming a
medically useful test in the research translation continuum. No
new test should be subjected to tedious trials and released to
the market if it is unlikely that the test will result in improved
clinical actions and measurable outcomes. Therefore in our
framework the clinical purpose and role of testing and the
intended application of the biomarker in a well defined clinical
pathway drive all stages of the test evaluation cycle and define
the most appropriate study designs that have the potential to
provide the highest level of evidence as proofs. The framework
aims to support and improve the understanding of key
stakeholders of the necessary steps to be taken when
evaluating a test and promotes that larger and more costly
studies are only initiated if there is prior evidence of sufficiently
high quality of the test’s value.
SY36
POLICY AND ECONOMIC PERSPECTIVES
C.J. Hyde
University of Exeter Medical School, UK
Increasing pace of innovation and burgeoning cost mean that
policy makers are no longer able to avoid the challenges
necessary to make decisions on new biomarkers. However,
while laboratory scientists and clinicians may arguably be able
to make adequate decisions based on accuracy data, it has
always been clear that decisions at population level require
information on effectiveness (impact on patient outcomes) and
cost-effectiveness. The challenge for policy making thus lies in
where the evidence on these features will come from. Ideally
it would be produced directly from clinical studies such as testtreat RCTs. However, the practicality of generating RCT
evidence on a large scale suggests that other approaches are
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biochimica clinica, 2013, vol. 37, SS
needed. One alternative is economic modelling, which not only
facilitates conclusions on cost-effectiveness but more
importantly provides a framework in which evidence on the
accuracy of a test and the effectiveness of down-stream
treatment, generated in separate studies can be integrated to
give an estimate of the clinical effectiveness of the whole testtreatment package. This is much easier said than done,
although there have been considerable advances in modelling
techniques over the past decade. NICE has recently become
active in making decisions about diagnostics in England and
Wales, and has placed great emphasis on the use of
economic modelling to inform its guidance. This presentation
will reflect on this experience from the perspective of a
member of its Diagnostic Assessment Committee and a
producer of health technology assessments on diagnostics. It
will particularly consider requirements for further
methodological research on economic modelling on
diagnostics and what the demand for research data on new
tests might be were economic modelling to become the main
means of informing policy decisions in the future.
SY37
IFCC PUBLIC RELATIONS: STRATEGY AND ACTIVITIES
E. Jacobs
New York University School of Medicine/Coler-Goldwater
Specialty Hosptial; IFCC Communications and Publications
Division
The role of the laboratory in the provision of medical care is
often underappreciated, if not appreciated at all by the public;
patients, physicians and other healthcare workers, hospital
administrators, and government & health policy makers.
Laboratory services are often seen as a commodity rather than
a professional activity. Additionally, within the laboratory
community, the IFCC is not always recognized for its role in
enhancing the scientific level and the quality and therapy for
patients throughout the world. In 2008 the IFCC created a
Committee on Public Relations (C-PR) within the
Communications and Publications Division (CPD), with an
advisor from each of the regional laboratory federations. The
C-PR's main mandate is to assist the IFCC in promotion of
both the organization and the discipline of laboratory medicine
internationally and to coordinate PR activities of the various
IFCC units The first major task on the C-PR was, and
continues to be, to work with the Labs are Vital (LAV)
international campaign to promote the field of laboratory
medicine as a career choice. Additionally, an IFCC PR slide
presentation was created and made available to all IFCC
officers and IFCC member countries for future presentations
at local, regional, and international conferences, to promote
the IFCC organization. Other activities have included
developing slide presentations (both for Medical Professionals
and for the lay public) on the role of Laboratory Medicine and
how the IFCC is promoting advances in the science and
management of Laboratory Medicine, and an IFCC
promotional brochure for distribution at various medical
conferences. Future activities include preparing a new PR
brochure targeted to the general public, governments,
industry; appointing PR-LAV regional ambassadors to help
sustain its activities/promotional campaigns; work with the LAV
program in preparing PR tools such as slide kits, webcasts,
news releases, etc.; and the initiation of studies that will
substantiate the laboratory’s role in saving healthcare dollars
and reducing costs associated with unnecessary and
expensive follow-up procedures.
EuroMEdLab 2013 - sciEntific sEssions
SY38
VALUE OF THE LABORATORY IN CLINICAL MEDICINE
K. Adeli
Professor and Head, Clinical Biochemistry, The Hospital for
Sick Children, University of Toronto, Ontario, Canada; Chair,
IFCC Communications and Publications Division
Background: Systematic evidence for the contribution of the
clinical laboratory to the overall assessment, diagnosis, and
management of patients is not readily available. Establishing
this evidence is vital to all promotional activities by the IFCC
and other organizations involved in laboratory medicine.
Evidence is unclear to support blanket claims that 60-80% of
medical decisions are influenced by laboratory testing. There
is a critical need for both a systematic review of the available
evidence in the published literature as well as the initiation of
new retrospective and prospective studies to more clearly
establish this crucial evidence.
Methods and Results: The IFCC has recently established a
new taskforce to evaluate the published evidence on value
and impact of laboratory medicine on clinical outcomes and
healthcare delivery, and if necessary propose new studies to
more clearly establish this evidence. The major aims of this
new Taskforce are to: a) Evaluate the available evidence
supporting the impact of laboratory medicine in healthcare (a
critical review of published literature); b) Develop the study
design for new retrospective and prospective studies to
generate evidence-based data to support IFCC promotional
activities to the healthcare community and the public.
Conclusions: In this presentation, I will review the evidence
supporting the key role of laboratory medicine in clinical
outcomes with specific examples in the areas of clinical
biochemistry, microbiology, pathology, hematology, and
molecular diagnostics. The key role of the IFCC in promoting
the visibility of the field among healthcare professionals,
hospital administrators, and governmental regulators and
funders will also be discussed.
SY39
DEMONSTRATING THE VALUE OF LABORATORY
TESTS: A CLINICAL AND ECONOMIC PERSPECTIVE
B. Jordan
Roche Professional Diagnostics, Rotkreuz, Switzerland
Introduction: The ability to identify patient sub-groups and better
understand disease mechanisms has ushered in an era of
developing new diagnostic tools and targeted drugs. New
biomarker and diagnostic tests are becoming increasingly
available to provide valuable information about which patients
benefit from novel agents.This pairing of targeted compounds
to patients with a high likelihood to be receptive to that
treatment offers an alternative to the traditional broad-spectrum
approach when treating disease. Translating excellence in
science into effective treatments for patients is at the core of a
scientific vision for “Personalised Healthcare” (PHC).
A prerequisite for pairing a therapy and a diagnostic test in
clinical development is a very high level of assay quality. Only
when a robust level of technical validation has been achieved,
should an assay be clinically validated in pivotal studies. Only
then can 'Fitting the treatment to the patients', add value to
patients, physicians, insurers, and society. PHC rationale for
society: From a healthcare insurer’s perspective, “fitting the
treatment to the patients” is imperative to optimize resource
usage. Additionally, Patient compliance increases when the
efficacy of a drug is clear to the person undergoing treatment,
which is important to insurance payers. PHC also helps avoid
unnecessary or disadvantageous treatment, reducing the risks
of side effects and costs for their treatments. PHC today & in
the future: The fields of cardiology, neurosciences and
inflammatory diseases are examples of therapeutic areas that
will potentially benefit from PHC in the future.
Conclusion: Tailoring treatments to specific patient sub-groups
who share similar characteristics in their genetic makeup or in
the molecular nature of the disease has proven to be highly
successful in a few examples. Although this field is just
emerging, and certainly is not without significant challenges
ahead, we expect to see many more success stories in the
future. The advent of new Companion Diagnostic (CDx) tests
that provide essential information required to inform treatment
decisions will further reinforce the value of the laboratory in
improving the management of patients and efficiently utilizing
healthcare resources.
SY40
ROLE OF SOCIAL MEDIA AND THE INTERNET IN
EDUCATION
P. Vervaart
Principal Scientist, Royal Hobart Hospital and Chair, C-IeL
IFCC
Since the advent of the Internet, and in particular the
development of the interactive version of the web, Web 2.0,
use of Social Media has developed into a major strategy for
businesses and organizations such as the IFCC to use for the
purposes of Public Relations and Education. The early Internet
‘Web 1.0’ was a largely static environment which did not allow
interaction between organizations and their customers and/or
members and as such was mainly used as an information
repository rather than a dynamic environment for the exchange
of ideas and active marketing and education. Since the
development of Web 2.0 we have seen a massive increase in
web based traffic which could be loosely called ‘social
networking’ which initially was mainly networking between
individuals but more recently has developed into a major
marketing resource allowing networking between organizations
and individuals on the web. It follows then that by developing
a Social Media presence on platforms such as Facebook,
LinkedIn, Twitter and other social media sites organizations can
use this networking for the purposes of marketing, public
relations, and in the case of IFCC, education of members and
other interested individuals across the globe.
SY41
PSA IN SCREENING FOR PROSTATE CANCER
C. Bangma
Department of Urology Erasmus University Medical Centre
Rotterdam, the Netherlands
Population based screening of prostate cancer has proven to
reduce its mortality with at least 20 %, while the reduction of
symptomatic metastatic disease is over 30 %. This is of interest
in countries that face a growing population of elderly male with
increasing life expectancy. Serial PSA testing can however also
lead to the diagnosis of and treatment of large number of
indolent tumours (23-50% of detected cancers). Population
screening likely produces a large benefit in quality of life in
those few men diagnosed and treated, but will also cause a
large number of men to know that they are having a cancer for
many more years of their life. The best age to start screening
is unknown, and might be dependent on risk factors like family
history or genetic factors. The optimal interval for repeated
biochimica clinica, 2013, vol. 37, SS
S27
EuroMEdLab 2013 - sciEntific sEssions
screening still has to be determined, but might be dependent on
the individual level of PSA. Men with intermediate risk tumours
appear to benefit most from screening. From a public health
perspective, the associated morbidity may or may not be
balanced by net health care benefits. To date, prostate cancer
screening has yet to satisfy public health criteria for population
based testing, leading many researchers to explore the efficacy
of individual risk assessment for early detection of this disease.
Risk assessment instruments based on PSA combined with
information on prostate cancer provide mechanisms to avoid
unnecessary prostate biopsies, and to reduce the potential for
overtreatment in men with low risk for prostate cancer.
SY42
BIOMARKER STRATEGIES CURRENTLY BEING
EXPLORED FOR PROSTATE CANCER
C. Sturgeon
Dept. of Clinical Biochemistry, Royal Infirmary of Edinburgh
Background: More sensitive and specific diagnostic testing that
can reliably distinguish aggressive from indolent prostate
cancers is urgently required. Measurement of prostate specific
antigen (PSA) is integral to the clinical management of patients
with prostate cancer, but its limitations for diagnosis and
population screening are increasingly well-recognised. Many
more men will be diagnosed with prostate cancer than will die
of it and many of these men will never have needed to know
they had the disease.
Method: Biomarker strategies currently being explored include
the Prostate Health Index (PHI) in which results for PSA, free
PSA, and a PSA precursor form [-2]pro-PSA are combined in
an algorithm to provide an estimate of the risk of prostate
cancer and the Prostate CAncer gene 3 (PCA3) urine test. An
age-based screening strategy with PSA which combines age
and the presence of common genes for prostate cancer so that
only the highest risk men are screened has been modelled.
Some men would start screening at 45 years, some at 60 years
and some would never be screened. Means of improving PSA
monitoring in patients with diagnosed prostate cancer are also
being developed, with major focus on the interpretation of serial
changes in the biomarker and the effective use of this
information in routine practice.
Results: Results suggest that personalised approaches to
screening could reduce the number of screens required by up
to 50% and decrease the number of men diagnosed with
prostate cancer by 18%, while also increasing the number of
quality adjusted life years and significantly decreasing costs as
compared with previously proposed screening strategies. More
efficient models for post-treatment monitoring of prostate
cancer patients, particularly those on active surveillance, are
also likely to be cost-effective as well as more attractive to
patients. Objective and rigorous evaluation of such strategies
is essential before they can be introduced into clinical practice
with particular attention paid to their effect on outcome.
Conclusions: Improving the diagnosis of prostate cancer and
the monitoring of diagnosed patients post-treatment remains a
high priority.
SY43
ADDED VALUE OF NEW TESTS FOR PROSTATE
CANCER DETECTION
A. Semjonow
Prostate Center, University Clinic Münster, Germany
Background: We compared urinary prostate cancer antigen 3
(PCA3), TMPRSS2:ERG gene fusion(T2:ERG) and the serum
S28
biochimica clinica, 2013, vol. 37, SS
(-2)pro-prostate-specific antigen (p2PSA)-based prostate
health index (Phi) for predicting biopsy outcome.
Methods: Serum samples and first-catch urine samples (after
digital rectal examination, DRE) were collected from consented
outpatients scheduled for prostate biopsy with PSA 0.5–20
µg/L. The PCA3 Score (PROGENSA PCA3, Gen-Probe) and
T2: ERG Score (Gen-Probe) were determined. Measurements
of serum PSA, free PSA, p2PSA (Beckman Coulter) were
performed and percent free PSA (%fPSA) and Phi
(p2PSA/fPSA * √PSA) determined.
Results: Of 246 enrolled men 110 (45%) were diagnosed with
prostate cancer (PCa) and 136 men had no evidence of
malignancy (NEM). 136 (55%) of all men underwent a first set
of biopsies and 110 (45%) had ≥1 repeat biopsies. PCA3, Phi
and T2:ERG differed significantly between PCa and NEM and
these markers showed the largest areas under the ROC curve
(AUCs) (0.74, 0.68 and 0.63, respectively). PCA3 had the
largest AUC of all parameters albeit not statistically different
from Phi. Phi showed somewhat lower specificities than PCA3
at 90% sensitivity. Combination of both markers enhanced
diagnostic power with modest AUC gains of 0.01 to 0.04.
Although PCA3 had the highest AUC in the repeat biopsy
cohort, the highest AUC for Phi was observed in DRE negative
patients with PSA in the 2-10 µg/L range.
Conclusions: PCA3 and Phi were superior to the other
evaluated parameters but their combination gave only
moderate enhancements in diagnostic accuracy for PCa at first
or repeat prostate biopsy.
OC17
SERUM ISOFORM [-2]proPSA DERIVATES (%P2PSA AND
PHI) SIGNIFICANTLY IMPROVES THE PREDICTION OF
PROSTATE CANCER AT INITIAL BIOPSY IN A TPSA
RANGE 2-10 mg/L: A MULTICENTRIC EUROPEAN STUDY
M. Lazzeri1, A. Haese2, A. de la Taille3, J.P. Redorta4, T.
McNicholas5, G. Lughezzani1, V. Scattoni1, V. Bini6, M.
Freschi7, M. Graefen2, P. Le Corvoisier3, A. Breda4, M.
Pontillo8, F. Ceriotti8, G. Guazzoni1
1
Department of Urology, Ospedale San Raffaele Turro, San
Raffaele Scientific Institute, Milan, Italy
2
Martini-Clinic Prostate cancer Center, University Clinic
Hamburg-Eppendorf Hamburg, Germany
3
Department of Urology, APHP Mondor Hospital, Créteil,
France
4
Urologic Oncology Section of the Department of Urology
and Radiology Department, Fundació Puigvert, Cartagena,
Barcelona, Spain
5
South Bedfordshire & Hertfordshire Urological Cancer
Centre, Lister Hospital, Stevenage, UK
6
Department of Internal Medicine, University of Perugia,
Italy
7
Department of Pathology, San Raffaele Scientific Institute;
Milan, Italy
8
Diagnostica e Ricerca San Raffaele, San Raffaele Scientific
Institute; Milan, Italy
Background. The current study is designed to test the
sensitivity, specificity and accuracy of [-2]proPSA (p2PSA) and
its derivatives in discriminating between patients with or
without prostate cancer (PCa) and in identifying cases of
clinically significant PCa within a prospectively collected,
European, multicentric, large and contemporary cohort of
candidates to initial prostate biopsy (IPBx) for suspected PCa.
Methods. A detailed description of study design, setting,
centres and patients, is available at http://www.controlledtrials.com ref. ISRCTN04707454. The study was designed
according the STARD methodology in order to test the
EuroMEdLab 2013 - sciEntific sEssions
sensibility, specificity and accuracy of p2PSA and its derivates:
%p2PSA and the Beckman Coulter PHI in 646 men who
underwent IPBx in a tPSA range 2-10 ng/mL. Multivariate
logistic regression models were fitted for the prediction of the
presence of PCa at biopsy, incorporating as explanatory
variables.
Results. Prostate cancer at initial biopsy was diagnosed in 264
(40.1%) of the overall population. Median tPSA (5.7 vs. 5.8
ng/mL; P=0.942) and p2PSA (15.0 vs 14.7 pg/mL) did not
differ between the two groups, conversely median fPSA (0.74
vs 0.95 ng/mL; P <0.001), %fPSA (0.14 vs 0.17; P <0.001),
%p2PSA (2.1 vs 1.6; P <0.001) and PHI (48.2 vs 37.9;
p<0.001) did differ significantly between men with and without
PCa. %fPSA (P=0.021), %p2PSA (P=0.015) and PHI
(P=0.012) were significantly associated with the presence of
PCa at biopsy but not tPSA (P=0.705) and p2PSA (p=0.368).
In unvariable accuracy analysis, %p2PSA (AUC: 0.67) and
PHI (AUC:0.67) were the most accurate predictors of PCa and
significantly outperformed PSA (AUC: 0.50; P <0.001), fPSA
(AUC: 0.62; P <0.001) and p2PSA (AUC: 0.51; P <0.001), but
not %fPSA (AUC 0.64; P >0.300). In multivariable logistic
regression models testing the predictors of PCa at biopsy,
p2PSA, %p2PSA and PHI significantly increased the accuracy
of the base multivariate model by a 6.4%, 5.6% and a 6.4%
extent, respectively (all P <0.001).
Conclusions. In patients with a tPSA between 2.0 and 10
ng/mL, %p2PSA and PHI are the strongest predictors of PCa
at initial biopsies and are significantly more accurate than the
currently used tests (tPSA, %fPSA) in determining the
presence of PCa at biopsy.
OC18
PROSTATE-SPECIFIC ANTIGEN (PSA) AND KALLIKREINRELATED PEPTIDASE 2 (hK2) FORMS IN PROSTATE
TISSUE LYSATES FROM RADICAL PROSTATECTOMY
PATIENTS
M.T. Peltola1, V. Väisänen2, K. Alanen3, M. Nurmi4, K.
Pettersson1
1
Department of Biotechnology, University of Turku, Finland
Syrinx Bioanalytics Oy, Turku, Finland
3
Department of Pathology, Turku University Hospital, Finland
4
Department of Surgery, Turku University Hospital, Finland
2
Background: Different forms of serum prostate-specific antigen
(PSA) and kallikrein-related peptidase 2 (hK2 or KLK2) have
been suggested to improve prostate cancer diagnostics. We
studied the presence of the different PSA and hK2 forms in
prostate tissue samples from radical prostatectomy patients.
Methods: The study panel consisted of 80 prostate tissue
samples from prostate cancer patients (n=40) who had
undergone a radical prostatectomy at Turku University Hospital.
Samples were classified as cancerous (n=38) or benign (n=42)
tissue by microscopic study of the adjacent tissue. Tissue was
lysed and total PSA (tPSA), free PSA (fPSA), intact PSA (fPSAI), free hK2 (fhK2) and total hK2 (thK2) levels were measured
with in-house immunoassays. The concentration of nicked PSA
(fPSA-N, internal cleavage at Lys145-Lys146) was calculated
by subtracting fPSA-I concentration from fPSA concentration.
All levels were normalized to total protein amounts. Differences
between cancer and benign tissue were studied by MannWhitney U-test.
Results: Of the tPSA concentration a median of 84%
(interquartile range 81–87%) was fPSA, 65% (55–76%) fPSAI and 17% (9.4–33%) fPSA-N. Of the fPSA a median of 79%
(64–88%) was fPSA-I. The median proportion of fhK2 from
thK2 was 73% (65–80%) and the median ratio of thK2 and
tPSA was 1.5% (1.1–2.0%). The median ratios of fPSA/tPSA in
benign and cancerous samples were 86% (81–90%) and 84%
(81–86%) and thK2/tPSA ratios were 1.3% (1.0–1.7%) and
1.7% (1.2–2.5%), respectively. These were the only
parameters which had statistically significant difference
between benign and cancerous tissue (fPSA/tPSA P=0.031
and thK2/tPSA P=0.016).
Conclusions: PSA in the prostate tissue lysates was mainly in
free form and the majority of this fPSA was intact containing no
internal cleavage at Lys145-Lys146 (fPSA-I). Larger sample
panel and comparison to tissue lysates from cancer-free
prostates are needed to assess the clinical usefulness of
measuring the levels of different PSA and hK2 forms in prostate
tissue lysates.
SY44
GENETIC AND BIOCHEMICAL RISK FACTORS FOR
ARTERIAL AND VENOUS THROMBOSIS: TWO SIDES
OF A COIN ?
A. D'Angelo
Coagulation Service and Thrombosis Research Unit and
Laboraf, Scientific Institute Ospedale San Raffaele, Milan,
Italy
Thrombotic disease is that which occurs in the venous system
of low flow and pressure or in the high-flow and pressure
arterial system. Basic distinctions exist between arterial and
venous thrombosis, such as the composition of the thrombi
(platelet rich in arterial and fibrin rich in venous) and the
presence of vascular wall damage (atheroma) in arterial
thrombosis. However, such distinctions are not absolute, and
there are common underlying mechanisms. Perturbation of
hemostasis is central to the pathogenesis of all thrombosis,
even though it differs in nature depending on location. Transient
or long-lasting environmental influences may play important
roles in perturbing hemostasis and influencing risk for
thrombosis in both the venous and the arterial systems. In the
last few years clinical evidence has been provided that risk
factors for arterial occlusive diseases (mainly acute coronary
syndromse) are shared by patients with venous
thromboembolism (VTE). For instance the metabolic
syndrome, an ascertained risk factor for cardiovascular
diseases, appears to duplicate the risk of VTE; in addition, both
moderate hyperhomocysteinemia and increased Lp(a) levels
are biomarkers of an increased risk of both arterial and venous
thrombotic disease with similar odds ratios. Genome-wide
association studies have investigated DNA loci potentially
associated with arterial and venous thrombosis. From these
studies, the AB0 system and the protein C pathway play a
major role in VTE. Interestingly, defects in the protein C system
are also responsible for a minor, but significant proportion of
arterial thrombosis occurring at a young age, when
atherosclerosis and lipid metabolism disorders play a minor, if
any, role. In such cases, selective occlusion of the
microcirculation, rather than of larger vessels is a rational
possibility. We report on a case of acute myocardial infarction
in a 27 years old patient with a combined heterozygous
deficiency of protein C and protein S, submitted to stent (DES)
implantation and treated with a combination of aspirin,
clopidogrel and dabigatran.
biochimica clinica, 2013, vol. 37, SS
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EuroMEdLab 2013 - sciEntific sEssions
SY45
LABORATORY ASSESSMENT AND MONITORING OF
THE NEW ORAL ANTICOAGULANTS
E.J. Favaloro
Haematology, Level 2 ICPMR, Westmead Hospital, Australia
The tests currently employed within most haemostasis
laboratories to monitor anticoagulant therapy largely comprise
the Prothrombin Time (PT)/International Normalised Ratio
(INR) and the Activated Partial Thromboplastin Time (APTT).
These are respectively used to monitor Vitamin K antagonists
(VKAs) such as warfarin, and unfractionated heparin. Additional
tests for assessing or monitoring unfractionated heparin include
Thrombin Time (TT) and the anti-Xa assay, which can also be
used to monitor low molecular weight heparin (LMWH). Several
new antithrombotic (or anticoagulant) agents have recently
emerged, or are in the final process of clinical evaluation.
These novel drugs, including dabigatran, rivaroxaban and
apixaban, theoretically not require laboratory monitoring;
nevertheless, testing is useful in specific situations. Tests
currently used to monitor VKAs and heparin are typically either
too sensitive or too insensitive to these new drugs, and some
methodological adjustments may be required to increase or
decrease their sensitivity. Alternately, different tests may be
better employed. Various expert guidelines are in development
to help guide laboratory decisions regarding assessment of
these new anticoagulants. In brief, the relative sensitivities for
existing routine assays are: TT>APTT>PT (dabigatran), and
PT>APTT (>TT) (rivaroxaban). Accordingly, routine coagulation
assays may play a role in the assessment of these agents
when used as a part of a panel. Alternatively, the laboratory
may opt to perform more specific testing, such as a Hemoclot
or dilute TT for dabigatran and a specific anti-Xa assay for
rivaroxaban. Whatever decision, the future coagulation
landscape is likely to change, with either a reduced or possibly
increased number of tests, the same kind of tests but perhaps
performed differently, or conceivably different assay panels
entirely. Specific laboratory guidance on the choice of the
appropriate test to be ordered according to the drug being
administered, as well as on appropriate interpretation of test
results, will also be necessary. The current report reviews the
current state of play and provides a glimpse to the possible
future of the coagulation laboratory.
SY46
STANDARDIZATION AND CINICAL UTILITY OF
THROMBIN-GENERATION ASSAYS
E. Berntorp
Lund University, Skane University Hospital Malmö, Sweden
Thrombin generation (TG) and other global assays have
gained much attention during recent years within the field of
haemophilia due to mainly two reasons: 1) the bleeding
phenotype in haemophilia does not correlate entirely to basal
factor VIII or IX levels and 2) by-pass therapy i.e. recombinant
activated factor VII and activated prothrombin complex
concentrate cannot be monitored by currently available clotting
factor tests. The hope is that global tests better can predict
haemostatic outcome of the treatment. Thrombin generation
tests have been available since many years . Some 20 years
ago Hemker described a quantitative method to measure
thrombin generation and described the parameter endogenous
thrombin potential. With the advent of automatic assays the
interest in the test has rapidly increased also among clinicians.
However, there is still no consensus regarding standardization
of the test. Preanalytic handling of samples as well as activator
S30
biochimica clinica, 2013, vol. 37, SS
constituents still create a problem when comparing results
between different laboratories. Issues like tissue factor and
phospholipid concentrations as well as presence of platelets
need to be addressed. A working group within the ISTH SSC is
addressing these issues and will soon come up with proposals.
At single centers working with TG the test seems valid and
reliable and results on clinical materials have been published.
So far the cohorts have been small and not well controlled but
results are promising. In haemophilia without inhibitors TG
indicate a relationship with bleeding frequency. Pre-testing in
vitro of plasmas from inhibitor patients with presence of by-pass
agents may help to choose the most appropriate product for a
specific patient. In a large study evaluating different factor VIII
products for immune tolerance induction (ObsITI) TG can
differentiate between products and concentrate lots in their
capacity to induce thrombin in inhibitor plasma. Collaboration
among international haemophilia centers will probably within
few years better delineate the role of TG and other global tests
for haemophilia treatment.
OC19
SIMULATION OF THE COST-EFFECTIVENESS OF
GENETIC SCREENING FOR THE SUSCEPTIBILITY TO
ORAL CONTRACEPTIVE ADVERSE REACTIONS
F. Rousseau3, J. Duplantie3, L. Nshimyumukiza3, M.
Gagnon3, X. Douville1, C. Lindsay5, M. Parent6, E. Bujold7,
A. Milot2, Y. Giguère4, C. Gagné2, D. Reinharz3
1
Centre de recherche, CHU de Québec
Département de biologie moléculaire, biochimie médicale
et pathologie, Faculté de Médecine, Université Laval
3
Département de médecine sociale et préventive, Faculté de
Médecine, Université Laval
4
Département de génie électrique et de génie informatique,
Faculté de Sciences et Génie, Université Laval
5
Département de pharmacie, CHU de Québec
6
Département d'obstétrique/gynécologie, Faculté de
médecine, Université Laval
7
Département de médecine, CHU de Québec
2
Background: Several studies have shown a strong association
between oral contraceptive (OC) use and venous thromboembolism (VTE). Various risk factors could explain this
association, among these, mutations in the factor V Leiden
and/or prothrombin F2 G20210A. Screening for these
mutations could help to reduce the incidence of OC-induced
VTE. The objective of this study was to determine the
cost/effectiveness ratio (C/E) and the cost/utility (C/U) of
screening options for the prevention of VTE in OC users.
Methods: A decision model was used to simulate the costeffectiveness of various screening options for genetic risk
factor. The virtual population consisted of 14 to 28 years old
women who wanted to start taking OC, and whose age and
BMI distributions were identical to the Canadian population.
Model inputs were taken from an extensive review of the
literature. The model considered three situations: no screening,
universal screening and targeted screening. In total, 19 options
were tested. Three outcomes (besides the estimated costs)
were considered: 1) the number of VTE events, 2) the number
of pregnancies, 3) QALYs.
Results: The most C/E and C/U options are a biochemical
screening (APC-r) and biochemical screening (APC-r)
combined with genetic screening (F5 G1691A and F2
G20210A), with overlapping confidence intervals between
them. All other options are dominated (i.e. less cost/effective
than the status quo). Moreover one option stands out as clearly
unfavorable: systematic genetic testing for Factor V Leiden and
F2 G20210A. Sensitivity analyses show that the results in term
EuroMEdLab 2013 - sciEntific sEssions
of C/E are robust, on the contrary of C/U results.
Conclusion: Genetic screening (F5 G1691A and F2 G20210A)
alone is not a favorable option for the prevention of
thromboembolism in women wishing to take OC. However
decision makers might consider an universal program of
biochemical testing (APC-r).
OC20
WARFARIN PHARMACOGENETIC PREDICTION
PERFORMANCE: CONTRIBUTION OF EXTENDED
PANELS OF CYP2C9 AND VKORC1 GENETIC VARIANTS
M. Pelloso1, C. Zambon1, S. Moz1, A. Padoan1, P. Fogar1,
M. Braga1, E. Gnatta1, R. Padrini1, V. Pengo2, D. Basso1, M.
Plebani1
1
Department of Medicine DIMED, University of Padova, Italy
Department of Cardiothoracic and Vascular Sciences,
University of Padova, Italy
2
Background: Warfarin is a widely used oral anticoagulant with
narrow therapeutic index and relevant interindividual variability
in dosing requirements. We have recently published an
algorithm based on clinical (body surface area and age) and
genetics (CYP2C9 *2 and *3 alleles, -1639G>A VKORC1 SNP,
CYP4F2 *3 alleles) variables (Zambon CF, et al.
Pharmacogenomics. 2011;12(1):15-25). The aim of this study
was to verify if the use of an extended panel of CYP2C9
(*2,*3,*4,*5,*6,*7,*11,*12,*18) and VKORC1 (-1639G>A,
+6009C>T,+6484C>T,+6853G>C,+7566C>T,+9041G>A) gene
polymorphisms could significantly improve our capability in
warfarin maintenance dose prediction.
Methods: CYP2C9, VKORC1 and CYP4F2 polymorphisms
were retrospectively analyzed (Taqman chemistry and
INFINITI®Autogenomics Analyzer) in 317 Italian patients
(median age 74yrs, range 43-91yrs) under stable warfarin
therapy (target INR=2.5 median weekly dose 31.25mg, range
6.25-80mg). Using stepwise regression and warfarin
maintenance dose as dependent variable we developed 3
algorithms considering BSA, age and 3 different panels of
polymorphisms: 1. CYP2C9 extended panel, VKORC11639G>A and CYP4F2 *3 2. CYP2C9 *2,*3, VKORC1
extended panel and CYP4F2 *3 3. CYP2C9 and VKORC1
extended panels and CYP4F2 *3 We compared these
algorithms with our present algorithm (algorithm 4).
Results: The percentage of explained warfarin variability
(R2adj%) was slightly different among the algorithms (55.6%,
53.1%, 55.3% and 53.4% for algorithm1,2,3 and 4
respectively). The Mean Absolute Error in the prediction of
maintenance dose ranged from a minimum of 7.52±0.64
mg/week (algorithm 3) to a maximum of 7.80±0.63 mg/week
(algorithm 4). Considering three classes of weekly warfarin
maintenance dose (<26.25 mg, 26.25-43.75 mg, >43.75 mg)
the predictive performance of the algorithms was statistically
higher in intermediate than in low (Wald test z=2.54, P=0.011)
and in high classes (z=2.11, P=0.035). Predictive performances
were not statistically different within classes.
Conclusions: the analysis of an extended panel of CYP2C9
alleles might improve the predictive ability of our algorithm.
Instead the use of high number of VKORC1 SNPs didn’t
increase our capability in warfarin dose prediction.
SY47
EPIDEMIOLOGY OF INFLAMMATORY BOWEL DISEASE
IN CHILDREN
P. Henderson
Department of Child Life and Health, University of
Edinburgh, Edinburgh, United Kingdom
25-30% of patients with inflammatory bowel disease (IBD) are
diagnosed in childhood. Recent epidemiological evidence has
shown that there has been a rising incidence of paediatric IBD
(PIBD) both in Europe and worldwide in recent decades,
although the pathogenic mechanisms involved in this rise are
yet to be elucidated. Although detailed genetic studies have
not uncovered a distinct genotype in those with early-onset
disease, a clear difference in clinical phenotype is observed.
Those with PIBD present with or quickly develop pan-enteric
disease in paediatric Crohn's disease (CD) or pancolitis in
paediatric ulcerative colitis, compared to those with adult-onset
disease. Additionally, isolated ileal disease is very uncommon
in paediatric CD (~5%), with colonic disease featuring
frequently in those diagnosed with CD less than 10 years of
age. There is currently a paucity of data with regard to
treatment strategies in PIBD, which much of the therapeutic
data extrapolated from adult studies. However, emerging
evidence now supports the use of exclusive enteral nutrition in
Crohn's disease with this modality now becoming utilised in the
adult population. With the rising incidence and extensive
disease at diagnosis the disease burden in those with PIBD is
high, with detrimental effects on growth, education and
psychosocial well-being.
SY48
PATHOPHYSIOLOGY OF INFLAMMATORY BOWEL
DISEASES
P.L. Lakatos
Semmelweis University, Hungary
The pathogenesis of inflammatory bowel diseases (IBD) is only
partially understood; various environmental and host factors
are involved. Genetics has been revolutionized in recent years
by the advent of genome-wide association (GWA) studies with
IBD being one of the most successful areas. So far, > 100
susceptibility loci/genes (71CD; 47UC) have been discovered
and replicated with a significant geographic variability. Both the
innate and the adaptive immune systems appear to be
disregulated. In CD, defective crosstalk between bacteria and
host seems to play a key role; according to the gene
discoveries in autophagy and innate immunity (associations
with NOD2, IRGM, and ATG16L1 are specific to CD). These
genes also play key roles in the homeostasis of a cell type that
stands at the interface of host-microbial interaction – the
Paneth cell by altering antimicrobial peptide production (socalled defensins). In contrast, the importance of barrier function
(HNF4A, LAMB1, CDH1 and GNA12) was shown to be more
important in the development of UC. In addition, impaired IL10
signaling has reemerged as a key pathway in intestinal
inflammation already in the first year of life. Another true IBD
pathway that seems critical in maintaining intestinal immune
homeostasis is the IL23/Th17 signaling with multiple genes
identified as susceptibility loci (e.g. IL23R, IL12B, STAT3 and
JAK2) affecting both innate and adaptive immune responses.
Nevertheless, the interaction between mechanisms is more
complex in vivo and influenced also by environmental factors
(e.g. smoking and NOD2). There is a mutual interaction
between gut microbiome, innate defense mechanisms and
barrier function, contributing to a balance that determines
biochimica clinica, 2013, vol. 37, SS
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EuroMEdLab 2013 - sciEntific sEssions
physiological or pathological inflammation. However, translation
from bench to bedside is sometimes difficult as highlighted by
the recent clinical trials failing to demonstrate a benefit by
targeting the IL17 or CTLA4. In conclusion, recent
advancement in basic research has significantly contributed to
the understanding of IBD pathogenesis and it may ultimately
lead to improved diagnostics, course prediction, identification
of possible targets for therapeutic intervention and hopefully to
a more optimized, personalized therapeutic armamentarium.
SY49
LABORATORY TESTING IN INFLAMMATORY BOWEL
DISEASE
D. Basso
Department of Laboratory Medicine, University-Hospital of
Padova, Italy
IBDs comprise an heterogeneous group of chronic
inflammatory disorders of the intestinal tract which onset is
typically during young adulthood, although about 20-25% of
patients are diagnosed during childhood. Faecal markers are
useful to evaluate patients with symptoms of IBDs. The two
most commonly used are calprotectin and lactoferrin, which
are markers of “neutrophilic intestinal inflammation”.
Calprotectin, a 36.5 kDa heterotrimer composed of one light
(S100A8) and two heavy (S100A9) chains, represents 60% of
granulocytes soluble cytosol proteins, while lactoferrin, an iron
binding protein, is a major component of the secondary
granules of neutrophils. The sensitivity and specificity of fecal
markers in detecting IBDs are 93% and 96% in adults, 92%
and 76% in children. Fecal markers do not allow to distinguish
CD from UC. In this setting the application of serological
markers is advisable. Serological markers include antibodies
towards bacteria and yeast’s components, and antibodies
which recognize perinuclear neutrophil cytoplasmic antigens
(pANCA). IgG and IgA antibodies anti the mannose residue
from the phosphopeptidomannan of the cell wall of S.
cerevisiae (ASCA) and pANCA IgG are established serum
biomarkers for CD and UC respectively. Their sensitivity is 5070% and their specificity is 80-85%. New serum biomarkers for
CD diagnosis include antibodies anti-bacterial proteins (antiI2, CBir, OMPc) and surface components (chitobioside ACCA,
laminaribioside ALCA, and mannobioside AMCA) of
microorganisms and human cells. Although as much as 80%
hereditability in IBDs is still unexplained, in approximately 30%
of CD patients mutations in NOD2 are found and the most
commonly identified mutations are R702W, G908R and
L1007fsinsC. Heterozygosity increases the risk 2- to 3-fold,
whereas homozygosity is associated with a 20- to 40-fold
higher risk of developing CD. NOD2 mutations are associated
with a more severe form of the disease, an early age at onset,
and ileal lesions. When treatment with thiopurines is needed,
thiopurine methyltransferase (TPMT) genetic analysis before
starting treatment should be performed in an effort to detect
individuals who have low enzymatic activity (*2 and *3 alleles)
to avoid potential adverse effects.
OC21
AUTOANTIBODIES TO GLYCOPROTEIN 2 (GP2) ARE
ASSOCIATED WITH DISEASE PHENOTYPE IN CROHN’S
DISEASE
D. Roggenbuck1, D. P. Bogdanos2, D. Reinhold3, T. Wex4, A.
Forbes5, K. Conrad6, M. Laass7
1
Faculty of Natural Sciences, Lausitz University of Applied
Sciences, Senftenberg, Germany
S32
biochimica clinica, 2013, vol. 37, SS
2
Division of Transplantation and Mucosal Biology, King’s
College London School of Medicine at King’s College
Hospital, London, UK
3
Institute of Molecular and Clinical Immunology, Otto-vonGuericke University, Magdeburg, Germany
4
Department of Gastroenterology, Hepatology and Infectious
Diseases, Otto-von-Guericke University, Magdeburg,
Germany
5
Department of Gastroenterology and Clinical Nutrition,
University College Hospital, London, UK;
6
Institute of Immunology, Technical University, Dresden,
Germany
7
Children’s Hospital, Technical University, Dresden, Germany
Background: Pancreatic antibodies (PAB) recognize zymogen
granule glycoprotein 2 (GP2) as major autoantigenic target in
patients with Crohn’s disease (CD). Anti-GP2 IgA and IgG have
been described as novel serological markers in CD and can
be used in the differential serological diagnosis of inflammatory
bowel disease. This study investigated the association of the
novel CD-specific anti-GP2 antibodies with disease
phenotypes in CD.
Methods: Anti-GP2 and anti-Saccharomyces cerevisiae
(ASCA) IgA and IgG were determined by enzyme-linked
immunosorbent assays (ELISA) in sera of 169 CD patients and
102 ulcerative colitis (UC) patients. PAB was assessed by
indirect immunofluorescence (IIF).
Results: Anti-GP2 and ASCA IgG/IgA were detected in 51/169
(30.2%) and 60/169 (35.5%) in CD, and 9/102 (8.9%) and
7/102 (6.9%) in UC (P <0.0001, respectively). Patients suffering
from CD with ileocolonic location (L3) demonstrated a
significantly higher prevalence of anti-GP2 and ASCA IgA/IgG
(P= 0.0495, 0.0010; respectively), whereas CD patients with
colonic location (L2) revealed a significantly diminished
prevalence thereof and PAB (P <0.05 respectively).
Occurrence of anti-GP2 and ASCA IgA/IgG was significantly
more prevalent in CD patients with age at diagnosis <16 years
(P=0.0083, P=0.0028). Appearance of one or more anti-GP2 or
ASCA IgA/IgG was significantly more prevalent in L3, B2, and
A1 and less prevalent in L2. (P <0.05, respectivley)
Conclusions: The novel CD-specific anti-GP2 IgG and IgA
antibodies are associated with distinct disease phenotypes.
They are more prevalent in patients with CD at a younger age,
with ileocolonic location, and stricturing behaviour with perianal
disease.
OC22
AUTOANTIBODIES DIRECTED AGAINST COMPONENTS
OF PROMYELOCYTIC LEUKEMIA PROTEIN NUCLEAR
BODIES IN PATIENTS WITH PRIMARY BILIARY
CIRRHOSIS
A. Bauer1, A. Habior2, W. Zych2, T. Rawa2
1
Department of Biochemistry and Molecular Biology, Medical
Centre of Postgraduate Education, Warsaw, Poland
2
Department of Gastroenterology and Hepatology, Medical
Centre of Postgraduate Education, Warsaw, Poland
Background: Primary biliary cirrhosis (PBC) is a progressive,
autoimmune liver disease. Some of patients have antinuclear
antibodies (ANAs). Part of these ANAs targets promyelocytic
leukemia protein (PML) nuclear body (NB) components such
as Sp100 and PML. Novel protein identified using serum PBC
patients designated as Sp140 is considered to be diseasespecific. The aim of this study was to analyze the sensitivity,
specificity and predictive values of this new anti-Sp140
antibody, as well anti-Sp100 and anti-PML antibodies in a well
characterized cohort of PBC patients.
EuroMEdLab 2013 - sciEntific sEssions
Methods: We studied 80 PBC patients, 55 pathological
controls with primary sclerosing cholangitis, autoimmune
hepatitis, rheumatoid arthritis and 30 healthy blood donors.
The ELISA “in-house” test was established for the detection
of anti-Sp140 antibody. The microtitration polystyrene plates
coated with recombinant protein Sp140 were consecutively
incubated with diluted sera, anti-human IgG antibody
conjugated with horseradish peroxidase and with TMB. Optical
density was read at 450 nm. Anti-Sp100 and anti-PML
antibodies were detected by commercially available kits.
Results: Anti-Sp140 antibodies were present in 22 (28%) PBC
patients, also in AMA negative cases. The results were
negative in healthy sera and in all but one (patient with primary
sclerosing cholangitis) pathological controls. The specificity of
the test and positive predictive value were 99% and 96%,
respectively. Anti-Sp100 antibodies were present in 27 (34%)
PBC patients and anti-PML in 28 (35%). Anti-Sp140 coexisting
with anti-Sp100 was found in 16/22 patients (73%) and with
anti-PML in 14/22 (64%). Anti-Sp140 antibodies were found
together with anti-Sp100 antibodies and with anti-PML
antibodies in 8 (36 % ) cases.
Conclusions: Sp140 is a novel, highly specific PBC
autoantigen. Our study identifies anti-Sp140 for the first time
in PBC group by ELISA method, using recombinant protein,
with very high specificity. The very frequent coexistence of
anti-Sp140, anti-Sp100 and anti-PML antibodies suggests an
autoimmune reaction against multiple nuclear body
components in some of PBC patients. The ability to detect antiSp140 antibodies expands the diagnostic armamentarium of
PBC-specific markers.
SY50
GENOMICS, EPIGENOMICS AND TRANSCRIPTOMICS:
BUILDING AN INTEGRATED VIEW OF DISEASE USING
NEXT GENERATION SEQUENCING DATA
E. Stupka
Center For Translational Genomics and Bioinformatics San
Raffaele Scientific Institute, Milan Italy
The sequencing of the human genome was meant to
revolutionise mechanistic understanding of disease, deliver
better diagnosis and better therapy. The subsequent emphasis
on GWAS studies has delivered numerous loci of relevance to
disease, but has fallen short of those promises. Touching on
examples spanning from basic science (our recent discovery of
a new class of ncRNAs) to translational science (biomarker
discovery) I will dwell on some of the reasons that in my opinion
underlie this failure. I will relate on my recent experience in
establishing a translational genomics center situated within a
hospital with the aim of eventually truly benefiting patients. By
explaining our current setup and projects I will try to convey my
view on how these failed promises still hold great potential for
understanding disease, as long as a new, more integrated and
patient-centric approach is taken. In this approach all
components and functions of the genome (the histone code,
DNA methylation, DNA sequence, transcription) need to be
taken into account together and need to be treated as
potentially heritable features. By viewing heritablity of the
genome in this way, we might begin to understand better the
relationship between environment and disease, the partial
heritability of complex disease, and, above all, the unique
puzzle which makes up a specific disease progression and
phenotype within the context of his/her environment and family,
as opposed to a "blanket" diagnosis.
SY51
BIOINFORMATICS FOR NEXT GENERATION
SEQUENCING: FROM DATA MANAGEMENT AND
ERROR CORRECTION TO MEDICAL INTERPRETATION
T. Rattei
Department of Computational Systems Biology, University of
Vienna, Austria
Next-generation sequencing (NGS) methods generate huge
amount of data that can only be handled and analyzed by
sophisticated computational approaches. Bioinformatic
methods are therefore relevant for all phases of NGS
experiments. Read simulators for the different NGS
technologies support the planning and design of NGS studies.
These programs generate reads from read sequence data and
incorporate the typical sequencing error types and
distributions. These simulated reads are widely used to
evaluate the efficiency and correctness of computational data
analysis pipelines, and to select the optimal sequencing
technology for a given diagnostic problem. The real
sequencing data are managed and organized through
specialized computational tools. The main challenge consists
in the very high data volumes and is addressed through
specific compression algorithms as well as distributed storage
and processing of raw sequence data. An important
requirement for subsequent algorithms is the error reduction
and correction of NGS sequence data. Different strategies for
the removal of erroneous reads as well as the direct correction
of particular error types, such as homopolymer InDels or
artificial amplification, allow for an efficient reduction of
experimental errors in the raw NGS data. The reconstruction
of the originally longer sequences from short reads is
necessary in many projects. Sequence assembly tools
implement alternative strategies such as mapping, de novo
assembly, hybrid assembly or comparative assembly. The
quantification of sequences requires additional computational
approaches. These first determine the raw read counts per
sequence position. These counts need to be corrected for
NGS-method specific biases, and are normalized for the
comparison between different samples. Statistical approaches
that were originally developed for microarray-based sequence
quantification needed substantial adaptations and
improvements in order to be suitable for quantitative NGS.
Bioinformatic tools and methods are crucial for the success of
NGS-based projects. A substantial portfolio of tools has been
developed during the last years. However, the rapid increase
in NGS throughput will keep this area an active research field
also in the next future.
SY52
MULTIGENE ANALYSIS IN THE MOLECULAR
DIAGNOSTIC OF GENETIC DISORDERS
B.H. Weber
Institute of Human Genetics, University of Regensburg,
Germany
In recent years, massive research efforts coupled with major
advances in high-throughput technologies have greatly aided
in the elucidation of the molecular causes not only of the
majority of Mendelian disorders but also of a multitude of gene
loci strongly associated with common, often age-dependent
human diseases. In the case of the hereditary disorders it has
become evident that genetic heterogeneity is widespread
rendering traditional genetic diagnostics approaches based
on Sanger sequencing of single genes mostly insufficient to
diagnose the molecular defect in the patient. A prominent
biochimica clinica, 2013, vol. 37, SS
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EuroMEdLab 2013 - sciEntific sEssions
example of genetic heterogeneity offers the group of retinal
dystrophies with retinitis pigmentosa caused by mutations in
probably more than 100 distinct genes. As an integral part of
customized healthcare, molecular diagnostics is essential to
tailor medical care to an individual. In particular, it is needed to
secure a clinical diagnosis, to establish carriers status, and to
allow sub-classification of a given disease state. Clarification
of an individual’s genetic defect provides the basis for accurate
evaluation of recurrence risk and paves the way for targeted
treatment approaches. Available state-of-the-art technologies
for high-throughput DNA analysis such as microarray-based
resequencing and massively parallel sequencing are suited to
address those needs of modern DNA testing. Such
technologies have the capacity to yield sequence information
of up to 600 Billion base pairs in a single analysis. Not
surprisingly, the resulting depth of information and the required
interpretation of the data pose enormous challenges to the
analyst and the medical geneticist. A particularly demanding
task necessitates the distinction of pathologically relevant
mutations from a plethora of neutral sequence changes. Here,
systematic approaches are needed to bring together available
resources from bioinformatics, population-based information
and functionally relevant data. The interpretation of such data
will be complex as will be the task to communicate such a
complexity to the patient.
OC23
NEXT GENERATION SEQUENCING IN RESEARCH AND
DIAGNOSTICS OF GENETIC CARDIOMYOPATHIES
V. D'Argenio1, V. Precone1, A. Boccia1, G. Limongelli2, G.
Pacileo2, R. Calabrò2, G. Paolella1, G. Frisso1, F. Salvatore3
1
CEINGE-Biotecnologie Avanzate s.c.ar.l., Napoli, Italia and
Dipartimento di Biochimica e Biotecnologie Mediche,
Università di Napoli Federico II, Napoli, Italia
2
U.O.C. di Cardiologia A.O. Monaldi, Seconda Università
degli Studi di Napoli, Napoli, Italia
3
CEINGE-Biotecnologie Avanzate s.c.ar.l., Napoli, Italia and
IRCCS – Fondazione SDN, Napoli, Italia
Background: Hypertrophic cardiomyopathy (HCM) is the most
frequent genetic cardiovascular disease worldwide and is the
first cause of sudden cardiac death in young people. HCM
molecular bases are highly heterogeneous, over 30 causative
genes having been reported to date.
Here, we report a next generation sequencing procedure
associated with DNA sequence capture that was able to
sequence simultaneously 202 cardiomyopathy-related genes.
Methods: The study was performed on 3 HCM patients and
on their genomic pool. Totally, 202 genes were selected and a
custom sequence capture array was designed for target
enrichment of all their coding regions, bounded by 500 nt at
each end. The size of our target was 3.9 Mb. Each selected
patient was individually analyzed. Briefly, each DNA sample
was enriched using one custom array, and then sequenced
with the GS FLX System. In this way, we were able to obtain
an average of 203 Mb/sample, being equivalent to 647,888
sequencing reads/sample with an average read length of
327.8 bp. A data analysis and annotation pipeline was
developed and used to prioritize the identified genetic variants.
Results: We identified a large number of variants in each of
the three HCM patients analyzed. Computational filtering
revealed some variants that may be involved in the
pathogenesis of HCM: a missense mutation in MYH7 and a
non-sense variant in INS-IGF2 (patient 1); a splicing variant
in MYBPC3 and an indel/frameshift variant in KCNQ1 (patient
2); and two concomitant variations in CACNA1C (patient 3).
Sequencing of the pool of the three DNAs produced similar
S34
biochimica clinica, 2013, vol. 37, SS
results, which indicates that this cost-effect approach is
feasible.
Conclusions: Our procedure allows the simultaneous analysis
of a large number of genes thus obtaining a molecular
diagnosis also in those patients for which traditional screening
was not informative. In addition, it can identify mutations in
other genes that, acting as phenotype modifiers, could be
responsible for clinical variability. Thus, reducing time and
costs and increasing the sensitivity of molecular testing, we
could implement routine HCM molecular diagnostics and
obtain a model easily applicable to other genetic diseases.
OC24
WHAT WE DON’T KNOW ABOUT THE GENETIC BASIS
OF BRUGADA SYNDROME
C. Di Resta1, A. Pietrelli3, R. Bordoni2, S. Sala4, P. Della
Bella4, G. De Bellis2, S. Benedetti5, M. Ferrari1
1
University Vita-Salute San Raffaele, Milan
Institute of biomedical technologies, National Council of
resarch (ITB-CNR), Milan
3
PhD course in molecular medicine, University of Milan
4
Department of arrhythmology, San Raffaele Hospital, Milan
5
Laboratory of Clinical Molecular Biology, Diagnostica e
Ricerca San Raffaele, Milan, Italy
2
Background:Brugada syndrome (BS) is cardiac arrhythmic
hereditary disorder that can lead to sudden death with a
prevalence of 1:5000 in Caucasian population,affecting mainly
male patients in their 3rd-4th decade of life. BS is inherited as
an autosomal dominant trait however to date genetic bases
have been only partially understood. Most mutations are
located in the SCN5A gene, encoding the alpha-subunit of the
Na+ cardiac channel, but more than 70% BS patients remain
genetically undiagnosed. In our project we expect to increase
the proportion of genetically diagnosed BS patients, identifying
new BS-related genes and causative variantsby high
throughput sequencing analysis
Methods: We analysed 100 BS patients for a panel of 158
candidate genes, mainly encoding ion channels, structural
proteins, modulators of ionic flow, regulatory proteins. We
performed the design of 2320 exons corresponding to 498.094
nucleotides using the eArraytool developed by Agilent. We
used the Agilent Sureselect target enrichment protocol and the
sequencing was performed on Illumina GA IIx.To manage the
sequencing data, we developed an automated bioinformatics
pipeline based on BWA aligner, which is able to map reads
versus the hg19 reference with great accuracy
Results: For each sample, at least 2 million paired-end reads
was successfully mapped. More than 98% of the target
sequences were covered with more than 230X mean depth
by gene and the 90% of the bases are sequenced above a
50X depth. We detected 225 new missense variants in 70
genes of our panel: 2 of them are in the splice-site donor in two
different cardiac voltage-dependent ion channels and 3of them
cause stop codon. Two of them are localized in regulatory
proteins of the cardiac excitability and the other one has an
important role in the cardiac action potential. All these
mutations are privates. We detected also some missense
variants in the same genes in different patients with the same
phenotype and it could suggest their important pathogenic
role.
Conclusions: Our preliminary results suggest that some of
investigated genes could have pathological role in the BS
onset that is never been considered until now.
EuroMEdLab 2013 - sciEntific sEssions
SY53
DOES THIS MEDICAL TEST WORK BETTER?
EFFECTIVENESS OF HbA1c POCT FOR MANAGEMENT
OF DIABETES
C.P. Price
Department of Primary Care Health Sciences, University of
Oxford
A recent systematic review of randomised controlled trials of
point-of-care testing (POCT) for HbA1c found insufficient
evidence of the effectiveness of POCT for HbA1c. What can
we learn from this review? The reviewers concluded that there
needed to be further development of the research
methodology, particularly in (i) employment of common
outcome measures in all studies, (ii) the stratification of
patients according to baseline HbA1c, (iii) clear definition of
current standard of care (control) and POCT supported care
(experimental) processes, (iv) confidence that the results are
discussed with the patients at the time they become available,
and (v) ensuring that the analytical performance meets the
required quality standards. Crucially (a) it was not possible to
pool data from several of the studies, and (b) there was
evidence that results were not discussed with the patients
during the clinic visit in the POCT arm of the study. The latter
is one of the key attributes for the use of POCT in the
management of long term conditions. The issue of stratification
of patients according to baseline HbA1c relates to two issues
(i) linking risk stratification to specific treatment protocols, and
(ii) enabling pooling of data according to risk. The two key
outcome measures in such studies should be an agreed
outcome measure [or surrogate] of clinical effectiveness – in
this case HbA1c measured in the laboratory, and evidence of
a change in practice, e.g. treatment intensification. If an
economic analysis is to be performed then there needs to be
identification of the costs associated with both arms of the
study, and for true cost effectiveness - long term follow up.
Interestingly there were two large observational studies that
did show a significant fall in the mean HbA1c levels with the
introduction of POCT for HbA1c. However again there was
little definition of the care processes, or any stratification of
patients in regard of treatment or pooling of data.
The conclusions drawn from analysis of this review are that
(a) patients should be stratified for treatment and follow up,
(b) treatment protocols should be transparent, and followed,
(c) the POCT care process must show evidence of action, and
(d) evaluation must be of a “test-and -treat” intervention.
SY54
DETERMINING WHAT WORKS BEST: THE
LABORATORY MEDICINE BEST PRACTICE INITIATIVE
R.H. Christenson
University of Maryland School of Medicine, Baltimore,
Maryland, USA
Background: The Laboratory Medicine Best Practices (LMBP)
program applies evidence-based medicine principles for
developing recommendations on laboratory medicine topics.
Topics are selected for systematic review based on relevance
with the Institute of Medicine’s healthcare priorities of safety,
timeliness, effectiveness, efficiency, equitability and patientcenteredness.
Methods: The LMBP A6 methodology includes the elements of
ASK, AQUIRE, APPRAISE, ANALYZE, APPLY and AUDIT.
Asking involves question formulation by specifying the Practice,
Indicator, Control and Outcome. Acquiring evidence includes
searching literature data bases and locating unpublished
studies. Appraisal of evidence is conducted by 2 trained
reviewers using a standard rating tool. Analyzing the evidence
includes use of meta-analytic techniques as appropriate.
Evidence based recommendations for Application to laboratory
practice are developed. Assessing the impact of LMBP
recommendations is also a component.
Results: Systematic reviews were performed on topics
involving hemolysis, critical value notification and positive
specimen identification. For reducing sample hemolysis in
emergency units, straight needle collection was compared with
IV starts finding a reduction in hemolysis rates [risk ratio = 0.16
(95% CI=0.11-0.24)]. Use of automated notification and
customer service call centers for reporting critical values
showed a standard difference in means (d=0.42; 95% CI=0.20.62), while studies reporting improved service with call centers
showed OR=22.1; 95% CI=17.1-28.6. Use of barcoding was
favored for reducing patient specimen and laboratory testing
identification errors. The mean odds ratio for use of barcoding
systems was 4.39 (95% CI: 3.05-6.32) and for use at point-ofcare testing 5.93 (95% CI: 5.28-6.67).
Conclusions: For reducing hemolysis rates in EDs, straight
needle venipuncture instead of IV starts is effective. Call
centers are effective in improving the timeliness of critical value
reporting but evidence for use of automated notification
systems is not sufficient for or against a best practice.
Barcoding is effective for reducing patient specimen and
laboratory testing identification errors in diverse hospital
settings and is recommended as an evidence-based best
practice.
SY55
TRANSLATING EVIDENCE INTO PRACTICE:
SUCCESSES AND CHALLENGES
S. Kahn
Ph.D., DABCC, FACB. Professor and Vice Chair, Clinical
Services, Pathology, Loyola University Health System,
Maywood, Illinois
In the United States (U.S.), considerable attention is presently
focused on the importance and impact of evidence-based
laboratory medicine (EBLM). With President Obama re-elected,
providers are ramping up efforts as they prepare for more
radical healthcare reform. Numerous professional and
governmental organizations are dedicating more resources
towards assessing the comparative effectiveness of diagnostic
interventions as well as fpcusing on the development of clinical
practice guidelines (CPGs) and laboratory medicine practice
guidelines (LMPGs). While many of these guidelines have
great potential to impact use of laboratory services, translating
the recommendations into real changes in practice remains a
challenge. At our academic medical center (AMC) outside of
Chicago, effective strategies have facilitated the
implementation
of
EBLM
developed
guideline
recommendations. These efforts involve multidisciplinary teams
of clinical faculty and staff in pathology working collaboratively
with physicians and staff from other departments. Our case
studies that will be presented involve adherence to and
implementation of key EBLM grounded practice changes. In
triage of chest pain patients, selected changes have
contributed to a 40% reduction in the ‘door-to-balloon’ time for
AMI patients also resulting in 100% of AMI patients receiving
percutaneous coronary intervention within 90 minutes of arrival.
Increased availability of lactate measurements at the point of
care with a critical value driven algorithm is currently being
implemented for rapid triage and identification of patients in our
early sepsis management protocols. A pilot study is underway
biochimica clinica, 2013, vol. 37, SS
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EuroMEdLab 2013 - sciEntific sEssions
evaluating use of 2-D bedside barcode label systems for
accurate administration of medications and laboratory
specimen identification. Over three years, evidence-based
major changes to our blood management program have led to
more appropriate utilization of blood products, reduction of
waste and decreased expenses. In one year, red blood cell
transfusions per discharge decreased by 11% while plasma
transfusions per discharge decreased by 23%. Our department
will continue to identify actions which lead to evidence-based
practice changes that improve the quality of services, use of
resources and patient care.
SY56
EVIDENCE-BASED INITIATIVES FROM NEW ZEALAND
C. Florkowski
Canterbury Health Laboratories, Christchurch, New
Zealand
The New Zealand (NZ) Guidelines Group has produced many
excellent documents in areas including cardiovascular risk
screening and type 2 diabetes that have received favourable
international recognition. Better guidelines, however tend to
be longer which may paradoxically render them less useful,
particularly to those who need them most. It is also clear that
there is a wide gap between what is actually achieved in
clinical practice compared with recommendations. There is
also inconsistency between guidelines, few clinicians access
them and they are only as good as the primary studies upon
which they are based. In particular, there is a paucity of good
outcome data in laboratory medicine. In NZ, we have
attempted to harness best practice through the development
of decision support tools at the point of request, eg for D-dimer
with a view to generating evidence-based, patient specific
comments. Coupled with this, is a focus on better
assessments of pre-test probability and also reporting of
likelihood ratios to improve test interpretation. More
importantly, at a local level, we have developed Health
Pathways, which are locally agreed, evidence-based best
practice guidelines, although also mindful of locally available
resources.
SY57
LABORATORY ISSUES IN CLINICAL GUIDELINE
DEVELOPMENT
K.M. Aakre
Laboratory of Clinical Biochemistry, Haukeland University
Hospital, Bergen, Norway
Background: Correct information provided by guidelines may
reduce laboratory test related errors during the pre-analytical,
analytical and post-analytical phase and increase the quality
of laboratory results.
Methods: Twelve clinical practice guidelines were reviewed
regarding inclusion of important laboratory investigations.
Based on the results and the authors` experience two check
lists were developed; one comprehensive list including topics
that authors of guidelines may consider and one consisting of
minimal standards that should be covered for all laboratory
tests recommended in clinical practice guidelines. Number of
topics addressed by the guidelines was related to involvement
of laboratory medicine specialists in the guideline development
process.
Results: The comprehensive list suggests 33 pre-analytical,
37 analytical and 10 post-analytical items. The mean
percentage of topics dealt with by the guidelines was 33%
S36
biochimica clinica, 2013, vol. 37, SS
(median 30%, range 17-55%) and inclusion of a laboratory
medicine specialist in the guideline committee significantly
increased the number of topics addressed. Information about
patient status, biological and analytical interferences and
sample handling were scarce in most guidelines even if the
inclusion of a laboratory medicine specialist in the
development process seemingly led to increased focus on e.g.
sample type, sample handling, and analytical variation.
Examples underlining the importance of including laboratory
items are given.
Conclusions: Inclusion of laboratory medicine specialist in the
guideline development process may increase the focus on
important laboratory related items even if this information is
usually limited. Two checklists are suggested to help guideline
developers to cover all important topics related to laboratory
testing.
SY58
GUIDELINE FROM THE EUROPEAN
ATHEROSCLEROSIS SOCIETY: CLINICAL VIEW ON
LABORATORY CHECKLIST AND ISSUES
M.R. Langlois
EFLM WG-Guidelines and -Cardiac Markers. Dept.
Laboratory Medicine, AZ St-Jan Bruges, Belgium
Background: Lipid testing is an important and integrated part
of cardiovascular prevention strategies. The European
Atherosclerosis Society (EAS)/EFLM Collaborative Project
was initiated in 2012 for making joint guidelines.
Method: The 2011 EAS/ESC guideline for management of
dyslipidemia was evaluated using the EFLM WG-Guidelines
checklist of laboratory issues necessary to ensure good quality
and application of in-vitro diagnostic test results.
Results: Characteristics of the target population are well
described and even incorporated in the risk score calculation
(age, gender); patients with cardiovascular disease, diabetes,
and chronic kidney disease are automatically assigned for
“very high-risk” treatment. Test indication is clear for all tests:
risk calculation (total cholesterol, HDL-cholesterol) vs.
therapeutic target (LDL-cholesterol, apolipoprotein B).
Sensitivity, specificity, and predictive values of the tests are
missing. With the exception of a recommendation for fasting
blood sampling, important pre-analytical issues are lacking.
Analytical performance goals are not described. Concrete
requirements of standardization are also missing. Direct LDL
methods are recommended in cases of invalid LDL calculation.
Well-known accuracy problems of direct LDL- and HDLassays are not mentioned. There are no warnings about
analytical interferences, except for the rare hyperglycerolemia
in triglyceride assays without glycerol blanking. Test reporting
units (mg/dL or mmol/L) and conversion factors are provided.
Risk-related cutpoints and therapeutic target values are clearly
given, with gender-specific cutpoints for HDL-cholesterol.
Biological interferences are summarized for triglycerides only.
Intra-individual variation data are given for total cholesterol
and triglycerides with a recommendation for repeat testing.
Testing frequency is described in detail for follow-up of lipidlowering therapy.
Conclusion: The EAS/ESC guideline includes some but not all
pre-analytical (test request) and post-analytical (test
interpretation) issues that are relevant to clinicians, but more
analytical recommendations should be taken into account for
medical decisions in cardiovascular risk management.
EuroMEdLab 2013 - sciEntific sEssions
SY59
CARDIAC TROPONIN: THE SENSE OF MORE
SENSITIVE ASSAYS
M. Van Dieijen-Visser
Central Diagnostic Laboratory, Maastricht University Medical
Center, The Netherlands, and EFLM Working group Cardiac
Markers
Cardiac troponin (Tn) is the biomarker of choice for diagnosis
of myocardial injury. The guidelines recommend the use of the
99th percentile upper reference concentration of cardiac
troponin - estimated in a healthy population - as the diagnostic
cut-off for acute myocardial infarction (AMI). The problem is
that for troponin T and especially for troponin I a broad range
of upper reference limits is employed, complicating the
diagnostic process. Major causes are lack of troponin I assay
harmonization and non-standardized selection of individuals
in healthy reference populations. The 99th percentile upper
reference limits should be estimated according to the
guidelines. However, by studying the results of about 45
different papers, we showed that none of the reference
populations used in the evaluated studies completely meet the
guidelines. Forty percent of the studies collected less than the
advised minimum of 300 subjects. Many studies did not report
their inclusion criteria. It appeared that lower 99th percentile
values are found when more stringent selection criteria are
applied. Higher troponin cut-offs are found in men and elderly
subjects, suggesting sex and age related cut-offs. These
results indicate that better implementation of guidelines is
required when estimating upper reference limits. With the
introduction of the more sensitive methods the number of
persons with measurable cTn concentrations increases, and
as a consequence the number of false-positive AMI diagnosis.
Methods used to exclude false positives are reference change
values or relative or absolute cardiac troponin changes in time.
These tools need further improvement and validation. Apart
from diagnostic purposes high-sensitive troponin methods are
also suitable for prognostic purposes, making reliable
estimation of the cut-off values even more important. It is clear
that extensive knowledge on cut-off values used by the
different laboratories is required. Several audits to evaluate
the implementation of guidelines with respect to above
mentioned aspects were performed and a new one will be
performed, all under auspices of the EFCC/EFLM. The results
will be discussed.
SY60
CURRENT GUIDELINES ON CARDIAC MARKERS: HOW
SHOULD THEY BE INTRODUCED AND HOW SHOULD
THE IMPLEMENTATION BE EVALUATED
P. Collinson
St George's Hospital and Medical School, Cardiology and
Clinical Blood Sciences, Cranmer Terrace, London, UK
There are a range of guidelines for the diagnosis and
management of cardiovascular disease. The significant
change that has occurred is that the use of cardiac biomarkers
has become an integral component of these patient diagnostic
and management pathways in a manner that would have been
completely unexpected 20 years ago. Laboratory diagnostics
has moved to the central stage of cardiac diagnosis. When
assessing how well the laboratory utilises and conforms to
these guidelines it is necessary to know the following. Is the
laboratory aware of the guidelines existence? Does the
laboratory incorporate the recommendations from the
guidelines into their standard operating procedures and
decision thresholds? Does the laboratory have dialogue with
its clinical users to ensure that the clinicians understand the
appropriate use of biomarkers and the strengths and
limitations of their use for clinical decision making in patients
with suspected cardiovascular disease? Assessment of the
laboratory understanding and introduction of current guidelines
has been investigated by performance of serial audits under
the auspices of the EFCC/EFLM with the assistance of
national societies of clinical biochemistry. It has taken the form
of a web-based questionnaire to assess overall understanding
by laboratory professionals of the implications of the current
guidelines for laboratory practice. The most recent audit is
targeted specifically at high sensitivity troponin assays and B
type natriuretic peptide. The two previous audits highlighted a
lack of independently verified data for decision thresholds for
cardiac biomarkers and inadequate engagement between the
laboratory and the clinical community. The current audit further
explores the present state-of-the-art. Since the initial two
audits, there have been minor amendments to one of the key
guidelines, universal definition of myocardial infarction, and
publication of a new recommendation on the use of high
sensitivity troponin measurement in patients presenting with
suspected acute coronary syndromes. It remains to be seen
how far the reports of the previous audits have modified
behaviour and being most recent clinical guidelines have been
translated into routine laboratory practice.
On behalf of the EFLM WG-CM
SY61
WHAT'S DIABETES IN 2013
D. Leslie
The Blizard Institute, University of London
In this talk I will explore three features of variation, which
impact our management of diabetes. First, genetic variation.
Second, variation in disease biomarkers. Third, variation in
therapeutic responses, which leads on to the concept of
personalized medicine. Evolution strives through natural
selection to maximize fitness and thereby enhance
reproductive success. Since natural selection selects optimum
genes to optimise survival, genes, by implication, must vary.
Without genetic variation there could be no genetic selection.
Genes adapt when the environment changes. But genotypes
are only as good as the environment allows them to be. A
genotype adapted to one environmental niche may be
maladapted to another, or even maladapted to the same niche
should that change. Common modern human diseases are
largely associated with good genes, which behave badly in
our modern environment. That variation in gene-environment
interactions has resulted in variation in biomarkers used for
diabetes diagnosis (e.g. HbA1c) as well as individual variation
in the risk of complications associated with diabetes. The
range of drugs now available to treat diabetes is also
associated with a range of responses to each therapy so that
there is a move to personalize medicine based on individual
needs, heterogeneity in the causes of diabetes and variation
in individual responses to drugs used to treat diseases. The
benefits of each given therapy varies substantially across a
population, but also from individual to individual and from one
drug to another. Finally, mortality rates can vary and have
varied substantially over the recent centuries, even over the
last century. Many of these benefits in the 20th century are not
noticeably linked to medical advances but benefit more from
the study of epidemiology and political responses to
epidemiological discoveries.
biochimica clinica, 2013, vol. 37, SS
S37
EuroMEdLab 2013 - sciEntific sEssions
SY62
HBA1C IN THE DIAGNOSIS OF DIABETES
A. Mosca
Dip. di Fisiopatologia Medico-Chirurgica e dei Trapianti
Centro per la Riferibilità Metrologica in Medicina di
Laboratorio (CIRME)
Background: HbA1c has a small intra-individual biological
variation, also in diabetic subjects, and is well accepted as an
integrated measure of circulating glucose levels, tracking well
in individuals over time. In 2009, on the basis of epidemiological
studies on microvascular complications, the American Diabetes
Association proposed HbA1c as one method for diagnosing
diabetes, and this proposal was endorsed by the World Health
Organization in 2011.
Methods: I have investigated several contributions published
in this area since 2009, some of them being new experimental
studies, some other being retrospective or longitudinal studies,
some other in the form of meta-analysis or reviews.
Results: In the majority of the contributions a comparison
between different diagnostic criteria is the main focus, and is
now clear that the criteria cannot be used alternatively, since
different subjects are diagnosed with type 2 diabetes in middleaged as well as in older subjects. Among the pre-analytical
confounding factors ethnicity and age has been well
investigated, and significant disparities have been found
among different groups, although no ethnic differences in the
association of HbA1c with retinopathy were found. Pregnancy,
hemolytic anemia, chronic renal insufficiency and liver cirrhosis
are the conditions which most frequently appear to give false
low values of HbA1c, and iron deficiency due to various
reasons is certainly the most common cause of false high
HbA1c values. Other biochemical and physiological
phenomena (red cell life span, glucose transport across the red
cell membrane and deglycating enzyme activities) may be
relevant in defining to the so-called fast or slow glycators
phenotypes.
Conclusions: There is uncertainty regarding the use of
HbA1cfor diagnosing diabetes. It appears more and more
evident that using both HbA1c and glucose tests to diagnosing
diabetes is convenient and efficient, since HbA1c alone is
adequate for screening but too insensitive for the diagnosis of
diabetes. Important issues still to be solved concern which
glycemia parameter is the best predictor of micro- and/or
macro-vascular complications, and if the use of HbA1c as an
additional diagnostic measure will improve the clinical outcome
of type 2 diabetic patients.
SY63
DESIRABLE REQUIREMENTS FOR POCT FOR
DIABETES IN HOSPITAL SETTINGS
D.E. Bruns
Dept. of Pathology University of Virginia Health System
Background: For over 10 years, controversy has reigned
regarding the adequacy of point-of-care glucose measuring
devices (often called meters) for use in hospitals. In the United
States, the Food and Drug Administration has made clear that
none have been cleared with an indication for use in protocols
to achieve “tight glucose control” in intensive care units via
intensive insulin therapy (IIT). Indeed, numerous studies in
which meters have been used for IIT have failed to achieve the
desirable patient outcomes reported by Van den Berghe and
colleagues when glucose measurements by a blood gas
analyzer were used to support IIT in their institution. Moreover,
the rates of hypoglycemia have been high, as has the variability
S38
biochimica clinica, 2013, vol. 37, SS
of patients’ glucose. Both hypoglycemia and glycemic variability
have been associated with adverse patient outcomes.
Methods: It is difficult to perform randomized clinical trials that
directly compare outcomes of patients treated with IIT protocols
in which glucose is measured by meters in comparison with
other devices. As an alternative to clinical trials, we have
undertaken simulation modeling of glycemic control in which
the imprecision and bias of the glucose measurement
procedure are variables.
Results: These studies have shown that both the rate of
hypoglycemia and glycemic variability are adversely affected
by errors in measurement of glucose. These studies also have
provided suggestions of the allowable total error of the
measurements, which includes inherent meter error, operator
error, and error associated with preanalytical and postanalytical
steps of the process. On-going studies are defining the effect
of frequency of measurement of glucose on this allowable error.
Conclusions: These studies are important as it is now possible
to measure glucose several times per hour rather than, at best,
hourly with meters. Devices with such capability for higher
frequency of measurement can also provide alarms to indicate
impending hypoglycemia, thereby offering potential to decrease
the frequency of hypoglycemia even if their analytical
performance is no better than that of comparison devices.
OC25
HbA1c MEASUREMENT FOR THE DIAGNOSIS OF
GESTATIONAL DIABETES MELLITUS: IS IT USEFUL?
P. Renz1, L. Weinert1, G. Cavagnolli1, S. Silveiro2, J.
Camargo3
1
Graduate Program in Medical Sciences: Endocrinology,
Universidade Federal do Rio Grande do Sul
2
Endocrinology Department, and 3Clinical Pathology
Department, Hospital de Clinicas de Porto Alegre, Brazil
Background: Gestational diabetes mellitus (GDM) is a
potentially serious condition that affects many pregnancies and
carries risk for the mother and the neonate. The current
recommendation is to perform GDM screening before 28
weeks of gestation by an oral glucose tolerance test (OGTT).
The aim of this study was to determine the usefulness of
hemoglobin A1C (A1C) as a diagnostic tool for GDM compared
with the traditional criteria based on glycemia measurements.
Methods: This was a study of diagnostic test accuracy. We
evaluated the status of carbohydrate metabolism by performing
OGTT and A1C in Brazilian pregnant women attending prenatal
visits at a university tertiary care hospital in southern Brazil.
A1C, OGTT, and clinical history were evaluated. GDM was
defined according to the American Diabetes Association (ADA)
criteria (fasting, 1-h, or 2-h plasma glucose concentrations
≥5.1, ≥10.0, or ≥8.5 mmol/L; respectively) or World Health
Organization (WHO) criteria (fasting or 2-h plasma glucose
≥7.0 mmol/L or ≥7.8 mmol/L, respectively). Presence of
anemia, variant hemoglobins and chronic renal disease were
excluded. The receiver operating characteristic (ROC) curve
was used to evaluate the diagnostic performance of A1C.
Results: A total of 262 pregnant women (mean age 30 years,
mean gestational duration 26 weeks) were enrolled and 83
(31.7%) were diagnosed with diabetes (40 by ADA criteria and
43 by WHO criteria). Based on ROC curve analysis, and
considering OGTT as the reference criterion, the cut-off point
obtained by the point with the best equilibrium between
sensitivity and specificity (100%-to-100% diagonal) was A1C
value of 31 mmol⁄mol (5.3%). The sensitivity and specificity for
this cut-off point were 67.7 % and 61.6 %, respectively. The
cut-off points of A1C of 40 mmol/mol (5.8%), 41 mmol⁄mol
(5.9%) and 42 mmol⁄mol (6.0%) presented specificities of 98%,
EuroMEdLab 2013 - sciEntific sEssions
99% and 100%, respectively. Our results showed that 38.5% of
GDM cases would be diagnosed by using the cut-off point of
A1C ≥40 mmol/mol (5.8%) solely.
Conclusions: A1C test presented low sensitivity but very high
specificity for GDM diagnosis when compared to traditional
criteria. A1C test, solely or in combination with OGTT, may be
a very useful diagnostic tool in GDM.
SY64
NON INVASIVE APPROACHES FOR THE GENETIC
ANALYSIS OF THE FOETUS
OC26
LOGISTIC REGRESSION ANALYSIS FOR IDENTIFYING
TYPE 2 DIABETICS WITH POOR RESPONSE TO
SULFONYLUREA THERAPY
Background: Since 1997, it is known that cell-free foetal DNA
is present in the plasma of pregnant women. Such circulating
foetal DNA is present at a mean fractional concentration of
approximately 15% and is detectable from the first trimester of
pregnancy.
Methods: Since 2008, much interest has been focused on the
use of massively parallel sequencing for the analysis of foetal
DNA in maternal plasma.
Results: With this development, the robust non-invasive
prenatal detection of foetal trisomy 21 has been achieved. This
application has been validated by a number of large scale
clinical studies from multiple groups. As a result, non-invasive
prenatal tests for trisomy 21 and a number of other foetal
chromosomal aneuploidies have been used clinically in a
number of countries since 2011. There are also recent
developments in the use of this technology for twin
pregnancies. Furthermore, the application for maternal plasma
DNA sequencing for the non-invasive prenatal diagnosis of
monogenic diseases has also been described. In addition,
since 2010, three papers describing the non-invasive prenatal
determination of the fetal genome have been published.
Conclusions: These rapid developments suggest non-invasive
prenatal genetic analysis will likely play an increasingly
significant role in future prenatal care. It is thus timely for
stakeholders to start exploring the ethical, social and legal
implications of such developments.
N. Nikolac1, A. Simundic1, A. Saracevic1, D. Katalinic2
1
University Department of Chemistry, Medical School
University Hospital Sestre Milosrdnice, Zagreb, Croatia
2
Division of Endocrinology and Metabolic Diseases,
Department of Internal Medicine, Sestre Milosrdnice
University Hospital Center, Zagreb, Croatia
Background: Sulfonylureas are used as first-line therapy drugs
in type 2 diabetics; however, therapy failure occurs in
approximately 30% of patients. We hypothesize that at least
one part of the cause lies in genetic factors. Sulfonylureas are
insulin secretagogues that act by binding to pancreatic beta
cells sulfonylurea receptor (SUR-1) encoded by two genes:
ABCC8 and KCNJ11. The aim of this study was create a
logistic regression model to identify patients with poor response
to sulfonylurea therapy using demographic (age, gender),
anthropometric (body mass index, BMI), biochemical (fasting
and postprandial glucose and lipid concentration) and genetic
(ABCC8 polymorphisms: SUR1 exon 16 (-3C/T), SUR-1 exon
31 (Arg1273Arg) and SUR-1 exon 33 (S1369A) and KCNJ11
polymorphism E23K) parameters.
Methods: The study included 251 unrelated type 2 diabetics on
sulfonylurea therapy. Polymorphisms were detected using
polymerase chain reaction - restriction fragment length
polymorphism. Biochemical parameters were determined on
automatic analyzer Olympus AU 2700 (Olympus, Hamburg,
Germany). Based on the HbA1c concentration, patients were
divided into two groups: patients with HbA1c concentration over
53 mmol/mol Hb were classified as patients with poor outcome.
All variables are analysed using univatiate regression analysis.
Statistically significant variables were included into multivariate
regression model.
Results: Univariate regression analysis identified following
variables as statistically significant: fasting glucose (OR (95%
CI) = 1.60 (1.37-1.88)); postprandial glucose (1.28 (1.17-1.40));
SUR1 exon 16 polymorphism (1.58 (1.06-2.36)) and SUR-1
exon 31 polymorphism (0.51 (0.33-0.77)), while age, gender,
BMI and lipid concentration didn't differ significantly across
subgroups. After inclusion into stepwise multivariate regression
model, fasting and postprandial glucose and SUR-1 exon 31
polymorphism remained significant (1.45 (1.22-1.74); 1.14
(1.03-1.27) and 0.48 (0.30-0.80), respectively). Percent of
correctly classified cases was 74.10%.
Conclusion: Type 2 diabetics with high fasting and postprandial
glucose and wild type allele of the SUR-1 exon 31
(Arg1273Arg) polymorphism are more likely to have poor
glycemic control expressed as high HbA1c concentration.
Y.M.D. Lo
Li Ka Shing Institute of Health Sciences and Department of
Chemical Pathology, The Chinese University of Hong Kong
SY65
BIOCHEMICAL MARKERS FOR EARLY PREGNANCY
SCREENING FOR PRE-ECLAMPSIA
J. Forest
Centre de recherche du CHU de Québec, Département de
biologie moléculaire, biochimie médicale et pathologie,
Faculté de médecine, Université Laval, Québec, Canada
Preeclampsia (PE) affects 2 to 5 % of pregnancies in
developed countries and may reach a much higher prevalence
in other parts of the world. It is still a major cause of maternal
and perinatal morbidity in particular when delivery occurs
before 34 weeks’ gestation (GA). Implementation of preventive
measures such as the prophylactic use of aspirin early in
pregnancy may reduce the prevalence of preeclampsia in
women considered at high risk and diminish mortality and
morbidity in both the affected mother and her child. Until
recently, only maternal history and risk factors were available
to identify women at higher risk with equivocal predictive values
(low detection rate, high false positive rate). The emergence of
Doppler ultrasonography parameters (e.g. uterine artery
pulsatility index) and biochemical markers related to
angiogenesis, placental function, inflammation and endothelial
dysfunction has led to more complex risk-prediction models
based on multivariable algorithms. Various models will be
reviewed which include maternal characteristics and history
(e.g. ethnicity, familial and personal history of PE, chronic
hypertension, diabetes, mean arterial blood pressure, body
mass index), candidate biomarkers such as placental growth
factor (PlGF), soluble Fms-like tyrosine kinase-1 (sFlt-1),
vascular endothelial growth factor (VEGF), pregnancybiochimica clinica, 2013, vol. 37, SS
S39
EuroMEdLab 2013 - sciEntific sEssions
associated plasma protein-A (PAPP-A), hCG combined or not
to biophysical markers such as uterine artery pulsatility index
(PI). So far, early pregnancy prediction algorithms combining
maternal characteristics, biophysical (PI) and biochemical
markers have reached in one specific large cohort detection
rates of over 90 %, 80 %, and 60 % for early-onset (GA <34),
intermediate-onset (GA <37) and late-onset (GA : term) PE
respectively at a false positive rate of 10 %. However these
very encouraging results have not yet been reproduced with a
similar performance in other independent studies. Before
concluding to the transferability of such models, there is a clear
need for investigating the performance of the most promising
predictive models in cohorts from different populations and
healthcare environments to demonstrate the clinical utility of
the screening procedures.
SY66
ANTENATAL SCREENING FOR DOWN SYNDROME
K. Spencer
Barking Havering & Redbridge University Hospitals NHS
Trust King George Hospital, Biochemistry Department,
Barley Lane, Goodmayes, UK
Down Syndrome screening over the past 20 years has
developed from the measurement of second trimester
maternal serum biochemical markers such as AFP, hCG, UE3
and Inhbin A, through to the early first trimester Combined test
utilising the ultrasound measurement of Nuchal Translucency
and maternal serum free beta-hCG and PAPP-A. Such
changes have allowed detection rates and false positive rates
to improve from the 30%/5% achievable using maternal age,
through the 70%/5% achievable using the second trimester
Quad test, to the 85-90%/5% achieved by the Combined test.
The focus of national screening programs in recent years has
been to move to the Combined test, whilst at the same time
aspiring to reduce the false positive rate and Invasive Testing
rate to 2-3%. This lecture will outline these developments and
suggest ways in which the Combined test can reach these
new targets. New models of pregnancy care based on early
first trimester screening for multiple conditions will also impact
on future screening services and these will be briefly
discussed.
OC27
MATERNAL VITAMIN B12 LEVELS DURING THE FIRST
TRIMESTER OF PREGNANCY AND INFLUENCE IN
NEWBORN SCREENING RESULTS
R. Yahyaoui, A. Dayaldasani, J.F. Ruiz-Escalera, M.
Rodriguez-Espinosa, I. Rueda, M.C. Casero, V. PérezValero
Metabolic Disease Laboratory and Clinical Laboratory,
Carlos Haya University Hospital, Málaga, Spain
Background. During pregnancy, vitamin B12 concentrations
may drop physiologically, and concentrations below reference
values may not alter certain parameters. The reference range
used for our general population is 254-1320 pg/mL. The use of
non-pregnant values may not be appropriate for assessing
vitamin B12 status during pregnancy.
Methods. Serum vitamin B12 concentrations were evaluated
in 204 pregnant women during the first trimester to calculate
the reference interval (LOCI®, Dimension Vista, Siemens
Healthcare Diagnostics). To assess the effects of the variables
BMI, vitamin supplements (including type and dosage), dietary
intake, parity and smoking habits on vitamin B12 serum
S40
biochimica clinica, 2013, vol. 37, SS
concentrations, stepwise multiple linear regression models
using backward elimination were used. Other factors including
the newborns’birthweight, and expanded newborn screening
results (propionylcarnitine levels, C3/C2 and C3/C16 ratios)
were considered.
Results. The women participating in the study ranged in age
from 15 to 46 (mean 30.0, SD6.11). The mean serum
concentration of vitamin B12 was 502.4 pg/mL (SD
142.81).The reference range calculated was 272.7-837.8
pg/mL. Vitamin B12 concentrations were significantly lower in
smokers, and in women with low meat consumption. The other
factors did not have any significant effect. Newborns of mothers
with lower vitamin B12 levels presented lower birthweight and
higher propionylcarnitine levels, with higher C3/C2 and C3/C16
ratios.
Conclusions. The reference interval for serum vitamin B12
concentrations obtained is narrower than the one currently
used for our general population. Smoking seems to have a
negative effect, and meat consumption a positive effect on
vitamin B12 levels. Mothers with lower vitamin B12
concentrations during the first trimester of pregnancy seem to
have children with lower birthweight and higher
propionylcarnitine levels.
OC28
A 1H-NMR STUDY OF BRONCHOPULMONARY
DYSPLASIA IN VERY LOW BIRTH WEIGHT INFANTS:
THE CONTRIBUTION OF THE METABOLOMIC
APPROACH
A. Noto1, F. Cibecchini2, E. Locci3, M. Lussu4, F. Murgia4, L.
Barberini5, M.C. Pintus1, M.A. Marcialis1, R. Irmesi1, M.
Puddu1, V. Fanos1
1
Pediatrics and Clinical Medicine, Section of Neonatal
Intensive Care Unit, Puericulture Institute and Neonatal
Section, Azienda Mista and University of Cagliari, Italy
2
Laboratory Medicine, IRCCS San Martino IST, University
Hospital, National Institute for Cancer Research, Genoa, Italy
3
Chemical and Geological Sciences
4
Toxicology, , University of Cagliari, Cagliari Italy
5
Public Health, Clinical and Molecular Medicine, University of
Cagliari, Italy
Background: Bronchopulmonary dysplasia (BDP) is an
important cause of mortality and morbidity in preterm infants;
its prevalence in very low birth weight (VLBW) infants receiving
mechanical ventilation ranges between 4.2% and 40%. The
etiopathogenesis of the disease recognize as determinants
the use of supplementary surfactant, the extreme prematurity,
lack of angiogenesis, and infections. However, the molecular
pathways triggering BPD are still undefined. Recently, the
development of BPD has been correlated with an alteration of
the metabolism. Metabolomics, the latest of omics disciplines,
has been successfully used elsewhere in neonantology,
pharmacology, toxicology, etc. Due to the ability to identify
metabolic abnormalities aims to identify metabolite patterns
with high specificity and sensitivity, each of them associated
with certain conditions. The aim of this experiment was to
analyze the urine metabolic profiles of VLBW infants affected
by BDP and to compare with those obtained in a group without
BDP (controls), by using the Nuclear Magnetic Resonance
(NMR) coupled with mathematical models.
Methods: Urine samples were collected from 6 VLBW infants
with BDP and 11 controls. Children were matched for birth
weight and gestational age. Before analysis, 540 µL of urine
sample were treated by adding 60 µL of phosphate buffer
(1.5M, pH7.4). Urines were analyzed using 1H-NMR Varian.
1H-NMR spectra were subjected to multivariate analysis using
EuroMEdLab 2013 - sciEntific sEssions
SIMCA-P+ (Umetrics, Sweden).
Results: Spectra were aligned, binned, normalized and
analyzed using a OPLS-DA (Orthogonal Partial least squares
discriminant analysis) model. The mathematical model was
able to discriminate between the group of BDP infants and
controls with a very high significant statistical value
R2X=0,613; R2Y=0,823. The most significant metabolites
discriminating the separation between the two classes
belonged to the aliphatic and aromatic regions. In addition,
among these metabolites, creatinine, hippurate, and urea have
been well recognized.
Conclusion: These preliminary results seems to be promising
for the characterization of the BDP urine profile, as well as for
the identification of predictors biomarkers characterizing the
condition which may help for the treatment of this type of
diseases.
SY67
LABORATORY TESTING IN BONE DISEASE: AN
INTRODUCTORY OVERVIEW
R. Eastell
Department of Human Metabolism, University of Sheffield,
UK
The key laboratory measurements in the evaluation of
metabolic bone disease are the measurement of calciotropic
hormones such as parathyroid hormone and vitamin D and the
measurement of bone turnover markers. The assay features
of biochemical markers of bone turnover (BTM) have markedly
improved in the past few years (Vasikaran 2011). The most
sensitive and specific markers of bone formation include serum
bone alkaline phosphatase, total osteocalcin (including the
intact molecule and the large N-Mid fragment) and the N
extension peptide of type I collagen (PINP) assay. Among the
various markers of bone resorption, measurements of the
urinary excretion N- and C- related telopeptides (NTX and CTX
respectively) and of serum CTX are the most sensitive and
specific ones. Bone markers can be used to predict the rate of
bone loss in postmenopausal women. BTM can be used to
assess the risk of fractures in borderline cases. The prediction
of fracture risk by BTM independently of BMD level has been
confirmed in 3 other independent studies. Bone markers can be
used to monitor the efficacy of antiresorptive therapy such as
hormone
replacement
therapy,
raloxifene
and
bisphosphonates. We and others have shown that the short
term (3 to 6 months) decrease of bone turnover is significantly
correlated with the long terms (2 years) increase in BMD of the
spine. In addition, the decrease of urinary NTX and CTX is
associated with the risk of vertebral fracture in osteoporotic
women treated with risedronate. Similar studies in patients
under alendronate or raloxifene show that the short term
decrease of bone turnover markers is correlated with the risk
of subsequent vertebral and non vertebral fractures. While the
increase in BMD over 2 to 3 years explains up to 25% of the
efficacy of bisphosphonates to reduce the risk of vertebral and
non vertebral fractures, the rapid (3 to 6 months) reduction of
bone resorption markers explain up to 70% of their fracture
efficacy. Thus, with adequate cut-offs, individual patients can be
monitored with bone markers earlier than with DXA. Finally,
bone turnover markers can be used to identify response within
individuals and so to encourage compliance.
Reference: Vasikaran S et al, Osteoporos Int. 2011; 22: 391
SY68
HOW USEFUL IS THE LABORATORY IN BONE AND
JOINT DISEASES IN CLINICAL PRACTICE?
B. Obermayer-Pietsch
Medical University Graz, Austria
Diagnosis and monitoring of bone and joint diseases include a
number of clinical, morphological and biochemical aspects. As
a new emerging field, biochemical markers of bone turnover
and joint tissues are able to shed light on the individual
degenerative, metabolic and inflammatory conditions of the
skeleton. Targets of biochemical analysis of bone and joint
status are enzymes and proteins or their respective
metabolites. The usefulness of these biochemical markers has
been widely recognized during the past years and increased
significantly with the technical improvement of biochemical
methods and knowledge of new compounds of bone and joint
environment. Many of these markers have been established
but only few of them have entered daily clinical routine
applications. Many options for characterization and diagnosis
of metabolic bone and joint diseases but also therapy decisions
and monitoring may be improved by these biomarkers.
SY69
THE NEED FOR STANDARDISATION OF BONE MARKER
ASSAYS
H. Morris
School of Pharmacy and Medical Sciences, University of
South Australia and Chemical Pathology Directorate, SA
Pathology, Adelaide, South Australia
The incidence of metabolic bone disease is highest amongst
the elderly and so with the ageing of the population, clinical
interest in diagnosis and prognosis of osteoporosis and
estimation of fracture risk has increased. Biochemical markers
of bone turnover (BTM) offer a means for assessing two major
clinical questions. Can baseline levels of BTM predict the rate
of bone loss or future fracture risk? Can BTM be used to
monitor the response to treatments for osteoporosis? Assays
for numerous BTM are readily available on automated clinical
chemistry analysers and point-of-care devices; however there
is still considerable debate as to their clinical utility. A position
paper published by the IOF-IFCC-IOF Working Group on Bone
Marker Standards for Osteoporosis concluded that there were
insufficient high quality data to provide clinical guidelines for
their use in individual patients because their clinical value is
limited by inadequate appreciation of the sources of variability,
by limited data for comparison of treatments using the same
bone marker and inadequate quality control. This paper
recommended that in future clinical trials serum β-CTx be used
to assess bone resorption and serum PINP be used to assess
bone formation. A consequence of these recommendations is
the need to standardize or harmonize the assays for these
BTMs as appropriate. Similar conclusions were reached by
the National Bone Health Alliance commenting on specific
requirements for the USA. A second working group was
established (IOF-IFCC WG-Standardisation of Bone marker
Assays) in January 2012 to undertake these projects.
Preliminary data from an external quality assurance scheme
suggest there is an approximate 30% bias between the two
automated serum sCTx assays while for the 3 major serum
PINP assays, although considered to measure different forms
of PINP, actually provide harmonised results. Current studies
are underway to extend the data on the comparability of
patient results for the two major serum CTx assays. Further
strategies will then be developed to harmonise these assays
biochimica clinica, 2013, vol. 37, SS
S41
EuroMEdLab 2013 - sciEntific sEssions
following which the serum PINP assays will be investigated.
OC29
DIFFERENCE BETWEEN TOTAL AND INTACT ASSAYS
FOR N-TERMINAL PROPEPTIDE OF TYPE I
PROCOLLAGEN (P1NP) DETERMINATION IN RENAL
IMPAIRED PATIENTS
E. Cavalier1, P. Lukas1, N. Ferrante1, O. Rousselle1, A.
Carlisi1, P. Delanaye2
1
Department of Clinical Chemistry, University of Liege, CHU
Sart-Tilman, Liege, Belgium
2
Department of Nephrology-Dialysis-Transplantation,
University of Liege, CHU Sart-Tilman, Liege, Belgium
Introduction: The amino-terminal propeptide of type I
procollagen (P1NP) circulates as different forms: the larger
intact trimeric and several fragment monomers. In healthy
individual, the circulating P1NP is predominantly the trimeric
intact with almost non-detectable monomers. Under certain
conditions, especially in renal impaired patients, the proportion
of monomeric form is elevated. Intact P1NP assay measures
the trimeric propeptide while Total P1NP assay measures both
trimeric and monomeric forms. In this study we compared these
two assays in renal impaired patients.
Methods: 84 serum specimens from CKD Stage 3 to 5 not on
dialysis and 125 specimens from Stage 5 Dialysis patients were
analyzed with the IDS-iSYS Intact P1NP and Roche Elecsys
Total P1NP assays.
Results: In CKD not on dialysis subjects, the observed ranges
for Total P1NP and Intact PNP were 8.5 – 822.8 ng/mL and 8.2
– 146.5 ng/mL, respectively. The correlation between the Total
P1NP and GFR was r= -0.3373 (P=0.0017) and between the
Intact P1NP and GFR was r= -0.1483 (P=0.1782). In Stage 5D
subjects, the observed ranges were 18.4 – 2192.0 ng/mL for
Total P1NP and 16.3 – 641.6 ng/mL for Intact P1NP. Their
Passing Bablok regression was Total P1NP = 3.68 x Intact
P1NP -64.4.
Conclusion: The Total P1NP values were much higher than
Intact P1NP confirming the Total P1NP assay measures both
trimeric and monomeric forms. The significant correlation
between the Total P1NP and GFR indicated the Elecsys Total
P1NP assay might not be suitable for renal impaired patients;
in these patients, the IDS-iSYS Intact P1NP is preferred.
OC30
KIDNEY TRANSPLANTATION AND OSTEOPOROSIS,
STUDY OF GENETIC SUSCEPTIBILITY: INFLUENCE OF
VITAMIN D RECEPTOR (VDR) AND ESTROGEN
RECEPTOR (ESR1) GENES IN RELATION TO BONE
LOSS AND FRACTURE RISK
M. Martínez-Villanueva1, J.A. Noguera-Velasco1, M.J.
González-Soriano2, M.L. Gil-del Castillo1, I. Tovar-Zapata1,
L. Jimeno-García2, P. Martínez-Hernández1
1
Clinical Laboratory Service, and 2Nephrology Service,
Universitary Hospital Virgen de la Arrixaca, Murcia, Spain
Background: Prevalence of osteoporosis in renal transplant
patients is 17-49% for lumbar spine (LS) and 11-56% for
femoral neck (FN) 22.5% developed some type of fracture in
the five years following transplantation. Osteoporosis is
genetically complex, the identification of the genes involved in
its development is made difficult by its multifactorial nature
The “B” and “f” alleles of Vitamin D Receptor gene(VDRBsmI:“BB”, “Bb”, “bb” genotypes; VDR-FokI: FF, Ff, ff
S42
biochimica clinica, 2013, vol. 37, SS
Genotypes) are associated with lower bone mineral density
(BMD). The “xx” genotype of the Estrogens Receptor
gene(ESR1X-XbaI: “XX”, “Xx”, “xx” genotypes) predisposes to
a bone mass reduction and the “P” Allele (ESR1P-PvuII: PP,
Pp, pp genotypes) is associated with having a greater benefit
from hormonal therapy. We aim to assess the influence of
genetic polymorphisms in bone loss measured by BMD in a
group of kidney transplant recipients.
Methods: We studied 139 kidney transplant recipients from a
reference Hospital(92 male,47 female,average age 50 and 48
years respectively). Polymorphisms genotyping: amplification
of 5 regions of the human genome and detection of the
amplified product (Clinical Arrays® MetaBone,Genomica).
BMD: at pre-transplantation (pre), 6 months (6m), 1 year (1y)
and 2 years (2y) post-transplant by Dual-Energy X-ray
Absortiometry, at LS and FN, measuring T-score and Z-score
Results: There´s a BMD decrease in LS (P <0.05) and FN (P
<0.001) 6 m after transplant. “BB” patients have lower LS BMD
pre (P=0.023) and after 2y (P <0.05). Patients with “xx”
genotype have lower FN BMD 6m (P=0.009) and 1y (P=0.028)
and in LS after 2y (P <0.05). Patients with “P” allele have more
FN BMD 6m (P=0.02), and those with “f” allele have more LS
BMD 1y (P=0.02), so both “P” and “f” allele could provide
protection against BMD loss. Calculation of risks: “xx” genotype
leads to 3.069 - fold odds of having lower FN BMD
6m(ExpB=3.069) and “PP” genotype leads to 0.423-fold odds
of having lower FN BMD 6m(ExpB=0.423).
Conclusion: Genotyping based on extended panels of several
SNPs markers might identify groups of people at high risk of
osteoporosis. Thus, the study of polymorphisms of genes
related to bone metabolism, may be useful in the preventive
treatment of kidney transplant recipients particularly susceptible
to bone disease
SY70
SEPSIS: EPIDEMIOLOGICAL AND CLINICAL ASPECTS
J.L. Vincent
Dept of Intensive Care, Erasme Hospital, Université libre de
Bruxelles
Sepsis is now defined as an infection associated with one
organ dysfunction (this was previously called severe sepsis,
and sepsis was referred to as infection). Several recent studies
have explored the epidemiology of sepsis in different patient
populations. Comparisons among these studies are difficult
due to differences in definitions and in organizational factors
among hospitals and ICUs, but some important data can be
derived: First, sepsis affects 20-30% of ICU patients with 0.53 cases per 1000 of the general population; second, the most
common sites of infection are the lung and abdomen, and
Gram-positive organisms are no longer the predominant
causative agents; third, hospital mortality rates remain high at
between 30 and 35%; fourth, in addition to increasing shortterm mortality, sepsis is associated with increased morbidity
and long-term mortality and with high costs; finally, although
mortality rates may have decreased slightly in recent years, the
incidence of sepsis is increasing so that overall deaths from
sepsis are also increasing. The treatment of sepsis can be
considered under 3 headings: Eradication of infection,
hemodynamic resuscitation, and modulation of the sepsis
response. With no new effective immunomodulatory strategies
currently available and few new antimicrobial agents in the
pipeline, the clinical focus must be on early diagnosis to enable
rapid initiation of antimicrobial therapy and optimal resuscitation
strategies. However, diagnosis can be difficult without specific
(bio)markers to better characterize the disease, and, in terms
of optimal therapy, many questions remain unanswered. For
example, evidence clearly supports the benefits of early
EuroMEdLab 2013 - sciEntific sEssions
appropriate antibiotic therapy, but the optimal duration of
antimicrobial therapy is less clear. Adequate fluid administration
is known to be important but which fluid and to which endpoints
is less certain. Norepinephrine is now considered the first-line
vasopressor but which hemodynamic endpoints to target and
whether we should also monitor the microcirculation remains
unclear. The place of vasopressin and its derivatives is also
still unsettled. Further study is needed to provide answers to
these questions as research continues to try and identify
effective immunomodulatory strategies.
SY71
NEW CONCEPTS IN PRO-/ANTI-INFLAMMATORY
RESPONSE IN SEPSIS
G. Monneret
Hospices Civils de Lyon, France
Septic syndromes (systemic inflammatory response associated
with infection) remain a major although largely underrecognized health care problem and represent the first cause
of mortality in intensive care units. It is well known that sepsis
deeply perturbs immune homeostasis by inducing first an initial
tremendous systemic inflammatory response. However, novel
findings indicate that sepsis initiates a more complex
immunologic response that varies over time, with the
concomitant occurrence of both pro- and anti-inflammatory
mechanisms alternately predominating. After a short proinflammatory phase, septic patients enter a stage of protracted
immunosuppression. This is illustrated in those patients by
reactivation of dormant viruses (CMV or HSV) or infections due
to pathogens, including fungi, which are normally pathogenic
solely in the immunocompromised host. These alterations
might be directly responsible for worsening outcome in patients
who survived initial resuscitation as nearly all immune functions
are deeply compromised. Both arms of immunity, innate and
adaptive, are indeed markedly suppressed (including
enhanced leukocyte apoptosis, lymphocyte anergy and
deactivated monocyte functions).
This lecture will attempt to integrate these new facts into an upto-date account of immuno-inflammation during sepsis
pathophysiology. It will be focused on immune dysfunctions
described so far in septic patients, on the mechanisms
sustaining this immune failure, on the monitoring of the pro/anti-inflammatory balance rapidly changing over time and on
new promising therapeutic avenues emerging from those
recent findings.
SY72
EMERGING BIOMARKERS FOR TARGETED AND
TAILORED THERAPY IN SEPSIS
J. Pugin
University Hospitals of Geneva, Switzerland
Biomarkers for sepsis have been tested in the clinical arena
for their usefulness in the diagnosis of sepsis, but also as
prognostic markers, and to guide therapy such as antibiotic
treatment duration. All six clinical studies testing this latter
concept have concluded that serum procalcitonin levels
decrease over time was a useful marker to stop antibiotic
treatment safely, cutting down the duration by a mean of 4-5
days in patients with severe sepsis and septic shock. This was
not accompanied by a resurgence of the primary bacterial
infection, nor by an increased mortality rate. This approach
based on procalcitonin-guided therapy has the advantage over
empirical rules to tailor the duration of the antibiotic treatment
on the response of a given patient and/or a given infection type.
A potential benefit for reducing treatment duration is the
decrease of the risk of emergence of multi-drug resistant
bacteria in the patient and within the intensive care unit, the
decrease of potential toxicity related to antibiotics, and also to
reduce costs related to prolonged antibiotic therapy.
OC31
A NEW RAPID, EASY AND COST-EFFECTIVE METHOD
THAT IDENTIFIES UNKNOWN PATHOGENIC
MICROORGANISMS WITHIN 3 H FROM SAMPLE
COLLECTION
H. Niimi1, T. Ueno1, S. Hayashi1, M. Mori2, H. Tabata3, H.
Minami3, S. Saito4, I. Kitajima1
1
Clinical Laboratory Center, Toyama University Hospital,
Toyama, Japan
2
Research Institute for Bioresources and Biotechnology,
Ishikawa Prefectural University, Ishikawa, Japan
3
Hokkaido Mitsui Chemicals Corporation, Hokkaido, Japan
4
Department of Obstetrics & Gynecology, Toyama University
Hospital, Toyama, Japan
Background: As current blood culture methods require at least
several days, empirically selected antibiotics are instead
administered until the pathogenic microorganisms are
identified. Though mass spectrometry is can be utilized as a
rapid identification method of pathogens, it requires the blood
culture process, so it takes more than 10 hours after sample
collection. We developed a novel rapid, easy, and cost-effective
method that identifies unknown pathogenic microorganisms
within 3 hours after collection of patient samples.
Methods: To detect pathogenic bacteria by PCR with high
sensitivity, we developed a novel “eukaryote-made” Taq
polymerase, which is free from bacterial DNA contamination (J
Clin Microbiol. 2011 Sep; 49(9):3316-20). We also developed
a novel method to identify the species of pathogenic
microorganisms using 7 primer sets, real-time PCR, and
original web-based identification software. After PCR is
performed, 7 amplicons are obtained. Next, the combination of
melting temperature (Tm) is acquired. These 7 Tm values,
when mapped on two dimensions, create a “fingerprint” of a
specific bacteria. Comparing the shape of the mapped Tm
values to the shapes in the database, the pathogenic bacteria
is identified. We named this method “Tm mapping method”.
Results: We performed blind tests to evaluate its accuracy and
specificity. Using the DNA samples of 107 kinds of bacterial
species, the novel method gave the correct answer almost
perfectly (106/107). Using the 140 bacterial colonies of 51 kinds
of bacterial species, the identification rate was 94% (5 kinds of
bacteria were not included in the database of our identification
software). Using 20 patient samples (blood, amniotic fluid,
aqueous humor, and artificial valve of the heart) of infectious
diseases, the novel method gave the correct answer (30/30)
within 3 h.
Conclusions: Our group developed this system for practical use
without any dedicated equipment. To use this method from
anywhere easily, we also developed the identification software
that can be available on the web. We are now planning to
perform the comparative studies between it and conventional
microbial testing with more patient samples, as well as
repeatedly evaluate its accuracy and specificity.
biochimica clinica, 2013, vol. 37, SS
S43
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OC32
PRESEPSIN (sCD14-ST) IS AN EARLY PREDICTOR OF
OUTCOME IN PATIENTS WITH SEVERE SEPSIS OR
SEPTIC SHOCK. PRELIMINARY DATA FROM THE
ALBUMIN ITALIAN OUTCOME SEPSIS (ALBIOS) STUDY
S. Masson1, P. Caironi2, E. Spanuth3, R. Thomae4, R.
Fumagalli5, A. Pesenti5, M. Romero6, G. Tognoni6, R. Latini1,
L. Gattinoni2
1
Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
Fondazione IRCCS Ca' Granda - Ospedale Maggiore
Policlinico, Università degli Studi di Milano, Milan, Italy
3
Diagnostics Engineering & Research GmbH, Heidelberg,
Germany
4
Mitsubishi Chemical Europe GmbH, Munich, Germany
5
Ospedale San Gerardo, Monza, Italy
6
Consorzio Mario Negri Sud, Santa Maria Imbaro, Italy
2
Background: Sepsis, a leading cause of death in critically ill
patients, is the result of complex interactions between the
infecting microorganisms and the host responses that influence
clinical outcomes. Optimal management requires early goaloriented therapies and may benefit from individualized
circulating biomarkers for early risk stratification. We evaluated
the prognostic value of presepsin (sCD14-ST), a novel marker
of bacterial infection.
Methods: This is a nested case-control study of the multicenter,
randomized ALBIOS trial that enrolled patients with severe
sepsis or septic shock in 100 ICUs in Italy. We selected 50
survivors and 50 non-survivors at the time of ICU discharge
(21±18 days) matched for age, sex, center and time of
enrolment after the presence of inclusion criteria. EDTA-plasma
samples were collected at days 1, 2 and 7 after enrolment to
assay presepsin (immune-chemiluminescence assay
PATHFAST Presepsin, URL 320 pg/mL, CV 5%, Mitsubishi
Chemicals) and procalcitonin (PCT, Elecsys BRAHMS Cobas®
PCT, URL 0.046 ng/mL, CV 8.8%, Roche Diagnostics) in a
central laboratory.
Results: Clinical characteristics were similar in the 2 groups,
but non-survivors had a worse SOFA score at day 1. Patients
with higher baseline presepsin had worse SOFA score, lower
mean arterial pressure and diuresis. Early presepsin (d1) was
higher in decedents (2268 [1145-4305] pg/mL, median [Q1Q3]) than in survivors (1184 [855-2158] pg/mL, P=0.001) while
PCT was not different (18.5 [3.3-45.7] vs. 10.8 [2.6-46.4]
ng/mL, P=0.31). Presepsin decreased over time in survivors
but remained elevated in non-survivors (974 [674-1927] vs.
2551 [1438-5624] pg/mL at d7, P=0.02 for time-survival
interaction); PCT decreased similarly in the 2 groups (P=0.19).
Differences in presepsin vs. outcome were more marked in
patients enrolled 6-24 h after ICU admission, and in those with
septic shock. Early presepsin had better prognostic accuracy
than PCT (AUROC at d1, 0.69 vs. 0.56, P=0.07) and improved
discrimination over clinical SOFA score.
Conclusions: We provide first evidence in a multicenter clinical
trial that early presepsin measurement provides relevant
prognostic information in patients with severe sepsis or septic
shock and may be of clinical importance for early risk
stratification.
SY73
THE NEW EDITION OF ISO 15189 WITH EMPHASIS ON
PATIENT SAFETY ASPECTS
W. Huisman
MCH, Leidschendam, the Netherlands
S44
biochimica clinica, 2013, vol. 37, SS
Work on modification of ISO15189 “Medical LaboratoriesRequirements for quality and competence” started immediately
after the first edition of 2003. After much debate and an enquiry,
it resulted in an FDIS in august 2012, which was accepted with
a 100% vote. The third revised edition of ISO15189 can be
expected in the first months of 2013.Important changes are:
clarification in terminology, adding headings to chapters, which
makes reading easier, stressing difference between verification
for well described methods and validation for home brew ones.
As in the earlier versions the whole process from request to
result , including interpretation, was maintained. Much attention
was paid to making it less prescriptive. All quality goals should
be related to requirements in favor of treatment of patients. The
patients and their clinical needs are in the middle. ISO15189 is
a combination of ISO17025 with its focus on competence in
testing, and ISO9001 with its focus on quality as expected by
the customer. In the new edition chapters have as headings:
resolution of complaints, identification and control of
nonconformities, corrective actions, preventive actions,
continuous improvement, control of records, evaluation and
audits with as subheadings: review of request, user feedback,
risk assessment, quality indicators and review by external
organizations. The ISO TC212 WG decided to start with a
revision of ISO/TS22367:2008 “Medical laboratories-reduction
of error through risk management and continual improvement”.
It underlines the approach which should be followed in
implementing ISO15189. Corrective actions related to identified
and preventive actions related to potential nonconformities,
errors and mistake, shall be taken by the management. There
is a need for classification, and use of risk analysis is promoted.
Examples are given of the Failure Mode and Effect Analysis,
supplemented with hazard or criticality analysis. In the new
regulation for CE marking of ivd’s their classification is
dependent on patient safety risk. In fertility laboratories risk
analysis to prevent harm to the patients is already instituted. It
is expected that this approach will be used in a modified form
in all kinds of medical laboratories Thus focus on patient safety.
SY74
LABORATORY MEDICINE QUALITY INDICATORS AND
PATIENT SAFETY
M. Plebani
Department of Laboratory Medicine, University-Hospital of
Padova, Italy
The identification of reliable quality indicators (QIs) in the total
testing process (TTP) represents a crucial step in enabling users
to quantify the quality of laboratory services as current evidence
underlines the multitude of errors that continue to occur in the
pre- and post-analytical phase. Unfortunately, while some
interesting programs on indicators of the extra-analytical phases
have been developed in some Countries, no consensus exists
for producing joint recommendations focused on the adoption of
universal quality indicators and common terminology in the total
testing process. In fact, different QIs and terminologies are
currently used and, therefore, there is the need to harmonize
proposed QIs that should comply with three main principles as
they must be patient-centered, consistent with the requirements
of the International Standard for medical laboratories
accreditation, and have to address all stages of the TTP. In
addition, the process of harmonization of QIs consists of two
compulsory steps: the identification of common QIs and a
standardized reporting system. Essential pre-requisites of QIs
appear to be: a) importance and applicability to a wide range of
clinical laboratories at an international level; b) scientific
soundness with a focus on areas of great importance for quality
in laboratory medicine; c) feasibility, both regarding the data
availability and the definition of thresholds for acceptable
EuroMEdLab 2013 - sciEntific sEssions
performance; d) timeliness and possible utilization as a measure
of laboratory improvement
A model of quality indicators (MQI) has been consensually
developed by a group of clinical laboratories according to a
project launched by a Working Group of the International
Federation of Clinical Chemistry and Laboratory Medicine
(IFCC). The model includes 57 QIs related to key processes (34
pre-, 7 intra- and 15 post-analytical phase) and 3 to support
processes. Therefore, the scope of harmonization in laboratory
medicine is more far-reaching than method harmonization and
should cover a wider range of topics, namely all steps of the
“brain-to-brain loop”. Valuable QIs, covering all steps of the TTP,
valuable QIs represent a key step in the journey towards quality
and patient safety in laboratory medicine.
SY75
ISSUES ON LABORATORY MANAGEMENT IN THE
ARAB REGION
G. Shannan
UNDP, Syria
The Arab Federation of Clinical Biology, AFCB represents
considerable parts of the Middle East and North Africa with 11
countries of the region are members of this organisation. The
population of AFCB countries is around 300 million inhabitants
with more than 4000 - 5000 practicing laboratory medicine in
the public and privates sectors. Practicing Clinical Chemistry
and Laboratory Medicine in AFCB Region varies from country
to country; as well as the regulations which govern laboratory
medicine practice. In this paper we will shed some lights on the
current practice of Laboratory Management in AFCB region
with discussion about the level of implementations; in addition
to the legislative, financial and/or scientific obstacles which
have prevented some countries of the region from prioritising
Laboratory Management Practice. The laboratory
Management concept has not been fully implemented in any
of the AFCB countries; however, there are various levels of
implementation in the Arab Region. In some countries only
basic practice of Quality Assurance have been considered
while in other countries advanced practice of laboratory
management including accreditation have been implemented.
The current practice with its prose and cones will be discussed
including the differences from country to country. The role of
legislation in shaping the future of Laboratory Medicine and
the challenges to unify these legislations will be discussed.
Quality issues will be a major target of any new developments.
The implementation of quality standards and Accreditation
Programme and the assistance required from various national
and international organisations will be presented. The region
faces some major problems with manufacturers of laboratory
equipment and instruments due to the size of the market which
in some instance is not so attractive in comparison with the
European and American Markets. We feel that the
manufactures are not so interested in investing in such
countries to provide proper after sale service. The training of
Laboratory Medicine in AFCB region is a key issue which
should be addressed and a plan of action should be
established to improve the quality of training to reach the
international standards.
OC33
USE OF STANDARDISED ALGORITHMS WITH CLINICAL
DECISION RULES AND D-DIMER TESTING IN CLINICAL
PRACTICE TO AID IN THE DIAGNOSTIC WORK-UP FOR
SUSPECTED VENOUS THROMBOEMBOLISM: A STUDY
IN 7 EUROPEAN COUNTRIES
A.H. Kristoffersen1, E. Ajzner2, D. Rogic3, E. Sozmen4, P.
Carraro5, A.P. Faria6, J. Watine7, P. Meijer8, S. Sandberg9
1
Laboratory of Clinical Biochemistry, Haukeland University
Hospital, Bergen, Norway
2
University Teaching Hospital Nyíregyháza, Nyíregyháza,
Hungary
3
Clinical Institute of Laboratory Diagnostics, Clinical Hospital
Center Zagreb, Croatia
4
Ege University School of Medicine, Dept of Biochemistry,
Bornova, Izmir, Turkey
5
Department of Laboratory Diagnostic Medicine, Hospital
Sant'Antonio, Padova, Italy
6
Instituto Nacional de Saúde Dr. Ricardo Jorge, Avenida
Padre Cruz, Lisboa, Portugal
7
Laboratoire de Biologie Polyvalente, Centre Hospitalier La
Chartreuse, Avenue Caylet, Villefranche-de-Rouergue,
France
8
ECAT Foundation, Leiden, The Netherlands
9
NOKLUS (Norwegian Centre for Quality Improvement of
Primary Care Laboratories), University of Bergen, Norway
Background: It has been shown that the need for radiologic
imaging can be reduced by about 1/3 if standardized algorithms
consisting of clinical decision rules (CDRs) and D-dimer tests
are used in the diagnostic work-up for patients with suspected
venous thromboembolism (VTE). The aim of this study was to
explore if such algorithms are used in different European
countries.
Methods: Two case histories related to diagnosis and exclusion
of suspected pulmonary embolism (Patient A, high pretest
probability) and deep venous thrombosis (Patient B, low pretest
probability) were sent to physicians working with VTE patients.
The physicians were asked about the estimated probabilities of
VTE before and after D-dimer testing, if clinical decision rules
were used to assess the probabilities and when to use D-dimer
and/or radiologic imaging.
Results: Altogether, 547 physicians from 7 different European
countries responded, after exclusion of 78 that did not regularly
diagnose VTE. For patient A, most physicians (63%) suggested
a high pretest probability or likely diagnosis of PE. Still 10% of
them would request D-dimer alone, 69% both D-dimer and
radiologic imaging and 19% radiologic imaging alone. If the Ddimer was negative in this patient, 16% suggesting a high
probability even would regard PE as excluded. For patient B,
the majority (81.6%) of the physicians suggested a low pretest
probability or unlikely DVT diagnosis. D-dimer alone was
requested by 60.8% of physicians, while 17.4% of clinicians
would request D-dimer and radiologic imaging in parallel and
11.4% only radiologic imaging. CDRs were always or often
used by 31.5% of physicians. The pretest probability estimates
in percent varied substantially for both patient A and B,
regardless of the use of CDRs.
Conclusions: Exclusion of VTE by negative D-dimer results
might underdiagnose VTE in high probability patients and puts
the patients into significant risk. Applying radiologic imaging
without or in parallel with D-dimer testing in low probability VTE
cases imply extra burden on the health care system, and could
be avoided if standardized algorithms were followed. Results
from this study suggest that standardized algorithms are not
systematically followed by a substantial amount of physicians.
biochimica clinica, 2013, vol. 37, SS
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OC34
ALERT VALUE REPORTING IN PRIMARY CARE
SETTING: A NEW STRATEGY FOR PATIENT SAFETY
M. Salinas1, M. Lopez-Garrigos1, A. Asencio2, J. Lugo1, M.
Gutierrez1, A. Santo-Quiles1, L. Flors3, C. Leiva-Salinas3
1
Clinical Laboratory; Hospital Universitario de San Juan
Primary Care Center of Mutxamel, Alicante-San Juan
Health District
3
Radiology Department, Hospital Universitario y Politécnico
la Fe
2
Background: In contrast to critical value reporting, alert value
reporting would not allude to a result that may imply a lifethreatening situation, but would indicate that an early
diagnostic/therapeutic action would improve the patient’s
management and quality of life. Objectives are to introduce the
“alert value reporting” concept, to propose a list of chemistry
and hematology alert limit tests that can be chosen for that
strategy, to show how this notification procedure can be
designed and established, and finally to evaluate the
effectiveness and physicians´ satisfaction regarding the
proposed approach.
Methods: Since laboratory requests were made on line and the
reports sent out electronically from the laboratory information
system to the patient’s electronic medical record, General
Practitioners (GP) daily habit of manually checking each
laboratory report in order to look for test results that might
necessitate a re-appointment was altered. A method was
devised that would automatically alert the GP to a result that
needed a follow up and alert value reporting concept was
established. A list of chemistry and hematology alert limit tests
to be used for the strategy was agreed upon between
laboratory professionals and GPs. Next, a retrospective 12month study involving more than 1 million laboratory tests was
made to check how many of these alert values would had been
communicated if this theoretical alert values had been applied.
A prospective analysis of every reported alert value during 6
months was carried out to assess the intervention effectiveness
and the requesting physician’s satisfaction with the new
strategy.
Results: The alert value reporting was successfully executed.
Regarding the 6 months period prospective analysis in a single
primary care center, 4309 requests were received. Among
those, there were 154 alert values (3.5%). 30 of them (19.5%)
motivated an anticipation of the patient next appointment. 90%
of physicians considered alert value reporting as an interesting
strategy.
Conclusions: The alert value reporting concept was introduced
and notification procedure designed. Alert value reporting
strategy motivated changes in patient’s management. Further
studies are needed to test the contribution to patient safety and
decision-ma.
EW001
HIV: DIAGNOSIS AND DRUG RESISTANCE
V. Ghisetti
Azienda Ospedaliera Amedeo di Savoia, Torino, Italy
Background: The availability of the highly active antiretroviral
therapy (HAART) has provided extraordinary clinical benefit to
HIV patients lowering morbidity and mortality. Beside this
astonishing success, the rate of viral suppression is far from
approaching all patients and drug-resistance is of increasing
concern as the development of novel agents addressing this
issue that is a major public health priority. Currently guidelines
S46
biochimica clinica, 2013, vol. 37, SS
for the treatment of HIV-1 infection state that maximal viral load
suppression (HIV-1 RNA <50 copies/mL) is the final goal of any
therapeutic strategy and that any virological failure should be
promptly identified in order to enhance patient treatment
options. HIV-1 genotypic tests for drug-resistance are validated
for viral load >1,000 copies/mL, but the definition of HIV-1
resistance profiles in low viremic (<1000 copies/mL) patients
is highly recommended in order to optimize therapeutic options.
Resistance testing in patients with low levels of HIV-1 RNA
have pointed out that major resistance mutations are commonly
detected in them, even more that in patients with higher viral
loads.
Methods: Patterns of antiretroviral-drug resistance mutations
at HIV-1 RNA levels <1,000 copies/mL were analyzed in a
population of 1277 HIV-1 infected patients who underwent HIV1 genotypic testing in routine clinical practice.
Results: Genotypic test from 1498 HIV-1 sequences
demonstrated that HIV-1 drug resistance was significantly
higher at HIV-1 RNA <1,000 copies/mL (50.8%) than at >1,000
copies (27.5%, X2 test: 63.0, P=0.0000). The highest rate of
drug resistance was against NRTI (45%) followed by NNRTI
(20%) and PI (15%). Most representative drug resistance
mutations were K103N (44.3%), the thymidine analogues
M41L, D67N and T215Y/F (36.3%), followed by M184V/I
(30.1%) and drug resistance was significantly higher in HIV-1
genotype B than non-B: 83.1% vs.16.9% (X2 10.51 P=0.001).
Conclusions: The finding of major resistance mutations at HIV1 RNA levels <1,000 copies/mL demonstrates that HIV-1
genotyping testing in these patients supports antiretroviral
therapeutic strategies as a guide to prompt changes of drug
regimen and a better patient management.
EW002
THE NEW ERA OF HCV TREATMENT AND
MONITORING
G. Foster
Queen Marys School of Medicine and Dentistry, London
Hepatitis C virus (HCV) infection is a global health problem
affecting around 3% of the population worldwide, with chronic
infection potentially leading to the severe consequences of
cirrhosis and liver cancer. Over 250,000 people are dying from
HCV-related liver disease each year. While chronic infection
with HCV can be cured with effective drugs, only a fraction of
those who could benefit are receiving therapy, highlighting the
need for effective screening programs. The first breakthrough
came when HCV was identified in 1989, allowing development
of blood screening tools that have virtually eliminated HCV
transmission via blood transfusion. Today, powerful
immunoassays as well as molecular tests are available for
diagnosis of all HCV genotypes and treatment monitoring of
patients infected with HCV. For those patients who have
acquired HCV by whatever means, interferon-based therapy
paired with ribavirin has been the standard of care. Recently,
new direct acting antiviral agents (DAAs) have been developed
which substantially improve cure rates. Once patients are
receiving treatment, HCV RNA monitoring indicates how well
they are responding. Response-guided therapy is allowing
physicians to shorten, extend or stop therapy based on the
HCV RNA levels, and to ensure that patients have not relapsed
during post-treatment follow-up. During this symposium we will
give an overview on current trends in HCV diagnosis, treatment
and treatment monitoring and will discuss how new treatment
strategies might impact the future of HCV management.
EuroMEdLab 2013 - sciEntific sEssions
EW 003
CLINICAL IMPLICATIONS OF HBSAG QUANTIFICATION
IN PATIENTS WITH CHRONIC HEPATITIS B
P. Lampertico
Fondazione IRCCS Ca’ Granda, Ospedale Maggiore
Policlinico, University of Milan
The quantification of serum hepatitis B surface antigen
(HBsAg) has been shown to help the management of patients
with chronic hepatitis B virus (HBV) infection. Median serum
HBsAg levels differ significantly during the natural history of
HBV infection, progressively declining from immune tolerance
to inactive phase. The combination of an HBsAg <1000 IU/mL
and HBV DNA <2000 IU/mL at a single time point accurately
identifies true inactive carriers. During antiviral treatment,
HBsAg levels decline more rapidly in patients under peginterferon (Peg-IFN) than in those under nucleos(t)ide
analogues (NUC), and in responders to peg-IFN compared to
non responders suggesting that a response-guided therapy in
both HBeAg-positive and -negative patients treated with PegIFN could improve to cost-effectiveness of this therapeutic
approach. Given the low rates of HBsAg clearance on NUC
therapy, new studies to test whether Peg-IFN and NUC
combination fosters HBsAg decline in long-term responders to
NUC, are being explored.
EW004
GENETIC TESTING FOR RISK OF CORONARY HEART
DISEASE: FACT OR FICTION?
S. Humphries
UCL Genetics Institute, Department of Genetics
Environment and Evolution, London, United Kingdom
Currently, estimation of an individual’s risk of future coronary
heart disease (CHD) risk is achieved using risk algorithms that
include only conventional risk factors (CRFs) such as age,
BMI, blood pressure, smoking status, family history and
plasma levels of lipids. What is the potential of improving risk
prediction by adding data from an individual’s genetic makeup? Since many SNPs can be cheaply determined
simultaneously in a single sample (for example using DNA
obtained from a buccal swab) this will not have major cost
implications. Meta-analyses have identified 8-10 “candidate”
genes with common functional variants that influence CRFs
(e.g. APOE on plasma lipids) and that have statistically robust
but modest effects on CHD (Relative Risk: 1.1-1.4), although
none of these singly have clinical utility when added to a risk
algorithm. Genome Wide Association Studies have now
identified > 30 SNPs associated with CHD risk, and the top
priority now is the determination of the functional variation at
each locus, their causal mechanism for CHD, and the accurate
estimation of their risk effect in prospective studies, in different
ethnic groups and in men and women. Although the effect
sizes of these SNPs is also similarly modest, recent data and
modelling suggests that, in combination, these will have at
least moderate clinical utility, primarily in risk stratification and
treatment prioritisation in individuals at intermediate risk. Here
we present data demonstrating this in a group of 3000 healthy
middle aged men (NPHS-II) followed prospectively for >18
years with >300 CHD events. Additional studies are necessary
to examine both the acceptability and the cost effectiveness of
any such DNA-based additions to CRF-based algorithms.
However further research is needed to explore different ways
to present such genetic risk information to individuals, so as to
find approaches that minimise a sense of fatalism and
maximise motivation for behaviour change.
EW005
GENE-GENE INTERACTIONS CAN MODIFY THE EFFECT
OF A SINGLE-NUCLEOTIDE-POLYMORPHISM
ASSOCIATED WITH BLOOD PRESSURE LEVELS
S. Visvikis-Siest
Université de Lorraine, Cardio-vascular Genetics Research
Unit, Nancy, France
Background: Although numerous genetic studies have been
performed, only 0.9% of blood pressure phenotypic variance
has been elucidated. This phenomenon could be partially due
to epistatic interactions. Our aim was to identify epistatic
interaction(s) associated with blood pressure levels in a preplanned two-phase approach.
Methods and results: In a discovery cohort composed of 3,600
French individuals, we found rs6046A allele in F7 associated
with decreased blood pressure levels (P ≤ 3.7x10-3) and
rs5355T allele in SELE associated with decreased diastolic
blood pressure levels (P= 5x 10-3). Both variants interacted in
order to influence blood pressure levels (P ≤0.048). This
interaction was replicated with systolic blood pressure in 4,620
additional European individuals (P=0.03). Similarly, in this
replication cohort, rs6046A was associated with decreased
blood pressure levels (P ≤8.5x10-4). Furthermore, in peripheral
blood mononuclear cells of a subsample of 90 supposed
healthy individuals, we found rs6046A positively associated
with NAMPT mRNA levels (P ≤9.1x10-5), suggesting an
eventual involvement of NAMPT expression in blood pressure
regulation. Confirming this hypothesis, further transcriptomic
analyses showed that increased NAMPT mRNA levels were
positively correlated with ICAM1, SELL, FPR1, DEFA1-3 and
LL-37 genes expression (P ≤5x10-3). The last two mRNA levels
were positively associated with systolic blood pressure levels
(P ≤0.01) and explained 4% of its phenotypic variation.
Conclusion: These findings reveal the importance of epistatic
interactions in blood pressure genetics and give new insights
for the role of inflammation in its complex regulation.
EW006
AUTOMATED SOLUTION IN A MULTI-DISCIPLINARY
LABORATORY FOR BETTER PROCESSES AND
CLINICALLY EFFECTIVE SERVICE
W.A. Bartlett
Joint Clinical Director Diagnostics, Access Directorate, NHS
Tayside Blood Sciences Department, Ninewells Hospital &
Medical School, Dundee, Scotland, United Kingdom
Background It is widely accepted that nearly 70% of medical
decisions are dependant upon patients' laboratory diagnostic
results and it is therefore clear that clinical diagnostics play a
critical role in helping to save lives and improve patient care. To
remain effective, clinical laboratories must be able to turn tests
results around quickly without compromising accuracy. More
so, laboratory staff must be utilized in a way that keeps them
focused on examining and managing test results and away
from laborious manual tasks that do not directly impact the
delivery of critical healthcare data. Facing a shrinking labour
force and budgets, clinical laboratories are increasingly turning
to advanced automation systems to help them meet the
demand for in vitro diagnostic testing. Laboratory automation
systems not only deliver workflow and efficiency improvements,
but have also been proven to reduce error rates and redirect
staff time to better use.
Methods: NHS Tayside recently merged its Biochemical
Medicine, Immunology, and Haematology departments into a
single Blood Sciences Department serving a population of
biochimica clinica, 2013, vol. 37, SS
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EuroMEdLab 2013 - sciEntific sEssions
470,000. As part of this transformation, the health care system
adopted the Siemens Healthcare Diagnostics Aptio™
Automation solution to facilitate the integration of a multidisciplinary workload onto a single track with a Lean approach
to sample management.
Results: The system is currently processing over 6,000 tubes
per day.
Conclusions: This paper describes NHS Tayside’s decision
process around its eventual acquisition of an automation
system as well as the metrics it used to measure anticipated
outcomes. Additionally, future key performance indicators are
discussed.
EW007
CENTRALLY MANAGING POINT-OF-CARE TESTING TO
IMPROVE PATIENT CARE AND STANDARDISE
PROCEDURES
G. Hall
Royal Free London NHS Foundation Trust
Background: The Royal Free London NHS Foundation Trust is
known worldwide for clinical excellence. The need to
demonstrate compliance across a range of point-of-care
testing (POCT) services was a major driver for upgrading to
version 4 of Siemens Healthcare Diagnostics’ RAPIDComm®
Data Management System. Achieving Clinical Pathology
Accreditation (CPA) for POCT services is extremely important
for the Trust. The RAPIDComm system facilitates record
keeping, remote troubleshooting, quality assurance
monitoring, operator management and auditing, all of which
are key to meeting regulatory requirements.
Methods: Accreditation standards require comprehensive
maintenance, patient, and quality assurance records for all
POCT devices. The RAPIDComm system allows maintenance
tasks to be scheduled when due and then recorded as
complete and we have gone paper-free with our maintenance
records. Patient safety is paramount; The system enables our
governance arrangements for POCT to be implemented
effectively. An ADT feed from our hospital information system
facilitates positive patient ID at the analyser. By using
RAPIDComm operator management capabilities, we can be
sure that only authorised, competent users have access to our
POCT devices. Ensuring quality of patient results; Internal
quality control data can be monitored and device performance
compared easily. Using the freetext comment feature allows us
to comprehensively document any corrective or preventative
actions taken, providing traceability and a full audit trail.
Results: The RAPIDComm system has significantly improved
our workflow. Daily analyser checks can be performed
centrally via the status screen and reagent levels and expiry
dates can be observed. This allows the POCT team to plan
routine maintenance effectively. Ascertaining in advance those
consumables to be replenished prevents unnecessary
journeys to and from the laboratory. Remote device monitoring
allows us to proactively troubleshoot issues before they
become a problem. We have realized increased analyser
uptime and more effective use of staffing resources; allowing
more time for training clinical users and auditing.
Conclusions: The RapidComm system has become a vital
member of our point-of-care testing team, helping us to recordreview-act.
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biochimica clinica, 2013, vol. 37, SS
EW008
CURRENT AND FUTURE LABORATORY
REQUIREMENTS IN A CONSOLIDATING MARKET
J. Wood
H&IOW Pathology Consortium Programme, Southampton, UK
In the United Kingdom the National Health Service (NHS)
spends over £2.5b each year on pathology services, equating
to 4% of the overall budget. In 2008, the “Report of the Second
Phase of the Review of NHS Pathology Services in England”
was published, which stated that consolidation was necessary
for pathology services to enable them to respond to future
challenges, system and workforce reform. The report is
focused on three main themes: improving quality and patient
safety; improving efficiency, and identifying the mechanisms
for delivering change. The review estimated up to £500m
(20%) per year could be realised by consolidating pathology
services. The following organisations agreed at CEO level to
set up a Consortium, for the management of pathology
services with a goal of 20% cost reduction: • Isle of Wight NHS
Trust (IOW); • Portsmouth Hospitals NHS Trust (PHT); •
University Hospital Southampton NHS Foundation Trust
(UHS). In April 2011 a project team was set up with the aim of
developing an outline business case (OBC) that described the
formation of a Consortium that would change the configuration
of pathology services. The preferred model for blood sciences
was to have a hub laboratory for the outpatient (OPD) and
primary care work based at PHT with essential services
laboratories (ESLs) on the IOW and UHS sites. A specialist
laboratory for referral work would be at UHS. In 2007 the
biochemistry departments jointly procured the Beckman
Coulter Power Processor system with DxC 800 and DxI 800
analysers. Within biochemistry the workload was IOW 198k
(2,494k), PHT 956k (8,163k) and UHS 886k (6,210k) samples
(tests) per year. In the future configuration the workload will
shift towards the hub; IOW 198k (2,494k), PHT 1,541k
(11,870) and UHS 300k (2,503k). To facilitate this transfer the
current analytical platforms are to be refreshed with a
combination of AU5800, AU680, DxI 800 and DxI 600
systems. This will enable the hub laboratory to process a
larger workload and allow further consolidation of tests from
other analytical platforms. At the time of writing the full
business case for the formation of the Consortium was being
finalised and it is anticipated that the Consortium will be
formed in April 2013.
EW009
ENHANCING EFFICIENCY IN A HUB AND SPOKE
ENVIRONMENT
T. Trenti
Clinical Pathology Department Azienda Unità Sanitaria
Locale, Modena I-41100 Italy
Until 2005 Modena area Public Health System consisted of a
network of 9 hospitals where six hospital local Clinical
Pathology laboratories provided the analytical and diagnostic
services serving 700,000 people. Laboratory workload ranged
from 680,000 to 3,000,000 test/year, mostly of specialized test
in outsourcing. Aims: To improve the quality of health service,
a new area hospital (approximately 600 beds) started its activity
in June 2005, together with the hospital re-organization, also
the Clinical Pathology system has been re-organized. The main
aim of project was to enhance patient services in terms of
access-equity to the diagnostic service, to reach in home
satisfaction for all the requested tests increasing types and
complexity of tests performed and to improve the efficiency in
EuroMEdLab 2013 - sciEntific sEssions
a Clinical Governance policy. Project state of the art: A central
laboratory, named BLU (Baggiovara Unified Laboratories), has
been created serving all Modena area. The new network
laboratory system was based on a “Hub” laboratory (BLU) plus
3 other laboratories and about 30 points of care, dealing only
with hot tests, as “Spoke”. The Core Lab, section of the area
laboratory, is based on two automated mirror lines performing
chemistry and immunochemistry analyses plus an automated
line devoted to hematology and coagulation. Further in BLU
laboratories new specialized activities were developed as
toxicology, pharmacology molecular biology, etc. Results: Now
Core Lab deals daily with about 4,000 in-outpatients and
30,000 tests plus the activity in emergency due to requests of
4 hospitals (1.100 beds). There is not an emergency laboratory
area as all tests are performed on the same automation lines
with different priority. In 2011 we have met some of the
expected project goals: the volume of activities incremented of
about 53% (7.3 millions in 2005 vs. 11.2 in 2011 on department
basis), the Core Lab located human resource decreased of
about 25% nevertheless the increase in activities. The human
resources saved in Core Lab reorganization allowed us to start
up new laboratory diagnostic activities with a consequent
strong increase in laboratory value production (24.7 euro
millions in 2005 vs. 39.9 in 2011, plus 60%).
EW010
WORKFLOW OPTIMIZATION WITH ISLANDS OF
AUTOMATION
F. Wisplinghoff
Laboratoriumsmedizin köln, Dres. med. Wisplinghoff and
Collegues, Cologne, Germany
In todays market for laboratory medicine in Germany a fairly
high-consolidated group of providers face an increasing
demand for tests. Demographic changes, medical innovation
and increasing numbers of younger patients with chronic
illness have all contributed to this increase. In contrast, the
healthcare budget remains limited and the continuous reforms
and austerity efforts of the government have led to significant
cuts in reimbursement (i.e. almost 15% cut for the 1st quarter
of 2013 compared to 2012). Companies are therefore forced
to increase their efficiency in order to continue operating in
this environment. Focusing on workflow efficiency, companies
choose different strategies to distribute analytical tests
between the different locations of their companies and within
each location. Interviews with different stakeholders identified
medical necessities and economic optimization as the main
decision criteria. Available hardware categories range from
fully automated track based systems to integrated analytical
platforms and “single purpose” analysers. The choice of which
strategy to apply depends on a variety of factors, which differ
between laboratories so that no universal recommendation
can be provided. Focusing on the challenges of a high
throughput laboratory, the choice of strategies becomes fairly
limited, since - as of today - track based systems as well as
integrated analytical platforms lack the capacity and speed to
efficiently handle a very high workload alone, so that they are
more suitable as a part of an “Islands of Automation” approach
than as a fully automated strategy.
In the Island approach, distribution of the analytical methods
becomes the main challenge. Looking at our available data,
we incorporated a cluster analysis in combination with an
association analysis to identify typical patterns of requests for
the different groups of physicians. This enabled us to identify
the medically driven distribution of tests within our laboratory
and make some adjustments to increase the efficiency.
As a result “stand alone” clinical chemistry with the availability
for a sequential analysis of a limited number of immunological
tests and separated immunological testing is currently the
most efficient way to organize our high throughput laboratory.
EW011
AUTOMATED DETERMINATION OF ALDOSTERONE AND
RENIN: CLINICAL INFORMATION AND
METHODOLOGICAL ISSUES
D. Gruson
Département de Biologie Clinique Cliniques Universitaires
Saint Luc 10 Avenue Hippocrate, B-1200 Brussels, Belgium
The prevalence of primary aldosteronism (PA) among patients
with hypertension is significant. PA is associated with major
adverse cardiovascular outcomes and an early diagnosis of
PA is needed to initiate the appropriate treatment and to
improve the patient’s prognosis and quality of life. The
aldosterone to renin ratio represents a reliable marker for the
screening for PA. Accurate measurements of aldosterone and
renin are therefore important for the screening and diagnosis
of PA and for the investigation of other diseases related to the
renin-angiotensin-aldosterone axis. The reference methods
for aldosterone and renin determination are still based on
radioimmunoassay. However, such methods are time
consuming, labor intensive and lack appropriate
standardization. Recently, new potential game changers such
as automated methods and mass spectrometry assays have
been developed and are now candidate for routine use.
Nevertheless, several barriers remain to be broken before a
broader community use of these new assays. Their analytical
accuracy, such as functional sensitivity and cross-reactivities,
as well as their clinical reliability will have to be determined.
Furthermore, laboratorians and physicians will need to be
educated and trained for their appropriate use and
interpretation. Lastly, the cost-effectiveness of these emerging
assays will have to be determined with large transversal
studies.
EW012
ALDOSTERONE TO RENIN RATIO: INCREASING
DEMAND FOR PRIMARY ALDOSTERONISM SCREENING
M. Bidlingmaier
Medizinische Klinik und Poliklinik IV, Klinikum der
Universitaet, Munich, Germany
Primary aldosteronism (PA) is characterized by inappropriately
high aldosterone and suppressed renin levels. It is caused by
autonomous hypersecretion of aldosterone from either an
adrenal adenoma or from uni- or bilateral hyperplasia of the
adrenal glands. The chronic aldosterone excess leads to
increased blood pressure and electrolyte imbalances.
However, it has recently been recognized that the “classical”
hypokalemic form is less frequent, and screening for PA should
not be restricted to patients with hypokalemia. PA is associated
with increased cardiovascular morbidity and mortality not only
in comparison to healthy subjects, but also in comparison to
other causes of hypertension. This has been demonstrated for
the frequency of strokes, myocardial infarctions, atrial
fibrillations and left ventricular hypertrophy. PA is also
associated with other comorbidities like depression. PA is more
frequent than previously assumed: In recent years, changes in
the screening methods used and the more widespread
availability of aldosterone and renin measurements have led
to a significant increase in the number of cases detected.
Population based studies revealed that a significant proportion
of patients with hypertension exhibit an elevated aldosterone to
renin ratio potentially is related to PA. Furthermore, systematic
biochimica clinica, 2013, vol. 37, SS
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EuroMEdLab 2013 - sciEntific sEssions
screening in large cohorts of hypertensive patients revealed
that up to 20% of patients with hypertension suffer from PA.
The diagnosis is more frequent in specific patient groups which
therefore must be screened for the disease: Patients with
hypertension stage II or above, drug resistant hypertension,
hypertension plus hypokalemia, cardiovascular events at
young age and patients with hypertension in the presence of an
adrenal incidentaloma. Screening for and early detection of PA
are important because the correct diagnosis can lead to
specific treatments: If PA is caused by an adrenal adenoma,
surgery can cure or at least ameliorate the disease. In case of
bilateral hyperplasia, pharmacological blockade of the
aldosterone receptor through mineralocorticoid receptor
antagonists is a rational treatment modality.
EW013
HOW THE USE OF HIGHLY SENSITIVE TROPONIN
ASSAYS IS CHANGING OUR DAILY PRACTICE
J. Ordonez-Llanos
Biochemistry Department, Hospital de Sant Pau, Barcelona
The Universal Definitions of Myocardial Infarction (MI) of years
2007 and 2012 endorsed cardiac troponins (cTn) as the
preferred biomarkers for the diagnosis of MI.
The so-called “conventional” cTn assays were those measuring
the cTn concentration corresponding to the 99th reference
percentile (p99th) with an analytical imprecision higher than the
recommended. Many authors showed that detectable cTn
concentrations, regardless the imprecision they were
measured, were associated with an increased risk of future
adverse outcomes. “High sensitive” cTn (hs-cTn) assays were
developed to detect very low cTn concentrations with the
recommended imprecision. Compared to conventional assays,
hs-cTn assays show an improved imprecision at the p99th
value and an increased proportion of detectable hs-cTn
concentrations in healthy subjects.
Hs-cTn assays are changing the clinical practice in those
centers which introduced them in routine. In MI, hs-cTn
concentrations increase above the p99th value time before the
required with conventional assays. The possibility of properly
measuring very low hs-cTn concentrations permits to calculate
biological variation, a key value for calculating what
increase/decrease in hs-cTn should be considered as clinically
significant. This would led to a clear differentiation between
patients with increased hs-cTn by MI or with chronic hs-cTn
increases caused by some cardiac and non-cardiac conditions
(arrythmia, renal and heart failure, pulmonary embolism,
myocarditis, etc). All these are advantages facilitating a more
rapid and specific diagnosis of MI. However, hs-cTn is now
detectable in many otherwise healthy subjects and some
population studies are showing that detectable hs-cTn
concentrations, even those below the p99th value, are
associated with increased risk of adverse outcomes. These
results challenge the current knowledge, but require
confirmation before changing the current risk evaluation in
supposedly healthy subjects. In conclusion, high-sensitive cTn
assays are providing increasing information that helps to
improve the management of patients and could open a new
era in the diagnosis, prognosis and therapy of cardiovascular
diseases, particularly those of coronary ischemic origin.
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EW014
THE BENEFITS OF HIGH-SENSITIVE TROPONIN T FOR
THE EARLY DIAGNOSIS OF ACUTE MYOCARDIAL
INFARCTION
C. Müller
University hospital Basel center
Background: Patients with acute chest pain or other symptoms
suggestive of acute myocardial infarction (AMI) account for
about 10% of all emergency department (ED) consultations.
Electrocardiography and cardiac troponin complement clinical
assessment and form the cornerstones of the AMI diagnosis
according to the universial definition. A limitation of former
generation cTn assays is a delayed increase of circulating
levels which mandates serial sampling for 6 hours. Delays in
diagnosing disease (“rule-in”) holds back prompt use of
evidence based therapies. Delays in excluding disease (“ruleout”) interferes with evaluation of alternative diagnoses and
contributes to expensive overcrowding in the ED. The recently
developed sensitive and high-sensitivity cardiac troponin (hscTn) assays have enabled measurement of cTn concentrations
not reliably detected with prior generations of tests. The aim of
this presentation will be to highlight an one-hour algorithm for
rapid rule-in and rule-out of AMI using hs-cTnT levels
Methods: In a prospective, observational, multicenter study
enrolling consecutive patients presenting with acute chest pain,
we derived and validated algorithms on how to best apply hscTnT data (including absolute changes) either alone or in
conjunction with other clinical information. Blood samples were
collected at presentation and after 1,2,3 and 6 h in a blinded
fashion. The final diagnosis was adjucated by 2 independent
cardiologists using all information. All patients also received
long-term follow up.
Results: The algorithm is able to accurately help clinicians to
quickly separate three groups of patients: 1) those with a
extremely high negative predictive value for AMI (100% in both
the derivation and validation data set) ready for early discharge,
2) a group with intermediate risk in need for regular observation
and serial blood sampling in the ED, and 3) those with a very
high likelihood for AMI (about 80%) who in general are
candidates for immediate coronary angiography. The detailed
results will be presented and discussed.
Conclusions: Validated algorithms will help clinicians to best
use the advantages provided by the hs-cTnT assays in the
early rule-in and rule out of AMI.
EW015
TOWARDS A BETTER UNDERSTANDING OF BIOMARKER
GUIDED HEART FAILURE CARE: THE PROTECT STUDY
J.L. Januzzi
Massachusetts General Hospital, Boston, USA
Background: The increasing incidence of heart failure (HF)
places an enormous economic and clinical burden on health
care systems. Significant opportunities exist in developing
therapeutic approaches to improve outcomes, maintain safety,
and reduce cost. It is unclear whether standard HF treatment
plus a goal of reducing N-terminal pro-B type natriuretic peptide
(NT-proBNP) concentrations improves outcomes compared
with standard management alone.
Methods: A total of 151 patients with HF resulting from left
ventricular systolic dysfunction (LVSD) were treated with HF
treatment by standard-of-care (SOC) management or
treatment with a goal to lower NT-proBNP ≤1000 pg/mL over 10
months.
Results: A significant reduction in the primary endpoint of total
EuroMEdLab 2013 - sciEntific sEssions
cardiovascular events was seen in the NT-proBNP arm,
compared to SOC (58 versus 100 events; P=.009; odds ratio =
0.44; P=.02), with particular improvements in rates of
worsening HF and HF hospitalization (both P <.003).
Compared to SOC, NT-proBNP guided patients had greater
improvements in quality of life and NT-proBNP guided patients
also had greater improvements in echocardiographic
parameters. Elderly patients treated with NT-proBNP guided
care had substantial benefit (1.76 events per patient versus
0.71 events per patient, P=.03), and NT-proBNP guided care
was substantially cost-saving. There was no increase in
treatment-related adverse events due to NT-proBNP guided
care.
Conclusions Natriuretic peptide-guided HF care results in
substantial improvement in cardiovascular event rates, quality
of life, echocardiographic parameters, and is cost-saving.
Results will be discussed in context of other biomarker guided
HF studies.
EW016
THE CLINICAL RELEVANCE OF URINARY SEDIMENT
EXAMINATION
G.B. Fogazzi
Fondazione IRCCS Ca' Granda Ospedale Maggiore
Policlinico, Milano, Italy
Urinary sediment examination is an integral part of urinalysis.
When performed with proper methodology, equipment and
knowledge of particles and profiles, urinary sediment
examination can supply relevant information in a wide
spectrum of clinical conditions, some of which are describe
here.
In isolated microscopic hematuria, the examination of
erythrocytes morphology make it possible to distinguish
hematuria of glomerular origin from non-glomerular hematuria,
which arises from the urinary excretory system. This
differentiation is important to decide whether the patient
requires a nephrological or a urological workup.
In glomerular diseases, urinary sediment examination can
identify different profiles such as “minor urinary changes”,
“nephritc profile”, “nephrotic profile”, “nephritc and nephrotic
profile”, which derive from variable combinations and numbers
of erythrocytes, leukocytes, renal tubular epithelial cells
(RTEC), fatty particles, and cast subtypes. The identification of
these profiles, influences clinical and therapeutic decisions.
In acute kidney injury, it is possible to separate pre-renal insult
from acute tubular necrosis, based on the absence or
presence in the urinary sediment of RTEC, RTEC casts and/or
granular casts. Again, this information helps in guiding the
clinical and therapeutic approach.
In kidney transplant recipients, the search of “decoy cells” (i.e.,
cells with typical morphological changes) is used to identify
the reactivation of polyomavirus BK, a diagnosis which leads
to the reduction of immunosuppressive treatment.
In urological disorders, a typical profile characterized by
isomorphic erythrocytes, leukocytes and transitional epithelial
cells (either superficial or deep) is found. This can be used to
monitor the course of the underlying disease.
In urinary tract infections, urinary sediment examination shows
leukocytes and bacteria, a finding which often leads to the
request of urine culture. Moreover, it can be used to monitor
the course of the infection during antibiotic treatment.
Today, automated urine microscopy is replacing manual
microscopy in many laboratories all over the world. It is
paramount importance that automated instruments be able to
identify the most important particles and the main urinary
profiles
EW017
AUTOMATED URINALYSIS: EXPERIENCE IN 50000
SAMPLES
J. Gras
Laboratoire de Biologie Clinique, Clinique Saint-Luc, 5004
Bouge, Belgique
Background: In our lab, urinalysis was performed using
manual dipstick testing and classical microscopy until 2010.
On the 08/10/2010, decision to automate urinalysis was taken
after the conclusions of an internal audit. The system that was
chosen was the Sedimax in combination with the AutionMax
for the following reasons: total automation of the testing
process, possibility to view images, low cost, low number of
reviews using classical microscopy, and positive review of the
system in the literature.
Methods: The Sedimax coupled with AutionMax system was
evaluated with 336 samples that were compared with classical
microscopy and manual dipstick. For validation, reproducibility
assessment was performed using Bio-Rad controls,
repeatability was performed on patient samples and trueness
was assessed with the comparison of 86 samples with
classical microscopy. Following validation, the Sedimax
combined with AutionMax were implemented in our lab on the
17/01/2011.
Results: From 01/2011 to 11/2012, a total of 55296 samples
were examined on the Sedimax. The software performed very
well for the identification of white and red blood cells, nonpathological casts, squamous epithelial cells, non-squamous
epithelial cells, bacteria as well as calcium oxalate, uric acid
and triple phosphate crystals. Other elements like cystine and
bilirubin crystals, as well as erythrocytic casts could not be
recognized by the software version in use at the time, but
could easily be identified on the images and notified on the
report as a comment. Urinalysis automation allowed saving
significant time for the medical laboratory technologists,
especially during evenings and nights on call. Turnaround time
(TAT) was also significantly improved. The digital microscopy
platform proved to be especially interesting for training,
continuous education and traceability.
Conclusion: Urinalysis automation with the Sedimax combined
with the AutionMax proved to be reliable and had positive
outcome regarding TAT, technologist time and overall quality.
Future works will include the implementation of the latest
version of the crosscheck software that allows comparing the
sediment results with the dipstick results. This could allow
increased standardization and additional workload reduction.
EW018
EXPERIENCES OF SCREENING FOR URINARY TRACT
INFECTIONS WITH THE SEDIMAX AUTOMATED DIGITAL
IMAGE ANALYSER: ROVIGO EXPERIENCE
A. Tessari
Microbiology Unit, Clinical Pathology Department, Azienda
ULSS 18, Rovigo, Italy
Background. Urinary tract infections (UTIs) are among the
most common bacterial infections and urine samples
constitute a large proportion of the specimens processed in a
microbiology laboratory. Urine culture is time and labour
consuming but it can produce up to 80% negative results. We
evaluated the sediMAX urinary analyser to screen for positive
samples in order to reduce the number of urines requiring
culture and to rapidly identify patients with UTIs.
Methods. Two thousand and forty seven urine specimens from
hospitalized patients and outpatients were collected during a
biochimica clinica, 2013, vol. 37, SS
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EuroMEdLab 2013 - sciEntific sEssions
6 months period. Samples were analysed in parallel by routine
culture and by the sediMAX instrument, adopting a single set
of cut-off values of both leukocytes and bacteria. Results were
evaluated first considering the entire population and then
dividing patients into subgroups based on their gender, age
and inpatients/outpatients status.
Results. The sediMAX compared to culture showed a global
sensitivity of 96%, a specificity of 74%, a positive predictive
value (PPV) of 56% and a negative predictive value (NPV) of
98%. High NPVs were observed among all the subgroups.
Compared to the global population investigated, samples
collected from male and female hospitalized patients revealed
high sensitivity (98%) but lower specificity (61% and 48%
respectively), mainly due to concomitant antimicrobial
treatment. Samples collected from female outpatients showed
higher sensitivity (97%) but lower specificity (72%), mostly
related to the large amount of false positive results observed
in urine of pregnant women. Compared to female samples,
specimens collected from male outpatients revealed lower
sensitivity (90%) but higher specificity (89%), probably
because bacterial cut-off values were not appropriate.
Conclusions. The sediMAX has demonstrated to be a suitable
screening system, able to rapidly detect true negative urine
specimens and to reduce the number of samples candidate
for culture. For some patient groups the sediMAX instrument
was able to identify with good probability patients with a
concomitant UTI. Clinical data management, coupled with
patient-specific cut-off values, could further improve the
performance of the sediMAX for the screening of UTIs.
EW019
EXPERIENCES OF SCREENING FOR URINARY TRACT
INFECTIONS WITH THE SEDIMAX AUTOMATED DIGITAL
IMAGE ANALYSER: DESIO EXPERIENCE
R. Falbo
University Department of Laboratory Medicine, Desio
Hospital, Italy
Background: Urine bacterial culture constitutes the cornerstone
for the diagnosis of urinary tract infection (UTI). Rather time
consuming and expensive, this procedure would benefit from
prior screening of urine for the presence of bacteria and
leukocytes, particularly since approximately 80% of urine
cultures are negative. In a previous study we demonstrated
that the automated urine sediment analyzer, sediMAX, rapidly
excludes negative bacteriuria samples from further processing
by culture. In the present study, we performed a similar
experiment focusing on the utilization of autoverification rules
to further improve screening with sediMAX.
Methods: One thousand and thirty-two consecutive midstream
and catheter sterile urine specimens were evaluated with the
sediMAX over a 2-month period using urine culture as the
reference method. The autoverification rules utilized were
obtained from the screening experience gained in the previous
study.
Results: Of the 1032 urine samples, 826 (80.0%) were culture
negative and 206 (20.0%) were culture positive. The
autoverification rules requested operator reclassification of
sediments in which debris could be erroneously classified as
bacteria. This approach determined an improvement of
performance (sensitivity, 99.0%; specificity, 85.3%; negative
predictive value (NPV), 99.4%; positive predictive value (PPV),
62.7%; false negative rate (FNR) of 1.0%; and false positive
rate (FPR), 37.3%). The false positive samples were evaluated
and it was found that the most frequent categories of patients
within this group were those with ongoing antibiotic therapy
(40.4%) and pregnant women (37.2%). The initial
autoverification rules were then modified according to the
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biochimica clinica, 2013, vol. 37, SS
characteristics of these two categories further improving
screening performance (specificity, 94.1%; PPV, 81.8%; FPR,
5.9%), and reducing the number of samples to be processed
for culturing by 70%.
Conclusions: The utilization of autoverification rules improved
screening with sediMAX, easing both costs and workload by
reducing the number of unnecessary urine cultures performed.
EW020
REVIEWING THE ROLE OF LEAN MANAGEMENT FOR
ERROR REDUCTION IN THE PRE‐ANALYTICAL PART
OF TTP
D. Hamer
Royal Bolton Hospital, Bolton, UK
This presentation will describe a system of Lean Management
and Daily Accountability Meetings which underpin the
Continuous Quality Improvement approach in Bolton. Together
with real time data collection and analysis and root cause
analysis of defects, this approach gives control of process
quality to the staff who perform the work.
The system provides an integrated set of planning,
measurement and problem solving tools to help the work group
focus on daily performance measurement and improvement;
improve effectiveness of supervisory communication;
encourage staff improvement ideas; and define and monitor
improvement objectives and Key Performance Indicators (KPI).
Essential to the effectiveness of these meetings are the visual
display boards which show metrics for the work area related to
KPIs; process control boards (PCB) which show the actual real
time performance against planned performance; and
Continuous Improvement (CI) sheets which staff use to record
observed defects and improvement ideas. The root cause of
any issue identified might not always be possible to determine
at the daily meeting. It may require the collection of more
metrics or it may require a more detailed problem solving event,
in which case a planned time out will be required with support
from trained facilitators.
Benefits from this system of Daily Accountability Meetings
include improving employee autonomy and commitment
through involvement; improved perceptions of management
through a tie-in to the vision and strategy of the organisation;
productivity is improved and the focus on quality leads to
reduced costs
The systems described in this presentation are, by and large,
just common sense. You already know how to do them; you
might already be doing something similar or have done so in
the past. The difference in a Lean transformation is that there
is a structure and a discipline to applying this common sense.
Plus a determination to make this ‘the way we do things here’,
to be relentless in the pursuit of continuous improvement and
(albeit unattainable) perfection.
Examples will be given of error reduction and quality
improvements in the pre-analytical phase using this
methodology.
EW021
ROLE OF INSTRUMENT DESIGN FOR ERROR
REDUCTION IN THE ANALYTICAL PROCESS
C. Grandone
Abbott Laboratories, USA
The analytical part of the total testing process is the ‘core’ of the
laboratory. With automation, improved laboratory technology,
assay standardization and well defined rules for assessing
EuroMEdLab 2013 - sciEntific sEssions
laboratory quality the error in this testing phase can be reduced.
In this presentation the critical role of instrument design from
the early research state to the final product and its role in
improving overall quality of results will be reviewed.
Setting quality requirements early in the instrument design
process allows to also set sub-system goals for quality, from
sample delivery, optics, temperature control, timing, carry-over
and more key instrument parts which will have an influence on
the quality of the final test result. Long before the final
instrument will be available on the market the performance is
tracked starting already with first instrument prototype. Any
results outside 5 standard deviations for the planned testing
menu is documented, investigated and followed-up right from
the beginning as outlier or defect. By the end of the feasibility
phase the defect rate is significantly reduced by focusing on
the subsystems potentially responsible for these outliers.
During the next development phase, the design control phase,
internal and external validation data are included in this
assessment and this will be continued also after instrument is
available on the market.
In conclusion following good manufacturing practices and
monitoring overall quality including sub-system quality from
early development to final analyzer reduces variability and
ensures instrument performance within established
specification.
EW022
ROLE OF THE SIX SIGMA QUALITY SOLUTION IN TTP
J. Westgard
Westgard QC, Madison, USA
A plan for Analytical Quality Management is presented and
“sigma-tools” are identified to support the achievement of
quality in laboratory testing processes. The objectives are to
make quality measurable by defining requirements for intended
use and to make quality manageable through optimized control
procedures. The plan includes steps to (1) define goals for
intended use, (2) select measurement procedures, (3) validate
method performance, (4) implement analytic method and
system, (5) formulate a “sigma QC” strategy, (6) select SQC
procedures, (7) develop an analytic QC Plan, (8) implement
the analytic QC Plan, (9) verify attainment of intended quality,
(10) measure quality and performance, (11) monitor failures,
and (12) make improvements to the testing process.
The Six Sigma concept of “tolerance limits” is consistent with
quality requirements in the form of Allowable Total Errors (TEa).
Method performance in terms of imprecision (CV) and
inaccuracy (bias) can be estimated from method validation
experiments. Then a “sigma-metric” can be calculated as (TEaBias)/CV to characterize quality on the sigma-scale. A Method
Decision Chart can be used to provide a graphical assessment
of method performance and to facilitate a judgment on the
acceptability of performance.
The sigma-metric can also be used to formulate a Total QC
strategy. Appropriate SQC procedures (control rules, total
number of control measurements) can be designed using the
QC Selection Tool found in CLSI C24A3 or by using a Chart of
Operating Specifications that is similar in form to the Method
Decision Chart. Priorities for controls in a risk management
based QC Plan can also be related to the sigma performance
of the testing process. One of the advantages of the QC Plan
is the capabilities of integrating pre-analytic and post-analytic
controls together with analytic controls. For analytic control,
high sigma methods can rely on SQC procedures with fewer
individual controls, whereas low sigma methods require
maximum SQC effort as well as maximum deployment of
individual controls that focus on specific failure-modes.
EW023
IMPORTANCE OF REFERENCE INTERVALS FOR THE
INTERPRETATION OF ANTI-MUELLERIAN HORMONE IN
CLINICAL PRACTICE
S. Nelson
Muirhead Chair in Obstetrics & Gynaecology, University of
Glasgow, Scotland
Anti-Müllerian Hormone (AMH), a member of the transforming
growth factor beta family, is produced by the preantral and
small antral follicles of the ovary. Serum concentrations of AMH
reflect the number of these follicles as well as the primordial
pool and, as such, can be used to provide an estimate of
“ovarian reserve”.
The age related decline in the primordial follicle pool/ovarian
reserve has been well described, based on cross sectional
observation of follicle numbers. However recent studies, using
AMH as a marker of functional ovarian reserve, have allowed
modelling of changes in the rate of active follicular recruitment
that underlie this decline. Furthermore studies of AMH during
childhood, adolescence and adult life, examined in the context
of human fertility, gives new insights into follicular development.
AMH** is increasingly used in clinical practice to quantify
ovarian reserve and tailor controlled ovarian stimulation
programmes but it is yet to realise its full clinical potential. Due
its relationship with functional ovarian reserve there are
indications that AMH may be useful in predicting the age of
menopause and possibly the reproductive lifespan in young
women. The latter indication may be important in determining
whether fertility preservation strategies are needed in women
undergoing chemo- or radiotherapy, but also for women
planning when to have their families. Finally there is also
interest in the use of AMH in the diagnosis of menstrual
disorders and polycystic ovarian syndrome.
The need for reference intervals and clear decision levels for
AMH is becoming increasingly important. Whilst these are
relatively well defined for use in fertility clinics more research is
required for the wider clinical applications of AMH particularly
in girls and young women below the age of 25.
**Note: Beckman Coulter's AMH Gen II ELISA kit does not
have any clinical claims.
W024
IMPACT OF PROSTATE HEALTH INDEX ON THE
MANAGEMENT OF PATIENTS WITH PROSTATE CANCER
M. Lazzeri
Department of Urology, San Raffaele Turro, Vita-Salute San
Raffaele University, Milan, Italy
Prostate cancer (PCa) screening programs using the prostate
specific antigen (PSA) remains controversial due to a
considerable number of unnecessary prostate biopsies and
the detection of low volume, non-aggressive prostate cancers
leading to overdiagnostic and overtreatment. Recent results
demonstrated that a molecular isoform of free PSA (fPSA), the
[-2]proPSA has a higher specificity for the detection of PCa as
compared with tPSA or f/tPSA. Beckman Coulter recently
developed the “Prostate Health Index” (phi) which combines
tPSA, fPSA and [-2]proPSA (phi=[-2]proPSA/fPSA)x√tPSA).
A multinational, multicenter prospective European study
(PROMETheUS,
http://www.controlled-trials.com,
ISRCTN04707454) was conducted to evaluate the clinical
performance of phi for the detection of PCa on 1026 patients
who underwent initial or repeat biopsy (IPBx and RPBx
respectively). In patients with tPSA between 2 – 10 ng/mL,
who underwent IPBx, phi was the best predictor of the
biochimica clinica, 2013, vol. 37, SS
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EuroMEdLab 2013 - sciEntific sEssions
presence of PCa at the biopsy with an area under the ROC
curve of 0.7 as compare to tPSA (ROC AUC 0.5). In
multivariable logistic regression models testing the predictors
of PCa at biopsy, p2PSA, %p2PSA and phi significantly
increased the accuracy of the base multivariate model with
tPSA, fPSA and %fPSA, to predict PCa presence, by a 6.4%,
5.6% and a 6.4% extent, respectively (all P <0.001). The
Spearman’s rho coefficient analysis demonstrated a significant
relationship between Gleason score, %p2PSA (rho: 0.245; P
<0.001) and phi levels (rho: 0.276; P <0.001). A significant
number of biopsies could be avoided with a negligible number
of cancers missed using phi at sensitivity of 90% (phi =28) and
at the best balance of sensitivity and specificity (phi=41). In a
subset analysis consisted of a nested case-control, %p2PSA
and phi are more accurate than the reference standard tests
(tPSA, fPSA and %fPSA) in predicting PCa in men with
positive family history of PCa and in men younger than 60
years of age. In conclusion in patients with a tPSA between
2.0 and 10 ng/mL, positive family history and younger than
60yrs, %p2PSA and phi are the strongest predictors of PCa at
initial biopsy, and are significantly more accurate than the
currently used tests (tPSA, %fPSA) in determining the
presence of PCa at biopsy.
EW025
NEW SOLUTIONS FOR TOTAL AUTOMATION OF
MOLECULAR DIAGNOSTICS TESTING
B.E. Spiess
Beckman Coulter Inc., Vice President Molecular Diagnostics
Sales and Marketing, Brea, USA
With increasing labour shortages in laboratory medicine,
molecular diagnostics instrumentation will need to evolve
toward central lab-like automation. In a report, Piper Jaffrey
described a recipe for success in the molecular market as
requiring a solid core technology, instrumentation, and menu.
Few platforms today meet those requirements. The new
Beckman Coulter molecular diagnostics platform will automate
the entire real-time PCR procedure, providing real “sample to
answer” capability, integrating the process of producing and
reporting a result, with a diverse menu. This new fully
automated random access system will make routine molecular
diagnostics testing as simple to perform as Immunoassay and
Chemistry. Description - Clinical lab users acknowledge
operational efficiency is limited by the solutions offered by most
MDx platforms. These platforms are usually batch analyzers
with extensive hands-on time, often requiring separate sample
prep stages or moving sample(s) from one instrument to
another to perform testing of a limited menu. As a result, labs
utilize multiple systems that are cumbersome, costly, and timeconsuming.
The new VERIS molecular diagnostics platform* automates the
entire real-time PCR procedure utilizing a proprietary extraction
methodology and innovative design for consumables to provide
real “sample to answer” capability, for a diverse, clinically
relevant menu. The benefits of this technology applied to
quantify ribonucleic (RNA) and deoxyribonucleic acid (DNA) in
human plasma will be reviewed. As an example, HCV RNA
viral load (VL) monitoring is a well-established diagnostic tool
for managing chronic hepatitis C patients. HCV RNA VL results
are used to make treatment decisions with the goal of therapy
to achieve an undetectable VL result. Therefore, a sensitive
assay with high specificity for quantifying HCV RNA across
genotypes is critical. The BEC HCV assay design achieves
clinically relevant performance across six HCV genotypes.
Qualification of system design elements will also be overviewed
such as utilization of a true internal process control, assay
reagents pack offering extended on board shelf life and
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biochimica clinica, 2013, vol. 37, SS
streamlined workflow for QC.
*product in development
EW026
EVALUATION OF QUANTITATIVE-LOOP MEDIATED
ISOTHERMAL AMPLIFICATION (Q-LAMP) IN THE
FOLLOW-UP OF TRANSPLANTED PEDIATRIC PATIENTS
C. Russo
Responsabile Struttura Semplice, Virologia, Dipartimento dei
Laboratori, Ospedale Pediatrico Bambino Gesù - IRCCS,
Roma
Bone marrow transplantation (BMT) and solid organ
transplantation (SOT) have evolved to become the preferred
treatment options for a number of malignancies and end-stage
organ dysfunctions, especially in children. Despite the success
of transplantation procedures, infections in transplant recipients
remain the leading cause of death in this population.
Although CMV, Epstein-Barr virus (EBV), HSV-1, HSV-2, VZV,
and HHV-6 are well recognized for their potential oncogenicity
in transplant patients, because at risk for induction of
uncontrolled cellular proliferation due to normal immune
surveillance “machine” , mostly specific cytotoxic T cell
mechanism, is compromised.
In immunocompromised individuals EBV is associated with
disorders with high rates of morbidity and mortality. The
spectrum ranges from benign B-cell hyperplasia resembling IM
to malignant lymphomas. Allograft organ transplant recipients,
especially children with pre-transplantation EBV seronegativity,
are at particular risk for the development of post-transplantation
lymphoproliferative disease (PTLD) during immunosuppressive
therapy.
The clinical microbiology laboratory plays an essential role in
the diagnosis and management of infection during all phases
of the transplantation process.
Quantitative EBV DNAemia is routinely performed to monitor
EBV Viral loads by using quantitative PCR methods.
Recently a new quantitative assay based on Loop-mediated
isothermal amplification (LAMP) as rapid detection of specific
nucleic acid EBV sequences demonstrated optimal sensitive
with good quantitative correlation to conventional quantitative
PCR.
Laboratories, that join transplant programs will be called upon
to support needs in term of TAT and optimal diagnostic
strategies, from early detection of EBV replication to a high
positive predictive value assay, also in respect to economic
climate of cost containment.
EW027
PRE- AND POST-NATAL DIAGNOSIS OF CONGENITAL
CYTOMEGALOVIRUS INFECTION
T. Lazzarotto
Operative Unit of Clinical Microbiology, General University
Hospital S. Orsola-Malpighi, University of Bologna, Italy
Recent development of advanced serological tests allow us to
identify pregnant women with primary cytomegalovirus (CMV)
infection who are at higher risk of transmitting CMV to their
fetus. Given the high risk of mother–fetus transmission and
fetal damage, prenatal diagnosis is recommended, between
20-21 gestation’s weeks and at least 6-8 weeks after the onset
of maternal CMV infection.
In this work we studied a cohort of 790 pregnancies at risk of
in utero CMV transmission; 796 amniotic fluid (AF) samples
were tested by real time PCR assay and virus isolation.
EuroMEdLab 2013 - sciEntific sEssions
Outcome was fully documented in 714 newborns and 82
fetuses. A total of 108 newborns were CMV infected; 25 were
symptomatic and 83 asymptomatic. Comparing symptomatic
and asymptomatic newborns, the mean viral load in AF was
significantly higher in symptomatic newborns (mean values
2x10^6 vs 9.4x10^5, P=0.009).
The 82 infected fetuses were divided in two groups: those with
histological damage in the brain and in 2 or more organs and
those with histological damage in only 2 or more organs.
When qPCR showed more than 10^6 copies/mL of AF, 62.5%
of fetuses had disseminated infection and brain damage
compared to 29.4% of foetuses with disseminated infection
alone. Although the highest median values of CMV-DNA in AF
tend to indicate an increased risk of severe infection, high viral
loads may be associated with symptomatic or asymptomatic
congenital infections leading to the conclusion that a
correlation between a high CMV load in AF and fetal/neonatal
impairment is uncertain.
The gold standard for the diagnosis of congenital CMV
infection in newborns remains viral isolation in the urine and/or
saliva within the first two weeks of life. But also urinary and
saliva molecular testing is a reliable, rapid and convenient
method to diagnose congenital CMV infection. In this work we
compared real-time PCR assays of urine specimens with rapid
culture of urine specimens obtained at birth. A total of 101 of
199 newborns were congenital CMV infected. Of 199
newborns screened with the use of the urine PCR assay, 98
were negative for CMV and the remaining 101 infants had
positive results on both culture and PCR assay. The sensitivity
and specificity of the urine PCR assay were 100% (95% CI,
95.8 to 100).
EW028
THE LABORATORY CONTRIBUTION TO DIAGNOSIS
AND MANAGEMENT OF RHABDOMYOLYSIS
D. Bobilewicz
Department of Laboratory Diagnostics Medical University
Warsaw, Poland
Rhabdomyolysis first described as crush syndrome during the
World War II appears as a breakdown of muscle cells and
leakage of their contents to extracellular fluid and circulation.
Etiological causes can be divided into several groups and
among them: mechanical trauma, including extensive blunt
injury and electric shock; muscular activity including different
intensity physical exercise in trained as well as untrained
persons and status epilepticus; toxins including carbon
monoxide, alcohol, hemlock herbs that the quails consume;
medications including statins; ischaemia of large muscle
groups as a result of patient’s position during long lasting
surgical operations mainly orthopedic and aneurysm of
abdominal aorta.
Clinical presentation of rhabdomyolysis depends on severity of
myocites damage and varies from subtle nonspecific
symptoms like mild muscle weakness and pain with slight
coloration of urine up to acute renal injury. That is why
laboratory tests are of a great importance in diagnosis and
management. The first finding is often (but not always)
brownish urine showing positive “blood” on dipstick with no
erythrocytes in sediment, what is caused by myoglobin. Very
typical is high serum creatine kinase (CK) and its heart
isoenzyme (CKMB) with normal ratio. Activity of aspartate
aminotransferase (AspAT) and lactate dehydrogenase (LDH)
are also increased. At first stage increase of serum potassium
is a result of its liberation from broken cells but it may aggravate
with deterioration of kidney function. Myoglobin is the most
significant, but usually not performed as a first line laboratory
test. Its serum concentration can reach values above 100 000
ng/ml (normal range about 100 ng/mL). In several critically ill
patients mainly in postoperative and intensive care units
persistent elevation of serum myoglobin is one of indications for
dialysis. As the acute renal injury is the most serious
complication of rhabdomyolysis the careful monitoring of renal
function by laboratory tests should be done. Serum CK and
myoglobin may also be successfully used in monitoring statin
therapy.
EW029
UMBILICAL CORD BLOOD ANALYSIS BY AUTOMATIC
HEMATOLOGY ANALYZERS
M. Hur
Departments of Laboratory Medicine, Konkuk University
School of Medicine, Seoul, Korea
Background: Umbilical cord blood (CB) is as an important
source of hematopoietic progenitor cells and also reflect the
hematologic status of neonates. Several morphological and
immunophenotypic characteristics of CB are different from
those of adult peripheral blood. The performances of
hematology analyzers have been studied mostly on adults’
peripheral blood. Moreover, the current use of their state-of-art
parameters seems to be limited. We evaluated the
performances of ABX Pentra DX 120 (Horiba Medical,
Montpellier, France) and Sysmex XE-2100 (Sysmex, Kobe,
Japan) in CB specimens. We questioned whether their data
are interchangeable and reliable in CB and whether their
specific parameters for hematopoietic progenitor/immature
cells, double matrix by ABX Pentra DX 120 and hematopoietic
progenitor cell (HPC) by Sysmex XE-2100, are reflective of
CD34+ cells.
Methods: The routine complete blood cell parameters were
evaluated in a total of 200 CB specimens. The white blood cell
differential and nucleated RBC (NRBC) counts were compared
with manual differential. Double matrix by ABX Pentra DX 120
and HPC by Sysmex XE-2100 were compared with flow
cytometric CD34+ cells.
Results: Most of the parameters, except mean corpuscular
hemoglobin concentration, showed acceptable correlation
between ABX Pentra DX 120 and Sysmex XE-2100. The
difference of white blood cells (WBC) and platelets between
ABX Pentra DX 120 and Sysmex XE-2100 tended to increase
as WBC and platelets increased. The difference of mean
corpuscular volume (MCV) tended to decrease as MCV
increased. Sysmex XE-2100 did not report WBC differentials in
five specimens. Both analyzers showed acceptable correlation
with manual differential for neutrophils, lymphocytes, and
eosinophils. Mononuclear cells (MNC) by ABX Pentra DX 120
better correlated with manual count than MNC by Sysmex XE2100. Double Matrix better correlated with CD34+ cells than
HPC. NRBC by Sysmex XE-2100 better correlated with manual
count than NRBC by ABX Pentra DX120.
Conclusion: The parameters from ABX Pentra DX 120 and
Sysmex XE-2100 were mostly interchangeable and reliable in
CB specimens. The double matrix by ABX Pentra DX 120 can
be a valuable option to evaluate the quality of CB for further
utilization in therapy and transplantation.
biochimica clinica, 2013, vol. 37, SS
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EW030
ANTI-PHOSPHOLIPID ANTIBODIES: MECHANISMS OF
ACTION
P. de Groot
Department of Clinical Chemistry and Haematology,
University Medical Center Heidelberglaan 100 3584CX,
Utrecht, the Netherlands
APS is an auto-immune disease characterized by thrombotic
complications in both arteries and veins as well as pregnancyrelated complications in combination with the presence of
so-called antiphospholipid antibodies in plasma of these
patients. It is now generally accepted that these auto-antibodies
are not directed against negatively charged phospholipids but
towards plasma proteins bound to these phospholipids. The
most prominent antigen in APS is beta2-Glycoprotein I (beta2GPI), a plasma protein with affinity towards anionic
phospholipids. Three assays are available to detect the
presence of these auto-antibodies; lupus anticoagulant, a
prolongation of a clotting assay and two ELISAs with cardiolipin
or beta2-GPI as antigen. Many studies have identified lupus
anticoagulant as the assay that correlates best with the clinical
manifestations that characterize the syndrome. The autoantibodies that cause lupus anticoagulant are gain-of-function
antibodies, when they bind to beta2-GPI, the affinity of beta2GPI for anionic phospholipids increases to such a extent that
the beta2-GPI-antibody complex can compete with clotting
factors for the binding to anionic phospholipids. Addition of
extra phospholipids can neutralize the effects of lupus
anticoagulant and this ‘conformation’ step has become the
hallmark to identify the presence of lupus anticoagulant. It
should be noted that the anionic phospholipids used in clotting
tests are poorly characterized, and the sensitivity of different
clotting assays for lupus anticoagulant is different. Moreover,
the auto-antibodies that cause lupus anticoagulant are a
heterogeneous population of antibodies. To circumvent that the
presence of lupus anticoagulant is missed, the official
guidelines require that two clotting assays should be performed
that are based on two different activation principles.
In this lecture the mode of action on how the auto-antibodies
can induce a prolongation of clotting times will be discussed.
EW031
LABORATORY DETECTION OF LUPUS
ANTICOAGULANTS
A. Tripodi
Angelo Bianchi Bonomi Hemophilia and Thrombosis Center,
Department of Clinical Sciences and Community Health,
Università degli Studi di Milano and IRCCS Cà Granda
Maggiore Hospital Foundation, Milano, Italy
Laboratory detection of lupus anticoagulants (LA) is of
paramount importance for clinicians as patients who are
persistently positive for these circulating anticoagulants and
have experienced previous episodes of venous/arterial
thrombosis or fetal loss are candidate for long term
anticoagulation. Since there are no specific tests to detect LA,
the laboratory diagnosis must be based on indirect evidence
provided by surrogate laboratory tests combined with
diagnostic criteria. The tests being recommended for LA
detection are two and include such phospholipid-dependent
tests as the activated partial thromboplastin time (APTT) and
dilute Russell viper venom test (dRVVT). The diagnostic criteria
are three: the first requires evidence that the clotting time of at
least one of the two tests (APTT or dRVVT) is abnormally
prolonged (screening procedure); the second requires
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biochimica clinica, 2013, vol. 37, SS
evidence that the abnormality of the screening test is due to
the presence of circulating anticoagulants and not the
deficiencies of coagulation factors [mixing (patients and normal
plasma) study] and the third requires that circulating
anticoagulants are directed to negatively-charged
phospholipids combined with plasma proteins and not to
specific coagulation factors (confirmation study). The rational of
the screening is that LA binds and neutralizes the
phospholipids included in the test reagents and therefore
prolong the clotting time of the APTT/dRVVT. The rational of
the mixing procedure is that any coagulation factor deficiency
is (nearly) corrected upon mixing equal amounts of patient and
normal plasma. Thus, normalization of the mixture clotting time
suggests a coagulation factor deficiency as the causes of the
prolongation observed in the patients plasma, whereas a
persistent prolongation of the mixture clotting time suggest the
presence of circulating anticoagulants. Finally, the rational of
the confirmation procedure rests on the fact that repeating the
screening test on patient plasma upon increasing the
concentration of phospholipids is able to quench the effect of
LA on these moieties and therefore the clotting time will be
normalized, but only if the cause of prolongation was due to
the presence of LA.
EW032
LABORATORY DETECTION OF ANTI-PHOSPHOLIPID
ANTIBODIES WITH SOLID PHASE ASSAYS
K. Devreese
Coagulation Laboratory, Ghent University Hospital, Ghent,
Belgium
Two out of the three laboratory classification criteria for antiphospholipid syndrome (APS) are defined as the persistent
presence of antibodies to cardiolipin (aCL) and/or β2glycoprotein I (aβ2GPI). These anti-phospholipid antibodies
(aPL) are measured by immunosorbent method, mostly
enzyme-linked immunosorbent assays (ELISA). The aPL
constitute a heterogeneous group of autoantibodies with
distinct specificity for cardiolipin, or for plasma proteins with
affinity for anionic phospholipids such as β2GPI, the most
important cofactor for the autoantibodies. After the discovery
of the cofactor function of β2GPI, assays that detect antibodies
directed against the protein itself were rapidly developed and
aβ2GPI were included in the classification criteria as separate
serological criterion.
The APS diagnosis relies predominantly on laboratory results
as the incidence of clinical symptoms is high and often
determined by other underlying factors. However, the
laboratory diagnosis is complicated by the lack of golden
standards. The aPL assays must be sufficiently sensitive and
specific to classify patients correctly as having APS since overas well as mis-diagnosis has severe clinical implications
regarding treatment. For aCL and aβ2GPI testing, several
factors contribute to variability in pre-, post- and analytical
conditions, many factors related to the assay itself and its
calibration. Despite consensus guidelines and proposals have
been published, standardization is not yet achieved and some
issues still remain unanswered.
Studies computing the risk for clinical complications in patients
with aPL demonstrate large discrepancies in reported risk for
aCL and aβ2GPI. One of the reasons for these discrepancies
is that laboratories use a wide variety of solid phase assays
(inter-assay variability). Although the solid phase assays are
easier to perform compared to the coagulation assays for
lupus anticoagulants large inter-laboratory variation persists,
a limitation which may be overcome by the introduction of new
automated methodologies. Awaiting better tests to detect the
pathogenic aPL, the solid phase assays need to be
standardized to improve inter-laboratory and inter-assay
EuroMEdLab 2013 - sciEntific sEssions
comparison and methodological
recommendations are needed.
and
interpretational
EW033
CURRENT STATUS AND FUTURE OUTLOOK OF IT
SOLUTIONS
J. Kay
Nuffield Department of Clinical Laboratory Sciences, Oxford,
UK
Laboratory medicine faces many challenges in managing
information including the request-report cycle for central
laboratory and point of care testing, advice to clinicians on the
selection and interpretation of investigations, communication
with other laboratories, external quality assurance,
management of organisational information within the
laboratory as well as the support of accountability for both
regulatory and financial purposes.
For central laboratory testing key task is computerisation of
the request-report cycle. Increasingly this will be done using
the clinical information systems the clinicians have selected
and implemented, rather than as an extension of the
laboratory information management system. Computerised
reporting is widespread but there are many residual problems,
including integrity of information and ensuring that reports are
seen by clinicians.
In Oxford we have used the clinical information systems in
primary care and now receive over 85% of our requests by
computer messaging, issue no paper reports and are making
our initials steps into using decision-support rules on the
requesting system in front of the clinicians. In secondary care
a new electronic patient record system is used. Paper reports
have been stopped. Specimens are checked against patient
wristbands using barcodes.
Laboratory Information Systems are being squeezed between
two developments: the introduction of computerised requesting
and reporting on clinical information systems and the inlaboratory systems which control and are supplied with
analysers. It is possible that smaller and simpler laboratories
will not need a LIS in the near future.
All laboratories need information on costs and workloads. The
information needed for clinical reports can also be reused for
research and development. The workload from primary care is
now so high that it can be used for population surveillance.
Modern data-mining techniques that are widely used in retail
are likely to be similarly productive in Laboratory Medicine.
Process efficiency and patients safety can be further improved
using disease management systems and improved knowledge
management centered all around the patient care.
Developments in all of these areas will be discussed and
demonstrated.
EW034
DECISION-MAKING IN UNIVERSITY CORE LABS AND
THE SUPPORT OF IT
U. Oesinghaus
University Hospital Göttingen, Germany
Background: Nowadays a lot of University Hospitals are
planning to invest in centralization and standardization of
laboratory activities. Beside the constructional, personnel and
analytical challenges there is an increasing demand of
implementing a consistent, integrative IT-solution that supports
maximum consolidation and workflow optimization.
Method: In 2011 the University Hospital of Goettingen placed
a European wide tender for a total laboratory automation
solution including an integrated IT concept.
Key requirements for the IT-Solution were the support of
existing IT-Systems, the flexibility to support Core Lab,
integration
of
3rd
party
analyzers,
different
Laboratoryinformationsystems (LIS), purchasing procedure,
suppliers relationship, accounting “pay per result contracts” and
stock-optimization through RFID-tracking-system. Metrics tools
like TAT, performance, efficiency and workload measurements
the automated generation and management of physician driven
information by case tools and/ or Business Intelligence
Systems played an important role for decision.
Results: The concept of the leading bidder was able to fulfill
most of the tendered challenges. Now our Lab will be able to
succeed in optimization the most common workflow´s pain
points of a University Lab like: •Reception of the tests preanalytic: labeling, aliquoting, centrifugation; •Handling of
exceptions through auto-validation features; •Easy
interpretation and acceleration of the workflow; •Delays and
delivery time in diagnosis and treatment as impediments to
optimal patient care, particularly in high-volume patient care
environments; •Avoiding discrepancies and effects due to an
inaccurate information.
Conclusion: As the main topics in the UMG-Lab have been
improved, the investment in a modern Lab- IT-Solution can not
only accomplish and satisfy nowadays requirements but also
support the value and return of investment. So a modern Lab
will benefit from Increasing the progress and the improvement
in the Lab operations through timely decision making.
EW035
MAXIMIZING STABILITY OF VENOUS BLOOD
SPECIMENS
C. Oddoze
University Hospital Marseille, Marseille, France
Background: Guidance is required to ensure blood sample
integrity during the preanalytical phase, especially to comply
with ISO 15189 requirements. Informations such as type of
tube, temperature conditions & delays before centrifugation
need to be known. We studied the pre-analytical stability of 81
analytes based on the variables of delay before processing,
storage as whole blood or serum/plasma, the storage
temperature and the type of tube the sample was stored in.
Methods: The mean difference between assays for samples
from 10 subjects was calculated with the samples being kept
under different storage conditions and for different times
between sampling and analysis: up to 24 h for biochemistry,
coagulation and hematology, and up to 72 h for hormonology.
This difference was compared to the acceptable limits derived
from the analytical and the intra individual biological variation
(RICOS).
Results: Most of the analytes investigated remained stable up
to 24 h under all storage conditions prior to centrifugation.
However, some analytes were significantly affected either by
delay, tube type or temperature, such as potassium, inorganic
phosphorus, magnesium, LD, glucose, lactate, mean
corpuscular volume, mean corpuscular hemoglobin, activated
partial thromboplastin time, insulin, C-peptide, PTH,
osteocalcin, C-telopeptide and ACTH.
Conclusions: This study may be useful to help defining
acceptable delay times and storage conditions when a short
time between sample collection and processing is not possible.
biochimica clinica, 2013, vol. 37, SS
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EW036
MAXIMIZING STABILITY OF URINE SAMPLES
T. Kouri
HUSLAB, Helsinki University Hospital, Helsinki, Finland
Urine specimens should be stabilised before analysis based
on the specific need of each requested test, rather than trying
to do all tests from the same non-preserved specimen. For
regional analysis, preservation at least overnight (preferably
for 3 days) must be considered. Specifications for
transportation of most common urine tests are to be included
in regional protocols, as given in the examples below:
Urine Bacterial Culture And Particle Counting: A new era of
regional analysis is possible by using documented preservative
tubes for storage at + 20 °C and transport for 1-3 days. A
separate primary tube for microbiology investigations is
recommended to avoid carry-over in automated instruments.
Demanding bacteria may survive in non-additive tubes only,
usually with a defined maximum storage time at +4 °C.
Chemical Test Strip Measurement: Use of a non-preservative
tube is possible with storage at +4°C for a maximum of 3 days.
A combined preservative tube can be used at + 20°C up to the
specified period of time only, because sensitive oxidative
reactions on the test pads are easily biased.
Urine Albumin Creatinine–Ratio: A non-preservative tube can
be used for single-voided samples within 7 days after collection
at + 20 °C. Preserve at +4 °C for a maximum of 30 days if
necessary.
Urinary Protein (24 hour collection): A non-preservative
collection container and aliquotting tube can be used for 1 day
after a home or hospital collection at + 20°C. Replace the test
with albumin creatinine-ratio of morning specimen if possible
(not a myeloma patient or tubular proteinuria).
Urinary Electrilytes (24 h collection): Calcium may precipitate
within two days if stored at +20 °C without acidification. Use
pre-made 10 mL bottles of 6 mol/l HCl solution to be added into
a 24-hour collection container after the first voided portion. No
preservatives are needed for sodium or potassium at +20°C
for 1 month.
EW037
ENSURING STABILITY THROUGH TRANSPORTATION
G. Lippi
U.O. Diagnostica Ematochimica, Azienda OspedalieroUniversitaria di Parma, Italy
Blood drawing, a primary requisite of in vitro diagnostics, is the
most vulnerable step of the testing process. An appropriate
venipuncture is essential to obtain a quality specimen, wherein
a mishandled or incorrect procedure can produce unsuitable
specimens, compromise the quality of testing and ultimately
jeopardize patient safety. The most frequent problems
attributable to inappropriate sample collection, in order of
frequency, entail spurious hemolysis, clotting, incomplete or
inappropriate filling of primary blood collection tubes, undue
clotting, inappropriate containers, contamination from infusion
liquids, as well as misidentification and unsuitable conditions of
temperature, time and humidity for transportation. The
venipuncture procedure is typically complex, requiring both
knowledge and skill. Although each phlebotomist usually
defines a comfortable routine, a series of sequential steps must
be fulfilled. These include correct patient identification,
assessment of patient physical disposition, (i.e., diet, physical
exercise, stress, basal state), check of requisition form,
selection of a suitable site, preparation of equipment and
puncture site. The tourniquet should applied to an area
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biochimica clinica, 2013, vol. 37, SS
approximately 10 cm above the intended site of venipuncture,
it should be tight enough to restrict venous flow but not arterial
circulation, and – especially – should be ideally removed after
1 min but never left in site for more than 3 min. The blood
samples must be labelled before venipuncture and collected in
the appropriate container. The ideal needles are those with
calibre comprised between 19-23 gauge, preferably straight.
There is no analytical reason to limit the use of butterflies, but
the incremental cost over the conventional straight needle
should be adequately weighted as well as the stringent
requisition of discarding the air volume with a discard tube.
When mixing of the tube is required for the presence of various
additives (anticoagulants, pro-coagulants, stabilizers), this
should be done by 3-6 times gentle inversion. Primary blood
tubes should never be mixed to prevent cross-contamination of
additives. The specimens should hence be sent to the
laboratory in a suitable time frame and under the best
environmental conditions, with no injury.
EW038
THE USE OF QUALITY INDICATORS TO IMPROVE
MEDICAL LABORATORY QUALITY
J. Barth
Leeds General Infirmary, Leeds, UK.
Clinical laboratories have an important role in improving patient
care. The past decades have seen enormous changes with
unpredictable improvements in analytical performance, range
of tests and capacity to manage large volumes of work. At the
same time, there has been a dramatic fall in the rate of
laboratory errors. However, there is now a growing awareness
that the testing process includes the time before samples reach
the laboratory and after reports have been printed and that
these areas need to be included in the quality assessment of
the total testing process.
Laboratory quality should include a focus on patient safety and
clinical effectiveness. Services should be patient centered,
timely, efficient and equitable, and finally, should be molded to
ensure optimal outcomes. There is a need to define quality
indicators that will ensure there is appropriate choice and
selection of tests, use of the appropriate assay standardization
and the correct interpretation of the assay results at the
appropriate time. These are the areas in which a quality
laboratory can, and should, now involve itself. This presentation
will describe the process of development of Quality Indicators
in the UK.
EW039
QUALITY INDICATORS: EXPERIENCE OF A LARGE
LABORATORY
L. Sciacovelli
Department of Laboratory Medicine, University-Hospital of
Padova
Background: The International Standard ISO 15189:2007 (IS)
requires the implementation of quality indicators (QIs) as a part
of quality improvement procedures but it does not define: what
has to be defined and how has to be managed; who has to
collect data; the times for data collection; the quality
specifications (QS) for each QIs. The aim of the present study
is to report the experience of our Department of Laboratory
Medicine of University-Hospital of Padova that defined a set of
quality indicators and realized a reporting system to manage
them.
Methods: QIs have been defined on the basis of IS
EuroMEdLab 2013 - sciEntific sEssions
requirements, on the evidences reported in literature and from
the project “Model of Quality Indicators” (MQI) of IFCC Working
Group “Laboratory Errors and Patient Safety”. Data have been
collected by means of a computer system specifically created
and QS have been defined taking into account the level of
performance achieved (state of the art). Moreover, the
laboratory participates in the MQI in order to analyze its data in
a benchmarking process.
Results: Sixty-six QIs have been defined: 35 concerning pre-,
11 intra- and 10 post-analytical phase; 5 to monitor the activities
of point of care testing (POCT); 5 related to support processes.
The periodic data analysis allowed to understand the trend of
performance over time (improvement or worsening), to know
the need of improving actions and of QIs revision (introduction,
deactivation, correction). The results analysis demonstrated
that processes under the control of the laboratory have
improved much more than those that require a close
cooperation between the laboratory and the care teams.
Conclusion: QIs are becoming an indispensable tool to monitor
and improve all activities of the total testing process. The
effectiveness of QIs depends on the reporting system used for
data collection, the procedures for data analysis and the staff
awareness about the need of improving actions
implementation. The reliability of QIs management in the single
laboratory must be evaluated through the participation to a
benchmarking process in which data of different laboratories
can be compared among them and large scale projects can be
carried out to decrease laboratory errors with the collaboration
of all participants.
EW040
EARLY BIOCHEMICAL SCREENING FOR FETAL
ANEUPLOIDY IN THE FIRST TRIMESTER
N. Tørring
Århus Universitetshospital-Skejby, Denmark
Background: Screening for foetal trisomy 21 in the first
trimester includes analysis of the serological markers
pregnancy-associated plasma protein A (PAPP-A) and free
beta human choriogonadotropin (free βhCG). With the recent
launch of the PAPP-A and free βhCG assays on the Roche
Cobas and Elecsys platforms, we investigated their clinical
and analytical performance in samples from gestational weeks
8+0 to 14+0.
Methods: We conducted a multicentre study based on serum
samples from 5397 pregnancies including 107 samples from
cases of verified fetal trisomy 21 at 8 to 14 weeks of gestation.
A technical validation of the Roche Elecsys® free βhCG and
PAPP-A assays was performed, including method
comparisons with the Brahms Kryptor, PerkinElmer
AutoDELFIA and Siemens Immulite assays. Furthermore a
clinical validation including generation of assay specific
medians for PAPP-A and free βhCG from gestational age 8+0
to 14+0 weeks, and clinical test performance of risk
assessment was conducted.
Results: The in-between day imprecision of the Elecsys® free
βhCG and PAPP-A assays was between 1.0 and 2.8%.
Comparison (Passing/Bablok regression) of free βhCG and
PAPP-A from Roche Elecsys® and the Brahms Kryptor assays
showed slopes of 0.94 and 0.95 and Pearson’s correlation of
r = 0.981 and r = 0.987 respectively. Similar comparison to
PerkinElmer AutoDELFIA gave slopes of 0,83 (free βhCG) and
1.20 (PAPP-A). With a cut off at 1:300 the overall sensitivity of
the first trimester screening including nuchal translucency
reached 94% for a 3% false positive rate. Blood sampling in
gestational weeks 8 and 9 gave a sensitivity of 95% for a 2%
false positive rate, and in gestational weeks 10 to14 the
sensitivity was 94% for a 3% false positive rate.
Conclusions: The Roche Elecsys® free βhCG and PAPP-A
assays apply with the standards for biochemical assays for
prenatal screening set by the Fetal Medicine Foundation, with
low assay imprecision and a high clinical performance of
prenatal screening for fetal trisomy in the first trimester.
EW041
PREECLAMPSIA AND ANGIOGENIC FACTORS: FUTURE
PERSPECTIVES IN CLINICAL MANAGEMENT
H. Stepan
University of Leipzig, Germany
The pathogenesis of preeclampsia is still not completely
known; however, in the recent decade, there have been
tremendous research efforts leading to impressive results
highlighting the role of a disturbed angiogenic balance as one
of the key features of the disease. Soluble fms-like tyrosine
kinase 1 (sFlt-1), induces a preeclampsia-like phenotype in
experimental models and circulates at elevated levels in
human preeclampsia. Although preeclampsia seems to be a
clearly defined disease, clinical presentation, and particularly
the dynamics of the clinical course can vary enormously. The
only available tools to diagnose preeclampsia are blood
pressure measurement and urine protein sampling. However,
these tools have a low sensitivity and specificity regarding the
prediction of the course of the disease or maternal and
perinatal outcome. The sFlt-1/PlGF ratio can now by
determined by a rapid, automated immunoassay and can
differentiate between preeclampsia and other hypertensive
pregnancy disorders. The ratio can indicate the severity and
progression of the disease and gives hereby a short term
prognosis that is useful for clinical management. Thus, the
sFlt-1/PlGF ratio has developed from an aid in diagnosis to a
robust biomarker for prediction and risk stratification.
Targeted therapies to stabilize the clinical manifestations and
prolong pregnancy in preeclampsia do not exist. Removing
sFlt-1 from circulation may benefit women with early-onset
preeclampsia, since maternal sFlt-1 levels are closely linked to
the severity of the symptoms and of the disease. A recent pilot
study has demonstrated that negatively charged dextran
sulfate cellulose columns adsorb sFlt-1 in vitro. In women with
preterm preeclampsia and elevated circulating sFlt-1 levels,
apheresis treatment reduces circulating sFlt-1 levels in a dosedependent fashion. Extracorporeal sFlt- apheresis lowered
circulating sFlt-1, stabilized blood pressure, and reduced
proteinuria without apparent adverse events to mother and
fetus. This approach opens the horizon to a real therapeutic
intervention and supports further clinical studies with apheresis
technique.
EW042
CERVICAL CANCER SCREENING AND DIAGNOSIS:
HOW TO ANSWER TODAY’S CHALLENGES
M. Sideri
European Institute of Oncology, Milan, Italy
Several population studies have established that tests for
human papillomavirus (HPV) have higher sensitivity than
cytology in detecting high grade cervical intraepithelial lesions
(CIN3) and that combined HPV and cytology testing has high
negative predictive value for CIN3. The randomised trials found
that the increased sensitivity for CIN3+ is not merely
overdiagnosis as there is a correspondingly lower incidence of
CIN3+ in the future. This in turn favourably affects invasive
biochimica clinica, 2013, vol. 37, SS
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cancer incidence. Increased sensitivity has two important
clinical outcomes: reduced mortality and elongation of
screening interval; this latter implies better compliance to
screening and lower costs. While the negative predictive value
of HPV testing has a direct and easy understandable clinical
outcome, the clinical meaning of HPV positivity does open a
new perspective in cervical cancer prevention: from a system
based on disease diagnosis and treatment to a system of risk
stratification and risk reduction interventions. HPV positive
women are stratified according to at least one of these
discriminators: age; grade of pap smear positivity; HPV typing;
molecular markers of oncogenic transformation; colposcopic
appearance of the cervix; HPV vaccination status. Based on
these characteristics optimal management strategy is selected
among the followings: three years, one year or six months
follow up; colposcopy and biopsy; excision of the
transformation zone. In this way molecular markers are going
to play a central role in the risk stratification exercise that is today the cervical cancer screening system.
EW043
METHODS FOR THE RAPID DETECTION OF SYNTHETIC
CANNABINOIDS
B. Dixon
Physicians Choice Laboratory Services, LLC, North
Carolina, USA
Background: We have implemented an ELISA screening and
semi-quantitative method targeted at illicit recreational drugs.
This test can be followed by liquid chromatography mass
spectrometry (LCMS) confirmation for specific compound
identification and quantitation. In these assays, we have
demonstrated analytical sensitivity and specificity for three
main classes of newer recreational drugs. From urine samples,
we can detect parent and metabolite for synthetic
cannabinoids, methcathinone and derivatives, along with
kratom and kava. In the U.S., the Drug Enforcement
Administration has placed synthetic cannabinoids and two bath
salt drugs as Schedule I Controlled Substances. In the
rehabilitation arena, practitioners need as much information
regarding the patient’s compliance with a treatment program
as possible.
Methods: Patient urine samples were collected and tested for
a broad panel of prescription drugs and drugs of abuse. These
samples were blinded for this study. Randox Enzyme-Linked
Immunosorbent Assay (ELISA) kits were utilized for semiquantitative analysis of urine samples for synthetic
cannabinoids. Preparation of the plates followed the standard
instructions provided with the kit. The ELISA plate was loaded
on a Biotek reader for spectrophotometric detection. A standard
curve was included on the plate for quantitation. Transition ions
were determined for the triple quadruple mass spectrometer
specific to each ion of interest. Multiple target compounds were
interrogated, including several JWH, RCS4 and AM
cannabinoids. Urine samples were subjected to base
hydrolysis and dilution prior to MS detection.
Results: Comparison of ELISA sensitivity and specificity,
included 25 samples positive for synthetic cannabinoids
reflexed to a mass spectrometry confirmation method. 25
negative samples were reflexed for MS analysis, and high
correlation was observed. The enzyme cross-reactivity was
>50% for 11 synthetic cannabinoid compounds. The MS
confirmation method, scanned for four of the most crossreactive synthetic cannabinoid compounds. A high correlation
was observed. With a combined analytical platform consisting
of both screening and confirmation techniques, rapid and
quantitative results can be obtained to facilitate high quality
patient care.
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biochimica clinica, 2013, vol. 37, SS
EW044
MULTI-TARGET DETECTION OF DESIGNER DRUGS BY
MULTIPLEX IMMUNOASSAY
J. Darragh
Randox Toxicology Ltd, Crumlin, UK
Background: The introduction of new designer drugs is evolving
continuously and as such the availability of immunoassay
screens for these compounds is limited. Evidence biochip array
technology provides a platform for the multiplex detection of
analytes from a single sample. Due to the extensive number of
designer drugs currently on the market, immunoassays
presenting wide specificity are of interest in test settings. This
study reports the analytical evaluation of simultaneous
immunoassays on a biochip array for the multiplex detection
of a wide range of designer drugs, including synthetic
cathinones (‘Bath Salts’), synthetic cannabinoids (‘Spice’),
phenylpiperazines, benzylpiperazines (‘PEP pills’), salvinorin
and mescaline in whole blood and urine.
Methods: The biochip (9 mm x 9 mm) is the chemically
activated solid phase where the ligands are immobilised and
stabilised, defining microarrays of test sites and the vessel for
the immunoreactions. For the screening of designer drugs on
this biochip platform, eleven test sites corresponding to
competitive chemiluminescent simultaneous immunoassays,
were applied to the Evidence Investigator analyser.
Results: One hundred and ten designer drugs were detected
on the biochip platform. The limits of detection ranged from
0.04-2.43 ng/mL (whole blood) and 0.05-17.6 ng/mL (urine).
The four immunoassays for synthetic cannabinoids on the
biochip detected eighty one compounds including JWH-018,
JWH-073, JWH-081, JWH-250 and RCS-4. Fifteen
phenylpiperazine and benzylpiperazine compounds were
detected across three immunoassays. Two ‘Bath Salts’
immunoassays detected 10 different compounds including
mephedrone, methcathinone, MDPV and MDPBP. The
Salvinorin assay (standardised to Salvinorin A) also detected
the deacetylated form Salvinorin B.
Conclusions: This analytical evaluation indicates applicability
of the biochip array to the multiplex screening of a wide range
of designer drugs from a single sample of urine or whole blood.
This methodology is a valuable tool for the rapid screening of
batches of samples, as only positive sample determinations
require further confirmatory analysis.
EW045
ADVANCES IN DIAGNOSIS AND MANAGEMENT OF
VIRUS C HEPATITIS
C. Sarrazin
Professor of Medicine, Med. Klinik 1 J. W. Goethe University
Hospital, Frankfurt am Main, Germany
Background: In Europe, the prevalence of hepatitis C virus
(HCV) infection varies from 0.2–7%, resulting in approximately
9 million patients with chronic infection. Due to long courses of
infections in majority of patients, in recent years a significant
increase of cases presenting with end-stage liver disease
and/or liver cancer has been recognized. Given current and
foreseeable future improvements in antiviral therapy, the main
obstacle is the lack of diagnosis of chronic hepatitis C in
30–70% of patients in different European countries, as well as
management of antiviral treatment.
Methods: Analysis of the importance of diagnosis and
management in the treatment of chronic hepatitis C infection.
Results: In developed countries, HCV RNA remains the primary
parameter to establish diagnosis of replicating HCV infection in
EuroMEdLab 2013 - sciEntific sEssions
patients with positive HCV antibodies because of broad
availability and superior sensitivity compared to HCV core
antigen assays. General screening of populations with the
highest risk of chronic hepatitis C ("baby boomers") may be
useful to enhance the rate of diagnosed patients. Respective
programs have been initiated in several countries. With the
approval of HCV protease inhibitors telaprevir and boceprevir,
a new standard treatment has been established for patients
with HCV genotype 1 infection. However, triple therapies in
combination with pegylated interferon and ribavirin are
associated with complex rules for determination of optimal
treatment durations in responders and stopping rules for nonresponders. This response-guided treatment of chronic
hepatitis C is managed with frequent measurements of HCV
RNA before and during antiviral therapy. Recently, significant
differences between commercially available HCV RNA assays
have been observed and must be taken into account for proper
management of treatment. Early results of phase 2 studies with
newer direct antiviral agents for IFN-containing and IFN-free
treatment regimens indicate the likelihood of further
improvements in efficacy as well as simplification of treatment
management.
Conclusion: The primary current challenges regarding HCV
infection are establishment of diagnosis in affected patients and
proper application of complex rules for triple therapies with NS3
protease.
EW46
NON-INVASIVE TECHNOLOGIES AND BIOMARKERS
FOR ASSESSMENT OF SEVERITY OF LIVER FIBROSIS
W. Rosenberg
Director UCLH/UCL Clinical Research Facility Clinical Lead Viral Hepatitis Scientific Advisor to the NIHR Office for
Clinical Research Infrastructure (NOCRI) Peter Scheuer
Chair of Hepatology UCL Institute for Liver & Digestive
Health Division of Medicine, University College London Royal
Free Campus, London, UK
Background: Liver fibrosis testing is used to determine the
extent of liver damage, aid in prognosis, assist with therapeutic
decision making, monitor disease progression and therapy.
Liver biopsy, the reference method, has significant
disadvantages, including risk to the patient and limited
diagnostic accuracy. Consequently, easy-to-use, noninvasive
serum markers are highly desirable. Advantages of serum
markers include reproducibility of results with a low coefficient
of variation, ease of collection, and test repeatability.
Methods: Published studies comparing noninvasive
technologies for assessment of liver fibrosis severity against
liver biopsy and clinical outcomes as reference standards have
been reviewed. The performance of the Enhanced Liver
Fibrosis (ELF™) test* in a range of chronic liver diseases has
been evaluated in depth. Results are compared to other
noninvasive technologies using liver histology and clinical
outcomes as reference standards. The use of combinations of
noninvasive tests was investigated. The use of the ELF test to
monitor changes in histology was evaluated.
Results: The ELF test performs well in the detection of liver
fibrosis and compares favorably to other noninvasive tests. The
ELF test is a better predictor of clinical outcomes than liver
biopsy over long-term follow-up. Combinations of ELF with
other noninvasive tests can be used to resolve indeterminate
test results. Changes in ELF test results reflect changes in liver
fibrosis and can be used to monitor treatment responses and
changes in fibrosis due to natural history. The generation of
continuous variable data for the assessment of liver fibrosis is
superior to categorical data.
Conclusion: The ELF test can be used for diagnosis,
assessment, prognosis, and monitoring, sometimes in
conjunction with other tests and modalities, and it has some
significant advantages over biopsy, especially since it is
noninvasive and nonsubjective. The ELF test can be integrated
easily into standard clinical practice, as it is reproducible, has
good discriminatory and predictive value, and can be readily
automated on high-throughput analyzers.
*Not available for sale in US. Product availability may vary from
country to country and is subject to varying regulatory
requirements.
EW047
EFFICIENT MANAGEMENT OF THE HEMATOLOGY
LABORATORY ACTIVITY
J. Naegelen
Beckman Coulter Marketing Manager Global Product
Management, Krefeld, Germany
Exalab laboratory is a group of 30 private laboratory sites
located in Southwest of France. Since March 2012, Exalab
has consolidated the hematology activity on its Core Platform
in Le Haillan, with an integrated hematology solution,
HematoFlow, from Beckman Coulter (BC). In the decision
process, the lab wanted to achieve the following objectives:
to improve TAT, to save time, to increase standardization of
processes, and quality of results. The laboratory has built its
organization in routine and expert islands around BC discrete
automation with the Automate 1250. All samples received are
checked and sorted by the Automate system and then directed
to the DxH 800 hematology analyzers. Tubes w/o differential
abnormalities are archived with other redirected to the
HematoFlow™ with a blood smear if necessary. The abnormal
Differentials are now checked by a new method using
automated flow cytometry analysis using CytoDiff* reagent,
the unique HematoFlow multicolor reagent. This process was
previously a manual task in the laboratory requiring reviewing
blood smears using a microscope. All information and data
management is automatically retrieved by the data manager,
REMISOL, from which the biologists consult and validate the
results. The HematoFlow with CytoDiff enhances the
traditional data produced from a manual differential. For
example, HematoFlow provides additional information,
regarding T lymphocytes and B lymphocytes subsets and also
greatly increased accuracy and precision for blast cell counts.
In fact, according to the Ruempke table, when counting
manually a 1% blast, values obtained can vary from 0.6 to 8.5
%, while HematoFlow gives a result with 12.9% CV (0.87 to
1.13%). . This additional information helps in the interpretation
of results by the laboratory in a very efficient workflow.
*Not for In Vitro Diagnostic use in the United States
EW048
ADVANTAGES IN THE HEMATOLOGY LABORATORY
USING THE HEMATOFLOW SOLUTION
o. Pradier
Laboratory Hematology Manager, Hopitâl Erasme, Brussels,
Belgium
HematoFlow is a new solution for the routine haematology
laboratory, which consists of DxH 800 analyzers, a sample
preparer FP-1000 and a dedicated FC500 flow cytometer. This
chain is controlled by the middleware Remisol and CytoDiff* is
the mixture of antibodies which allows differentiation of the
leukocyte populations and provides 9-part differential WBC
count.
biochimica clinica, 2013, vol. 37, SS
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EuroMEdLab 2013 - sciEntific sEssions
Retrospective 18 months study of the use of HematoFlow in
routine diagnostic in the haematology laboratory of an
academic middle size hospital. In March 2011, the autogating
software to analyze CytoDiff has been implemented.
Between September 2010 and February 2012, we ran 14,336
CytoDiff (mean=796 patients by month, median=752 patients).
It concerned 5,658 different patients. The control of the
CytoDiff differential by microscopy represents 7 to 10
slides/day. Those samples are difficult and require all the
expertise of the biologist. HematoFlow allows a precise
differential count for leucopenia as low as 0.3 G/l. Even in
these conditions the accuracy of the blasts count remains
close to 0.8%. We analyze the sensitivity of the flag variant
lymphocytes. The analysis of the balance kappa/lambda by
flow cytometry when B cells are greater than 0.52 G/l
lymphocytes and NK/T <3.2 G/l, revealed monoclonality in 44
patients, while the lymphocytes count was within the normal
range and there was no morphological abnormality
microscopically detectable. In 9 cases, the continuity of care
has changed, four with a change in treatment.
HematoFlow and CytoDiff effectively automate the routine
haematology reducing TAT with the help of autogating strategy
and Remisol waterfall rules. The additional cost reagent is
offset by the benefits of the increased precision (20 000 cells
counted instead of 100 cells), the blast count precision, the
new information; T/NK and B cells count, resulting in better
care for patients and the drastic reduction of the use of
microscopy allowing the transfer of technologists to new
posting. Beckman Coulter, the stylized logo, DXH 800,
CytoDiff and HematoFlow are trademarks of Beckman Coulter,
Inc. Beckman Coulter, the stylized logo, is registered with the
USPTO. All other trademarks are the property of their
respective owners. *Not for In Vitro Diagnostic use in the USA
EW049
DETECTION OF CELL CHANGES IN NEONATAL SEPSIS
BY AUTOMATED WHITE CELL MORPHOLOGY
F. Raimondi
Assistant Professor of Pediatrics, Division of Neonatology,
Department of Pediatrics, Università Federico II, Napoli, Italy
Background: Larger, immature neutrophils pour in the
bloodstream during neonatal sepsis. Current technology
allows to assess the neutrophil volume and distribution, an
index that has previously shown been significantly different in
patients with bacterial infections in the adult. We have studied
automated neutrophil volume and its distribution in late onset
sepsis from very low birth weight neonates.
Patients and methods: Consecutive very low birth weight
symptomatic neonates were screened for sepsis using
complete blood count (CBC), absolute neutrophil count (ANC),
immature /total (I/T) ratio, C- reactive protein (CRP).
Mean Neutrophil volume (MNeV) and neutrophil volume
distribution width (NDW) were determined both in infants with
suspected sepsis and in a group of controls matched for
gender, birth weight and gestational age who were not
symptomatic for sepsis. Blood culture was used as the gold
standard for infection. Receiver operator curves, area under
the curve, sensitivity, specificity, positive and negative
predictive values were calculated for each test.
Results: We enrolled 120 neonates with suspected sepsis and
60 controls. MNeV analysed in cases with sepsis on a single
determination have shown a sensitivity =95% and a
specificity=88%; cut off =148 arbitrary units) performing
statistically better than CRP (sensitivity=65%; specificity=96%;
cut off =0.9 mg/dL) , white blood cells count, ANC and I/T ratio.
NDW was of poor value (sensitivity=80% specificity=52% cutoff=27.5). When CRP and MNeV were considered together,
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biochimica clinica, 2013, vol. 37, SS
sensitivity was unchanged while specificity rose to 97%. MNeV
was positive in 1 out 60 controls.
Conclusion: MNeV is a reliable and inexpensive adjunct and
performs statistically better than the current screening tests
evaluated in patients with neonatal late-onset sepsis.
EW050
EVALUATION OF EMERGING BIOMARKERS IN RENAL
DISEASE
M. Wolf
University of Miami, Miller School of Medicine
The discovery that mutations in fibroblast growth factor 23
(FGF23) cause autosomal dominant hypophosphatemic
rickets transformed our understanding of phosphate
homeostasis in health and disease (White et al. Nat Genet
2000). Since then, the critical role of FGF23 in mineral
metabolism in chronic kidney disease has been established
(Larsson et al. Kidney Int 2003; Gutierrez et al. J Am Soc
Nephrol 2005). Elevated FGF23 has emerged as the earliest
alteration of disordered mineral metabolism in chronic kidney
disease (Isakova et al. Kidney Int 2011). Several studies now
demonstrate that elevated FGF23 is also a novel biomarker
of risk for CKD progression, adverse cardiovascular outcomes
and death among patients with chronic kidney disease (Fliser
et al. J Am Soc Nephrol 2007; Gutierrez et al. N Engl J Med
2008; Isakova et al. JAMA 2011; Kendrick et al. J Am Soc
Nephrol 2011; Jean et al. Nephrol Dial Transplant 2009). Most
recently, FGF23 was demonstrated to be a contributing
mechanism of left ventricular hypertrophy, which may underlie
an important component of its association with high rates of
adverse cardiovascular outcomes (Faul et al. J Clin Invest
2011). These studies elevated FGF23 and disordered
phosphate homeostasis from powerful biomarker to novel
mechanism of cardiovascular disease in chronic kidney
disease. Other novel biomarkers of bone and disordered
mineral metabolism, for example, sclerostin, are under intense
investigation. In addition, controversy continues to swirl as to
the best approach to measure parathyroid hormone in patients
with chronic kidney disease. This session will describe the
latest data on assessing disordered mineral metabolism in
chronic kidney disease and how these biomarkers may
potentially impact the care of the millions of individuals
worldwide who suffer from chronic kidney disease.
EW051
MEASUREMENT OF VITAMIN D METABOLITES IN
PATIENTS WITH CHRONIC KIDNEY DISEASE
J. Souberbielle
Hôpital Necker-Enfants malades Laboratoire d'explorations
fonctionnelles, Paris, France
Until recently, nephrologists neglected the use of native
vitamin D in patients with chronic kidney disease (CKD),
especially in those undergoing haemodialysis, and active
vitamin D analogs were almost exclusively used. Indeed,
native vitamin D was considered ineffective as it would not be
converted to its active metabolite by the damaged kidneys.
Over the last few years, a large body of data on vitamin D in
CKD has accumulated, and practices have changed
substantially. In several observation studies, a negative
association between serum 25OHD levels and all-cause
mortality, but also between serum 25OHD levels and the
progression of renal failure has been reported in CKD patients.
Furthermore, treatment with native vitamin D has been shown
EuroMEdLab 2013 - sciEntific sEssions
to reduce modestly but significantly serum PTH levels in nondialysis, and in dialysis CKD patients, as well as in kidney
transplant recipients. The recent KDIGO guidelines suggest
measuring serum 25-hydroxyvitamin D (25OHD) levels, the
biochemical index of vitamin D store, in patients with CKD
stages 3-5, including those undergoing dialysis, and repeating
this measurement depending on the baseline value and
therapeutic interventions. They also suggest to correct vitamin
D deficiency/insufficiency using treatment strategies
recommended for the general population. These guidelines
do not recommend to measure calcitriol, the active vitamin D
metabolite, with the exception of a few special cases.
However, the fact that calcitriol levels increase in some dialysis
patients when they are given native vitamin D is puzzling and
deserves further studies. Recent data which need to be
confirmed suggested that bioavailable 25OHD levels could be
of better clinical value than total 25OHD level. However, this
index is calculated with the aid of the vitamin D binding protein
serum level, and a careful, evidence-based, cost-benefit
analysis is needed. Finally, as FGF23, which is increased
precociously during the course of CKD, stimulates the 24hydroxylase pathway (inactivation pathway) of vitamin D
metabolism, research on the clinical/biological value of
measuring serum levels of 24-hydroxylated vitamin D
metabolism is currently underway.
EW052
BIOMARKERS IN STROKE DIAGNOSIS,
CLASSIFICATION AND PROGNOSIS
K. Makris
KAT General Hospital, Athens, Greece
Stroke is a devastating condition that encompasses a wide
range of pathophysiological entities that include thrombosis,
hemorrhage, and embolism. Current diagnosis of stroke relies
on physician clinical examination and is further supplemented
with various neuroimaging techniques. The current diagnosis of
stroke remains hampered and delayed due to lack of a suitable
mechanism for rapid (ideally point-of-care), accurate, and
analytically sensitive biomarker-based testing.
A single blood biomarker or better multiple sets of biomarkers
that could be used in an acute setting to diagnose stroke,
differentiate between stroke types, or even predict an
initial/reoccurring stroke or predict the severity and the outcome
of an acute stroke would be extremely valuable.
Also prediction of the severity and the outcome after an acute
stroke is important for clinicians, patients, and researchers. The
best validated clinical prognostic models are probably not
accurate enough to predict outcome in individual patients with
stroke. The performance of clinical models might be improved
by blood markers of any of the pathological processes in acute
stroke such as inflammation, hemostasis, neuronal or glial
injury, and cardiac dysfunction.
We discuss here the diagnosis and classification of acute
stroke focusing on use of novel biomarkers (either solitary
markers or multiple markers within a panel) that have been
studied in a prospective study. For this purpose we have used
the analytical platform of Evidence Investigator from Randox
and the technique employed here is the biochip array
technology (BAT) that allows the quantitative determination of
multiple markers simultaneously. The reason for a multi-marker
approach is that • No single biomarker has ever been
demonstrated to be clinically useful as a standalone diagnostic
test for stroke. •One way to address this difficulty is by
simultaneously evaluating multiple biomarkers that contribute
complementary information. •Preliminary studies suggest that
such a biomarker panel may add time-sensitive diagnostic
information in the early evaluation of stroke
EW053
TOWARDS DEVELOPMENT OF A NOVEL MULTIPLEX
TEST FOR ACCURATE STROKE DIAGNOSIS
EMPLOYING BIOCHIP ARRAY TECHNOLOGY
C. Richardson
Randox Laboratories Ltd, Crumlin, UK
Stroke is the third leading cause of death worldwide and can
be defined as the rapidly developing loss of brain function due
to interruption in the blood supply to the brain. In order to
minimise neurological damage following stroke, it is crucial
that stroke patients are rapidly and accurately diagnosed so
that appropriate treatment can be administered.
At present, the diagnosis of ischaemic stroke is particularly
challenging due to the poor sensitivity of computerised
tomography for ischaemic stroke identification. Magnetic
resonance imaging (MRI) does have improved sensitivity for
ischaemic stroke detection but the employment of MRI can be
limited by restricted accessibility and the unsuitability of this
approach in certain acutely ill patients. Consequently, there
remains a reliance on an experienced stroke clinician to make
an ischaemic stroke diagnosis by supplementing brain
imaging results with a physical examination of the
patient.There is an urgent need for a rapid blood test for
ischaemic stroke diagnosis to be developed to confirm clinical
and imaging observations. This test would ideally be low-cost
and applied to near patient technology. It is anticipated that a
panel of biomarkers will be required for the development of a
robust diagnostic test for acute stroke diagnosis. Randox aims
to develop such a test by employing their proprietary biochip
array technology (BAT) to multiplex a unique collection of
stroke biomarkers.
In this talk, we will detail on-going efforts to develop a stroke
multiplex test and discuss the clinical promise exhibited by
candidate biomarkers for this multiplex array. Candidate
biomarkers include glutathione S-transferase pi (GSTP1),
nucleoside diphosphate kinase A (NDKA) and Parkinson
disease protein 7 (PARK7 also called DJ-1). A recent
publication concluded that these 3 biomarkers performed best
from a total of 29 biomarkers evaluated with respect to
differentiating stroke patients from controls and discriminating
early time-point from late time-point stroke patients. This study
has suggested that GSTP1 monitoring has the potential to
significantly increase the number of patients having access to
life-saving thrombolytic therapy due to the ability of this
biomarker to accurately predict the time of stroke onset.
EW054
EARLY DIAGNOSIS OF MYOCARDIAL INFARCTION
USING HIGHLY SENSITIVE TROPONIN I ASSAYS
C. Müller
Cardiology, University Hospital Basel, Switzerland
Background: Patients with symptoms suggestive of acute
myocardial infarction (AMI) account for about 10% of all
emergency
department
(ED)
consultations.
Electrocardiography (ECG) and cardiac troponin (cTn) form
the diagnostic cornerstones and complement clinical
assessment. A limitation of former generation cTn assays is a
delayed increase of circulating levels for mandating serial
sampling for 6-12 h with delays in diagnosing disease (“rulein”) and delays in excluding disease (“rule-out”). The recently
developed sensitive and high-sensitivity cardiac troponin (hscTn) assays have enabled measurement of cTn
concentrations not reliably detected before. The new tests
have been shown to improve the diagnostic accuracy for AMI
biochimica clinica, 2013, vol. 37, SS
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EuroMEdLab 2013 - sciEntific sEssions
at presentation, and rule-in and rule-out of AMI might be
feasible more rapidly. On the other hand the number of
positive hs-cTn results in various acute and chronic conditions
with cardiac involvement other than AMI has increased. As a
consequence, the positive predictive value (PPV) of an
elevated hs-cTn level has decreased, and many physicians
treating patients with symptoms suggestive of AMI have been
confused. It is currently unknown how to best take advantage
of the novel hs-cTn tests in clinical practice. Accordingly, there
is an on-going debate whether and to what extent a shortening
of the time interval to the second sample is feasible and safe.
The aim of this presentation will be to highlight an algorithm for
rapid rule-in and rule-out of AMI using hs-cTnI levels
Methods: In a prospective, observational, multicenter study
enrolling consecutive patients presenting with acute chest
pain, we derived and validated algorithms on how to best apply
hs-cTnI data either alone or in conjunction with other clinical
information. Blood samples were collected at presentation and
after 1,2,3 and 6 h in a blinded fashion. The final diagnosis
was adjucated by 2 independent cardiologists using all
information including hs-cTnT values. All patients also
received long-term follow up.
Results: The results will be presented and discussed.
Conclusions: Validated algorithms will help clinicians to best
use the advantages provided by novel hs-cTnI assays in the
early rule-in and rule out of AMI.
EW055
GALECTIN‐3 AS A BIOMARKER IN HEART FAILURE
MANAGEMENT
R. De Boer
University Medical Center Groningen, The Netherlands
Cardiac remodeling in response to myocardial stress and
injury is the main precursor for heart failure (HF). Despite the
availability of numerous pharmacological and device
therapies, HF remains a major burden to global health care
associated with substantial morbidity and mortality. Therefore,
there is an ongoing need for better HF diagnostics, risk
stratification, and improved therapeutics. Experimental and
clinical research has suggested that galectin-3, a βgalactoside-binding lectin, acts a key player in the maladaptive
response to myocardial injury. Galectin-3 exerts its role in
inflammation and fibro genesis, which are key mediators of
cardiac remodeling and HF. In experimental studies, it was
shown that galectin-3 is secreted by activated macrophages,
and turns quiescent fibroblasts into active matrix secreting
myofibroblasts. Disruption and blockade of galectin-3
attenuates and reverses the HF progression. By hitherto
unknown mechanisms, galectin-3 is secreted into the systemic
circulation and can reliably be measured. Plasma galectin-3
levels independently predict outcome in human patients with
acute and chronic HF. Furthermore, in the general population,
plasma galectin-3 levels strongly associate with
cardiovascular risk factors and independently predict mortality
and new-onset HF. There a several issues that need further
clarification. First, there are indications that galectin-3 may be
particularly important in specific forms of HF, e.g. HF with
preserved ejection fraction and the cardio renal syndrome.
Second, to date no studies have been conducted to show that
the use of galectin-3 as a biomarker changes our daily clinical
routine. Such galectin-3-based clinical decision making would
clearly strengthen the case for the use of galectin-3, and
currently trials are ongoing that endeavor this concept. Finally,
galectin-3 seems to be more than just a marker: it may be a
pathophysiogical layer in HF. If proven, this would open up
possibilities for galectin-3-targeted therapy.
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biochimica clinica, 2013, vol. 37, SS
EW056
BIOMARKERS OF CARDIO‐RENAL RISK AND CLINICAL
OUTCOME
P. Murray
Mater Misericordiae University Hospital, Dublin, Ireland
Congestive heart failure is commonly (30%) associated with
chronic kidney disease (CKD), which complicates
management and worsens outcomes. Furthermore, acute
kidney injury (AKI) is common (30% incidence) in patients
hospitalized with acute decompensated heart failure (ADHF),
and is associated with increased morbidity, mortality,
management complexity, and cost. Efforts over many decades
to prevent or treat AKI in such high-risk patients have been
hampered by lack of time-sensitive and mechanism-specific
markers for AKI to target early interventions. In AKI, serum
creatinine (the generally accepted “standard of care” test for
the clinical diagnosis of AKI) may not increase until days after
renal tubular injury has begun. Furthermore, because serum
creatinine is primarily a functional marker of glomerular
filtration, it is not optimally suited to diagnose AKI, but rather
serves to define severity of the resulting loss of renal function.
Use of serum creatinine increments for AKI case definition has
led to the conduct of numerous unsuccessful clinical trials of
putative therapies for AKI in patients with established acute
tubular injury and a significantly elevated creatinine. Creatinine
changes that define AKI by validated classification systems
(RIFLE, AKIN, WRF- worsening renal function), are currently
the most useful biomarkers for AKI case identification and
staging. Whichever functional criterion is used for AKI case
definition (oliguria is another), appropriate differential
diagnosis and prognostic assessment can be further improved
by the use of traditional and novel biomarkers of renal tubular
damage. These markers can be used to differentiate cases of
acute tubular necrosis (ATN) versus prerenal azotemia or
chronic kidney disease, potentially leading to more accurate
diagnosis, and improved triage and management. In patients
with CHF, the use of cardiac biomarkers such as BNP can help
to effectively reverse prerenal azotemia caused by ADHF,
while monitoring of kidney damage markers can provide
additional safety and prognostic information. In tandem with
timely, sensitive, and specific markers of kidney damage, more
time-sensitive markers of acute functional GFR change may
further improve the monitoring and diagnostic assessment of
AKI in the future.
EW057
LABORATORY PERSPECTIVES IN THE DIAGNOSIS AND
MONITORING OF PLASMA CELL DYSCRASIA
J.A. Katzmann
Department of Laboratory Medicine and Pathology, Mayo
Clinic, Rochester, MN, USA
Background: Quantitative immunoassays for serum free light
chain (FLC) have changed the approach to identifying and
managing monoclonal gammopathies. The FLC assay has
been incorporated into diagnostic screening panels, prognostic
testing, and disease monitoring.
Methods: Summary of current published data on the impact of
FLC assays on diagnosis, monitoring, and prognosis of
proliferative plasma cell diseases. International guidelines and
recommendations by expert groups will be reviewed.
Results: The diagnostic sensitivity of the FLC K/L ratio for
detecting monoclonal free light chains has decreased the need
for urine as part of the screening panel for monoclonal
gammopathies. The recommended panel is serum PEL, IFE,
EuroMEdLab 2013 - sciEntific sEssions
and FLC (urine studies are also suggested if AL is suspected).
For the laboratory, this means that urine PEL will be
predominantly performed for assessment of renal function and
quantitation of urine M-spikes and that highly concentrated
urine will rarely be required. The FLC K/L ratio is also useful for
prognosis of MGUS and SMM progression to MM. MGUS
progresses at 1%/yr. Patients with a normal FLC ratio
(0.25–1.65), an M-spike <15 g/L, and a gamma heavy chain
have a 0.1%/yr risk of progression (2% lifetime risk). Low-risk
MGUS patients don’t need monitoring unless clinical symptoms
occur. Identification of low-risk MGUS will decrease medical
costs and patient anxiety. For the laboratory, this means we
need to change our recommendations for long-term follow-up.
FLC quantitation also has a role in disease monitoring. To date,
that role has been restricted to patients with no measurable
serum or urine M-spike. The long-term variability of serum FLC
and urine M-spike measurements, however, are comparable,
and either should suffice for monitoring. For the laboratory, this
means additional requirements to reduce inter-assay variability
and eliminate artifacts due to dilution and antigen excess.
Conclusions: Quantitative FLC immunoassays must be
integrated into the electrophoretic and nephelometric
processes used for evaluating plasma cell dyscrasias. Their
use increases diagnostic sensitivity, reduces the need for highly
concentrated urine, and increases the need for consistent
laboratory test protocols for disease monitoring.
EW058
MULTIPLE MYELOMA IN CLINICAL PRACTICE: FROM
DIAGNOSIS TO TREATMENT AND FOLLOW-UP.
O. Decaux
Internal Medicine Department, Rennes University Hospital,
France
Background: Measurement of serum free light chains (FLC)
is a valuable laboratory test for monitoring of patients with light
chain or oligosecretory multiple myeloma and AL amyloidosis.
A single test available since 2001 has been used to establish
value thresholds for response criteria. A new test for serum
FLC* was developed recently. These tests differ in the
characteristics of the antibody employed (monoclonal vs.
polyclonal). Absolute concentrations of FLC observed with
these tests are different without the possibility of applying a
conversion factor. The objective of our study is to evaluate if
the tests are comparable for follow-up of patients, in particular
for the evaluation of response to treatment.
Methods: This study aims to compare these two tests in the
follow-up of patients with multiple myeloma or AL amyloidosis.
The secondary objective is to estimate the percentage of
discrepancy between the tests in a large cohort of patients with
various plasma cell proliferative disorders. All the patients in
our institution for whom the serum FLC assay is prescribed
will be included, regardless of the reason for prescription. The
planned period of inclusion runs from July 1 to December 31,
2012. During this period, the Biochemistry laboratory will
perform measurements with both tests for all prescriptions of
the serum FLC assay. Patients treated for multiple myeloma or
AL amyloidosis are followed every 3 or 6 weeks (according to
the plan of chemotherapy) and will thus have samples
collected at least four times during the 6-month period of the
study.
Results: As of December 31, 2012, we have collected 1380
samples corresponding to 771 patients. 203 patients have
been tested at least twice. Diagnosis is known for 249 patients.
The main diagnoses are multiple myeloma (142 patients),
MGUS (103 patients),and AL amyloidosis (15 patients). We
observed good agreement between the two tests for kappa
(concordance 88% and Cohen’s κ 0,789), lambda (82%,
0,690) and kappa/lambda ration (85%, 0,759). We compared
evolution of FLC concentrations during follow-up of 127
multiple myeloma. Evolution was concordant for 121 patients
(95%). We observed discordant evolution in 6 patients (5%).
Conclusion: Our results confirm good agreement between the
two tests for diagnosis but also for evaluation of response.
However we observed few discordant results which
emphasize the need to correlate the results of FLC tests with
results of traditional tests and with clinical outcome.
*not available for sale in the U.S.
EW059
APPLICATION OF NEW MONOCLONAL FREE LIGHT
CHAIN METHODS IN MONITORING MONOCLONAL
GAMMOPATHIES
D. Ricotta
Dept. of Molecular and Translational Medicine, University of
Brescia, Italy
Background: Para proteins are made up of intact
immunoglobulin, single light chains (Ig free light chains [FLC]),
or, more rarely, single heavy chains. FLC kappa and lambda
have long been considered by-products of plasma cells, but
recently published data indicate that FLC may account for
some specific functions during immune response. An abnormal
FLC ratio (FLCR) has proven to be predictive for progression
of MGUS, solitary plasmacytoma of bone, amyloidosis, multiple
myeloma (MM), Waldenstrom’s macroglobulinemia, and
smoldering MM. Development of a first assay that evaluates
FLC production has allowed study of many instances of
“plasma cell dyscrasia” and identified a novel FLC MGUS
population. Recently, new N Latex FLC kappa and lambda
assays have been introduced, and the scenario has become
more complex.
Methods: We began working with FLC assays 6 years ago, and
we introduced the N Latex FLC assays* in May 2012 with the
following protocol: a) Each previously undiagnosed is tested
with both assays. If no differences are observed, the N Latex
FLC results are included in the database, and the patient is
assigned for further monitoring with N Latex FLC assays alone.
If differences are observed, both serum/urine immunofixation
and clinical history are evaluated for decision making. b)
Patients with previously diagnosed gammopathies are tested
with the N Latex FLC assays, and if major discrepancies are
observed, the complete profile is evaluated (serum
immunofixation and urine immunofixation) and discussed with
clinicians.
Results and conclusions: The data are validated, and each
patient is assigned accordingly to the chosen method (the
assigned method is only visible for the laboratory operators).
To date, 800 routine samples have been processed. We were
able to compare 593 patients data and history (50% polyclonal
and 50% monoclonal). Considering the ratio we found a good
correspondence in policlonal samples (95%) and a lower
correspondence (81%) in monoclonal samples. The analysis
of 5 specific monoclonal components revealed that FLCs
quantification can be affected by the presence of FLCs dimers
and trimmers.
*not available for sale in the U.S.
biochimica clinica, 2013, vol. 37, SS
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EW060
METHODOLOGICAL APPROACH TO QUANTIFY
CLINICAL AND ECONOMIC CONSEQUENCES
L. Annemanns
Ghent University and Brussels University, Belgium
Background: The conflict between what societies are able to
pay for health care and the population’s need for health care is
still increasing. Health economics aims to find the best possible
way to spend the available financial means. In order to apply
economic thinking to healthcare, one should view the health
sector as a productive sector whose aim is to produce health,
by ensuring that people live longer and/or more healthily.
Priority must be given to those health investments which result
in the greatest amount of health for the money that is invested.
Interventions with a good ratio between the invested money
and the resulting health outcome are called cost-effective. Over
the past years several health economic evaluations have been
performed and published in the field of diagnostics.
Methods: A review of the literature was performed to obtain
insight in the differences in methods and in applied decision
criteria. A common tool was proposed and presented to payers
and to experts in the field.
Results: Many different health economic approaches towards
diagnostics are observed, applying different perspectives, and
different outcome parameters. The level of required evidence
varies a lot among advisory bodies and decision makers. HTA
bodies such as NICE in the UK or the KCE in Belgium require
high methodological standards and expect results in the format
of cost per QALY (quality adjusted life year) gained. The QALY
combines quality and quantity of life in one parameter and is
theoretically the best approach to express health gains. Other
decision makers criticize the practical implementation of the
QALY and yet other only consider costs and budget impacts
thereby missing an important part of the picture. We proposed
a set of common criteria (a ‘tool’) for the evaluation of health
investments for diagnostics. A key observation is that without
added clinical utility of a diagnostic test there can be no
additional economic value.
Conclusions: Current decision making on paying for
diagnostics with public means is characterized by high diversity
in methods and applied criteria. Diagnostic companies should
strive to show the clinical utility of their diagnostic tests as a
key requirement to demonstrate value for money.
EW061
IVD ADDED VALUE IN CARDIAC SURGERY
O. Stanger
Royal Brompton & Harefield NHS Trust, London, UK
Background: Patients after cardiac surgery have an increased
risk to develop acute kidney injury (AKI), which can significantly
increase the length of stay (LOS) in the intensive care unit
(ICU) and the overall stay in the hospital. The decision to initiate
hemofiltration therapy (HF), the treatment of choice for AKI after
cardiac surgery is currently made on decrease in urine output
and increased plasma creatinine levels, a late marker for
detection of AKI. The novel urine marker NGAL (neutrophilgelatinase-associated lipocalin) is able to measure the acute
structural ischemic damage after renal reperfusion can
therefore identify need for HF earlier.
Methods: From 2006 to 2009 an average of App 503
patients/year underwent cardiac surgery in Salzburg from 2006
to 2009, and the identical experienced medical team was
responsible for ICU and RRT patient management between
2006 and 2010.
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biochimica clinica, 2013, vol. 37, SS
In 2010, urine NGAL as early was included into the decisionmaking algorithm as the only change as compared to
2006-2009. Incidences of HF need and length of therapy (LOT)
were recorded and compared. Costs associated with routine
NGAL testing, need for HF and ICU stay were analyzed, and
the economic impact of the new algorithm was determined.
Results: In 2010, 528 patients were operated with no statistical
differences in numbers, case mix, risk scores and outcomes to
previous years. With the inclusion of NGAL into the algorithm
for HF-initiation (2010) HF was initiated in 26% less patients
(14 patients) but also start of HF was on average 1.1 days
earlier compared to 2006-2009. Length of therapy decreased
by 25%. Comparison of direct costs for HF therapy based on
expected versus actual seen HF cases in 2010 resulted in
calculated overall savings of more than € 120 000, which
corresponds to more than € 200 per cardiac surgery patient.
This does not yet include savings associated with reduced or
avoided ICU stay. In the current study this would result in more
than 200 ICU days saved.
Conclusion: Routine NGAL testing in patients after cardiac
surgery and consecutive changes in management reduced the
number of HF therapies, the length of therapy and the overall
ICU stay in our institution resulting in substantial net savings
maintaining high quality of patient care.
EW062
DIFFERENT TECHNICAL APPROACHES TO
CLOSTRIDIUM DIFFICILE DIAGNOSIS
F. Barbut
National Reference Laboratory for Clostridium difficile, Paris,
France
The epidemiology of C. difficile infection (CDI) has dramatically
changed over the last decade. Currently, C. difficile is
recognized as the most frequent etiologic agent of healthcareassociated diarrhoea in hospitalized adult patients. In this
context, a rapid diagnosis of CDI is a key step in the successful
management of the disease. It enables the physician to initiate
treatment of the patient expeditiously and to implement control
measures rapidly to avoid cross-contamination. Moreover, an
accurate diagnosis is also essential to get reliable data for
surveillance, in order to assess the efficacy of intervention
measures to reduce CDI. Currently there is no single “gold
standard” for the diagnosis of CDI but two reference methods
which actually detect different targets: the stool cytotoxicity
assay detects the presence of “free” C. difficile toxins in stool
samples (primary toxin B but also toxin A) and the toxigenic
culture detects C. difficile isolates in stool that have the
potential to produce toxins. The crucial question about the
clinical significance of the presence of a toxigenic C. difficile
strain in the stool without any free detectable toxin is still matter
of debate. Both reference methods are long, time consuming,
and require 24-48 h to produce results. Since 2009, nucleic
acid amplification tests (NAATs) based on the detection of
either tcdA or tcdB genes (which encode for toxins A and B,
respectively) have become commercially available. These
methods showed a good correlation with toxigenic culture.
Results can be provided to clinicians within the same day as
the stool sample. According to the different assays, the tests
are amenable to both batch and on demand testing. The cost
of these assays is still prohibitive for many laboratories and
their place among the different diagnostic options remains to
clarify. A two-step algorithm using the detection of glutamate
dehydrogenase (GDH) as a rapid screening test followed by a
confirmatory test for the GDH-positive stools was proposed by
the recent American and European guidelines. The impact the
rapid methods for the diagnosis of CDI on patient’s
management should be evaluated.
EuroMEdLab 2013 - sciEntific sEssions
EW063
THE PROBLEMATIC OF NOSOCOMIAL INFECTIONS BY
CLOSTRIDIUM DIFFICILE
M. Delmee
UCL Microbioly Unit, Brussels, Belgium
Since its discovery in 1978, Clostridium difficile has emerged
as a major nosocomial pathogen. It is the leading cause of
antibiotic-associated diarrhoea, with a clinical spectrum of the
disease ranging from mild diarrhoea to life-threatening
pseudomembranous colitis. The main virulence factors are two
high molecular weight exotoxins, namely toxins A and B that
both exhibit cytotoxic and enterotoxic activities.
Ten years ago, the epidemiology of C. difficile infections (CDI)
dramatically changed in North America and Europe. A
significant increase of incidence as well as of severity of CDI
were reported on both sides of the Atlantic ocean. The rapid
emergence and spread of a specific clone of C. difficile was
rapidly demonstrated. This clone constitutes a specific type
that belongs to PCR-ribotype « 027 » or pulsotype « NAP1 ».
The increased virulence of this clone is associated with the
overproduction of toxins A and B and the production of binary
toxin. Primarily detected in North America, C. difficile « 027 »
was rapidly identified in outbreaks that occurred in several
european countries (UK, The Netherlands, Belgium and
France). In elderly patients, the mortality linked to CDI caused
by the 027 ribotype reached sometimes percentages higher
than 10%. Hospital outbreaks of CDI are frequent. They are
mainly due to the rapid contamination of the environment by
spores disseminated by the diarrhoeal stools. Hence, an early
and accurate diagnosis of CDI is a keystone in the optimal
management of this nosocomial disease. Firstly it allows to
initiate an adequate therapy but, moreover, it also allows to
implement hygiene and infection control measures in the
patient’s room. All strategies should aim at a same-day
diagnosis in case of suspicion of CDI. In case of a positive
result, the immediate treatment of the patient will improve his
condition and limit the risk of room contamination. And the
rapid implementation of hygiene measures will prevent further
spread of the disease. With such a goal and such implications
however, the accuracy of the laboratory diagnosis is of crucial
importance. False positive results may induce inadequate
treatment and increase cost due to isolation procedures and
false negative results may lead to outbreaks.
EW064
LABORATORY MANAGEMENT OF DIABETIC PATIENTS
CARRYING HEMOGLOBIN DISORDERS
D.Sacks
National Institutes of Health, Bethesda, USA
The prevalence of diabetes is increasing rapidly. There are
estimated to be 366 million people in the world with diabetes
and by 2030 this number is expected to reach 552 million. The
clinical laboratory has a fundamental role in the management
of patients with diabetes. The analyzes most commonly
measured are glucose and hemoglobin A1c (HbA1c). Glucose
is measured in the clinical laboratory for diagnosis and by the
patients themselves for monitoring. The HbA1c concentration
indicates the average glucose over the preceding 8-12 weeks
and provides an additional criterion for assessing glycaemia.
Large prospective randomized clinical trials, most notably the
Diabetes Control and Complications Trial (DCCT) and United
Kingdom Prospective Diabetes Study (UKPDS), documented
that HbA1c predicts the risk for developing micro vascular
complications. Several influential clinical organizations have
recently advocated HbA1c for diagnosis of diabetes,
augmenting the contribution of HbA1c to diabetes.
Hb abnormalities may be cause by defects in the Hb molecule
(Hb variants) or change in the production of one of the subunits
(thalassemia). Over 1150 Hb variants have been identified, the
most common of which are HbS, HbE, HbC and HbD. HbA1c
can be measured accurately in individuals heterozygous for
the common Hb variants, provided an appropriate method is
used (see www.ngsp.org). In subjects with homozygous variant
Hb or altered erythrocyte survival, HbA1c does not reflect
glycaemia. Extracellular markers of long-term glycemia (10-14
days), most commonly fructosamine or glycated albumin, are
independent of both erythrocyte lifespan and Hb modifications.
However, they are altered by changes in albumin turnover and
clinical studies are limited. Moreover, there are neither outcome
data that unequivocally link these analyses to diabetic
complications nor agreed target values for optimum glycemic
control. While useful in conditions where HbA1c cannot be
used, until more data are available their clinical value is limited.
Measurement of HbA1c provides valuable information for the
overwhelming majority of diabetic patients. A knowledge of the
conditions that alter HbA1c enables appropriate use of HbA1c
in patient management.
EW065
CARBAMYLATED HEMOGLOBIN IN DIABETES AND
RENAL DISEASES
P. Gillery
Laboratory of Pediatric Biology and Research, University
Hospital of Reims, France
HbA1c, the major glycated hemoglobin fraction, is
characterized by the binding of glucose to the N-terminal valine
residues of globin beta chains. It is considered the gold
standard of diabetic survey and has been proposed for
diabetes diagnosis. Besides glycation, other nonenzymatic
modifications can affect hemoglobin and other proteins. During
chronic renal failure (CRF), Hb is also modified by
carbamylation, due to the nonenzymatic binding of isocyanic
acid, mainly formed in vivo by spontaneous dissociation of
urea, to N-terminal extremities of globin b chains, generating
carbamylated hemoglobin (cHb).
Whereas cHb has been described as a classical interference
in HbA1c assays, since cHb could co-migrate with HbA1c,
most of currently available methods are no more prone to this
interference in the majority of patient samples. However, the
threshold of interference varies according to the method used.
Besides, the formation of other adducts due to the
accumulation of various mid-sized molecules modifies the
chromatographic pattern of hemoglobin. Thus, the
interpretation of HbA1c results in patients with renal disease
must be cautious.
cHb assay has been proposed during CRF as marker of
"uremic memory", cHb rate being correlated with uremia and
duration of exposure to urea. Besides, cHb could be used to
differentiate acute renal failure (ARF) from CRF, and could
constitute a time-integrated urea index in hemodialysis.
However, like in the case of HbA1c, many factors may interfere
with red blood cell metabolism in patients with CRF (e.g.:
shortened RBC lifespan, erythropoietin therapy) and alter the
semiological value of the assay. The assessment of markers of
plasma protein carbamylation (e.g.: e-carbamyl lysine, also
called homocitrulline) may constitute a valuable alternative.
Finally, it must be noticed that carbamylation and glycation,
which both alter structural and functional properties of proteins,
compete for the same NH2 sites, especially at the N-terminal
valine of globin beta chains. It may be hypothesized that HbA1c
formation may depend on the actual Hb carbamylation rate.
biochimica clinica, 2013, vol. 37, SS
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EW066
ACHIEVEMENT OF DESIRABLE ANALYTICAL GOALS
AND WORKFLOW IMPROVEMENT FOR HBA1c
TESTING: AN INNOVATIVE PROPOSAL
A. Mosca
Dip. di Fisiopatologia Medico-Chirurgica e dei Trapianti,
Centro per la Riferibilità Metrologica in Medicina di
Laboratorio (CIRME); Università degli Studi di Milano, Italy
The use of HbA1c for diagnosis increases the need for
improved assay precision and accuracy, as well as reduced
interferences. In addition, variant detection is critical in the aid
of diagnosis since the clinical cut-off of HbA1c in patients
carrying a variant is unknown. The growing epidemic of
Diabetes is also increasing HbA1c testing volumes and,
consequently, this drives the need for workflow efficiencies.
Automated testing systems should deliver faster time to result,
easy to use technology and reduced time for interpreting
results. Laboratories are experiencing the tightening of criteria
for accuracy and precision from the National Glycohemoglobin
Standardization Program (NGSP) for certification. Effective
September of 2012, NGSP requires that 37/40 HbA1c results
must be within ±7% of target value for an HbA1c method to
pass NGSP certification. The FDA is also expected to have
more stringent requirements for HbA1c testing such as
improved precision of <2% CV, reduced bias to <±2%, and little
to no interferences with any hemoglobinopathies for tests used
in the diagnosis of Diabetes. In Europe, laboratories are
expected to maintain IFCC criteria and, for most of the
countries, to report in mmol/mol units. To this regard, recent
evidences based on biological variation indicate that the
desirable goals for imprecision, bias and total error be ≤1.3%,
≤±1.9% and ≤±3.9%, respectively. This presentation will
introduce the D-100 Hemoglobin Testing System from Bio-Rad
Laboratories and show how this system offers a solution to the
new guidelines and requirements for HbA1c testing. The D-100
Hemoglobin Testing System offers the security of High
Performance Liquid Chromatography (HPLC) HbA1c results
and focuses on innovative solutions for workflow efficiency.
Partnered with an accurate and precise HbA1c assay, workflow
efficiencies are demonstrated with a quicker time to result,
reduced hands on time with reagents, simple calibration,
automatic test parameter updates, stat capability, intuitive user
interface and automated result review.
EW067
A PERSONALISED SOLUTION FOR CLINICAL
CHEMISTRY LABORATORIES.
M. Plebani
Department of Laboratory Medicine, University-Hospital of
Padova, Italy
Several pressures have strongly affected and still influence the
organization of laboratory activities and workflows, through
processes of consolidation, merger, and downsizing of existing
clinical laboratories. In several countries, there is also a
widespread and often deregulated introduction of point-of-care
testing devices that sometimes integrate or replace clinical
laboratories. Therefore, a key characteristic of present and
future laboratory instruments is flexibility. In particular, an IVD
manufacturer should offer a personalised solution to allow the
individual clinical laboratory to meet specific clinical needs.
Mindray BS-800 Modular System Unit 1 (BS-800M1) and
Mindray BS-2000 Modular System Unit 1 (BS-2000M1)
represent two modular systems manufactured by Shenzhen
Mindray Bio-Medical Electronics Co., Ltd. (Mindray Shenzhen,
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biochimica clinica, 2013, vol. 37, SS
China) offering a considerable range of spectrophotometric and
immunoturbidimetric assays with different throughputs
(tests/hour): 800-1200 for BS-800M1; 2000 (up to 2200 with
ISE) for BS-2000M1. The main analytical characteristics of both
analyzers have been evaluated and compared according to the
Clinical Laboratory Standard Institute (CLSI) guidelines. In the
imprecision study (within run, n=20), the obtained analytical
coefficients of variation ranged between 0.28 and 2.67% (BS800M1) and 0.26 and 1.71% (BS-2000M1). In the method
comparison studies, 120 serum and lithium-heparin plasma
(respectively immunoturbidimetric and spectrophotometric
assay) samples from the routine analysis have been analyzed
on both the BS-800M1, BS-2000M1, the Modular DP and
Cobas 6000 analyzer (chemical analytes, Roche Diagnostics,
Germany) and Dimension Vista (serum proteins, Siemens
Health Care Diagnostics, USA): the resulted range of linear
regression coefficients (r2) was 0.89 -1.00 (BS-800M1) and
0.90 - 1.00 (BS-2000M1).
The observed analytical performances, speed and
practicability, endorsing current recommended quality
specifications, resulted satisfactory and comparable between
the evaluated systems. Therefore, BS-800M1 and BS-2000M1
represent flexible and expandable analytical platforms meeting
specific clinical needs in different clinical laboratories, ensuring
reliable and comparable results at the same time.
EW068
MANAGING DEMAND FOR LABORATORY TESTING IN A
TIME OF ECONOMIC CRISIS.
J.L. Bedini
Sociedad Española de Bioquímica Clínica y Patología
Molecular, Spain
With a constant increase in laboratory testing and a consistent
decrease in health care resources, clinical laboratories need
more active management in laboratory testing.It is well known,
especially within hospitals, that some laboratory tests are
ordered too often, time intervals being too short between
consecutive tests, with no real clinical or patient care
justification. Moreover, the use of request protocols, in which a
number of tests are carried out simultaneously, and the everincreasing general use of electronic ordering for laboratory
tests mainly through the Hospital Information System (HIS),
has also decisively contributed to increased activity, sometimes
unnecessary or redundant. Whether laboratory testing is
genuinely needed or not is an ongoing point of discussion.
Different studies have suggested that up to 40% of the testing
is questionable and 30% is attributed to unnecessary test
repetitions. Managing the demand for laboratory tests can be
useful for improving laboratory efficiency and the reduction of
unnecessary activity. Due to the complexity of work in the
laboratory area, development of managing tools are limited,
based mainly on automated test rejection, avoid repeat testing,
and redefinition of clinical and request protocols. At this
moment, we would like to offer our experience in the
development and implementation of a tool for managing the
demand for laboratory testing. Via HIS, in the moment of an
electronic laboratory order, the following information appears:
minimum time suggested between two consecutive
measurements of the same parameter, and the date and result
of the previous order. When the order for a particular test is
requested before the end of this suggested interval, an alarm
is displayed on the HIS screen. With this information, the
physician, taking into account specific patient care needs, can
decide whether or not to order routine tests, while more
specialized tests can be automatically rejected.
The implementation of this tool, together with regular updates
and redefinitions of request protocols, including the
EuroMEdLab 2013 - sciEntific sEssions
agreements between clinical departments regarding laboratory
activity, has led to a remarkable reduction in both activity and
budget.
EW069
INTRODUCTION TO RENIN AND ALDOSTERONE
TESTING
A. Morganti
U.O. di Medicina Interna, Centro Ipertensione Arteriosa,
Ospedale San Giuseppe
Derangements in the activity of the renin-angiotensinaldosterone system (RAAS) play a pivotal role in causing a
number of frequent and serious cardiovascular diseases. On
the other hand a large body of evidence was accumulated
showing that pharmacological blockade of RAAS may prevent
or relent the unfavourable outcome of these diseases. Thus, it
would be highly desirable having accurate and reproducible
methods for measuring the components of RAAS.
Unfortunately this is not the case. Indeed renin, the driving
force of RAAS, is traditionally measured as plasma renin
activity (PRA, ng/ml/h) i.e. as a function of the action of renin
on angiotensinogen to generate Angiotensin I which is
subsequently quantified by radioimmunoassay. This timehonoured enzymatic assay is admittedly very accurate but
time-consuming and scarcely reproducible among laboratories.
As an alternative to PRA, new assays, which measure plasma
renin concentration (PRC, pg or µU/ml), were developed.
These direct assays exploiting the high specificity of
monoclonal antibodies directed against a specific epitope of
the renin molecule, have the advantage of being fast and
reproducible but were criticized because of the lack of
sensitivity that is required for measuring the very low levels of
renin which are found in primary hyperaldosteronism (PHA).
However recent refinements of these direct assays have further
improved their sensitivity and PRC is progressively replacing
PRA. The appropriate assessment of the aldosterone/renin
ratio, that is, at present, the recommended screening test for
PHA, brings about the reliability of aldosterone assays.
Aldosterone is usually quantified by radioimmuno assay after
an extraction from plasma, an essential step that is often
overlooked in many laboratories. This limitation, in combination
with the use of an array of detection antibodies with different
sensitivities, make the measurement of aldosterone among
laboratories quite erratic, at best. However also in this area the
availability of monoclonal antibodies and of new
chemiluminescent tracers promise to provide new, accurate
and fast methods very convenient for assessing aldosterone
in the every day clinical setting.
EW070
PLASMA ALDOSTERONE TO RENIN RATIO ON AN
AUTOMATED ANALYSER USING TWO NOVEL
CHEMILUMINESCENCE IMMUNOASSAYS: ONE-YEAR
EXPERIENCE
J. Manolopoulou
IDS, Boldon, UK
Inappropriately high levels of aldosterone as in Primary
aldosteronism (PA) can lead to cardiovascular damage and
other complications. According to recent guidelines the
aldosterone to renin ratio (ARR) is recommended for screening
in groups with an increased prevalence, and aldosterone after
salt load testing can be used to confirm the diagnosis. Due to
the lack of assay harmonization, method specific cut-off values
are mandatory. We present data on our experience with two
novel immunoassays for aldosterone and renin on the IDSiSYS automated analyser. Aldosterone and renin levels were
measured in 130 healthy, 166 essential hypertensive (EH) and
117 PA patients to determine the ARR using the IDS-iSYS
analyser (Boldon, UK). Furthermore, the iSYS Aldosterone
assay was also used to examine levels during the salineinfusion confirmatory test in PA (n=27), EH (n=49) and
confirmed non-PA (n=65). Based on our experience with our
previous routine assay, PA was defined by lack of aldosterone
salt-load suppression to <5 ng/dL using the Siemens RIA.
Mineralocorticoid receptor antagonists and b-blockers were
excluded. Hypokalemia was controlled in all subjects. Our
traditional cut-off during screening for PA is 1.2 [Siemens PAC
(ng/dL)/Liaison DR (mU/L)]. Good agreement was seen
between the iSYS and Siemens aldosterone assays (y=1.1x ±
0.02, R2=0.942, n=275) and iSYS and Diasorin Liaison renin
assays (y=1.05x ±3.13, R2=0.921, n=137). ROC curve analysis
of PA vs EH ARR values showed that a slightly lower cut-off at
1.1 [ng/dL]/[mU/L] would provide a 96.6% sensitivity with 87.4%
specificity using the iSYS assays, equivalent to the currently
used methods. Sodium-load confirmatory testing revealed 3 of
27 PA cases with false negative suppression and 1 confirmed
non-PA patient case with a borderline non-suppressible
aldosterone using both the Siemens and iSYS assays. In
conclusion, the data suggest a similar cut-off to the one
currently used for the ARR at >1.1 [ng/dL]/[mU/L] could be used
to diagnose PA as well as a similar confirmatory post-saline
cut-off at >5ng/dL. The availability of a completely automated,
single-sample method would provide a simpler and higher
throughput alternative to facilitate the screening and diagnosis
of PA in larger population studies.
EW071
ANALYTICAL CONSIDERATIONS ON THE IDS-ISYS
ASSAYS FOR HYPERTENSION
A. Fortunato
Clinical Pathology Department, 'San Bortolo' Hospital,
Vicenza, Italy
Introduction: Aldosterone, the founder of mineralocorticoid
hormones, is produced in the adrenal cortex by a distinct
biosynthetic pathways from glucocorticoids. Aldosterone plays
an important role in electrolyte balance and blood volumepressure regulation, its secretion is the result of the action of
several factors among which the most important is the increase
of the plasmatic potassium concentration and the renninangiotensin-aldosterone system activation when sodium
concentration decrease. Measurement of Aldosterone and
Renin levels is very useful in hypertension as part of the
diagnostic protocol to highlight hyper or hypo secretion.
Measurement of Aldosterone in urine is needed as a 24 hour
collection gives the whole estimation of its secretion over the
entire day. In this study we evaluated the analytical
performance of a new automated chemiluminescence
immunoassay.
Methods: Aldosterone was measured in 88 urine remnant
samples and 95 plasma EDTA samples from subjects referred
to our laboratory (48.4+18.3 years of age, 93 females, 90
males). Determinations were run with the ALDOCTK DiaSorin
RIA assay (Stillwater, US) and the IDS-iSYS Assay (Boldon,
UK) on the automated iSYS platform. Aldosterone
concentrations ranged from 1.3 to 40.5 ng/dL and from 12.6 to
94.1 ng/dL for urine and plasma respectively. Reproducibility
was evaluated according to CLSI EP5-A2 in urine samples with
Aldosterone concentrations ranging from 14.1 to 97.7 ng/dL.
Results: the Passing-Bablok regression of iSYS against RIA
shows a slope of 1.20 (95%CI 1.11-1.28) and intercept 2.1
biochimica clinica, 2013, vol. 37, SS
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EuroMEdLab 2013 - sciEntific sEssions
(1.08-3.19) for urine and a slope of 0.84 (0.76-0.92) and
intercept 3.78 (-6.28-13.57) for plasma samples. Pearson
correlation coefficient was 0.951 (P <0.0001) and 0.953 (P
<0.0001) for urine and plasma respectively. The obtained
Bland-Altman %Mean (+ 1.96 SD range) was -39.7 (-99.8 to
20.3) for urine and 5.8 (-77.9 to 89.5) for plasma. CV values
from 5.5 to 12.7% within run and from 2.8 and 8.4% between
run were observed in the reproducibility evaluation.
Conclusions: The positive correlation of automated IDS with
RIA, the good reproducibility of results, the reduced turnaround
time and hands on labour gives a significant improvement in
the use of Aldosterone measurement in hypertension
diagnosis.
EW072
SUCCINYLACETONE AS NEW PARAMETER IN
NEWBORN SCREENING
D. Kasper
Research Core Unit of Pediatric Biochemistry and Analytics,
Department of Pediatrics and Adolescent Medicine, Medical
University of Vienna, Austria
Background: Newborn screening (NBS) for hepatorenal
tyrosinemia (HT1) has continuously evolved in recent years.
The analysis of tyrosine (Tyr) alone, detected in NBS by LCMS/MS, is convenient but limited due to non-specific elevations
in transient tyrosinemia, and insufficient for HT1. Therefore,
HT1 may be missed with normal/moderately elevated Tyr
levels. Consequently, unambiguous screening for HT1 is
performed by the additional analysis of succinylacetone
(SUAC) in dried blood spots (DBS). Increased concentrations
of SUAC significantly improve the specificity of HT1 screening.
Different protocols for the analysis of SUAC in DBSs are simple
to perform but require a separate extraction that doubles the
number of samples run on LC-MS/MS per day. Additionally, the
laboratory must be set up to deal with hydrazine, a suspected
carcinogen. Here, we implemented a novel, certified,
commercially available, multiplex high-throughput screening
LC-MS/MS assay for amino acids, acylcarnitines and SUAC in
routine NBS. The assay was run from the same DBS without
a second specimen and dispenses with the use of hydrazine.
The aim was to assess the feasibility on a routine basis of the
detection of elevated SUAC levels, and the successful
evaluation of the assay in the detection of newborns with inborn
errors of metabolism (IEMs).
Methods: A commercial kit was evaluated to analyze amino
acids, acylcarnitines and SUAC with a significantly less harmful
hydrazine derivative in a NBS laboratory. DBS specimens from
4,683 newborns and samples from known patients with IEM
were analyzed by a novel protocol and compared to an inhouse method. All samples were derivatized with butanol-HCl
after extraction from DBS punches. The residual blood spots
were extracted separately for SUAC, converted into hydrazone,
combined with amino acids and acylcarnitines, and analyzed
by mass spectrometry using internal isotope-labeled standards.
Results and conclusion: All newborns were successfully tested,
and 74 patients with IEMs including three with HT1 were
detected. The mean SUAC level in non-affected newborns was
0.68 µmol/L (cut-off 1.29 µmol/L). The novel assay was
demonstrated to be accurate in the detection of newborns with
IEM, robust, and without the risk of the exposure to toxic
reagents.
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biochimica clinica, 2013, vol. 37, SS
EW073
THERAPEUTIC DRUG MONITORING OF ANTIEPILEPTIC
DRUGS DURING PREGNANCY
J.C. Ritchie
Emory Medical Laboratories, Emory University School of
Medicine, Atlanta, Georgia, USA
Epilepsy is the most frequent neurological disorder worldwide
with a prevalence of approximately 0.5 % in western countries.
Around one quarter of people with epilepsy are women of
reproductive age and most of them use antiepileptic drugs
(anticonvulsants, AEDs) for adequate control of their seizures.
Additionally, anticonvulsants are also used for the treatment of
a broad range of other medical conditions such as bipolar
disorders, cancer or neuropathic pain. Recent clinical studies
revealed that physiologic changes during different stages of
pregnancy may lead to altered pharmacokinetics for AEDs and
broad individual variations resulting in difficulty to predict the
appropriate drug dosage. It is well known that fetal drug
exposure to some AEDs like valproic acid increases the risk of
minor or major congenital malformations. Therefore,
therapeutic drug monitoring for AEDs plays an important role in
improvement of the effectiveness of treatment while minimizing
fetal and maternal drug exposure. Here, we describe the
evaluation of a commercially available mass spectrometry kit
(MassTox TDM Series A) from Chromsystems, Munich for the
fast and efficient monitoring of AEDs in serum/plasma samples
from pregnant women. The modular MassTox TDM System
consists of three components: The BASIC Kit A, the Analytical
Column A, and 14 PARAMETER Sets which specify the
measurement of up to 150 analytes. The specific parameter
set for AEDs encompasses 26 drugs. Preparation of samples
including AEDs is same for all parameters, based on a simple,
effective protein precipitation process. Briefly, precipitation is
achieved by addition of 25 µL of extraction buffer and 250 µL
of precipitation reagent containing all labeled internal
standards. After centrifugation supernatants are diluted with
buffer to adjust required concentrations of the individual drugs
according to MS/MS instrument sensitivity and parameter set.
Results were generated on an ABI Sciex API 4000 equipped
with an electro spray ionization source.
EW074
POINT‐OF‐CARE TESTING OF CARDIAC MARKERS –
COMING OF AGE?
P. Venge
Dept of Medical Sciences, Uppsala University, Sweden
The assessment of blood levels of biomarkers such as cardiac
troponins and brain natriuretic peptides have become more or
less indispensable in the management of patients with heart
disease, be it in patients with acute coronary syndromes or in
heart failure. The assay of cardiac troponins is included in the
universal definitions of acute myocardial infarction and the
assay of brain natriuretic peptides may help the doctor in the
decision of the rapid rule-in or rule-out of acute heart failure
when a patient presents as an emergency with symptoms
reminiscent of heart failure, such as dyspnea. The introduction
in recent years of more and more sensitive cardiac troponin
assays has clearly shown their advantages in the care of
patients with the acute coronary syndrome. One is the earlier
recognition of myocardial injury and another is the recognition
of significant changes in troponin levels around the diagnostic
cut-off levels of the 99th percentile URL i.e. objective signs of
myocardial injury, which may stay unrecognized by less
sensitive assays. These advantages are important since they
EuroMEdLab 2013 - sciEntific sEssions
allow lifesaving interventions more rapidly. However, in order to
take full advantage of these assay improvements the time
between blood sampling, “vein”, to the actual decision made
by the doctor, “brain”, should be kept at a minimum. In most
hospitals the vein-to-brain time is 1-2 h if the blood sample is
sent to the laboratory. The development of point-of-care (POC)
assays for cardiac troponins and brain natriuretic peptides to be
used in the emergency room has the potential to reduce the
vein-to-brain time, since these assays can provide results
within 15-20 min. One disadvantage of POC-assays for
troponins, however, is their relative insensitivity, since we
showed that the most popular and wide-spread POC-assays
would miss many patients with adverse outcomes that were
recognized by the sensitive laboratory assays.
Conclusion: There is still a gap between the analytical and
clinical performances of laboratory and POC assays for cardiac
troponins and it is a major challenge to develop POC assays
that match the high sensitive laboratory assays.
EW075
CLINICAL DECISION SUPPORT SYSTEMS, PROCESSES
AND INTEGRATION OF POINT‐OF‐CARE TESTING IN
ACUTE CARDIAC PATIENTS
R. Bingisser
University of Basel, Switzerland
Clinical support systems are crucial in Emergency Medicine,
as decisions often need to be taken under time pressure and
in patients in critical situations. We have therefore developed a
support system (www.emergencystandards.com), open to
professionals, with the aim to improve decisions in Emergency
Medicine.
Our research focuses on the evaluation of fast and frugal
decision trees, a method that has been described to be equal
or even superior to mor complicated tools aiming at decision
making in terms of diagnostic reasoning. The diagnostic
challenge in Emergency Medicine is often focusing on unclear
or non-specific presentation where decision trees might help
the speed, timing, and accuracy of establishing an early
working diagnosis in order to give treatment to patients with
serious disease, such as myocardial infarction, at the earliest
timepoint possible. The majority of elderly patients with
myocardial infarction in the previously described BANC cohort
does not present with typical complaints, such as chest pain.
Therefore, a strategy involving broad testing for frequently
occurring problems, such as myocardial infarction is warranted.
We have taken the subset of patients with myocardial infarction
that did not present with typical symptoms in order to
retrospectively analyze the timepoints at with the crucial steps
in diagnosing myocardial infarction took place. In order to
calculate the theoretical benefit of point-of-care testing for
troponins, we have chosen the real lag-time in these patients
as compared to an estimated lag-time, if point-of-care testing
would have been performed. This analysis showed a
hypothetical advantage of point-of-care testing over the
traditional laboratoy analysis. We will discuss the advantage of
clinical support systems in Emergency Medicine in general, the
use of fast and frugal decision trees, and the possible
advantages of point-of-care testing in situations where decision
support is available and point-of-care is most likely a benefit to
patients.
EW076
A REVOLUTIONARY OPTOMAGNETIC IMMUNOASSAY
TECHNOLOGY FOR POINT‐OF‐CARE TESTING
J. Nieuwenhuis
Philips Healthcare Incubator, Eindhoven, Netherlands
Point-of-care (POC) diagnostics is very demanding in a number
of areas: performance, ease-of-use, and reliability. We are
developing the Minicare handheld instrument designed with a
focus to specifically address these demands. The performance
of a POC system should preferably be comparable with the
quality that can be obtained in the central lab to be a viable
alternative. Not only in terms of sensitivity, but precision is
equally important; in particular with respect to the latter there is
still a gap between the central lab and current POC systems
available. We present an optomagnetic immunoassay
technology based on nanoparticles that are magnetically
actuated and optically detected in a stationary sample fluid.
The dynamic control of nanoparticles by magnetic fields
impacts the key immunoassay process steps, giving
unprecedented speed, assay control and seamless integration
of the total test. The optical detection yields sensitive and
multiplexed assays in a cost-effective disposable cartridge.
Applications are foreseen in the emergency department and
the first application under development is a TnI assay with a
turn-around time of less than 10 min. The system is selfmetering and works with a single droplet (25-40 µl) of whole
blood. The results of the test are automatically transferred to
the laboratory information system to ensure a smooth
integration in the clinical workflow.
EW077
MEDICAL AND HEALTH‐ECONOMIC CHALLENGES OF
SEPSIS
F. Brunkhorst
Paul-Martini-Clinical Sepsis Research Unit, Department of
Anaesthesiology and Intensive Care Medicine, Jena
University Hospital, Germany
Sepsis incidence: According to new data from the Center for
Sepsis Control and Care (CSCC) funded by the Federal
Ministry for Science and Research (BMBF) and located at
Jena University Hospital, a total of 180,311 patients developed
septic conditions in Germany in 2010 (1). Of these, 78,208
patients had sepsis, 81,073 severe sepsis, and 21,708 a septic
shock. Figures are based on the new ICD-10 encodings
introduced by the German Sepsis Society (DSG) in 2007 (1).
The peak age was between 70 and 75 years and 60,199
patients died in hospital. Hospital mortality rate for sepsis was
12 %, for severe sepsis 46.9 % and 60.5 % for septic shock
exceeding data on incidence and mortality reported by the
German Competence Network, SepNet prevalence study in
2004 (2). Given the increasing age of the population, figures
can be expected to continue rising and there is no reason to
believe that there are substantial differences between
European countries. Sepsis costs: A calculation of direct
hospital costs according to the actual costs for a large German
health insurance fund agency revealed that annually
5,822,098,251 US$ are spend for sepsis treatment in German
hospitals. The mean costs per case are 76,048 US$ for
survivors and 67,022 US$ for non-surviving patients.
Furthermore, the indirect costs by premature death are
calculated to an additionally 4,634,718,126 US$ per year.
Sepsis – a call to action: Both the currently being revised
guidelines from the German Septic Society on "Prevention,
diagnosis, treatment and long-term care of sepsis" and the
biochimica clinica, 2013, vol. 37, SS
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EuroMEdLab 2013 - sciEntific sEssions
next congress of Weimar sepsis update 2013, will question
issues relating to improving structure and process quality to
counter the continuing high mortality. Questions to be
answered are: • Where are the deficits in diagnosis and what
new therapeutic approaches need to be taken? • Is there an
iatrogenic post-therapy-related (adverse event) that we should
have paid too little attention to? • Have we underestimated the
potential for preventive measures, since about 70% of sepsis
patients show a nosocomial infection ? • And finally, is their an
association of the shorter length of stay in hospitals and the
quality of outcomes? What is the long-term survival rate and
the health-related quality of life?
EW078
CURRENT CLINICAL PRACTICE IN SEPSIS TESTING
S. Krüger
Department of Pneumology, Florence Nightingale Hospital,
Düsseldorf, Germany
Background: Sepsis and severe sepsis are increasing in recent
years. Early recognition and diagnosis of severe sepsis is a
crucial part to improve outcome.
Methods: The current literature has been reviewed with respect
to laboratory testing in sepsis. Results: Several laboratory
parameters are currently used in patients suspected to suffer
from sepsis. Most of these are markers of inflammation and
infection. In daily clinical practice clinicians use white blood
count, C-reactive protein (CRP) and procalcitonin (PCT). Major
advantage of PCT is its early and highly specific increase in
response to bacterial infections. In sepsis increased PCT levels
can be observed 3-6 hours after infection. Low PCT values
(<0.25 µg/L) in patients with clinical signs of infection indicate
a low probability for blood culture proof of bacterial infection,
whereas elevated PCT values (>0.25 µg/L) seem to correlate
with positive blood culture result. PCT levels in sepsis are
generally >1-2 µg/L peaking to 10-100 µg/L. In healthy people,
plasma PCT concentrations are below <0.05 µg/L. PCT levels
are usually low in viral infections, chronic inflammatory
disorders or autoimmune processes. PCT has been
demonstrated to be the best marker for differentiating patients
with sepsis from those with systemic inflammatory reaction not
related to infectious cause. Moreover, PCT was shown to be
the only laboratory parameter that made a significant
contribution to the clinical diagnosis of sepsis. Information
obtained from IL-6, IL-8 and CRP had no impact on the clinical
diagnosis of sepsis on admission. As the septic infection
resolves, PCT reliably returns to values below 0.5 µg/L,with a
half-life of 24 h. Consequently PCT can be used to monitor the
course and prognosis of life-threatening systemic bacterial
infections and to tailor the therapeutic interventions more
efficiently.
Conclusions: Currently several inflammatory biomarkers are
used for sepsis diagnosis. The only biomarker with sufficient
specificity, positive and negative predictive value for sepsis
diagnosis and prognosis is PCT. C-reactive protein and
leukocyte count are too unspecific and cannot reliably
differentiate patients with sepsis from those with systemic
inflammatory reaction not related to infectious causes.
EW079
FUTURE OUTLOOK OF SEPSIS TESTING
S. Blincko
Abbott GmbH & Co. KG, Wiesbaden, Germany
Nearly 200 markers have been reported in the literature to aid
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biochimica clinica, 2013, vol. 37, SS
in the diagnosis and management of sepsis. The markers
reflect the diversity of the causative agent and response
mechanisms that are activated. However, only a small number
have demonstrated sufficient potential to warrant further
investigation. A brief review will be made of some of these
markers and their potential application. A report will be given
on a recent study of Procalcitonin, Pancreatic Stone Protein
(PSP), solubleCD25 (alpha chain of the IL2 receptor) and
interleukin 6 with comments on how they could aid in the
detection of sepsis and severe sepsis/septic shock. Plasma
levels of the biomarkers, PCT and selected inflammatory
cytokines were measured in samples taken from 219 patients
during the first 6 hours of admission to intensive or high
dependency care. Patients with a systemic inflammatory
response were categorised as having a non-infective aetiology
or sepsis, with or without markers of severity, using standard
diagnostic criteria. Both PSP and sCD25 performed well as
biomarkers of sepsis irrespective of severity of illness. For both
markers the Area Under the Receiver Operating Curve (AUC)
was greater than 0.9; PSP 0.927 (0.887-0.968) and CD25
0.902 (0.854–0.949). Procalcitonin and IL6 also performed
well as markers of sepsis; PCT 0.840 (0.778–0.901) and IL6
0.805 (0.739–0.870). Levels of both PSP and PCT reflected
severity of illness and both markers performed well in
differentiating patients with severe sepsis from severely ill
patients with a non-infective systemic inflammatory response;
AUCs 0.955 (0.909-1) and 0.837 (0.732-0.941) respectively.
Although levels of sCD25 did not correlate with severity,
addition of sCD25 to either PCT or PSP in a multivariate model
improved the diagnostic accuracy of either marker alone.
Studies in 3 hospital emergency room departments are
ongoing to demonstrate if any of these markers are efficacious
in the early detection of sepsis.
EW080
DIAGNOSTICS OF AUTOIMMUNE DISEASES USING
INDIRECT IMMUNOFLUORESCENCE TESTS FOR
DETECTION OF ANTINUCLEAR ANTIBODIES: 60 YEARS
OLD AND IT DOES NOT SHOW
A. Wiik
Statens Serum Institute, Denmark
The indirect immunofluorescence test certainly has withstood
the test of time, still being used after the introduction in 1957.
Though a number of modifications have been added since its
first presentation the same simple principle is used. The cell
substrate nowadays consists of thoroughly tested and
reproducibly grown cell lines such as human laryngeal
carcinoma HEp-2 cells) attached to glass slides, sometimes
supplemented by cryosections of animal tissues. Substrate is
fixed to ascertain access of patient serum immunoglobulins
into the various compartments of the cell, and fluoresceinated
anti-immunoglobulin is added to allow binding to and excitation
of fluorescence pattern in a fluorescence microscope. The
technique is somewhat labour intensive and demands visual
expertise of the microscopist interpreting the results.
International committees on standardization of ANA detection
as well as European and American rheumatology
organizations recommend that the IIF ANA test using HEp-2
cells be used as the primary screening method for ANA
detection. The ANA test today includes detection of
autoantibodies to cytoplasmic as well as nuclear structures,
these antibodies being found at a clinically relevant level (titer).
The test should focus only on IgG antibodies by use of an IgG
(Fcγ chain) specific conjugate. Today presence of IgG ANA is
used as support for or even classification criteria for certain
systemic rheumatic diseases (SRD). A positive ANA result is
used as an initial stepping stone for detecting the specific
EuroMEdLab 2013 - sciEntific sEssions
autoantibodies underlying the IIF reaction using other methods
e.g. enzyme immuno-assay, micro-array or addressable laser
bead immuno-assays. Until recently no unified nomenclature
for HEp-2 cell IIF reaction patterns existed, but collaboration
between expert diagnostic laboratories in the CANTOR project
supported by the European Commission has led to the
proposal on a contemporary IIF HEp-2 cell nomenclature.
Details of this proposal will be presented in the symposium.
EW081
THE USE OF DIFFERENT TECHNOLOGIES FOR
AUTOMATED DETECTION AND CLASSIFICATION OF
ANTI-NUCLEAR ANTIBODIES
E. Tonutti
Laboratory of Immunopathology and Allergy UniversityHospital, Udine
Background: The Zenit G-Sight system (Menarini Diagnostics,
Italy) is a motorized microscope for the screening of antinuclear
antibodies (ANA) on HEp-2 cells. The system is capable to
discriminate between positive/negative samples, to measure
fluorescence intensity (probability index), and interpret and
classify 5 fluorescence pattern (homogeneous, nucleolar,
speckled, centromeric and mitochondrial).
Methods: We evaluated the Zenit G-Sight (I-Sight IFA) on 134
selected sera. 98 of these sera were positive and 36 were
negative by the conventional immunofluorescence method (IIF)
on HEp-2 cells (HEp-2 Zenit IMMCO). The 98 positive sera
showed the following patterns: 17 homogeneous, 24 speckled,
22 cytoplasmic, 3 dense fine speckled, 3 centromeric, 1 CENPF, 5 nuclear matrix, 5 nuclear membrane, 2 midbody, 1 NuMa,
5 multiple nuclear dots, 5 nucleolar, 4 PCNA. 14 had a titer of
1:80, 13 of 1:160, 12 of 1:320, 20 of 1:640 and 39 of ≥1:1280.
Results: Positive/negative concordance between conventional
microscopic results and the Zenit G-Sight reading was 92.5%.
83 sera agreed for positivity; 27 for negativity; 14 IIF-positive
and 7 IIF-negative were in the Zenit G-Sight grey zone; 1 IIFpositive serum was negative with the G-Sight and 2 IIFnegative sera were positive with the G-Sight. Agreement was
100% for the homogeneous pattern, 77.1% for the speckled
pattern, 100% for nucleolar and centromeric patterns, and 75%
for the mitochondrial pattern. In 36 IIF-positive sera, Zenit GSight did not assign any pattern, despite a positive probability
index. Correlation between titer and G-Sight fluorescence
intensity was excellent for sera with speckled, homogeneous,
nuclear membrane, centromeric and nucleolar patterns,
whereas a non-linear correlation was observed in positive sera
with other patterns.
Conclusion: The Zenit G-Sight system is highly accurate in
picking out ANA-positive sera; the use of this instrument in
clinical laboratories is able to standardize the first step of ANA
detection; Zenit G-Sight gives good performance in
discriminating 5 patterns but is not yet able to replace the
pathologist in this interpretative phase. The fluorescence index
must be related to the type of pattern in order to express marker
concentration correctly.
EW082
THE CLINICAL RELEVANCE OF AUTOMATED MODERN
METHODS FOR PLATELET COUNTING IN 2013
S.J. Machin
University College London Medical School, London, UK
Impedance Platelet (PLT) counting methods still have
limitations. Cell size analysis cannot discriminate PLT from
other similarly sized particles. More recently fluorescence
methods have been introduced for PLT counting on
haematology
analysers.
International
Council
for
Standardization in Haematology (ICSH) introduced a reference
method for PLT counting which utilises monoclonal antibodies
to PLT surface antigens. This enables the calibration of cell
counters, to assign values to calibrators, and to obtain PLT
counts in a variety of pathological samples. The Sysmex XN
performs fluorescence analysis of PLT (PLT-F) using a novel
marker. Algorithms are designed for thrombocytopenic samples
for an accurate PLT count and immature PLT fraction (IPF) by
prolonged counting sequence and elimination of interference
from non-platelet particles or platelet abnormalities. The PLTF channel can be selected for testing or only used as a reflex
test if there are abnormalities or if the PLT count is below a preset limit. PLT counts and IPF were evaluated on 390 samples
compared to the XE-2100. PLT counts were compared to the
ICSH flow cytometric method on samples, range 1-1728 x
10^9/l (n=185), 67 samples were at, or below, the PLT
transfusion threshold. Carryover, linearity, precision and
stability for PLT and IPF were also investigated according to
ICSH guidelines. Results for all samples were similar between
instruments for the impedance method compared to the
reference method, XE-2100 R^2 0.986, XN 0.972. The PLT-F
method was superior to the XE-2100 optical method when
compared to the reference method on samples with a PLT
count of <20 x 10^9/l, XE-2100 R^2 0.500 and XN 0.875.
Discrepancies on 8 patients were demonstrated for IPF
between the XE-2100 and XN (low on the XN and high on the
XE-2100). From the diagnosis of the 8 patients it may be results
were more correct on the XN. 6 patients were undergoing
chemotherapy and 2 had aplastic anaemia, all had low PLT
counts. Results for carryover, linearity, precision and stability
were good. The evaluation showed excellent correlation of PLTF count with the flow cytometric reference method for all
samples, and an improved accuracy in thrombocytopenic
samples, especially at platelet transfusion thresholds of 10-30
x 10^9/l.
EW083
MANAGING THROMBOCYTOPENIC SAMPLES IN THE
ROUTINE WORKFLOW
H. Bauch
St. Johannes Hospital, Dortmund, Germany
When dealing with thrombocytopenic patients, the clinical
need in daily routine workflow is to determine whether the
patient is truly suffering from thrombocytopenia, and to monitor
the recovery success of thrombopoiesis in patients undergoing
therapy. The Sysmex XN-Series counts platelets using two
different methods: impedance counting and dedicated
fluorescence analysis. Impedance counting is suitable for
routine platelet measurement using the principle of
differentiation by cell volume. In contrast, fluorescent platelet
counting using a prolonged counting sequence and
fluorescent RNA labeling can solve possible interferences
derived from non-platelet particles or platelet abnormalities in
thrombocytopenic samples. Managing thrombocytopenic
samples in routine workflows is challenging for several
reasons: i) in the presence of interfering particles one may
have to use multiple methodologies for platelet counting. ii)
One has to report an accurate “delta value” for platelets – the
difference compared to previous results. This is only feasible
when iii) the platelet results derive from the same
methodology. These issues should not negatively influence iv)
turnaround time and v) costs. To make this possible, one
needs an intelligent set of algorithms embedded in a work area
manager. This optimizes the workflow of thrombocytopenic
biochimica clinica, 2013, vol. 37, SS
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samples in routine settings. We tested the Sysmex evaluation
software, which includes an algorithm set for managing the
platelet workflow. The study consisted of two parts: the first
monitored the recovery success of thrombopoiesis. One
hundred thrombocytopenic patients from the surgical intensive
care unit (ICU) were examined over a period of five days. In
the second part, current best practice was compared with the
new algorithm by including 10,000 routine samples from
around 1,500 patients to monitor turnaround time and costs.
EW084
HBA1C STANDARDIZATION IS ESSENTIAL FOR
DIAGNOSIS AND MONITORING OF DIABETES
W.G. John
Clinical Biochemistry Department, Norfolk and Norwich
University Hospital, Norwich, UK
If we are to limit the global effect of diabetes and its financial
burden then a globally accepted standardization system for
HbA1c measurement is vital. This will allow an international
approach to the formulation and implementation on guidelines
for diagnosis and monitoring of diabetes. The lack of
international standardization of HbA1c resulted in several
countries developing national standardization programs. The
most widely recognized being the National Glycohemoglobin
Standardization Program (NGSP); utilizing a High Performance
Liquid Chromatography (HPLC) system which Secondary
Reference Laboratories these in turn standardize Clinical
methods. There are two main concerns with the NGSP
solution: results reported are not true HbA1c concentrations,
but the best estimates that analyzer technology from the 1980s
could deliver. Secondly there is no primary reference material
to allow true calibration of the HPLC system. Implementation of
this program resulted in laboratories reporting similar values
with the same sample; but, the similar values were not the true
HbA1c value. This was also the case with the Swedish and
Japanese standardization programs; these were also based
on optimized HPLC methods (referred to as Designated
Comparison Methods [DCMs]). These national initiatives were
important steps toward improvement of the comparability of
HbA1c test results; but national standardization programs
based on different DCMs cannot replace uniform worldwide
standardization anchored on a metrological sound international
reference measurement system. To address the global issue
the IFCC WG on HbA1c standardization has developed a
complete reference measurement system. The system fulfills
the concept of a Metrological Reference Measurement
Procedure; thus providing clinical laboratories with calibration
traceable to primary reference material with known uncertainty,
and that uncertainty kept to a minimum due to the processes
involved. But there remains a divide on the reporting of results;
although much of Europe has standardized on mmol/mol as
the reporting unit, this SI units has not yet been universally
accepted. If global comparability is to be achieved, then the
recommendations of the consensus statement on HbA1c
reporting must be adopted.
EW085
QUALITY OF HBA1C TESTING: EXPERIENCE OF AN
IFCC REFERENCE LABORATORY
E. Lenters-Westra
Isala klinieken, Zwolle, The Netherlands
Hemoglobin A1c (HbA1c) point-of-care (POC) instruments are
widely used to provide rapid turnaround results in diabetic care
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centers. Most of the POC instruments are NGSP certified but
the analytical performance in daily use is not really known due
to the fact that most of the users of HbA1c POC instruments
are not members of external quality schemes. The results
shown in the article: “Six of Eight Hemoglobin A1c Point-ofCare Instruments Do Not Meet the General Accepted Analytical
Performance Criteria” (Clin Chem 2010;56:44-52), clearly
showed that manufacturers need to improve their methods.
Most of the manufacturers took this message seriously and,
indeed, re-evaluation of these methods showed improved
analytical performance. Also new HbA1c POC instruments
entered the market and some of these methods are even better
than most of the laboratory based methods. Given these
results, the question arises if it is correct to exclude all HbA1c
POC instruments for the diagnosis of diabetes as
recommended by the American Diabetes Association (ADA).In
our lab (European Reference Laboratory for HbA1c at the Isala
klinieken in Zwolle, the Netherlands) the analytical performance
of different HbA1c methods (POC and laboratory based
methods) was investigated, using certified CLSI protocols and
results of external quality schemes. Furthermore, the
interpretation of HbA1c values among different health care
professionals was investigated which produced, in combination
with the outcome of the evaluation studies, remarkable results.
In this presentation I will focus on the results of these studies.
EW086
BETWEEN METHOD VARIABILITY IN LABORATORY
MEDICINE: 'THE GOOD, THE BAD, AND THE UGLY'
G.H. Beastall
International Federation of Clinical Chemistry and
Laboratory Medicine, University of Glasgow, UK
Background: The primary responsibility of a laboratory
medicine specialist is the delivery of a high quality analytical
and interpretive service. Patients are increasingly mobile and
so liable to be investigated at centres and laboratories that use
different methods for the same measurand. Between method
differences in results can impact on patient safety, reduce the
effectiveness of clinical practice guidelines and undermine the
reputation of the clinical laboratory in the eyes of the user and
the patient. Therefore, the laboratory medicine specialist has a
secondary responsibility to facilitate a reduction in between
method variability.
Methods: A survey was conducted of External Quality
Assessment (EQA) schemes in the UK. This was used to
estimate the number of measurands commonly available
across the spectrum of laboratory medicine. This outcome was
compared with the database of the Joint Committee for
Traceability in Laboratory Medicine (JCTLM), which contains
listings of reference materials, reference measurement
procedures and reference laboratory networks. Method
performance characteristics were assessed for selected
measurands from clinical chemistry, haematology and
microbiology and these were compared with the recommended
use of these measurands in clinical practice guidelines.
Results: Only a small percentage of the measurands commonly
available in laboratory medicine have been standardised or
have the current potential to be standardised. Cholesterol and
haemoglobin are examples of measurands that have been
standardised and the between method variability is
correspondingly small giving credibility to the recommendations
in clinical practice guidelines. Parathyroid hormone and
haemoglobin A2 are examples of measurands where there is
no current method standardisation and the high between
method variability compromises the validity of clinical practice
guidelines.
Conclusions: It is not currently possible to standardise many
EuroMEdLab 2013 - sciEntific sEssions
of the measurands currently available in laboratory medicine.
High between method variability compromises patient safety.
Therefore, a more pragmatic approach is required that will
facilitate method harmonisation. This must be a collaborative
effort between the laboratory medicine specialist and the
diagnostics industry.
EW087
FROM CHAOS TO ORDER: THE ROLE OF
HARMONIZATION
G. Miller
Virginia Commonwealth University, Richmond, Virginia, USA
Background: Results between different clinical laboratory
measurement procedures should be equivalent, within clinically
meaningful limits, to enable optimal use of clinical guidelines for
disease diagnosis and patient management. When laboratory
test results are neither standardized nor harmonized, a different
numeric result may be obtained for the same clinical sample.
Unfortunately, some guidelines base decisions on test results
from a specific laboratory measurement procedure without
considering the possibility or likelihood of differences between
various procedures. When this happens, aggregation of data
from different clinical research investigations and development
of appropriate clinical practice guidelines will be flawed. A lack
of recognition that results may not be equivalent when
measured with different procedures can lead to erroneous
clinical, financial, regulatory, or technical decisions.
Methods: Standardization of clinical laboratory procedures has
been accomplished for a number of measurands for which
primary (pure substance) reference materials exist and/or
reference measurement procedures have been developed.
However, the harmonization of clinical laboratory procedures
for measurands that do not have reference measurement
procedures has been problematic owing to inadequate
definition of the measurand, inadequate analytical specificity
for the measurand, inadequate attention to the commutability of
reference materials, and lack of a systematic approach for
harmonization.
Conclusions: To address these problems, an International
Consortium for Harmonization of Clinical Laboratory Results
will enable a systematic approach for identification and
prioritization of measurands to be harmonized based on clinical
importance and technical feasibility, and for management of
the technical implementation of a harmonization process for a
specific measurand.
EW088
IMPORTANCE OF SERUM FREE LIGHT CHAIN
MEASUREMENTS IN AL AMYLOIDOSIS
A. Wechalekar
University College London, Royal free & University College
Medical School, London
AL amyloidosis is caused by aberrant folding of monoclonal
immunoglobulin free light chains (FLC) which leads to the
aggregation and deposition of these light chains in organs and
tissues. Historically, the presence of monoclonal light chains
was identified using serum or urine protein electrophoresis
(SPE, UPE), however <70% of patients detectable monoclonal
proteins and less still are quantifiable by these methods.
The introduction of the Freelite® immunoassay for the
quantification of serum FLC)changed the diagnostic and
monitoring paradigm for AL amyloidosis patients. It is the single
most sensitive test for detecting abnormal FLC’s and whilst not
diagnostic (which relies upon tissue biopsy) of AL amyloidosis,
patients frequently present with abnormal FLC kappa / lambda
ratios.
In a retrospective analysis of 262 patients 98% had abnormal
FLC ratios (by contrast only 3% had serum FLC concentrations
sufficiently high for SPE quantification). The prognosis of
patients with AL amyloidosis is often determined by cardiac
involvement – patients with cardiac involvement having
significantly poorer outcomes than patients with other end
organ damage. A prognostic model utilising cardiac biomarkers
troponin-T (cTnT) and N-terminal pro-B type peptide (NTProBNP) is routinely used. However, this model fails to account
for the underlying light chain burden and a recent update
utilises elevated FLC, cTNT and NT-ProBNP to allow for
accurate patient stratification. Such prognostic models help risk
stratify patients for appropriate therapy including stem cell
transplantation. The importance of FLC measurements in this
disease is now well established and has been recently
validated in a large international collaborative effort to define
response criteria in using reductions in the serum FLC
components. Achieving a dFLC (difference in the involved and
uninvolved serum FLC) of <40 mg/L is now the minimum goal
of therapy in AL amyloidosis.
To date all guidelines and utilities for FLC measurements have
utilised the Freelite assay. More recently a monoclonal antibody
based assay has been introduced, preliminary assessments of
this assay suggest international response criteria cannot be
applied and further work is required to evaluate its clinical utility.
EW089
THE IMPORTANCE OF SERUM FREE LIGHT CHAIN
MEASUREMENT IN KIDNEY DISEASE
P. Cockwell
Consultant Physician and Nephrologist, Clinical Service
Lead Renal Medicine at University Hospital Birmingham
Kidney disease is a serious complication of multiple myeloma
and other monoclonal diseases. Serum free light chain (sFLC)
measurements have a central role: (i) in diagnostic algorithms
for patient with newly diagnosed acute kidney injury (AKI) or
chronic kidney disease (CKD); (ii) as early determinants of
clinical outcomes, particularly in patients with dialysis
dependent AKI. It is now clear that rapid and accurate
identification of the nature and burden of the monoclonal
disease and confirmation of the role of the disease in kidney
injury is a crucial determinant of patient outcome. This allows
the prompt commencement of disease specific treatment and
protects the kidneys against the profound toxicity of some light
chain clones. This field is rapidly developing: recent insights
include; the recognition of light chain monoclonal gammopathy
of uncertain significance (LC-MGUS) as an entity; the
developing concept of monoclonal gammopathy of renal
significance (MGORS), clinical studies evaluating the direct
removal of sFLC in MM and AKI, the impact of kidney
impairment on the ‘normal’ range of sFLC and the capacity of
polyclonal sFLC to risk stratify for mortality and other . Serum
FLC measurements had and have a crucial role in these and
other recent advances. The assay is now established as a
standard of care of laboratory assessment in the diagnosis,
monitoring and management of kidney involvement in the
setting of monoclonal disease.
biochimica clinica, 2013, vol. 37, SS
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EW090
ROLE OF HEVYLITE FROM A LABORATORY
PERSPECTIVE
J. Bornhorst
Department of Pathology, University of Arkansas for Medical
Sciences
Background: Identification and quantification of monoclonal
immunoglobulins by serum protein electrophoresis (SPEP) and
immunofixation (IFE) are fundamental to diagnosis and
monitoring of multiple myeloma (MM) and other plasma cell
disorders. The biochemical nature of some intact
immunoglobulins can present significant challenges to the
laboratory in the accurate quantification by SPEP either
because of their co-migration with other serum proteins (seen
in up to 60% of IgA monoclonal protein) or concentrations <10
g/L which leads to substantial imprecision. Methods: In 2009,
3 paired immunoassays (Hevylite-HLC) identifying the Ig’κ/Ig’λ
variants for IgG, IgA and IgM isotypes became available. These
assays are targeted against conserved, junctional epitopes
between the light and heavy chain. Calculation of an Ig’κ/Ig’λ
ratio (as with the serum free light chain (FLC) κ/λ ratio) can be
used to detect clonality. In a series of MM monitoring patient
samples we compared commonly utilized methods for
detection of monoclonal protein, including HLC chain
determination. Results: While concordant results were
achieved between HLC and SPEP monoclonal protein
determination in the abundance of clonal protein, IgA HLC
ratios to have a greater sensitivity than SPE at low
concentrations. In IgG patients the two assays were broadly
concordant, thus Hevylite may alleviate issues associated with
accurate quantification. Additionally, substantial, yet
incomplete, concordance was observed between IFE, SPEP,
FLC and HLC monoclonal protein detection. Conclusions: The
clinical impact of the HLC assay is still incompletely
understood. Further studies delving into the utility of HLC in
diagnosis, monitoring, and prognostic application continue
across the globe. Published studies looking at MM patients
indicate HLC ratios identified all patients. However in a large
MGUS study the HLC ratio sensitivity did not match that of IFE
(97% IgA, 90% IgM and only 56% of IgG patients). Intriguingly,
the suppression of the uninvolved Hevylite pair had a strong
impact on outcome. In MM this suppression may precede
relapse, prior to measurable increases in monoclonal
immunoglobulin production; therefore HLC determinations may
represent beguiling tools for patient monitoring.
EW091
THE IMPACT OF PROCALCITONIN ON CLINICAL
DECISION MAKING: WHY THE CLINICAL LABORATORY
SHOULD OFFER PROCALCITONIN TESTING
P. Schuetz
Department of Internal Medicine, Kantonsspital Aarau,
Switzerland
The limitations of clinical signs and microbial techniques for the
diagnosis of bacterial infections are eminent. Procalcitonin, a
novel biomarker for infection, is released in multiple body
tissues in response to bacterial infections via direct stimulation
of bacterial cytokines. The use of Procalcitonin provides a
promising novel approach to better diagnose infection and for
antibiotic stewardship. Today, the concept of guided
stewardship has been evaluated in fifteen randomized
controlled trials including >4000 patients for efficacy and safety.
PCT guidance lowered antibiotic prescription rates by 65% in
primary care patients, 35% in the emergency department
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biochimica clinica, 2013, vol. 37, SS
setting, and almost 30% in the critical care setting. A recent
meta-analysis found no difference in mortality in procalcitonin
group patients compared to control patients. However, a lower
risk for treatment failure in procalcitonin-guided patients
compared to control patients (19.1% vs 21.9%, adjusted Odds
ratio 0.82, 95%CI, 0.71 to 0.97) was found. Today, there is
strong evidence supporting the use of procalcitonin in
respiratory infections and for sepsis in the intensive care unit.
For other infections, disease and setting specific cut-off ranges
must be validated and proposed and intervention studies
conducted to tackle the existing vicious cycle of diagnostic
uncertainty, antibiotic overuse and emerging multi-resistance.
EW092
CT-proAVP (COPEPTIN) IN THE DIFFERENTIAL
DIAGNOSIS OFT HE POLYURIA-POLYDIPSIA
SYNDROME
W. Fenske
Dept. Endocrinology and Diabetology, University Hospital
Würzburg, Germany
Arginine vasopressin (AVP) is a key hormone for fluid and
electrolyte regulation in the human body. Despite its clinical
relevance in maintaining fluid balance and vascular tone,
measurement of the bioactive mature AVP is difficult and
subject to preanalytical errors. Copeptin, a 39-amino acid
glycopeptide that comprises the C-terminal part of the AVP
precursor (CT-proAVP), was found to be a stable and sensitive
surrogate marker for AVP release that can be quickly and easily
measured. The predictive and diagnostic relevance of copeptin
has been demonstrated for various clinical indications,
including the diagnosis of hyponatremia and the monitoring of
sepsis and cardiovascular diseases. Recent data strongly
suggest that copeptin may be an extremely useful and specific
diagnostic marker also for the differential diagnosis of diabetes
insipidus. The water deprivation test is currently the diagnostic
routine procedure for differentiation of hypotonic polyuria, with
either direct or indirect measurement of the AVP activity. But
the test protocol is exhausting and its results offer only an
extremely low diagnostic accuracy, especially in the
identification of patients with central and nephrogenic forms of
diabetes insipidus. Additional direct copeptin measurement
during the dehydration test offers a much more accurate
diagnostic differentiation. More importantly, even baseline
copeptin measurement, without a functional test design, is able
to reliable identify patients with a nephrogenic and a severe
central diabetes insipidus; whereas the copeptin increase in
response to an appropriate osmotic stimulation is able to even
reliable differentiate between the two most difficult to diagnose
forms of hypotonic polyuria, which is the primary polydipsia and
a mild form of central diabetes insipidus. The pros and cons of
the current diagnostic test standard in polyuria polydipsia
syndrome will be discussed, and a concept of possible future
diagnostic simplification and improvement in diagnostic
accuracy will be illustrated based on the current state of
research.
EW093
FROM THEORY TO PRACTICE: SAVING COSTS BY
ADDING BIOMARKERS TO INFECTION MANAGEMENT
M. Wilke
Dr. Wilke GmbH - clinical economic research; Munich,
Germany
Severe infections cause medical and economic problems in
hospitals. While the importance of treating infectious patients
EuroMEdLab 2013 - sciEntific sEssions
with the right antibiotic, as early as possible is well known and
excellently investigated, the economical side of story is yet to
be told. Especially the right moment to finish antibiotic therapy
is an economical factor that cannot be underestimated. Not
only does the termination of treatment save costs for
antibiotics, it also contributes to a shorter length of stay in
hospital and last but not least is an important part in the big
puzzle of limiting antibiotic resistance. Using procalcitonin
(PCT) as a biomarker to detect and to monitor bacterial
infections is widely accepted in the area of sepsis and severe
airway infections such as pneumonia. It was shown recently in
randomized controlled trials, that an optimized monitoring
algorithm using PCT to manage antibiotic therapy, can realize
savings in antibiotic use by reducing the initiation as well as
the duration of antibiotic treatment and intensive care unit days
(ICUD) without affecting clinical outcome. Applying these
savings to medical data from 16 German hospitals resulted in
savings of 886 € per ICU patient with sepsis. However the
savings were calculated via a medical economic model and
derived from a meta-analysis of several trials.
Also cost economic benefits of PCT-algorithms were proven in
clinical trials, we started the implementation of the new
algorithm from mid 2012 in ICUs in three German hospitals to
test its benefit in real life clinical settings. ICU staff was trained
for the PCT algorithm, cases were peer reviewed and
treatment data collected. Additionally ICUD were collected as
well as the adherence to the PCT-algorithm. Analysis will be
done after 12 months with an interims analysis after 6 months.
Results will be statistically analyzed via a comparison with
historical control groups before introduction of the new PCTbased treatment algorithm. It will be investigated, whether the
introduction and adherence to the PCT-algorithm in real-life
ICU settings will confirm the results being computed in the
medical-economic model.
EW094
CONDITIONS FOR AN EFFECITVE COLORECTAL CANCER
SCREENING PROGRAMME: THE FRENCH EXPERIENCE
J. Faivre
University of Burgundy, Dijon University Hospital
Colorectal cancer (CRC) fulfills the conditions defined for mass
screening. Currently the simplest screening method for CRC
is periodic stool testing for occult blood.
An organized screening program is being carried out in France
(covering the whole country since 2009). Subjects aged 50 to
74 are invited to perform a guaiac fecal occult blood test every
two years. The practical organization of CRC screening is
decentralized. At the level of the department a coordinating
center is in charge of organizing breast and CRC screening.
Each screening round begin by sending an information letter to
each invited subject. During the first 6 months of the screening
round GPs offer the test free of charge to eligible patients seen
at their office. For subjects who did not consult their GP during
the medical phase, the coordination center subsequently
mailed the test. However, because of the limits of guaiac-based
tests, they are no longer the preferred tests for populationbased screening programs. Studies conducted in France and
in other European countries indicated that immunochemical
fecal occult blood tests outperform the guaiac tests and are
associated to greater participation, a key element in the
effectiveness of CRC screening. They allow the detection rate
of CRC to be doubled and a 3-4 fold increase in the detection
of advanced adenoma. The Ministry of Health has announced
in March 2012 the shift from guaiac to immunochemical tests,
without précising when it will occur. It will be based on a
biennial one-stool immunochemical test. The choice of the test
will be based on test performances, the ease of sample
collection and test interpretation and cost-effectiveness
analyses.
EW095
SCIENTIFIC AND TECHNICAL ATTRIBUTES SUPPORTING
WIDE ADOPTION OF FECAL IMMUNOCHEMICAL TESTS
S.P. Halloran
NHS Bowel Cancer Screening Programme, Guildford, UK
Colorectal cancer is the third most common cause of cancer
deaths worldwide and the second most common cause in
Europe. Whilst biochemistry tumour markers largely play
second fiddle in frontline cancer diagnosis, the clinical utility of
faecal occult blood testing (FOBt) has finally been recognised
after decades of making an uncertain contribution to the
process of diagnosing colorectal cancer. During the 1990s, four
randomised controlled trials demonstrated the clinical efficacy
of FOBt as a screening tool to reduce mortality from colorectal
cancer in an average risk population. England was one of
several countries that adopted guaiac-based FOBt for
population screening and between 2006 and October 2012,
following 15.5 million invitations, had identified and treated over
14,000 cancers and removed 42,600 advanced adenomas .
The diagnostic attributes of guaiac were recognised in 1862
but detection of haem using its peroxidase properties exposes
it to interference and limits analytical specificity. The
introduction of faecal immunochemical tests for haemoglobin
(FIT) to detect human globin offers major analytical and clinical
advantages and FIT was adopted two years ago by the
European Union in revised guidelines on population screening
for colorectal cancer. FIT is simpler to use and it enables
automated, instrument-based analysis, which is essential for
large throughput population-based screening. The numeric
haemoglobin (Hb) concentration allows selection of a
positive/negative cut-off level tailored to available endoscopic
resources. FIT technology brings both opportunities and
challenges. Globin is more susceptible than haem to
accelerated denaturation from extended periods at high
temperature, the reliability of quantitative measurement is
dependent upon reproducibility of sampling across an
expanding range of devices and the faecal matrix presents
challenges for internal and external quality monitoring.
Can the international biochemistry community guarantee
consistent, high quality, professionally-led services for this
major public health initiative? As this ‘Cinderella’ analyte moves
‘centre stage’ we are challenged to develop safe systems of
analysis, adequate sample preservatives, traceable calibration
and internationally agreed units of reporting.
EW096
HEMOGLOBIN STABILITY IN FECAL IMMUNOCHEMICAL
TEST DEVICES:BETWEEN EXPECTATIONS AND
REALITY
M. Zaninotto
Department of Laboratory Medicine, University-Hospital,
Padova, Italy
Background: The assessment of faecal occult blood (FOB) is
a fundamental tool for the early diagnosis in colon-rectal
cancer even if, the stability of Faecal Haemoglobin (HbF)
represents a major criticism because different storage
temperatures as well as different time-delays between
sampling and analysis may significantly affect the accuracy of
the test. Some different devices have been commercially
proposed with the aim to guarantee a better stability of fecal
biochimica clinica, 2013, vol. 37, SS
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EuroMEdLab 2013 - sciEntific sEssions
samples as well as an improved analytical performance, such
as FOB Gold Tube Screen and FOB Gold Tube NG with
storage buffer H (BH) and N (BN) (Sentinel CH, Milan, Italy)
recently evaluated in our laboratory
Methods: Stability tests were performed on three real positive
stool samples (HbF= 96.5, 227.8 and 649.5 ng/mL) collected
with FOB Gold Tube Screen and on other three different
samples (HbF=131.9, 277.2 e 632.3 ng/mL) collected with
FOB Gold NG, both stored for 15 days at 4, 23, 30 e 37°C.
One aliquot of each pool and of each temperature has been
tested in triplicate at 0, 1, 3, 5, 8, 11, 14 and 15 days. All
determinations have been performed using Cobas c6000
analyzers (Roche Diagnostics, MI).
Results: The HbF shows, as expected, a different degradation
percentage according to time and storage temperature being
after 5 days about 4% at 4 °C , about 10% at 23 °C and more
than 30% at 30 °C. Similar results have been obtained after 8
days of storage in the same conditions. The analytical
performance evaluated for BH storage buffer, show
satisfactory results in terms of LOQ=18,9 ng/mL; total
imprecision=6.5-9.41%; linearity (slope=0.99 intercept=1.26,
range: 74.8-800.8 ng/mL) also in samples with haemoglobin
variants (HbS, HbC e HbA1c).
Conclusions: The results of our study evidence the criticism
related to the storage condition for the accuracy of HbF test.
The comparison of the described storage buffers shows that
BN assures an improved and adequate stability of HbF , but
any of buffers evaluated assure the preservation at
temperatures >23 °C . These preanalytical aspects should be
carefully considered in the organization of screening program
for the assessment of fecal occult blood .
EW097
NEW APPROACHES IN BODY FLUID MANAGEMENT
C. Fleming
Erasmus MC, University Medical Center Rotterdam,
Netherlands
Accurate and rapid analysis of white blood cells (WBC) and
red blood cells (RBC) in body fluids can provide clinicians with
useful information related to diagnostics and treatment effect.
As matters stand, manual microscopy is considered the “gold
standard” for counting WBC and RBC in body fluids, but it is
time-consuming, with significant imprecision and interobserver variability. As a consequence, many laboratories
have replaced conventional manual differential counting with
automated haematology analysers for initial screening and
detection of cellular abnormalities so as to standardise their
routine procedure. In this study, we evaluated the body fluid
(BF) module of the XN-1000 automated haematology analyser
for counting WBC and RBC and compared it with the manual
reference methods. A total of 187 BF samples (73
cerebrospinal fluids (CSF), 48 continuous ambulatory
peritoneal dialysis fluids (CAPD), 46 ascites fluids, and 20
pleural fluids) were collected randomly. All samples were
analysed within 1 hour of entering the laboratory. Samples
were first measured on the automated XN-1000, followed by
manual microscopy. By setting manual microscopy as the
reference method, total WBC and RBC were counted using
the Fuchs-Rosenthal chamber followed by WBC differentiation
into mononuclear cells (MN) and polymorphonuclear cells
(PMN) by May-Grünwald Giemsa-stained cytospin slides. We
also assessed precision, carry-over and linearity. Good
agreement was found for counting WBC (y=1.06 x+0.09,
n=67, R^2=0.96) and MN (y=1.04 x – 0.01, n=40, R^2=0.93)
in CSF. However, the XN-1000 systematically counted more
PMN (y=1.48 x + 0.18, n=40, R^2=0.99) compared to manual
microscopy. Excellent correlation for RBC > 1×10^9/L (y=0.99x
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biochimica clinica, 2013, vol. 37, SS
+ 116.56, n=26, R^2=0.99) in CSF was found. For other fluids
(CAPD, ascites and pleural fluid) excellent agreement was
found for counting WBC, MN, PMN and RBC. The lower limit
of quantitation for WBC was defined at 5×10^6/L. Linearity
was excellent for both the WBC (R^2=0.99) and RBC
(R^2=0.99) and carry-over never exceeded 0.05%. In total, we
concluded that the BF module on the XN-1000 is a suitable
tool for fast and accurate quantification of WBC (differential)
and RBC counts in CSF and other body fluids in a diagnostic
setting.
EW098
THE CLINICAL USEFULNESS OF AUTOMATED
MEASUREMENT OF BODY FLUIDS
R. de Jonge
Erasmus MC, University Medical Center Rotterdam,
Netherlands
Normal cerebrospinal fluid (CSF) contains no or very few white
blood cells (WBC). An increase in WBC can be an indication
of several diseases, including meningitis, encephalitis,
malignancy or other neurological diseases. The total WBC
count and the WBC differentiation into mononuclear cells (MN)
and polymorphonuclear cells (PMN) can help clinicians with
useful diagnostic and treatment effect information. CSF
analysis is also useful for detecting or monitoring the response
to intrathecal chemotherapy for detecting minimal residual
disease (MRD) in patients with leukaemia. A high red blood
cell (RBC) count indicates a cerebral haemorrhage or
traumatic spinal tap. To answer whether it is fresh or older
bleeding, finding certain macrophages such as erythrophages
or haematoidin-containing macrophages can be helpful. Since
erythrophages do not occur earlier than 12-18 hours after a
bleeding, and haematoidin-containing macrophages are
usually not found earlier than two weeks after the incidence,
the appearance of those cells strongly points to a cerebral
bleeding rather than a traumatic tap. Microscopic analysis of
CSF is known as the gold standard for total WBC and RBC
counting, and WBC differential. This procedure has several
disadvantages, however: low precision, high cost, delayed
results, the need for skilled personnel, and inter-operator
variability. The obvious answer to these problems could be to
introduce advanced automated analysis methods. They could
reduce inter-operator variability and improve turnaround time
and precision. However, in contrast to blood, the automated
haemocytometric analysis of body fluids is a relatively
unexplored area of research. This prospective clinical
research study was designed to improve research software of
the Sysmex XN-Series automated haematology analyser,
which support the clinical questions: i) Is an infection or
inflammation ongoing?; ii) Is the infection bacterial or viral?;
iii) Did fresh bleeding or old bleeding occur? This evaluation
analysis mode does not require pretreatment of the samples
(dilution, enzyme digestion) and provides a full WBC count
and WBC differential, an RBC count, and research parameters
for detecting tumour cells and activated WBC.
EW099
QUANTIFICATION OF BTP FOR DIAGNOSIS OF
CEREBROSPINAL FLUID LEAKAGE
A. Huber
Center of Laboratory Medicine Cantonal Hospital, Aarau,
Switzerland
Background: Complications, morbidity, and mortality are high
after trauma with injury to the meningeal space and leakage of
EuroMEdLab 2013 - sciEntific sEssions
cerebrospinal fluid (CSF) into the nose, ears, and wounds. Due
to its high concentration in CSF, BTP has been shown to be a
sensitive, specific, robust and timely marker for detection of
such leaks. Using BTP determinations in secretion and serum
in 122 patients, we were able to define positive and negative
cut-offs as well as a small, indeterminate gray zone (0.68-1.11
mg/L).
Methods: We will present the results of a retrospective study.
Over 500 samples were received from over 400 patients from
2004 until 2012 and included in the study. The patients were
seen in different clinics, predominantly ear-nose-throat,
traumatology, and emergency room, but also neurosurgery,
intensive care units, and orthopedics. Collection of specimens
was done in a standardized process using defined containers.
After high-speed centrifugation, BTP was measured in
secretion and serum on a nephelometer (Siemens BN™ II
System) using reagents, calibrators, and controls for BTP from
Siemens. When possible, determinations were performed in
duplicate.
Results: Of the 418 patients, 284 (67%) were found to be
negative for CSF leak into the secretion. Of the remaining
patients, 111 were found to be positive and declared to have a
significant CSF leak. Only 23 cases had a result that fell within
the gray zone, mostly due to increased serum BTP and mildly
elevated secretion BTP values. In comparison to the clinically
defined endpoints, we were able to calculate a sensitivity of
>99% and a specificity of >97%. Loss of specificity was mainly
due to the “intermediate” cases, probably caused by small and
perhaps intermittent leaks or collection errors.
Conclusions: Rapid, timely measurement of BTP in secretions
that are suspicious for CSF leakage using a standardized
nephelometric assay seems to be very helpful in detecting
liquorrhoea syndromes. Our previously published data were
validated through this retrospective study. BTP determination
has important consequences for patient management, such as
additional surgical procedures, treatment with antibiotics, and
intense monitoring of positive and intermediate cases.
*For research use only. Not for diagnostic use.
EW100
SERUM BTP AS A MARKER OF RESIDUAL RENAL
FUNCTION IN DIALYSIS PATIENTS
T. Shafi
Division of Nephrology, Department of Medicine & Welch
Center for Prevention, Epidemiology and Clinical Research,
Johns Hopkins University, Baltimore, Maryland, USA
Background: Survival on dialysis remains poor, with a 5-year
mortality exceeding 60%. Kidney function in patients on
dialysis, also known as residual kidney function (RKF), is
associated with better survival, but there are no simple
methods for assessing RKF. Beta-trace protein (BTP) is a novel
endogenous filtration marker of kidney function. BTP is highly
correlated with measured glomerular filtration rate (GFR). BTP,
unlike urea and creatinine, is not removed during dialysis and
may allow assessment of RKF, similar to serum creatinine in
patients not on dialysis. The objective of this presentation is to
discuss the role of serum BTP for assessment of RKF in
dialysis patients.
Methods: We will present the results of two studies in this
presentation. In the first study, we measured serum BTP in
baseline samples from 503 participants of a U.S. national
prospective cohort study of incident dialysis patients with
enrolment during 1995–1998 and follow-up until 2004.
Outcomes were all-cause and cardiovascular disease (CVD)
mortality analysed using Cox regression adjusted for
demographic, clinical, and treatment factors. In the second
study, which is on-going, we are measuring GFR in dialysis
patients and correlating it with serum BTP.
Results: In our first study, serum BTP levels were higher in
individuals with no urine output at baseline compared with
those with urine output (9.0±3.5 vs. 7.6 ±3.1 mg/L; P <0.001).
There were 321 deaths (159 from CVD) during follow-up
(median 3.3 years). Higher BTP levels were associated with
higher risk of mortality. The adjusted hazard ratio (HR) and 95%
confidence interval (95% CI) for all-cause mortality per doubling
of serum BTP was 1.36 (1.09–1.69). Analysed as tertiles, the
adjusted HR (95% CI) for all-cause mortality in the middle and
highest tertiles compared with the lowest tertile was 0.95
(0.69–1.32) and 1.72 (1.25–2.37). Similar results were noted
for CVD mortality. In our second study, preliminary results
demonstrate that serum BTP is moderately correlated with
measured GFR in dialysis patients; correlation coefficient for
BTP is 0.609 compared with 0.407 for creatinine.
Conclusions: The serum level of BTP is associated with RKF
and is an independent predictor of death in incident
hemodialysis patients.
EW101
CHALLENGES IN HIV INFECTION DIAGNOSIS
S. Laperche
National Reference Center for HBV, HCV and HIV in Blood
Transfusion, National Institute of Blood Transfusion, Paris,
France
Diagnosis of HIV infection deals with several challenges: virus
genetic variability, the epidemic level of the disease, the level
of undiagnosed infection and resources involved in laboratory
investigations.
HIV shows a high degree of genetic variability: 4 HIV-1 groups
(M-P) were described. Group M is divided into 9 subtypes (AK) and more than 50 circulating recombinant forms (CRFs),
have been identified. HIV-2 includes 8 groups (A-H). The
geographical distribution of HIV-1/M subtypes and CRFs is
worldwide and linked to the epidemic level of the disease. HIV2 and HIV-1 non-M are limited to West Africa and Western
Central Africa, respectively and countries with links to these
regions. This complex diversity has implications for diagnosis
since false negative results attributed to viral diversity have
been reported with serological assays and with some PCRbased commercial assays.
The diagnosis of HIV primary infection is crucial to prevent
further transmission, to facilitate clinical management and early
treatment, and to avoid viral transmission through blood
transfusion. Traditionally, HIV infection is diagnosed on the
basis of the detection of antibodies (Ab). Due to the Ab negative
early phase, French health authorities mandated the use of HIV
Ag/Ab assays able to detect at least 2 p24Ag IU/mL. These
assays exhibit an overall high sensitivity for the detection of Ab
from individuals infected by different HIV strains. However,
even though their analytical sensitivity fulfills the legal
requirements, many of them could fail to detect HIV primary
infection due to HIV-1 non-B, non-M strains and HIV-2.
Access to HIV testing in undiagnosed individuals who can
unknowingly transmit infection is essential in resource-limited
areas as well as in high-income countries. In these cases, even
though globally less sensitive than EIAs, rapid tests which are
affordable and easy to use, might improve medical care and
reduce transmission of infection.
In conclusion, as the prevalence of HIV genotypes varies
geographically and is continuously changing, there is a need to
develop diagnostic tools able to detect a large spectrum of HIV
polymorphism. Moreover, the high level of undiagnosed
infections creates the need of highly sensitive rapid tests.
biochimica clinica, 2013, vol. 37, SS
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EW102
HIV SERODIAGNOSIS IN 2013
T. Duong Ly
Laboratoire BIOMNIS, Ivry sur Seine, France
Due to technical improvements, the reliability of serological
laboratory diagnosis of HIV has improved considerably. The
recommendation in the UK National Guidelines for HIV testing
2008 is the use of the fourth generation immunoassays, called
HIV Ag/Ab assay, for the first-line testing of blood in all
healthcare settings in order to reduce the window period. In
2010, French health authorities mandated the use of a CEmarked HIV Ag/Ab assay able to detect at least 2 IU/mL of p24
Ag (based on the WHO HIV-1 Ag standard), which is the
minimum threshold required by the current European
legislation applicable to p24 Ag detection assays. HIV viruses
have a high level of genetic diversity. Although HIV-2 is
distributed into 8 genotypes, HIV-1 has been classified into 4
groups, M (major), O (outlier), and two non-major and nonoutlier (N and P). This diversity can have an impact on the
capacity of HIV Ag/Ab assays to equally detect all HIV
genotypes. Ten HIV Ag/Ab CE-marked assays for their
sensitivity in the detection of p24 Ag of diverse HIV-1 and HIV2 isolates were evaluated. The Ag p24 limit of detection (LOD)
ranged from 0.505 to 1.901 IU/mL with the WHO standard. But
this analytical sensitivity obtained is not predictive for the
performance of p24 Ag detection of different HIV-1 subtypes
since the majority of investigated HIV Ag/Ab assays were not
able to detect every HIV-1 strain with an optimal sensitivity.
According to the mean LODs of different subtypes obtained,
there are three categories of HIV Ag/Ab assays: the first
category included those which failed to achieve the minimum
required threshold of 2 IU/ml regardless of the genotype; the
second gathered those which fulfil the requirements not for all
genotypes and the third category comprised all the others
assays which provided a mean threshold below 2 IU/ml
independently on the genotypes. The variable sensitivity of HIV
Ag/Ab assays observed in the detection of p24 Ag could
compromise the diagnosis of early infection due to HIV-1 nonB genotypes, and HIV-2. As the prevalence of HIV-1 subtypes
varies geographically and is continuously changing driven by
such factors as immigration, travel and tourism there is a need
to develop diagnosis tools able to detect a large spectrum of
HIV polymorphism.
EW103
ENHANCED HIV SCREENING THROUGH MULTIPLEX
ANALYSIS
W. Link
Bio-Rad Laboratories, Inc., Benicia, USA
Objective: Create the next generation of HIV tests: an
automated HIV assay with 4th generation sensitivity that can
report antibody and antigen results separately, and distinguish
HIV-1 from HIV-2 positives.
Methods: The BioPlex 2200 HIV Ag-Ab assay uses multiplex
flow immunoassay, a methodology that permits simultaneous
detection and identification of many analytes in a single
reaction vessel. The assay is performed by the Bio-Rad
BioPlex 2200 automated analyzer. A mixture of four
populations of dyed beads is used. Assay performance has
been characterized in house using CLSI methods to determine
limit of detection and precision (20 days, 2 runs/day) using
weakly reactive specimens. Clinical sensitivity and specificity
were evaluated using 24 commercial HIV seroconversion
panels and 5239 routine specimens of unknown risk for HIV
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biochimica clinica, 2013, vol. 37, SS
infection. HIV-2 detection was assessed using 177 known HIV2 positives from West Africa and 90 known HIV-1 positives.
Results: Total precision of index values (S/CO) were <10% for
all analytes. Limit of detection of p24 is 0.63IU/mL based on
the WHO Standard. p24 antigen was the first analyte detected
in all 24 seroconversion panels. BioPlex 2200 detected HIV
infection one donation sooner than Abbott Architect Combo
HIV (4th generation) in three panels. BioPlex 2200 missed one
donation positive by Architect. To assess specificity, 5239
samples of unknown risk were tested. Nineteen were reactive
on BioPlex and confirmed by Abbott Architect Combo. Nine
other specimens were reactive on BioPlex, but could not be
confirmed, resulting in specificity of 99.83%. All known HIV-1
and HIV-2 specimens tested were reactive. All 90 HIV-1
samples were correctly identified as HIV-1, 153/177 HIV-2
samples were correctly identified as HIV-2; 24 were
undifferentiated. Of BioPlex 2200 undifferentiated samples, 18
were undifferentiated on Immunocomb.
Conclusion: The BioPlex 2200 HIV Ag-Ab assay, which is
currently in development, is highly sensitive and specific, and
can provide detailed screening results that will assist in
identifying specimens from primary infection and HIV-2
positives. Its ability to report separate results for p24 antigen,
HIV-1 antibody, and HIV-2 antibody qualify it as the 5th
generation of HIV testing.
EW104
A BETTER PATIENT OUTCOME WITH A WIDE
APPROACH ALGORITHM
R. Berni Canani
Department of Pediatrics and European Laboratory for the
Investigation of Food Induced Diseases, University of
Naples “Federico II”, Naples, Italy
The evaluation of gastrointestinal symptoms has a major role
in pediatric clinical practice. Careful patient’s history evaluation
and physical examination are crucial for the formulation of a
correct diagnosis and identification of useful tests for a
definitive diagnosis. Cases in which the suspected diagnosis is
poorly defined are frequent and the risk of a diagnostic delay
or incorrect use of invasive or non-invasive tests is high. This
is the case of many children with inflammatory bowel disease
(IBD) in which the presence of non-specific intestinal symptoms
or extra-intestinal manifestations can result in a significant
diagnostic delay responsible for serious impact on body growth
and development, unnecessary dietary regimens or therapies,
and medical and familial costs. In these situations, as well as
in the differential diagnosis of functional gastrointestinal
disorders or food allergies, having effective laboratory tests can
be of great help. Recently, several non-invasive diagnostic tools
have been proposed to make a timely and accurate diagnosis
of IBD. Among these fecal calprotectin, serological specific
markers (i.e., anti-Saccharomyces cerevisiae and perinuclear
staining anti-neutrophil cytoplasmic antibodies), together with
the study of small intestinal permeability, and of bowel wall
thickness by ultrasonography have a major impact on a modern
approach to these subjects. The sequential incorporation of
these new diagnostic tools into the work up facilitate clinical
decision making when the diagnosis of IBD in children is
uncertain. The diagnostic test should ideally be able to identify
and quantify the risk of developing a disease, reflect the degree
of severity and activity, be specific as well as easy to apply in
daily clinical practice. These requirements seem more
theoretical than real, but in recent years many advances have
been made in this direction and several new tests are now
available. In several cases a careful standardization is still
advocated, but it is essential for the physician to know
existence, potential and limits of these tests in order to meet the
EuroMEdLab 2013 - sciEntific sEssions
needs of the patients and make diagnostic process as accurate
and fast as possible.
EW105
A FRUITFUL AND EFFICIENT MODEL OF LABORATORY
ORGANIZATION
M. Plebani
Department Of Laboratory Medicine, University-Hospital,
Padova, Italy
Background: Recent technological developments in laboratory
medicine have led to a major challenge, maintaining a close
connection between the search of efficiency through
automation and consolidation and the assurance of
effectiveness. The adoption of systems that automate most of
the manual tasks characterizing routine activities has
significantly improved the quality of laboratory performance;
total laboratory automation being the paradigm of the idea that
"human-less" robotic laboratories may allow for better operation
and insuring less human errors.
Methods: After reviewing the number and types of tests
requested in the field of allergy and autoimmune diseases, and
the number of tubes and patients with tests requested in both
diagnostic areas, we have integrated the diagnostic pathway by
linking through a track the instrumentations used for allergy
and autoimmune testing.
Results: A significant reduction of the analytical turnaround time
and the laboratory reporting within 24 h for test requested for
suspected allergies and/or autoimmune diseases was found.
The possible addition of appropriate laboratory tests (reflective
testing) on the basis of the initial data was also demonstrated.
Conclusions: This experience confirms that automation allows
clinical laboratories to improve analytical performances if
trained staff operate in accordance with well-defined standard
operative procedures, thus assuring continuous monitoring of
the analytical quality. In addition, laboratory automation may
improve the appropriateness of test requests through the use
of algorithms and reflex testing. This should allow the adoption
of clinical and biochemical guidelines. In conclusion, in
laboratory medicine, technology represents a tool for improving
clinical effectiveness and patient outcomes.
EW106
AUTOMATED, HIGH-THROUGHPUT WORKFLOW FOR
THE ANALYSIS OF 25-HYDROXYVITAMIN D AND 3-EPI25-HYDROXYVITAMIN D3 BY MULTIPLEXED
TURBOFLOW LC-TANDEM MS
L. Couchman
Kings College Hospital, Department of Clinical Biochemistry,
London, UK
Measurement of total serum 25-hydroxyvitamin D (25OHD) is
considered a reliable marker of vitamin D status. In the past
decade, there has been a move towards the use of liquid
chromatography-tandem mass spectrometry (LC-MS/MS) for
the analysis of 25OHD. However, MS/MS alone is an achiral
technique. This can be problematic for some isobaric 25OHD
metabolites, notably 3-epi-25-hydroxyvitamin D3 (3-epi25OHD3). For accurate analysis of 25OHD3, LC-MS/MS
methods require routine chromatographic resolution of 3-epi25OHD3, but this requires extended chromatographic analysis
times, which impacts on assay throughput. We have
developed a method for the analysis of serum 25OHD2 and
25OHD3, which resolves interference from 3-epi-25OHD3,
using automated sample preparation and multiplexed
TurboFlow LC-MS/MS to maximise throughput without
compromising assay specificity. All liquid handling was carried
out using a VersetteTM automated system. Calibration, quality
control standards and samples (100 µL) were transferred to a
96-well filter plate. Internal standard solution and precipitation
reagent were separately added from reagent reservoirs. Filter
plates were capped and vortex mixed (10 min). Supernatants
were collected into a microtitre plate by centrifugation (200 g,
3 min). An Aria Transcend TLX-II system (Thermo Scientific)
was used. Sample supernatants (100 µL) were injected onto
a C18-XL TurboFlow column (50 x 0.5 mm i.d.). Retained
analytes were back-flushed from the TurboFlow column onto
an Accucore PFP analytical column (total 2.6 µm aps, 50 x 2.1
mm i.d.) at 40 °C. Mass spectrometry was carried out in
positive ionisation mode using APCI. Retention times were
10.94 min, 11.47 min and 11.82 min for 25OHD3, 3-epi25OHD3 and 25OHD2, respectively. Total analysis time was
13 min, including column re-equilibration. MS/MS data were
acquired for 5 min per analysis to allow multiplexing (analysis
time with multiplexing 7 min per sample). Human serum
samples from the international Vitamin D External Quality
Assessment Scheme (DEQAS, samples 404 and 405) were
analysed. Sample 405 was correctly found to contain 3-epi25OHD3, which would have been misidentified as additional
25OHD3 using our previous LC-MS/MS method.
EW107
DETECTION OF DRUGS OF ABUSE IN EXHALED
BREATH USING MASS SPECTROMETRY AND A SIMPLE
COLLECTION DEVICE
O. Beck
Department of Medicine, section of Clinical Pharmacology,
Karolinska Institutet, Stockholm, Sweden
It has recently been demonstrated that amphetamine,
methadone and tetrahydrocannabinol are detectable in exhaled
breath following intake. Exhaled breath therefore constitutes a
new possible matrix for drugs of abuse testing. The present
work was aimed at exploring this possibility further by a study
on patients treated for acute intoxication with abused drugs.
Forty-seven patients were included in the study and breath,
plasma and urine samples were collected following recovery
together with interview data. Analyses of breath and plasma
samples were done with liquid chromatography-mass
spectrometry methods. Urine was screened using
immunochemical reagents and positive findings confirmed with
liquid chromatography-mass spectrometry methods. The
following analyses were investigated; methadone,
amphetamine,
methamphetamine,
6-acetylmorphine,
diazepam,
oxazepam,
alprazolam,
morphine,
benzoylecgonine,
cocaine,
buprenorphine
and
tetrahydrocannabinol. In most of the studied cases recent
intake of an abused substance prior to admission was reported.
In 43 of these (91%) the breath analysis gave a positive finding.
Identifications were based on correct chromatographic
retention time and product ion ratios obtained in selected
reaction monitoring mode. Generally, data from breath, plasma,
urine and self-report were in agreement. Detected substances
in breath comprised amphetamine, methamphetamine,
buprenorphine, 6-acetylmorphine, morphine, methadone,
tetrahydrocannabinol, diazepam, oxazepam, alprazolam and
cocaine. This study gives further support to the possibility to
develop exhaled breath into a new matrix for drugs of abuse
testing by extending the number of analyses that are
documented to be detectable in breath.
biochimica clinica, 2013, vol. 37, SS
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EW108
THE INFLUENCE OF THE BLOOD DRAWING
TECHNIQUE
G. Lippi
U.O. Diagnostica Ematochimica, Azienda OspedalieroUniversitaria di Parma, Parma, Italy
Blood drawing, a primary requisite of in vitro diagnostics, is the
most vulnerable step of the testing process. An appropriate
venipuncture is essential to obtain a quality specimen, wherein
a mishandled or incorrect procedure can produce unsuitable
specimens, compromise the quality of testing and ultimately
jeopardize patient safety. The most frequent problems
attributable to inappropriate sample collection, in order of
frequency, entail spurious hemolysis, clotting, incomplete or
inappropriate filling of primary blood collection tubes, undue
clotting, inappropriate containers, contamination from infusion
liquids, as well as misidentification and unsuitable conditions of
temperature, time and humidity for transportation. The
venipuncture procedure is typically complex, requiring both
knowledge and skill. Although each phlebotomist usually
defines a comfortable routine, a series of sequential steps must
be fulfilled. These include correct patient identification,
assessment of patient physical disposition, (i.e., diet, physical
exercise, stress, basal state), check of requisition form,
selection of a suitable site, preparation of equipment and
puncture site. The tourniquet should applied to an area
approximately 10 cm above the intended site of venipuncture,
it should be tight enough to restrict venous flow but not arterial
circulation, and – especially – should be ideally removed after
1 min but never left in site for more than 3 min. The blood
samples must be labeled before venipuncture and collected in
the appropriate container. The ideal needles are those with
calibre comprised between 19-23 gauge, preferably straight.
There is no analytical reason to limit the use of butterflies, but
the incremental cost over the conventional straight needle
should be adequately weighted as well as the stringent
requisition of discarding the air volume with a discard tube.
When mixing of the tube is required for the presence of various
additives (anticoagulants, pro-coagulants, stabilizers), this
should be done by 3-6 times gentle inversion. Primary blood
tubes should never be mixed to prevent cross-contamination of
additives. The specimens should hence be sent to the
laboratory in a suitable time frame and under the best
environmental conditions, with no injury.
EW109
PNEUMATIC TRANSPORT SYSTEMS: FACTS AND
SPECULATIONS
D. Giavarina
Laboratorio di Chimica Clinica ed Ematologia, Ospedale San
Bortolo, ULSS 6, Vicenza
The pneumatic tube system (PTS) provides a rapid mode of
sample transportation. Modern PTSs with soft start and
variation of speed for different transports offer fast, reliable, and
efficient transportation of blood samples to the laboratory.
However, during transport in a PTS, blood samples are often
subjected to high speeds and rapid acceleration and
deceleration, which can lead to hemolysis. Usually, this
problem can be revealed variously from sample to sample, and
some recent reports have studied the different possible causes
of this pre-analytical problem. The tube type can be correlated
with the hemolysis caused by PTS. Serum samples are more
susceptible than plasma samples, when sent through PTS, and
serum tube with gel seems to confer some protection against
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biochimica clinica, 2013, vol. 37, SS
the damage of erythrocytes and leukocytes. Hemolysis can be
due to the specimen bumping on the internal sides of the
shuttle, during the rapid accelerations or decelerations. Put the
tube in a sponge-rubber or in a bubble wrap can reduce the
chance of damage to red cells in whole blood specimen during
the trip along the PTS. Speed of sample transportation by a
PTS can influence the degree of hemolysis. Moreover also the
distance is correlate with the level and percentage of
hemolysed samples. Distance and speed can have a synergic
effect, so that a higher speed can be accepted for short
distance, while a slow movement can reduce the percentage of
hemolysis in a longer route of PTS.
Last, some specific populations of patients (for instance,
hematology and/or oncology patients) seems to have blood
samples more susceptible to damage.
Each installation of a PTS is uniquely characterized by
architecture, technical specifications, and differences in speed
and length, thus demanding individual evaluation of every
single system. Each hospital should validate the PTS at the
center before use to ensure that this pre-analytical step does
not cause any spurious results. It is possible to avoid, or
reduce, hemolysis by interventions like reducing speed,
blocking samples inside the shuttle, changing tube type,
centrifuging samples before the run and using plasma gel
separator.
EW110
APPROACHES TO BE USED IN VERIFICATION OF IVD
METROLOGICAL TRACEABILITY
F. Braga
Centre for Metrological Traceability in Laboratory Medicine
(CIRME), University of Milan, Italy
To be accurate and equivalent laboratory results should be
traceable to higher-order references. Furthermore, their
analytic quality should fulfill acceptable measurement
uncertainty as defined to fit the intended clinical use. To this
aim, IVD manufacturers should define a calibration hierarchy to
assign traceable values to their system calibrators and to fulfill
during this process uncertainty limits for calibrators, which
should represent a proportion of the uncertainty budget allowed
for clinical laboratory results. It is therefore important that, from
one hand, laboratory profession clearly defines the clinically
acceptable uncertainty for relevant tests and, from the other
hand, end-users may know and verify how manufacturers have
implemented the traceability of their calibrators and estimated
the corresponding uncertainty, including, if any, the employed
goal. Currently, the full information is usually not available as
manufacturers only provide the name of higher-order reference
material or procedure to which the assay calibration is
traceable without any description of steps and their
corresponding uncertainty of the implemented traceability
chain. In general, it should be possible to establish if the current
status of the measurement uncertainty budget associated with
the proposed traceability chain is suitable or not for clinical
application of the test. Important post-market tools for IVD
traceability surveillance are related to the verification by clinical
laboratories of the consistency of declared performance during
routine operations performed in accordance with the
manufacturer’s instructions and the organization of
appropriately structured EQAS. The former activity should be
accomplished by analyzing system control materials and
confirming that current measurements are in control range, with
no clinically significant changes in the assumed unbiased
results. With regard to EQAS, it is mandatory that target values
to materials (including their uncertainty) are assigned with
reference procedures by an accredited reference laboratory,
that materials are commutable and a clinically allowable
EuroMEdLab 2013 - sciEntific sEssions
inaccuracy for participant’s results is defined in order to prove
the suitability of laboratory measurements in the clinical setting.
EW111
CURRENT PITFALLS OF CONTROL MATERIALS: THE
WAY FORWARD
C. Ottomano
Laboratory of Clinical Chemistry and Hematology, Academic
Hospital of Parma, Italy
EU Directive on In Vitro Diagnostic (IVD) Medical Devices
obliges manufacturers to ensure traceability of their analytical
systems to recognised higher-order references. According to
IVD regulations, manufacturers should provide control
materials (CM) that shall give the user confidence that the
values obtained by use of the test system are traceable. Clinical
laboratories should verify the consistency of the performance
declared by the manufacturers through the organization of
appropriate analytical internal (IQC) and external (EQA) quality
controls. IQC used to monitor the analytical performance of the
methods should be reorganised to check the trueness of CEmarked systems and to evaluate system imprecision. EQA
Assessment Programs provide an assessment of laboratory
performance. The CM used to check trueness and imprecision
must be provided by the manufacturer of the analytical systems
and by an independent source, respectively. The CM for
imprecision must be commutable and, when clinical decision
cut-points are employed, their concentrations should be around
those values. The CM for trueness and imprecision should
satisfy the analytical goals derived from biological variations of
each analyte. The EQA materials should suit the following
characteristics. First, the values must be assigned with
reference measurement procedures by an accredited
reference laboratory to check the measurement uncertainty of
participating laboratories against the established reference
measurement systems. Second, EQA materials should display
proved commutability to allow transferability of participating
laboratory performance to patient samples. Finally, the clinically
allowable uncertainty of measurements should be defined in
order to verify the suitability of laboratory measurements in a
clinical setting. A survey commissioned to the Working Group
for Analytical Quality by the Italian Society of Clinical
Biochemistry (SIBioC) demonstrated a gap from what reported
above and what at the moment is provided from manufacturers
and EQA organizers. For instance, the acceptable range of CM
for trueness respects manufacturer’s criteria rather than those
derived from biological variation and the CM for imprecision is
often the same used to check trueness.
approach). To overcome the inherent difficulties in the
systematic application of this approach in a clinical laboratory
alternative ways were proposed. The so called “top-down”
approaches derive the calculation of measurement uncertainty
from already existing data provided by Internal Quality Control
(IQC) and External Quality Assessment (EQA).
In fact measurement uncertainty has a random component
than can be derived from IQC data and a systematic
component that should be minimized, but includes the
uncertainty of the value assigned to the calibrator. The amount
of bias to be considered for the calculation of the uncertainty
can be derived from different sources: measurements of a
value assigned reference material, peer group means of IQC
or EQA results.
We propose a practical way of calculating the uncertainty of
measurement of each measurand based on a spreadsheet that
uses all these parameters.
Knowing the uncertainty of a measurement provides an
indication of the analytical quality of the result and allows
checking whether it is suitable for clinical purposes. Moreover
it allows a statistically sound comparison with previous results
of the same patient or with results from other laboratories. A
basic requirement for these comparisons is an easy,
homogeneous and standardized way of calculating the
measurement uncertainty and the tool we provide represents
an important step in this direction.
EW112
HOW TO ESTIMATE THE MEASUREMENT
UNCERTAINTY IN CLINICAL LABORATORIES: IS THE
GUM APPROACH MANDATORY?
F. Ceriotti
Diagnostica e Ricerca San Raffaele, San Raffaele Scientific
Institute, Milano, Italy
It can be stated that the result of a measurement is only an
approximation (or estimate) of the true value of the measurand,
and thus it is complete only when accompanied by a statement
of the measurement uncertainty. The standard approach to
calculate the measurement uncertainty proposed by the Guide
to the expression of uncertainty in measurement (GUM)
requires the quantification of each and every source of
variability to sum them up for the final calculation (bottom up
biochimica clinica, 2013, vol. 37, SS
S83
EuroMEdLab 2013 - IndEx of authors
20th IFCC-EFLM European Congress of Clinical Chemistry and Laboratory
Medicine (EuroMedLab)
45th Congress of the Italian Society of Clinical Biochemistry and Clinical
Molecular Biology (SIBioC)
Milan, 19-23 May 2013
Index of Authors
Author
Code
Aakre K.
SY57
Abbiyesuku F.
M334
Abbruscato R.
T124
Abd Alrahman S.
W163
Abdalla L.
M094
Abdel Rahman M.
W079
Abdel-Maksoud S.
W079
Abdel-Rahman S.
W331
Abdollahi H.
M342
Abeysena C.
M348
Abir B.
W030
Abizanda-Soler P.
M386, M408
Abo Haimad A.
M376
Abo-Taleb E.
M302
Abo-Zeid M.
M194
Abramyan M.
M299, T029
Abrate A.
M153
Abu El Kassem A.S.
M302
Abusoglu S.
M314, W171
Acar A.
M175
Accattato F.
W178
Achouri A.
T132
Acosta I.
W255
Adami F.
W230
Adavane S.
W032
Adebayo T.O.
W229
Adebusoye L.
W023
Adedosu O.T.
T133, W229
Adeli K.
SY38
Adell J.
T017, W075
Ademi J.
W313
Ademoglu E.
M134
Adler T.
T349
Agbedana E.O.
W121
Aghemo A.
M035
Agnello L.
M245
Agodi A.
M073
Agosti A.
W208
Aguirregoicoa E.
M231
Ahioglu S.
T134
Ahmadi S.
M339
Ahmed T.
W048
Author
Code
Ahmed Y.
W117
Ahn S.A.
W078
Aigbe A.
W026
Aita A.
M061, M173, T068, T093,
T288, T194
Ajdzanovic V.
T036, T050, T055
Ajili F.
M140
Ajmal J.P.
W090
Ajuria I.
W135
Ajzner E.
OC33, T244
Akagac Etem A.
T135
Akalin A.
W162
Akalin-Ciftci G.
W162
Akan I.
M210
Akanni O.E.
T133, W229
Akbal E.
W370
Akbas H.
M210, T289, T290
Akbiyik F.
T262
Akdagli S.
M406
Akin O.
M357
Akkarathikarn K.
W172
Akpamu U.
M356, W181
Aksu K.
W162
Akter S.
T291
Akyol S.
W007
Alabakovska S.
W097, W149
Alanen K.
OC18
Alatas O.
T070, W162
Albaladejo M.D.
T011, T017,
W075
Albanese A.
M081
Albayrak A.
W370
Albea B.
T292
Albertini R.
W270
Alberto G.
T001
Albini A.
M167
Albo G.
M156
Albuquerque A.M.
T031, T237
Albuquerque D.
OC15
Aldabó-Pallás T.
T006
Aldrimer M.
T193
Aleksandrovic J.M.
M202
Author
Code
Alepaki M.
W363
Alessio M.G.
M303
Alexay S.
M265, W340
Alfieri A.
W191
Alfonso-Pestano A.D.
T213
AlGarawi A.
W144
Algeciras-Schimnich A.
T034
Algrooni K.
W144
Al-Hazza A.
M376
Alhomida A.
W144
Ali S.H.
W322
Alía-Ramos P.
W041
Alijo F.
M231
Alinezhad S.
M141
Aliño S.F.
M246
Aljicevic M.
W228
Allal-Elasmi M.
W027, W028
Allison J.
T328
Allkanjari A.
W302
Almadani H.
W144
Almeida R.F.d.
W231
Almeida T.C.
M205
Aloe R.
W351
Alonge T.
W023
Aloni R.
W308, W320
Alonso C.
W396
Alonso-Araujo I.
T144
Alonso-de-la-Peña C.
W168
Alonso-Garcia J.
M057, M331,
M336, T254
Aloui R.
W330
Alpini C.
W328
Al-Sadie R.
T281
Alsina M.
M044
Alsoaeitiv S.O.
M211
Altemus M.
T150
Altinier S.
W230
Aluma A.
M044
Alvarez A.I.
W135
Álvarez F.V.
T217
Álvarez-Fernández I.
T217
Álvarez-Rueda M.A.
M401
biochimica clinica, 2013, vol. 37, SS
S705
EuroMEdLab 2013 - IndEx of authors
Author
Code
Alvaro-Ortega R.
Alvi A.J.
Alzahrani S.
Amadii G.
Amaral-Valentim C.A.
Amato A.
Amato F.
OC16,
Amira D.
M315,
T092
T392, T393
M011
W321
T086
T293, T294
M055, M059
M316, M327,
M333
Amira S.
W029
Amirfallah A.
T245
Ammouri S.
T349
Amolak B.
W233
Amr K.
W079
Amundsen E.K.
W256
Amunni G.
M207
Amzazi S.
T196
Anastasi E.
T334
Anastasia L.
OC14
Andergassen U.
M212
Andjelic T.
W341
Andrada R.
M375
Andrade A.
T117
Andrade-Campos M.
W272
Andrés C.
T138
Andrés-Fernández C.
M104
Andria G.
M056, M082, M083
Andriamanana I.
T320
Anelli M.C.
M113, W349
Angeletti S.
M116
Angelidis C.
M363
Angelone A.
T185, T186
Angelov A.
T058
Anghebem-Oliveira M.I.
W185
Angioni A.
M059
Anıl M.
M349
Annemanns L.
EW060
Annesley T.
T267
Anselmo M.
T004
Antal L.
T226
Antalfi B.
T169
Antal-Szalmás P.
M201
Antenucci M.
T100, T377
Antic A.
W303, W325
Antic D.
W240
Antico F.
M271, T044, W310
Antonelli G.
T032, T365
Antonenko A.
M016
Antonijuan-Parés A.
W118
Antunes F.
W246
Antunovic T.
T045
Aouni Z.
W029, W030, W204
Apjok A.
W263
Apple F.S.
T381, T385
Arabadzhiev G.
T028
Aralica M.
T295
Aramouni E.
T188
Araoud M.
W346
S706
Author
Code
Arapceska M.
M136, T399
Araujo A.
OC15
Araujo Alencar Brandão do Vale M.
M017, M089, M090, M091, M092
Araújo F.
W311,
W231
Arcangeli L.
T089, T090
Arcaro M.
M220
Arcoleo F.
M040
Ardoino I.
W071
Arfaoui Toumi A.
W330
Arfini C.
M317
Aribi M.
M235
Armando C.
M172
Armutcu F.
W370
Arnaldi G.
T037
Arnaldi L.
T001
Arosio B.
T145
Arppe R. T296, T358, T386, W114
Arrebola M.M.
T198
Arroyo M.
W289
Arsene C.
OC13
Arteaga S.
T138
Artero J.M.
T011, T017
Artusi C.
M317, T032, T365
Arzuhal A.
W371
Asanin M.
W147
Asencio A.S.
OC34
Asensio Antón J.
M018, T113
Ashavaid T.
M237
Ashour E.
M011
Aslan D.
T261
Aslan F.
W368
Aslan M.
M293
Assandri R.
M033, T369
Assi L.
T332
Aston-Abbot L.W.
T394
Atanasova A.
W119
Atanasova B.
W269
Atanasova E.
W001
Atanasova Boshku A.
W031
Atashzar M.R.
M342
Atef S. M251, T199, W163, W331
Ates A.
T162
Attallah A.
M194
Atti M.
M259
Augé J.M.
M169
Auger S.
T047
Aulesa C.
M044
Aupetit J.
W050
Autilio C.
T100
Autolitano S.
T301
Avalos M.
W255
Avanzini P.
W351
Avbersek Luznik I.
M252
Avdagic N.
W228
Avellan T.
T085
Avgerinos P.
W067
biochimica clinica, 2013, vol. 37, SS
Author
Code
Avilés-Plaza F.
W154
Avivar-Oyonarte C.
M128
Avram S.
M014, T246
Avveduto G.
W287, W288
Awadallah S.
W164
Awasthi G.
M192
Awess E.
M093
Axel K.
M069
Axelson M.
T033, W342
Aydin F.N.
M229
Aydoğdu Çolak A.
M349
Ayhan H.
T070
Ayo O.
T138
Azdajic S.
T164
Aziz S.
M219
Babetto E.
T274
Baburina I.
M215, T171
Baccouche A.
W018
Backman Johansson C.
W376,
W353
Bacun T.
M384
Bačvanski L.
W002
Badciong J.
W106
Badowska W.
W285
Badura R.
W246
Bærug A.
T201
Bagci S.
W368
Bagdonaite L.
M019
Baginska E.
T099
Baglin J.
T214
Bagnarelli P.
M132
Bagnati M.
M317
Bahr M.J.
W350
Bailey A.
W369
Baiocco R.
M190
Bairaktari E.
M363
Bakr N.
M011
Bal R.
T135
Balafrej A.
T196
Balahoroglu R.
W139
Balas M.
T187
Baldi A.
W180
Baldi L.
M298
Baldovino S.
W232
Balgkouranidou I.
M142
Ballesteros C.
W135
Balogh I.
M088
Bamonti F.
W203
Bangma C.
SY41
Banhara L.M.
M092
Banjoko B.
OC08
Bantel H.
W350
Baquer N.Z.
T153
Barak M.
M020, M093, T349,
W332
Baraka A.
M243
Baral N.
T040, W217
Baraldi E.
T060, T069, W134
EuroMEdLab 2013 - IndEx of authors
Author
Code
Barallat J.
W073
Barany P.
T347
Baranyai E.
M021
Barassi A.
M166
Barassi C.
W320
Barbera J.L.
T117
Barberini L.
OC28
Barberio G.
M064, T129
Barbetseas J.
W067
Barbieri M.
T297, T298
Barbin B.
T192, W290
Barbina G.
T039
Barbosa Carvalho N. W247, W248,
W249, W274
Barbullushi A.
W234
Barburina I.
T166
Barbut F.
EW062
Barbuzano-Safont C.
W214
Barchiesi V.
M253, T318
Barchitta M.
M073
Bardallo-Cruzado L.
T177
Bardet V.
T004
Barinov E.
W326
Barišić I.
M238
Barlogie B.
W242
Baroni S.
M003, M297
Barra G.
M094
Barrague H.
W045
Barreau M.
M054
Barrera R.
M267
Barreto S.
M279, M280
Barth E.
T104
Barth J.
EW038
Bartlett N.
EW006
Bartlett W.A.
T247
Bartoszewicz Z.
M343
Baruti Z.
M309
Baruti-Gafurri Z.
T175
Basco D.
M168, W343
Basar O.
W370
Baser U.
M134
Basheer T.M.
W090
Basilotta N.
M374, M375
Baskin Y.
T072, T073, T245,
Bassa N.
W235, W404
Bassani N.
W071
Bassiouni Y.
M382
Basso D.
OC20,SY49, M061,
M143, M148, M149, M173, T194,
M196, M249, T288, T373
Basso G.
M173
Basu S.
T176
Batra G.
M109
Battaglia D.
T248, W036
Battista M.
M003
Battistelli L.
M022
Batuecas-Mohedano M.
M385
Bauch H.J.
EW083
Author
Code
Baudin B.
T173, W032
Bauer A.
OC22
Baum H.
M378
Baumann N.A.
T034
Baumgarten A.
M254
Bay P.
M112
Baydas G.
T135
Bayes-Genis A.
W073
Baykal A.T.
M362
Bayrak C.
T070
Bayraktar- N.
T262
Bazeley S.
W286
Bazza F.
M245
Bazzan M.
W317
Bazzi C.
M303
Beaney M.
M200
Beastall G.
SY23
Beastall G.H.
EW086
Beaudeux J.L.
T002
Becerra Fernandez A.
T050
Beck O.
EW107
Beckmann M.W.
M212
Bedford D.
W033
Bedin R.
M318, T160
Bedini J.L.
EW068
Będkowska E.
M183, M184
Bednarz N.
M150
Beer-Ljubic B.
T164
Begcevic I.
T142
Beger T.
W003
Begic L.
T167, T168
Bego T.
W170, W195, W196
Begolli G.
T175, W333
Begolli L.
M309, T175
Begovic D.
W236
Behera V.M.
W090, W322
Beji Y.
W030
Bekaert A.
M347
Bekir A.
W025, W033
Bekmez M.
T070, W162
Bel Habib M.
W025
Bel waer I.
M316, M327
Belabbas K.
M054
Belfiore A.
W052
Belhabib M.
W033
Bellantone R.
OC09
Bellei E.
M144, M259, M267,
M288, W223
Belli S.
T060
Bellia C.
M245
Bellomo G.
M317
Beloscar J.
W062
Belth B.
M121
Beltrandi E.
M381, W237
Belwaer I.
M315, M333
Ben T.
M039
Ben Abdelghani A.
W116
Ben Hamda K.
W150
Author
Code
Ben Khedija W.
W025, W115
Ben Salem N.
W115
Benakova H.
T003
Benchikh M.
W021
Benedetti S.
OC24, M050, W061
Beneteau-Burnat B.
W377
Benítez A.J.
W396
Benitez D.
T117
Ben-Khedija W.
W116
Benmostefa A.
W378
Ben-Osman A.
W028
Benrais N.
T196
Benvenuti C.
W052
Bequer Mendoza L.C. T200, T213
Beranek M.
T041, T299
Berenguer-Piqueras M.
W250
Berestovskaya V.
T115
Berg J.P.
T201
Berg T.
M095, M254
Bergamini S.
M144, M259, M288,
W223
Bergante S.
OC14
Bergesio F.
W287, W288
Bergmann K. M345, W034, W035
Bergner M.
W157
Beridze N.
M383, T043, T080
Berki T.
W362
Berkouk Y.
W268
Berlanga O.
W299, W239
Bermudo F.
T110
Bermudo Guitarte C. M255, T136,
T177
Bernal-Bolaños L.
M057
Bernardi G.
M159, T137
Bernardini S.
T143
Berni Canani R.
EW104, M055
Berntorp E.
SY46
Berska J.
M224, M225
Bertacca G.
M112
Bertalot G.
M190
Bertero M.
W317
Berthoux A.
M366
Berti S.
OC10, W074
Bertone C.
W232
Beshara S.
T347, W192
Bettencourt P.
W142
Bettinelli A.
M298
Bezerra M.
OC15
Bezmarevic M.
W341
Bhatnagar M.K.
W131
Bhattacharjee J.
W131
Bhattacharya C.
M262
Bhattoa H.P.
M201
Bhawalkar S.
M237
Biagioli T.
W287, W288
Bianchi G.
M144
Bianchi L.
M096, M114, T300
Bianchi S.
T248, W036
biochimica clinica, 2013, vol. 37, SS
S707
EuroMEdLab 2013 - IndEx of authors
Author
Code
Bianchi V.
M317
Bianciardi P.
M170
Bibi A.
M074, T132
Bidlingmaier M.
EW012, EW070
Bienias P.
W057
Bieniewska Z.
M346
Biganzoli E.
W070, W071
Bignamini D.
W203
Bigot-Corbel E.
M256, W037
Biljali S.
M257, M258, M289
Bilka F.
W143
Binello G.
W232
Bingisser R.
EW075
Bini V.
OC17
Birkeland K.
T201
Bittera I.
T195
Bjelanovic J.
W240
Blachon G.
T047
Blanchet J. S.
M145, M146
Blanchon L.
T236
Blanco Cristobal C.
M026
Blanes Gonzalez M.
T178
Blank D.
T326
Blankenstein M. A.
T035
Blankenstein R.
SY25
Blaton V.
W095
Blazquez R.
T117
Blazquez-Ortiz A.
W209
Blennow K.
T166, T171
Blincko S.
EW079
Blinova T.
T191
Blond E.
W165, W337
Blotta M.
OC15
Bobilewicz D.
EW028, T030
Bobillo-Lobato J.
T321
Boccara F.
W032
Boccia A.
OC23, M049
Bochi G.V.
M205
Bodea C.
M403
Bodell M.
W253
Bodell Davoody M.
W352
Boden H.
W048
Boemi M.
M268
Bogavac-Stanojevic N.
M284
Bogdanos D. P.
OC21
Bogdanovic J.
M001, M009
Bogosavljevic V.
M402
Bohórquez A.
T005, T008
Bois A.
T235
Bojadzhiev L.
T325
Bojanin D.
T202
Bojko M.
M346
Bolaños-Bernal L.
T254
Bolayirli I.
W003
Bolbach G.
T173
Bolinaga-Moral I.
M344
Bomcheva M.
M289
Bonadonna P.
M002
S708
Author
Code
Bonaguri C.
M022, T160, T367
Bonaque J.C.
W155
Boncheva M.
M257, M258
Boned Juliani B.
M344
Bonet-Marqués R.
W118
Bonetto M.G.
W068
Boneva T.
W241
Bonfigli A.R.
M268
Bongo A.S.
W070, W071
Bonjean S.
W008
Bonomi E.
M112
Bonomini F.
M170
Bonou M.
W067
Bootsma M.
W048
Boracchi P.
W070
Bordás N.
M147, M222
Bordoni R.
OC24
Borges M.
W323
Borghi M.O.
M036
Borisova M.
W119
Bornhorst J.
EW090, W242
Borovac-Stefanovic L.B.S.
T164
Borque L.
W293, W294
Borsetti F.
M267
Borsotti M.
T255
Bortolozzo K.
M081
Boscaro M.
T037
Boschetti G.
W337
Bosch-Jimenez V.
T179
Boscolo-Bariga A.
T044, W309
Boscolo-Panzin C.
W309
Boshkovska M.
T203
Bosi A.
W288
Bosic J.
T227
Boslkova G.
W097
Bosoni T.
W270
Bosselut N.
W367
Bossuyt P.M.
SY33
Botelho J.C.
T047, T249
Botella-Martínez S.
W006, W013
Botsivaly M.
T102, W383
Bottacin A.
W318
Bottero J.
W367
Bottini P.V.
W243
Botto N.
OC10, W074
Boubaker S.
M140
Bouchniba A.
W029
Boudaya M.
M074
Boundi Z.
T018, T204
Bountziouka V.
W067
Boursier C.
T173
Bousrih H.
W025, W116
Boutmarzourhte M.
T196
Boutoille D.
M256
Boutten A.
W378
Bouvier D.
T236
Bovani S.
M114
Boveda O.
W225, W292, W294
biochimica clinica, 2013, vol. 37, SS
Author
Code
Bovino G.
W244
Bovo G.
OC01
Boyer-Chatenet L.
W032
Bozic R.
T051
Božičević S.
W166, W226
Božina N.
M244, M238
Bozovic D.
T045
Bozzato D.
M148, M149, M173,
M196, T068, T194, T288, T373
Brady J.J.
W004
Brady J.
W106
Braga F.
EW110, T282, W070,
W071, W244, W366
Braga M.
OC20
Bragato G.
T404, W161
Brakocevic D.
M117
Brambilla P.
M298, W053
Brambilla S.
T071, W245
Brand K.
W350
Brandstetter T.
W379
Brandt B.
M150
Braun P.
M095
Bravo Espinosa M.A. M078, M122
Breda A.
OC17
Brent Dixon R.
EW043
Brevers E.
W102
Brevet A.
W153
Briguglio M.G.
M131
Britez-Rodriguez S.
T178
Brízido H.
W246
Brkic B.
T036, T050
Brochet J. P.
SY20
Brockbank S.
W020
Brockmann E.
M186
Brodska H.
T003
Brogi M.
M291, T124, W205,
W287, W288
Broquedis P.
W153
Brugia M.
T037
Brugnolo L.
T032, T365
Brugnon F.
T220
Brum L.M.P.
W193
Brunetti A.
W178
Bruni F.
M259
Brunkhorst F.
EW077
Bruno G.
T001
Bruns D.E.
SY63
Bruyère O.
M264
Bucciol G.
T192, W290
Buckley C.
T332
Buckner R.
T381, T385
Bucur A.
M163
Budagova K.
W056
Budima N.
T175
Budina M.
T263, W390
Buendía-Moreno J.
M408
Buettner T.
M036
Bugajska J.
M224, M225
EuroMEdLab 2013 - IndEx of authors
Author
Code
Bugrov A.
W038
Bujold E.
OC19, T235
Bulo A.
M070, M272, W095
Bulsa J.
W285
Bulusu S.
W117
Buño Soto A.
W039
Buono A.
M267
Buono P.
W191
Buran İ.
T135
Burbello A.
T107, W098
Burda K.
W088
Burki D.
M377
Burkov A. T206, T218, T225, T232
Burokiene N.
W199
Busà M.
M131
Busco F.
M268
Bushkevich M.
W112
Bustos M.F.
W160
Butch A.W.
T381, T385
Buti E.
W287
Buttari F.
T143
Büttler R.
T035
Buzas R.
W167
Cabañas-Perianes V.
W250
Čabarkapa V.
T161
Caberlotto L.
M064, T098, T129
Cabezas-Fernandez T.
M128
Cabezas-Martínez Á. M031, T156,
T264
Cabral M.
W105
Cabrera-Morales C.M.
T271
Caccamo A.
T301
Caccia C.
T157, T158
Cafissi A.
M114
Caiazzo M.
M288, M259
Caironi P.G.
OC32
Caixeta M.
M094
Cakmak M.
T243
Calabrese A.
M161
Calabrò R.
OC23, W060
Calcagno M.d.L.
W125, W340
Caldarella A.
M220
Caldini A.
W287, W288
Calibasi G.
T072, T073, T245
Calin G. A.
SY31
Callà C.
T234
Calla' C.
M379
Callanquin M.
W378
Calle-Luna J.
T204
Calton L.
M165, T267
Calvo M.
W396
Camacho-Benitez I. W249, W274
Camacho-Luque R.
M099
Camacho-Martinez P. T027, T241
Camargo E.G.
M250
Camargo J.L. OC25, M250, M306,
W193
Camargo-Coronel A.
M027
Author
Code
Cambisano M.
M035
Camil F.
W127
Camiña F.
W168
Campanile G.
T185, T186
Campbell J.
M063, M273, W081,
W082
Campelo M.D.R.
T086
Campioli D.
M022, T367
Campos M.
T151
Campos L.
W261, W262
Can A.
M151
Can G.
T330
Canales M.
W039
Canali C.
M318
Candás-Estébanez B.
W040,
W041
Candelieri G.
T258
Canhetê R.F.R.
M089, W231
Canic V.
T250
Canistro R.
W309
Cañizares F.
W042
Cañizares-Hernández F.
T204
Cannata M.
W278
Canovi S.
T367
Canta I.
W318
Cantagrel N.
W045
Cantiello P.
M161
Cantù M.
T302, T303
Canu G.
OC09, M075, M041,
M042, M043
Canu L.
M216
Cap J.
T041
Capanni C.
M317
Caparrós Canovas S. M255, T177
Capeau J.
W104
Capobianchi M.R.
M132
Capobianco V.
M023
Capoluongo E.
M041, M042,
M043, M075
Caporale R.
T255
Caporaso J.G.
M024
Capoun O.
M176
Cappellani A.
M275, T074, T082,
T305
Cappelli G.
W223
Cappellini F.
W053
Cappuccio G.
M046
Capuano M.
M023
Caracciolo M.B.
W340
Caragheorgheopol A. M204, T038
Carati L. M275, T074, T082, T305
Carbia C.D.
M265
Carbone M.R.
W061
Carbonell R.
T011
Carbonne B.
T265
Cardinaels E.
W043
Cardullo S.
OC10, W074
Cargnin L.P.
M205, W120
Author
Code
Cariani E.
Carignola R.
Carlisi A.
M399, W334
W317
OC29, M152, M260,
M347, W009
Carlomagno N.
W180
Carnevale A.
T087
Carobene A.
T260
Caroli D.
T044
Carpeggiani C.
W036
Carpenè E.
M267
Carra D.
T069
Carraro P.
OC33,T129, T244,
T274, W044, W161
Carrascosa C.
W301
Carratala A.
T117
Carreiro S.
T317
Carretero-Gómez J.F. M031, T156
Carrillo S.
M279, M280
Carrión-González M. M386, M408
Carrozza C.
OC09, M297
Carr-Smith H.D.
T304
Carstens C.
W379
Carugno M.
W221
Caruso A.
M245, T234
Caruso B.
M002, M157
Carvalho M.
W311
Carvalho-de-Sousa J.P.
W246
Casaburi G.
M024
Casals E.
M044
Casamitjana M.
W404
Casanova A.
M045
Casarini S.
W270
Casas-Losada M.L.
M006, M007,
T338
Casas-Maldonado F.
M099
Casas-Pina T.
W155
Casati M.
M275, T074, T082,
T145, T305
Casellato D.
M303
Casero M.C.
OC27
Caslake M.
W033
Caso F.
M061
Cassarà F.
W278
Castagna P.
M112
Castaldo G.
OC16, M059, M085
Castellana C.N.
T306
Castelli C.
M146
Castellini H.
T292
Castellví-Griso A.
W118
Castiglioni S.
M317
Castoldi G.
M275
Castro-Castro M.
W040
Çataloğlu B.
T140
Cattoretti G.
OC01
Cauci S.
T039, T205, W169
Causevic A.
W170, W195, W196
Causevic-Ramosevac A.
W170
Caussé E.
W045
biochimica clinica, 2013, vol. 37, SS
S709
EuroMEdLab 2013 - IndEx of authors
Author
Code
Cavagnolli G.
OC25, W193
Cavalcanti E.
M253, T318
Cavalier E.
OC29, M152,
M260, M264, M347, T048, T066,
T360, W009, W101, W102, W103,
W251
Cavallo M.R.
W384
Cava-Valenciano F.
T259, T338
Cavenagh J.
W239
Caylan R.
M406
Cebreiros-Lopez I.
M097,
M098, T018, T179, T222, T223,
T224, W250, W006, W155, W250,
W273, W382
Ceccanti M.
M321
Cecere S.
M253
Cecoli S.
T126
Ceglia C.
M071
Cekovska S.
M261, W190
Celap I.
T251
Celauro N.
M279, M280, W105
Çelebi G.
W368
Čelebić L.
T141
Celik H.T.
W171
Cellai F.
M227
Cembrola B.M.
M172
Centonze D.
T143
Centurion A.
T178
Cepa A.
T242
Cerasuolo D.
M253, T318
Cerezuela P.
T011
Ceriotti F.
OC17, EW112, M153,
T260, W380
Cermakova Z.
T077
Cerna M.
T242
Černelč P.
W277
Cerruti R.
T368, T376
Cerutimaria J.
W062
Cerutti L.
T307
Cerviño F.
W308
Cerviño F.M.
W320
Česla P.
M337, W356
Cevik A.
M362, M368
Chabraoui L.
T196
Chackrewarthy S.
M348
Chae S.
T252
Chahed H.
M039, W025, W033,
W115, W116
Chaieb A.
W115
Chait G.
T099
Chakraborty S.
M262, T075
Chaler E.A.
T180
Champarnaud E.
T267
Chan S.W.
T391
Chandra S.
W374
Chandrasekaran A.
W222
Chang C.
T276
Chang H.E.
W219
S710
Author
Code
Chang L.
M154, W335
Chang W.
T130
Chantratita W.
M130
Chapelle J.
W101, W102, W103,
W251
Charitonidis I.
T053, T054
Charles K.
M248
Charles-Davies M.A. M334, W121
Charlois A.
W337
Chaudhary N.
T122, W124
Chauvet D.
W251
Chaves-Lameiro P.
W249, W274
Chawla P.
M237
Cheah J.S.
W194
Chekir-Ghedira L.
M323
Chekkal M.
W304
Chen C.
W335
Chen G.G.
M155
Chen Y.
M154, W008
Chenevier-Gobeaux C.
T004
Cheng N.
M236
Chepurchenko N.
T206
Cherepanova V.
W297
Cherguelaine K.
W268
Cheuiche A.V.
M250, M306
Chevy F.
M054
Chiabchalard A.
W172
Chiari M.
T211
Chiba T.
W116
Chiefari E.
W178
Chiesa I.J.
M078, M122
Chilelli C.
T180
Chinchilla V.
T117
Chinello C.
OC01, M156
Chiras D.
M058
Chiriacò G.
T039
Chittamma A.
T308, T366, T401
Chkioua L.
M039
Chmura A.
M343
Choudhury M.
T380
Christensen P.A.
M398
Christensen P.
T309, T310, T311
Christenson R.H.
SY54
Chrostek L.
W336, W338, W345
Chuang T.
M001, M009
Chun S.
M319, M393, W092
Church S.
T081, T099, T253,
W397
Ciacci C.
M024
Ciaccio M.
M245
Cianciulli M.
M187
Ciardelli L.
T307
Ciavarella N.
W305
Cibecchini F.
OC28
Cibinel M.
W317
Çiçekler H.
M175
Cicilano M.A.
W232
Cicillini L.
M379
biochimica clinica, 2013, vol. 37, SS
Author
Code
Ciećko-Michalska I.
W360
Ciepiela O.
W267
Cifarelli R.A.
M242
Cigalini E.
W270
Cillari E.
M040
Cimpoesu-Preotu D.
W046
Cingirt M.
T262
Ciniselli C.
T116, T266
Ciraci M.
T262
Ciurzyński M.
W057
Ciusani E.
M159, T137, T158
Civelek S.
W003
Claessens Y.
T004
Clarke S.
M248
Clerico A.
OC10, T404, W074,
W113
Climent S.
M077
Clodic G.
T173
Clunie I.
T328
Coban J.
M351
Coban S.
W370
Cobbaert C.M.
W047, W048
Cocci A.
T340, T375
Cocco C.
M002, M157
Cochat P.
M274
Cockwell P.
EW089
Codazzo C.
M321
Cohen A.
W032
Coj A.
W049
Cojoaca M.
M203
Colacicco L.
W386, W402
Colak E.
M380, W173
Colantonio C.
W148
Colao A.
T185, T186
Coley M.D.
T312, T313, T314
Collin-Chavagnac D.
W050
Collinson P.
SY60, W076
Colombo G.
T001
Colorado-Castillo A.G.
T284
Comino J.M.
M231
Concettoni C.
T037
Concolino P.
M075
Condés E.
M231
Conde-Sánchez M.
T321
Confortini M.
M227
Conrad K.
OC21
Constanso-Conde I.P.
M401
Contaldo F.
M395, W191
Contardi L.
T278, T315
Conte P.F.
M157
Contestable P.
T166, T171
Cook M.
W239
Cooney J.
W033
Coppola P.
W051
Corbella-Inglés E.
W040, W041
Corbetta S.
M298
Cordella A.
W060
Coric J.
M158
EuroMEdLab 2013 - IndEx of authors
Author
Code
Coronado Alvarez N.M.
M057
M099, M100, M331, M335,
M336, T254, W209,
Correa V.
T278, T315
Corsale P.
T100, T377
Corsini E.
M159, T137
Corsi-Romanelli M.M.
W063,
W065
Cort A.
M210, T139, T147
Corte-Arboleya Z.
W276
Cortelazzo S.
W282, W321
Cortey A.
T265
Coşar A.
OC12, T134, T140,
W085
Ćosić I.
M174
Ćosić V.
M038, M051, T015,
T141, W132
Cosma C.
T207
Cosmi E.
T207
Cosseddu D.
T001, W232
Costa A.
M131
Costa E.
W123
Costa F.
OC15
Costa I.L.D.
M091
Costa M.
T317
Costa P.
W323
Costa S.
M094
Couchman L.
EW106
Couderc F.
W045
Couturier J.
T337
Covelli B.
M187, W052
Covili-Faggioli E.B.G.
W237
Coyle P.
M110, M125
Cozzolino C.
M046, M056,
M082, M083
Craddock C.
W239
Creanza B.C.
T316, W381
Creixell M.
W404
Crespi I.
W232
Crespo E.
W225, W292, W294
Cretich M.
T211
Crine Y.
T048, T360
Crispo A.
M072
Cristoni S.
M399
Croal B.
T078, W066
Croce C.
SY30
Crocetti E.
M220
Crockard M.
M110, M125, M200
Cruz A.D.D.
M089, T110
Cruz M.d.C.
T063
Csiki Z.
T169
Csípő I.
M021
Csobán M.
M201
Cuculi F.
W157
Cuerq C.
W337
Cugini A.
W351
Culej J.
M239, M240
Culhane J.F.
T205
Author
Cullhaj B.
Cunha N.
Cuoghi A.
Code
W302
T317
M144, M259, M267,
M288, W223
Cuomo M.
T318
Curi R.
T272
Curti M.
M377
Curto G.
M231
Cusi D.
W061
Cusini M.
M036
Cusserne C.
W008
Cvetkovic T.
M038
Cylwik B.
W336, W338, W345
Czygier M.
M160
D’Auria G.
T185, T186
D’Isa G.
T180
Da Molin S.
W053
Da Silva A.S.
M306
Da Silva N.R.
T265
Dabla P.
T181
Dadoniene J.
M019
D'Agnese I.
W349
D'Agostino M.N.
M047
Dahlfors G.
T347
D'Aiuto G.
M161
D'Aiuto M.
M161
Dajak M.
M263, T056, T057,
W087, W240
Dale P.
W233
Dalgaard K.
W388
Dali D.
T322
Dall'Olio E.
T060
Daloiso P.D.
T100, T377
Damin F.
T211
Damjanović A.
T165
Danese E.
W207
D'Angelo A.
SY44, M047
Dangol S.
W197
Daniel R.
M093
Daniele A.
M048
Danielsson J.
W100
D'Antonio M.
M049, M072
Danza F.M.
M297
Daperno M.
T368
D'Argenio V.
OC23, M024, M048,
M049, M161,
Darouiche A.
M140
Darragh J.
EW044
Darrigo M.
W062
Das B.
T076, W054
Das S.
W054
Dastych M.
T077
D'Atena T.
M381
Daulay D.Y.
W055
Däumer M.
M095
Davceva O.
W005
David A.
T333
David D.
M412
Author
Code
Davis T.
Davran F.
Dayaldasani A.
De Antonio M.
De Armas L.
De Béjar A.
De Bellis G.
De Boer R.
De Buyzere M.L.
De Caprio C.
De Carvalho J.A.M.
De Carvalho N.B.
T381, T385
T289
OC27, T198
W073
W200
T017
OC24
EW055
M320
M395
W120
T151, W261,
W262
De Cesaris M.
M116
De Corso E.
M003
De Cristofaro T.
M187
De Cunto C.
W349
De Falco F.
M049, M172
De Francesco D.
M317
De Giuseppe R.
W203
De Graan A.
M248
De Grande L.
T279
De Groot P.G.
EW030
De Haro Muñoz T.
M057, M099,
M100, M331, M335, M336,
T254, W209
De Jonge R.
EW098
De la Fuente-Gonzalo F.
W289
De la Taille A.
OC17
De la Torre-Prados M.
M102
De Liso F.
W203
De Lózar de la Villa A.
T259
De Lózar de la Viña A.
M006,
M007, T338
De Miguel Elizaga I. M097, M098,
T018, T179, T222, T223, T224,
W006, W013, W156, W250,
W273, W382
De Nardi C.
T319, T320
De Santis M.C.
T069, W134
De Souza E.M.
W185
De Souza V.C.
M274
De Stefano A.
T143
De Valentin L.
T287
De Vita C.
W203
Deane C.
M125
Deans K.
T078
Debbia D.
M004, M012
Debeljak Z.
M330
Debijadji V.
M313
Debord J.
T382
Decaux O.
EW058
Dechappe P.
W153
Dechecchi M.C.
M081
Deelder A.M.
M156, W047
Deenmamode J.
W369
Dehoux M.
W378
Dejanovic B.
M338, T172
biochimica clinica, 2013, vol. 37, SS
S711
EuroMEdLab 2013 - IndEx of authors
Author
Code
Dejou-Bouillet L.
T220
Del Castillo-Figueruelo B.
T321
Del Giudice E.
M046
Del Mese G.
T137
Del Pozo R.
W339
Del Rey Sanchez J.M.
M365,
T050, W111
Del Valle E.
W105
Delaby C.
OC11
Delanaye P.
OC29, M260, M264,
M347
Delanghe J.
SY01
Delanghe J.R.
M320
Delaroche O.
M256, W037
Delas I.
T164
Delas M.
T164
Deleanu C.
W220
Delgado B.
W311
D'Elia M.
T101
Deligiannis I.
M363
Della Bella P.
OC24, M050
Della Bruna R.
T303
Delmee M.
EW063
Dembowski S.
W106
Dementjev V.
T115
Demidchik L.
M394
Demidkina A.
W056
Demir M.
W174
Demircan K.
W007
Demirtas C.
T262
Demkow U.
W057, W267
Deneva T.
W316
Deneva-Koycheva T.
W058
Dente B.
W257
Deo P.
T322
Depierre L.
W104
Depreter B.
T323
Derek L.
W372
D'Errico M.P.
W059
Dervishi E.
W287
Dervisoglu E.
M277
Derwich K.
W285
Dessì M.
M379, T143, T234
Desvignes P.
T324
Detta N.
W060
Devereaux P.
W091
Devreese K.
EW032
Dhakal N.
T040, W217
Dherai A.
M237
Di Biagio P.
T293, T294
Di Carlo M.B. M265, T230, W160,
W340
Di Ciocia S.
T137
Di Francia R.
M187
Di Giovanni S.
M131
Di Iorio V.
M072
Di Maio M.
M253
Di Matteo S.
T001
S712
Author
Code
Di Paola F.
M253
Di Resta C.
OC24, M050, W061
Di Santolo M.
T205
Di Serio F.
OC04, W393
Di Somma E.
W237
Di Taranto M.D.
M047
Diakoumi-Spyropoulou P.
T102,
T103, W383
Diamandis E.P.
T142
Diamantino I.
W323
Dias T.
T031
Diaz J.
T117
Díaz-Maroto I.
T138
Diaz-Maroto S.
W404
Diaz-Mediavilla J.
W289
Dicuonzo G.
M116
Diczfalusy U.
W342
Didziariekiene V.
W283
Dierge L.
W251
Dikshit P.
W218
Dilillo D.
T182
Dima K.
M058, M079
DiMagno L.
T166, T171
Dimitrova-Karamfilova A.
M241
M247
Dimova I.
W296
Dinckan A.
T290
Dineva D.
T325
Ding J.
M236
Dipace N.
T316
Dirienzo G.
T316, W305, W381
Diss T.
M200
Diviani R.
W062
Divjak I.
T161
Dixit R.
W131
Dizaye K.
W175
Djaffar-Jureidini I.
T188
Djamouri F.
W104
Djiana R.
T326
Djidjik R.
M080, W268
Djogo A.
T045
Djordjevic B.
M038, M051
Djordjevic I.
M181
Djordjevic T.
T015
Djordjevic V.
M051, W132
Djurasinovic T.
W341
Dmitrašinović G.
T056, T057
Dmitrenko O.
T379
Dmytruk I.
M162
Dobrosevic B.
M384
Dogan N.
T243
Doğan N.
M349
Dogan S.
M293
Dogan-Ekici I.
M351
Dogliotti G.
W063, W065
Dogru T.
W368
Doğru-Abbasoğlu S.
M351, T067
Doherty J.
M200
biochimica clinica, 2013, vol. 37, SS
Author
Code
Dojcsak É.
M322
Dolcemascolo N.
T278
Dolci A. T087, T182, T350, W244
Dolgov V.
W038
Domínguez-Pascual I.
T321
Dompmartin A.
M054
Donalson K.
T208
Donati M.L.
M096
Donati S.
M096, M114, T300
Doncheva E.
T325
Dondi F.
M267
Donnelly E.
M063
Dopsaj M.
M010
Dopsaj V.
M010, M284
Đorđević A.B.R.J.
T209
Dorofeichik-Drygina N.
M353
Dorofeykov V.
W064
Dos-Santos B.P.
M013, M025,
M052, M053, M086, M087,
M401, T327
D'Osualdo A.
T068
Douki W.
M332, W150, W346
Dousi E.
W252
Douville X.
OC19, W324
Doventas A.
W003
Doyle R.
T298
Dozio E.
W063, W065
Drago L.
W014
Dragutinovic V.
M193
Drai J.
W165, W337
Draskovic-Pavlovic B.
M312
Drastikova M.
T041, T299
Dreier J.
W128
Drozd E.
W112
Drybańska B.
M392
Drygina L.
M353, W010, W077
Du S.
W106
Dublish S.
T181
Dubourg L.
M274
Dubovik T.
W089
Dufernez F.
M054
Dujic T.
W170, W195, W196
Dukic L.
T142
Dumache R.
M163, M412
Dumitrascu V. M163, M412, T187
Dumnicka P.
W348
Dundar Yenilmez E.
T210
Dundr P.
M185, T023
Dunjić-Kostić B.
T165
Dunlop A.
T078, T328, W066
Duong Ly T.
EW102
Dupke S.
M254
Duplantie J.
OC19, T235, W324
Dupret-Carruel J.
M366
Ďuračková Z.
W143
Durand C.
M366
Duranti F.
T143
Duretz B.
T319, T320
EuroMEdLab 2013 - IndEx of authors
Author
Code
Dursun O.
M210
Duvnjak V.
M101, M286
Dyląg S.
M392
Dymicka-Piekarska V.
M164
Eakins E.
W321
Eastell R.
SY67
Eastwood M.
M165
Ebelt H.
M129, T021
Eberle J.
M095
Ebesunun M. W023, W211, W398
Echolc B.
W306, W329
Ederhy S.
W032
Efremova-Aaron S.
W176
Egashira S.
T363
Egea-Guerrero J.J.
T005, T006,
T007, T008, T020, T027, T144
Eggertsen G.
OC06, W253,
W342, W352
Ehret R.
M095
Eidukaite A.
M228
Eilertsen H.
W254, W260
Eintrei J.
W192
Eisaburo S.
T128
Ekiz F.
W370
Ekim H.
W139
Ekim M.
W139
El Bendary O.
W355
El Hasafy M.Y.
W361
El Kouhen R.
W106
El Oudi M.
W204
El Sayed M.K.
W361
El Shiwy Y.
W355
El-Baz H.
M194, M195
Elbracht R.
W379
Elce A.
OC16, M055 M059,
M085
Elens L.
M248
Elezovic I.
W240
El-Fawaeir S.
M305
Elia G.
W318
Elias C.
W255
El-Kafoury A.
W213
Ellidokuz H.
T072, T073, T245
Ellouze S.
M315
El-medany A.
M382
Eloisa U.
W293
Elonen N.
W114
El-Oudi M.
W029, W030
El-Samak M.
M243
Elsasser S.
W157
El-Sherbiny M.
M194
Emdin M.
W074, W113
Emmer J.
M322
Enamorado-Enamorado J.
T006,
T007, T020
Engelmann P.
W362
Engelstein A.
M093
Enguix A.
M102
Author
Code
Enpuku K.
T363
Ens K.
T104
Erasmus R.
M266, M283, T148
Erasmus R.T. W080, W187, W198
Erba D.
W014
Ercin C.N.
W368
Erden G.
M406, W371
Erdincler D.S.
W003
Erdogan H.
OC12
Erdoğan S.
W007
Erguez A.
W116
Erne P.
W157
Eror T.
T055
Erroi L.
W317, W318
Ersoy F.
M293, M294
Ertorun I.
W162
Erwa W.
M088
Escanero J.F.
W293, W294
Escobar L.
M099
Escobar R.
M102
Escudero A.
T217
Escudero J.M.
M044, M169
Eskils J.
W192
España R.
W396
Español I.
T011
Esposito G.
M072, M172
Esposito M.V.
M161
Essaidi R.
W116
Esteban M.
W135
Esteban P.
T011, T017, W075
Estela-Burriel P.L.
M354
Esteve S.
M060
Esteve Poblador S.
T079, T123,
T329, T342, T374
Etem A.A.
T330
Eun-Kim P.
M314
Evangelopoulos A.
W067
Evruke C.
T210
Fabbri S.
T300
Faccini G.B.
W068
Facco M.
M173
Facente A.
T234
Fache C.
T388
Fadda G.
OC09
Faes C.
M308
Faggian A.
T273, T274, T275
Faggian D.
T207, W321
Faint J.
T332
Faísca M.
T270
Faivre J.
EW094
Falbo R.
EW019, W053
Falcou Briatte R.
T333
Fallacara F.
M278
Falliti G.
M131
Falzarano R.
T334
Famodu A.
W026
Fan M.D.
M155
Fan S.
W335
Author
Code
Fandino A.
Fanelli A.
Fanelli F.
Fania C.
T310
T255
T060
OC14, M166, M167,
T145
Fanos V.
OC28
Fantz C.R.
T034
Farah F.
W330
Faria A.P.
OC33, T244
Farid E.
W355
Farinaro E.
M395, W191
Farkas G.
M147
Farkas N.
W362
Farnia A.
T129
Faro-Viana J.
T335
Fasoli L.
M153
Fassan M.
M149
Fassina A.
M149
Fatas M.
T117
Fattakhov N.
W069
Fattoh A.
M251
Favaloro E.J.
SY45
Favaro F.
W321
Faye S.
W008
Fechner K.
T104
Fedak D.
M008, W348, W360
Fedorenko A.
T107
Fejfar T.
W151, W152, W373
Feki M.
M062, W027, W028
Fekih O.
W150
Felicetta I.
W221
Feliu J.
W039
Feng W.
M340
Fenske W.
EW092
Feoktistova V.
W327
Ferchichi S.
M039, W025, W033,
W115, W116
Ferlizza E.
M267
Fernández H.
W154, W156
Fernández Codejón O.
W111
Fernandez Fraga M.
SY12
Fernandez Leivas A. M026, M383,
T042, T043, T080, T339
Fernández-García J.L.
M052
Fernández-Grande E.
T271
Fernández-Ramos M.
M013
Fernandez-Rodriguez E.
M026,
M383, T042, T043, T080, T339
Fernádez-Rodríguez F.
T327
Ferraguti G.
M321
Ferrai G.
T129
Ferrante N.
OC29, M347
Ferrari C.
W334
Ferrari M.
OC24, M050, T211,
W061
Ferrario F.
OC01
Ferraro D.
T160
Ferraro S.
M168, M197, W070,
biochimica clinica, 2013, vol. 37, SS
S713
EuroMEdLab 2013 - IndEx of authors
Author
Code
W071, W343
T063
OC15
M084
T257
T117
W232
M156
T146, W180
M268
M325, M326,
W083, W182
Fiaz N.
W119
Fibbi B.
M217
Fic A.
W357
Figuero L.
M018
Fijacko M.
M384
Fijacko V.
M384
Filella X.
M169
Filik H.
T336
Filiopoulos1 V.
M295
Fillet M.
W101, W102, W103
Finati E.
M170, T009
Findeisen R.
M171, T105,
T106, T256
Finderle P.
W344
Findik R.B.
W171
Fínek J.
M300
Fink M.
W277
Fink N.E.
W307
Fioravanti M.
M116
Fioretti T.
M172
Fiorio E.
M157
Fitzgerald S.
M063, M110, M125,
M200, M273, W020, W021,
W081, W082
Fleming C.
EW097
Fleury G.
W032
Flisiak R.
W336, W338, W345
Florín A.
M374
Florkowski C.
SY56
Flors L.
OC34, T125
Flourie B.
W337
Flynn L.
T099
Foco M.
W232
Fodor B.
M322
Fogar P.
OC20, M148, M149,
M173, M196, M249, T194,
T288, T373
Fogazzi G.B.
EW016
Foj L.
M169
Fomichev M.
M411
Fonfrede M.
T337
Fontana L.
M317, M395
Fontana P.
M190
Forbes A.
OC21
Ford K.
T081
Forest J. C.
SY65
Ferreira M.F.
Ferreira R.
Ferrer-Dufol A.
Ferrero C.A.
Ferrero J.A.
Ferrero P.
Ferrero S.
Ferrigno M.
Festa R.
Festus O.O.
S714
Author
Code
Forestieri P.
W180
Fornal M.
W088
Forti G.
M217
Fortova M.
M185, M269
Fortun M.
W104
Fortunato A.
EW071, M352
Fortunato G.
M047
Foster G.
EW002
Foti D.
W178
Fouda M.
M195
Fracassi F.
M267
Fragoso-Morales L.E.
T284
Fraissinet F.
M256
Francescantonio P.L.C.
M017
Francescato G.
W208
Francescato M.P.
W169
Francone M.
T301
Franekova J.
M270, W072
Franzini M.
W113
Fraschini F.
T009
Fraser W.D.
T280
Frassoldati A.
M157
Frasson C.
M173
Frati L.
T334
Freire R.V.C.
W231
Freire-Aragón M.D.
T007
Freitas A.M.M.S.
T270, W126
Freschi M.
OC17
Fressl Juros G.
T010
Friese K.
M212
Frigerio F.
T368
Friggeri M.
M112
Frisso G.
OC23, M046, M056,
M082, M083, M161, W051,
W060
Froissart R.
M039
Frolova M.
W212
Frusciante E.
T257, T260
Fulla Y.
M182
Fuller D.
T381, T385
Fumagalli G.
M275
Fumagalli R.
OC32
Futardo C.
W395
Fuzzi G.
M153
Gabalec F.
T041, T299
Gabelle A.
OC11
Gacuta-Szumarska E. M183, M184
Gad M.
W079
Gadisseur R. M152, M260, W009
Gae Ryung C.
T252
Gafoor A.
W090
Gagné C.
OC19, T235, W324
Gagnon M.
OC19, W324
Gaia P.
W123
Gaidano G.
W282
Gaikovaya L. T107, W099, W327
Galan A.
W073
Galavani K.
W106
biochimica clinica, 2013, vol. 37, SS
Author
Code
Galbiati S.
T211
Galeazzi R.
M268
Galić J.
M174
Gallardo J.M.
M027
Gallesi D.
T306
Galli C.
M103, M132
Galli E.
OC10, T182, W074
Galli V.
M318, T160
Gallot D.
T236
Galozzi P.
M061
Galvez-Lopez R.
M100
Gambaro A.
M297
Gambaro G.
T340
Gambhir J.K.
W218
Gammoudi N. W025, W115, W116
Gana I.
T320
Ganeva M.
M296
Ganie Y.
W407
Gantuya P.
M405
Ganz T.
PL1
Garabet L.
W256
Garagnani M.
T126
García D.N.
W320
García J.V.
T117, W396
García L.
M374, M375
García M.G.
M078, M122
Garcia Alonso S.
M026, M383
García Basavilbaso N.
M374
García Cano A.M.
M365
García Collia M.
M365, T050
García de Guadiana L. T011, T017,
W075
Garcia de Paoletti D.N.
W308
García de Veas Silva J.L.
M255,
T136, T177
García Íñigo F.J.
M006, M007,
T259, T338
García Linares S.
M057, M100,
T254, W209
Garcia Moreira V.
M026, M383,
T042, T043, T080, T339
Garcia-Chico P.
T117
García-Chico Sepúlveda P.
T271
Garcia-de-la-Torre A.
M102
García-del-Moral R.
M331
Garcia-de-Vicuña A.
W248
García-Mayo S.
M025, M086
García-Menéndez L.
M385
Garcia-Pinilla M.
T241
García-Sanchez M.I.
T136
García-Teijido P.
M367
Garelli D.
T370, T371
Garlaschi C.
M035
Garlipp C.R.
W243
Gärtner C.
W379
Gascón F.
T108, T109, T110,
T117
Gąsiecka-Czapla M.
M066
EuroMEdLab 2013 - IndEx of authors
Author
Gassiot P.
Gattinoni L.
Gauchez A.S.
Gava A.
Gawlik K.
Code
W235
OC32
M182
M061
T215, W177, W360,
W403
Gaykovaya L.
W098
Gaze D.
W076
Geat M.
W169
Gekas J.
T235
Gelfi C.
OC14, M166, M167,
T145
Gelis L.
W089
Gelisgen R.
M277
Gelli A.M.G.
T255
Gelmini S.
T116, T266
Genc H.
W368
Genini E.
T307
Genova M.
T212
Gentile M.
M047
Georges A.
M182
Georgieski K.
T046
Georgievski O.
W031
Georgieva J.
M296
Gerani C.
W068
Germagnoli L.
T111
Germano L.
T368
Gerónimo-Pardo M.
M104
Gerrard G.
W062
Gerrier F.
W377
Geršak K.
T229
Gerthoux P.
W053
Gervasoni J.
T340, T375
Gessoni G.
M271, T044, T341,
W309, W310
Getsim C.
M058
Geyer R.
M377
Gezginç K.
M175
Ghaffor M.
M080, W268
Ghani F.
W086
Ghedira K.
M323
Ghedira Z.
M323
Ghelardi A.
M112
Gheorghiu E.
M403
Gherlinzoni F.
W321
Ghiandai G.
W287
Ghisetti V.
EW001, M132
Ghorbel H.
M315, M333
Giacobbe C.
M047
Giambona A.
W278
Gianazza E.
M156
Gianicolo E.
W059
Giannecchini R.
M096
Giannelli I.
M112
Gianni D.
T293, T294
Giannitsis E.
T022, W145
Giannoli J.M.
T085
Giardina B.
M041, M042, M043,
Author
Code
M075
Giarin E.
W232
Giavarina D.
EW109
Gibbs S.D.
W299
Giguère Y.
OC19, T235, W324
Gil del Castillo M. L.
OC30
Gillery P.
EW065, W284
Gillmore J.D.
W299
Gimenez-Lopez M.J.
M128
Ginis Z.
W370, W371
Giona A.
T234
Giordano S.
OC16, M059, M085
Giovanni M.
M190
Giovannini S.
T248
Giraldo P.
W272
Giubbilini P.
W123
Giuliani G.
T089, T090, T258,
T370, T371
Giuliano R.
T230
Giunta E.
M131
Giusti L.
M112
Givler D.
M215
Gjorgoski I.
T203
Glaysher J.
T097
Gligorovic Barhanovic N.
T045
Gnatta E.
OC20, M173, M249,
T194
Gocheva N.
M296
Gogeliene L.
M178, M359
Goi G.
W014
Gök D.
M175
Golaboska J.
T046
Goldobin V.
T170
Gomez C.
W073
Gomes H.
W311
Gómez Hernández T. T200, T213
Gómez J.
T017
Gomes M.A.
T270
Gomes P.
M205
Gómez-Rioja R.
T092
Gómez-Serranillos M.
T156
Gómez-Serranillos-Reus M. T264
Gonçalves F.
W126
Gonzalez-Alvarado J. W249, W274
Gonzalez B.
T117
Gonzalez F.A.
W289
González-González O.L.
T213
González M.
T011, W075
González M.L.
M139, T138
González M.M.
W307
González Moral M.L.
M104
González-Soriano M.J.
OC30
González-Villalba M.J.
T092
Gooch J.
W369
Gordillo-Escobar E.
T006, T007,
T020, T144
Goreiko T.
M353, W010, W077
Gorji B.V.R.
W322
Author
Code
Gorokhova V.
M387
Gorrin G.
M105
Górriz Pintado S.
M060, M354,
T079, T123, T183, T184, T329,
T342, T374
Górska E.
W057
Gottardi M.
W321
Gottschalk A.
T189
Goudable J.
W165
Goutas N.
M079
Govender S.
T064
Gozdzik J.
M199
Gozzo M.
M379
Grabowska A.
M224
Graefen M.
OC17
Gramegna M. M113, T343, W349
Grande G.
T185, T186, M207,
W205
Grandone C.
EW021
Granero V.
W384
Granizo V.
T117
Gras J.
EW017
Grasa-Ulrich J.M.
W272
Grassi E.
M324
Grasso K.
W106
Grasso M.
M156
Grau-Agramunt M.
W118
Graziani M.S.
M002, M157
Greaves R.
T214
Greco E.
M061, M148, M173,
M196, T194, T288,
T373
Greco L.
M023
Greco M.
W178
Green G.
T166, T171
Gremeau A.S.
T220
Gressner O.
T344
Grgurevic I.
W372
Griesmacher A.
T389
Grieveson R.E.
T395
Grigore C.
M005
Grigore N.
M005
Grigoriou E.
W252
Grigorov I.
W183
Grill D.E.
W136
Grillone R.
W257
Grimaldi E.
W257
Grimaldi L.
W059
Grimmler M.
T388
Grimoud A.M.
W045
Grinberg M.
M020
Grisolia D.
M157
Grodzicki T.
W088
Groppa F.
M249
Gross J.L.
W193
Grubb A.
SY02
Gruccio S.
T230
Grudzień U.
T215, W177, W403,
biochimica clinica, 2013, vol. 37, SS
S715
EuroMEdLab 2013 - IndEx of authors
Author
Code
W360
Gruev T.
M257, M258, M289
Grueva A.
M257, M258, M289
Gruson D.
EW011, W078
Gruszewska E.
W336, W338,
W345
Gryko M.
M164, M188, M198
Guarda N.S.
W120
Guariso G.
T194, T288
Guarneri V.
M157
Guazzoni G.
OC17, M153
Guechot J.
W367
Guenter K.
T266
Guenther K.
T116
Guerra E.
W380
Guerrero L.
M375
Guerrero J.M.
T005, T006, T007,
T008, T020, T144, T321
Guerrero-Montávez J.M.
T241
Guerri G.
M048, M049
Guezlane S.
W268
Guhr A.
T106
Guhr E.
T256
Guida M.
T316, W381
Guidi G.C.
T086, W068, W207
Guillot-Suay V.
M099
Guimarães J.T.
W142
Guimarães N.C.
M089
Guiotto C.
T368
Gulbahar O.
M357, T262
Gulcubuk A.
M368
Gulletta E.
W178
Gultepe M.
OC12, T134, T140,
T162, W085
Güney N.
M151
Gupta S.
W054
Gurban C.V.
T187
Gurda-Duda A.
W348
Gurdol F.
M362, M368
Gürdöl F.
M151
Gutierrez M.
OC34, M400, T125
Gutiérrez M.
M400
Gutiérrez-Cecchini B.
W276
Gutierrez-Fornes C.
T117
Gutiérrez-Menéndez M.L.
M385
Gutiérrez Moreno S.
M006,M007,
T259, T338
Gyawali P.
W130
Haase M.
SY03
Haaslahti V.
T398
Habior A.
OC22
Haddour N.
W032
Hadj F.
T132
Hadj Fredj S.
M074
Hadj-Aïssa A.
M274
Hadjiev E.
W296
Hadj-Rabia S.
M054
Hadj-Taieb S.
W027
S716
Author
Code
Haertle D.
W279, W280
Haese A.
OC17
Hafez S.
T199
Hagui A.
W030
Hagve T.
W254, W256, W260
Hakime N.
T188
Haliassos A.
T233
Hall G.
EW007
Halloran S.P.
EW095
Hamada E.
T331, T345
Hämäläinen S.
M138, W295
Hamasaki N.
T363, W312
Hameed A.
W004
Hamer D.
EW020
Hammami M.B.
M062
Hampl R.
T240
Han M.
T346, W015, W219
Hanikoglu F.
T147, T139
Hansen A.T.
T216
Hansen J.
M121
Hansson C.
T347
Hansson H.
OC03
Hansson L.O.
W353
Haq P.A.
M355
Harding S.J.
T312, T313, T314,
T332, T390, T391,
T392, T393, T394,
T395
Hardouin J.
W037
Harju E.
T358
Harney R.
M215
Harter L.
T267
Hartmann C.
T116
Hartwich P.
M015
Hasa R.
M272
Hasanefendić B.
M158, W228
Hashad D.
M302
Hashad I.
W079
Hassan M.
M266, M283, W198
Hassan M.S.
W080
Hassanaly F.
T324
Hassiakos D.
T233
Hassona E.M.
W361
Hastir D.
W251
Hatae H.
W312
Hatellari A.
W258
Haufroid V.
M248
Haugh M.
M182
Hausmann M.
M366, W153
Hautala H.
T348
Hawala H.
W030
Hawkins P.
W299
Haxhibeqiri V.
M309, T175, T219
Haxhibeqiri S.
M309, T219
Hayashi S.
OC31
Hazan M.
M296
Hdo de Larramendi C. M018, T113,
T151, W261, W262
biochimica clinica, 2013, vol. 37, SS
Author
Healy M.
Hedberg P.
Hédhili A.
Code
M364
W391
M315, M316, M327,
M333
Heichman K.
SY10
Heijboer A.
T035
Heijboer A.
T323
Hektor T.
T388
Helander A.
OC06
Helgeland M.
W260
Hellara I.
M332, W150, W346,
Hellara O.
W346
Hellberg D.
T193
Helmy S.
T199
Henderson P.
SY47
Hendig D.
T352
Hendrix B.
T034
Henig C.
M020, M093, T349
Henrion A.
OC13
Henry C.
M063, M273, W081,
W082
Hepnar D.
W179
Hepp P.
M212
Herkner K.R.
T189
Hermens W.
W048
Hermes C.L.
M205
Hernández A.
T272
Hernandez J.
T127
Hernández-Moreno V. T200, T213
Hernández-Romero D.
W155
Hernando A.
T011, T017
Herrera I.
T108, T117
Herrera-Rey M.T.
T321
Herrero M.J.
M246
Hess G.
M254
Heude E.
W104
Hevessy Z.
W263
Higashijima A.
W312
Hill S.
W091
Hines J.
T034
Hirano K.
W314
Hirohata S.
W007
Hirtz C.
OC11
Hisamatsu K.
T363
Hlawatsch N.
W379
Ho C.S.
T214
Hodorowicz-Zaniewska D.
M224,
M225
Hoedemakers R.
M034
Hojman M.
M374
Homs-Serradesanferm R.
W259
Hon G.
T148, W198
Hong S.
W015
Honova H.
M176
Honović L.
T112
Höög-Hammarström K.
W376
Hoogslag G.
W048
Horacek J.M.
M230
EuroMEdLab 2013 - IndEx of authors
Author
Code
Horta B.L.
M306
Horvat V.
M174, M330
Horvath A.R.
SY35
Horváthová M.
W143
Horvath-Szalay Z.
T014
Hoskova L.
M270
Hoste L.
M274
Houlgatte A.
M145
Hovanec-Burns D.
M001, M009
Hoxha-Muhaxhiri M.
T047
Hrabric S.
T396
Hua L.
T322
Huang H.
M105
Hubbard S.
T388
Huber A.R.
EW099
Hughes R.G.
W299
Huguet-Jacquot S.
T265
Huisman W.
SY73
Hulek P.
W151, W152, W373
Hulin A.
T320
Humphries S.
EW004
Hur Y.M.
EW029, M108, M276,
M311,W264, W265
Hurtado J.A.
W155
Husby K.
W260
Huseyinoglu N.
T147, T139
Hussein Y.M.
M011
Hvas A.M.
T216
Hyde C.J.
SY36
Hyder Ali S.
W090
Hyytiä H.
W385
Iacono M.
M075
Iaffaldano L.
W180
Iannuzzi A.
M047
Iapichino G.
T009
Ibrahimi E.
W313
Ichihara K.
T121
Ichiyanagi T.
T263
Idonije B.
M356, W181, W182
Idonije O.B.
M325, M326, W083
Iervasi G.
OC10
Ige O.
OC08
Iglesias E.
W073
Ignat-Romanul I.
T226
Ignjatović S.
M263, M287, M290,
M380, M397, T056,
T057, W087, W147,
W240
Ilic M.
W183
Ille K.
T238, W084
Ilva T.
W138
Ilyinsky I.
W140, W141
Imbesi N.
T301
Incaurgarat B.
W153
Incir S.
W003
Indelicato A.
M190
Infusino I.
T260, T350, T182,
T257, W244
Author
Ingiliz P.
Insúa A.
Intantri H.Y.
Ionescu D.
Ipcioglu O.M.
Code
M254
M374, M375
W184
M163
OC12,
T134, T140, T162
Ippi G.
T086
Ippolito S.
M275, T082, T074,
T305
İren Emekli D.
T261
Irmesi R.
OC28
Irzyk K.
W057
Isahak M.
M226
Isani G.
M267
Isbilir S.
W085
Isgrò M.A.
W386
Işık B.
W007
Işik G.
M134
Ismail S.
M243
Ispir E.
M357, M358
Itkonen O.
T149
Iturzaeta-Sánchez J.M.
T092
Ivaldi G.
M064
Ivandic B.
M129, T021, W145
Ivanov A.
W387
Ivanova L.
W316
Ivković M.
T165
Izcara C.
W225, W292, W293
Izzo V.
M023
Jablonskiene V.
M178, M359
Jabor A.
M270, W072
Jachymova M.
OC02
Jackson N.
T059
Jacobino J.
W137
Jacobs E.
SY37
Jacobs L.
M388
Jadrić R.
M158
Jaeken J.
OC06
Jaffe A.S.
W091, W136
Jafri L.
W086
Jäger B.
M212
Jaglikovski B.
W149
Jakab K.
W263
Jakubowicz J.
M214
Janatková I.
M032
Janchanoun S.
W406
Jancikova M.
M176
Janikowski G.
W127
Jankovic S.
T268
Janni W.
M212
Janny L.
T220
Jansa R.
W347, W358, W359
Jansen R.
SY19
Jantawong C.
M391
Jantunen E.
M138, W295
Januzzi J. L.
EW015
Jarjees H.
W175
Jarrah J.
M215
Author
Code
Jarrari A.
Jarvis M.
M211
M360, M361, T048,
T150, T351
Jašović-Gašić M.
T165
Jaulent L.
W075
Jayasena D.
M310
Jebavy L.
M230
Jedrejčić K.
T112
Jelačić R.
W002
Jelassi M.
M332
Jelic M.
W303, W325
Jelić S.
T055
Jelic-Ivanovic Z.
M284, T202
Jelski W.
M177, M208, M209,
T155
Jemaa R.
W027
Jenum A.
T201
Jeon Y.
W015, W219
Jeong T.D.
M319, M393
Jerin A.
T012
Jiandon N.
W281
Jiménez E.
T017, W075
Jimenez I.
W135
Jimenez M.
T108, T117
Jiménez P.
T109
Jiménez J.J.
T109
Jimenez-Gonzalez D.
W248
Jiménez-Jiménez J.
M018,
T113, T151, W261, W262
Jimeno-García L.
OC30
Jin D.
M076
Jin W.
T150
Joergensen B.
W388
John W.G.
EW084
Johnston H.
W082
Joki L.
T357
Jonas M.
M343
Jones G.
T083
Jordan B.
SY39
Jordán-Bueso J.
M386, M408
Josel H.
T356
Jossa F.
M047
Jovanova S.
W149
Jover E.
W155, W156
Jovičić S.
W087
Jridi G.
W025
Juan J.
M065
Jückstock J.
M212
Judith B.
W233
Julián-Jiménez A.
T264
Jun S.H.
T346
Jungtrakul Y.
W281
Juntunen E.
W401
Jurado A.
T108
Juricek J.
T251
Jurkeviciene J.
M178, M359
Jurkowska G.
M188, M198
Juutilainen A.
M138, W295
biochimica clinica, 2013, vol. 37, SS
S717
EuroMEdLab 2013 - IndEx of authors
Author
Code
Kaabachi N.
M062, W027, W028
Kabanov V.
W064
Kacar C.
W024
Kaczmarczyk G.
M066
Kaczmarek E.
W380
Kaczmarska M.
W088
Kádár L.
T195
Kahn S.
SY55
Kaimakamian M.F.
M078, M122
Kaiser R.
M095
Kaiserlian D.
W337
Kakolyris S.
M142
Kalaz E.B.
M351
Kale R.K.
T153
Kalender B.
M277
Kalfakakou V.
M363
Kaliadka M.
W089
Kalinic D.K.
T164
Kaljadka M.
W112
Kallco M.
W302
Kallenberg C.
SY14
Kalnovičová T.
T154, T163
Kalousova M.
OC02
Kamińska J.
M179, W189
Kamocki Z.
M160
Kanani M.
M342
Kanďár R.
T240
Kaneva R.
M241, M247, W119
Kang D.
M319
Kang S.Y.
M028
Kangrga R.
W087
Kanmaz-Özer M.
T067
Kanonidou C.
M389, W186
Kanonidou E.
M389
Kanyua A.
M106, T088
Kapetanovic S.
W236
Kappelmayer J. M088, M201, W263
Kapusta M.
M008, W348, W403
Kara M.
W368
Karadağ B.
T067
Karagyozov I.
M180
Karajan T.
W157
Karakitsos P.
W363
Karampas G.
T233
Karatayli R.
M175
Karatzas I.
M295
Karciauskaite D.
W199
Karesova I.
W151, W152, W373
Karhunen U.
M127, T357
Kariya T.
W011, W022
Karlović D.
M239, M240
Karlsson P. G.
OC03
Karolczyk G.
W285
Karppelin M.
T383, T384
Karslioglu Y.
W368
Kartaljevic G.
W240
Karydi A.
W161
Kasabova L.
M350
S718
Author
Kashif W.
Kasper D.C.
Katalinic D.
Katip P.
Katsagoni C.
Katya M.
Katzmann J.A.
Kaufman D.
Kaur A.
Kausar S.
Kaux J.
Code
W086
EW072, T189
OC26
W389
W067
M283
EW057
T388
T391, T395
T393
T048, T360, W101,
W102, W103
Kavaric S.
T045
Kavraiskaia A.
M353
Kavsak P.
W091
Kawato T.
M107, W011, W012,
W016, W022
Kay J.
EW033
Kaycsa A.
M412
KC R.
T040
KC S.
T114
Kędra B.
M188, M198
Keller F.
T302, T303
Kemona H.
M164, M179, W189
Ken-Dror S.
W332
Kengne A.P.
M266, M283, W187,
W198
Kerdmongkol J.
W146
Keten A.
M314
Khalil M.
W213
Khalilulin T.
W141
Khan A.
W322
Khan H.
W144
Khan S.
T094
Khanal M.P.
W130
Khatiwada S.
W217
Khattab M.
M382
Khiari H.
T132
Khishigbuyan D.
M405
Khlifi F.
M316, M327
Khushvaktova Z.
W098, W327
Ki C.
M076
Kiertiburanakul S.
M130
Kim H.
M276, M311, M319
Kim H.J.
M319
W265
Kim J.
M076
Kim M.H.
M028
Kim S.Y.
M319, W264
Kim S.
M393
Kimura A.
W012
Kiraka G.
T084
Kishinewsky M.
M020
Kitagawa A.
W188
Kitajima I.
OC31, W314
Kitiyakara C.
T308
Kitsos G.
M058, M067
Kiviniemi M.
T361
biochimica clinica, 2013, vol. 37, SS
Author
Code
Kiyan E.
M134
Klapkova E.
M269
Kleiman J.
M374
Kleinveld H.
T285
Klimovich L.
W399
Klingberg S.
W286
Klinkenberg L.
W093
Klocheva E.
T170
Kluiters-de H.
T285
Kluyev D.
M394
Kłyszejko-Molska J.
T228
Knabbe C.
T352, W128
Knauff C.
T344
Knudsen K.K.
W388
Ko S.
M154
Ko Y.J.
M108, M311, W264,
W265
Kobayashi K.
W315
Kocabiyik M.
T262
Kocak H.
M362, M368, T290
Kocaturk E.
T070
Kochina E.
T218, T225
Kocna P.
T263
Koivula I.
M138, W295
Kojima Y.
W227
Koklu S.
W371
Kolarov V.
T325
Kolb B.
W284
Kolesnikova E.
M394
Koleva V.
M180
Koleva-Topova V.
T277
Komanasin N.
W094, W281
Komosinska-Vassev K. M390, T197
Kondracka A.
M343
Koni M.
W313
Konstantinova I.
W098
Konukoglu D.
M277, W003
Koopman N.
T148
Koper O.M.
M179, W189
Kopyltsova E.
T191
Korita I.
W095
Korkmaz G.G.
M277
Kormer A.
W140, W141
Korn K.
M095
Korneti P.
M261
Korniluk A.
M164
Kosanovic-Jakovic N.
M380
Kosatica M.
W170
Köse E.
M349
Köse K.
W174
Kost A.
T152
Kost G.
T013, W389
Kostara C.
M363, W096
Kostić Z.
M101
Kostin G.
W266
Kostina N.
W266
Kostovska I.
W190
Kosturski N.
T046
EuroMEdLab 2013 - IndEx of authors
Author
Code
Koszegi T.
M328, T014, T016
Kotackova L.
M329
Kotori A.
T219
Kotula I.
W267
Kotur-Stevuljevic J.
M010, M284
Kourda N.
M140, W330
Kouri T.
EW36
Koutsandrea C.
M067
Kovacs E.
W220
Kovacs G.L.
T014, T016
Kowalczyk J.
W285
Kozak M.
T319
Kozlov A.
T115
Kozłowska D.
M066, M346
Kozo D.
T166, T171
Kralovics R.
PL3
Kratochvila J.
W390
Kratunkov P.
M241, M247
Kratzsch J.
OC13
Kraus I.
M117
Kraus N.
M117
Krause C.
T104
Kravdal G.
W260
Kretowicz M. W034, W035, W127
Krintus M.
W108
Kristoffersen A.H.
OC33
Kristoffersen A.H.
T244
Król D.
M392
Kroll M.
M130, W146
Krook Persson C.
OC03
Kroupis C.
M058, M067, M079
Krska Z.
T023, T024
Krstevska M.
W097
Krueger C.
M068, M069
Krüger S.
EW078
Kruit A.
T035
Krzesinski J.
M264
Krznaric I.
M254
Ksol M.
W306, W329
Kubena A. A.
OC02
Kubista M.
T116, T266
Kubota H.
M001, M009
Kucharská J.
T154, T163
Kücherer C.
M095
Kucinskiene Z.A.
M359, W049,
W199
Kucukcoskun M.
M134
Kucukgergin C.
M351
Kuentz M.
T220
Küest S.
W157
Kufner K.
M377
Kuhi L.
M029
Kuhn J.
T352
Kukharchik G.
W098, W099
Kulichenko T.
T190
Kulig J.
W348
Kullolli S.
M030
Kuloglu T.
T135
Author
Code
Kulpa J.K.
M233, M234
Kuma H.
T363, W312
Kumar P.
T153
Kundalic J.
T015
Kundalic S.
M038, T015
Kundalić S.
T141
Kunsagi-Mate S.
M328
Kuo W.
T130
Kuprijanova A.
W140, W141
Kupsa T.
M230
Kurabekova R.
W140
Kuračka L.
T154, T163
Kurapeev D.
W064
Kurki K.
T353, T354
Kurki M.
T355
Kurt I.
M229, M305, M357,
M358, W368
Kurt E.
W162
Kuśnierz-Cabala B.
M008, W177
W348, W360
Kustan P.
T016
Kusters R.
M388
Kuusela E.
M109, M186
Kuzaj P.
T352
Kuznetsova E.
T115
Kuznik-Trocha K.
M390
Kvasnicka J.
T024
Kytzia H.J.
T286, T356
La Malfa M.
T373
La Motta M.
W349
Laaksonen P. W100, W137, W138
Laaradi S.
M039
Laass M.
OC21
Laborda-González B.
T080
Labruna G.
W180, W191, M395
Labudovic D.
W149
Lachmann H.
W299
Lacombe K.
W367
Ladetto M.
W282
Laforgia N.
W393
Lahdenperä S.
T357
Lahtinen S.
T296, T358, T386,
W114
Laird E.
M364
Laitinen H.
T279
Laiz B.
T117
Lakatos P.L.
SY48
Lalatta F.
T211
Lalaurie E.
T085
Lalic D.
M181
Lalic J.
M181
Lam C. W.
T359
Lam L.
T269
LaMarr W.
T297
La Marra F.
T039
Lamazière A.
M054
Lambert Porcheron S.
W165
Lamminmäki U. M109, M186, T291,
Author
Code
T403
M110, M125, M200
M113
W277
EW003
T353, T354, T355,
T383, T384
Lamsal M.
T040, W217
Lamy P.J.
M182
Lana P.
M244
Lanaro C.
OC15
Landi P.
W036
Landin B.
W192
Lane P.
W315
Lang S.
W032
Langlois M.R.
SY58, W095
Langlois M.
T323, T372
Laniewska-Dunaj M.
M177, T155
Lanza O.
W255
Lanzillotto C.
M278
Lapanan S.
T401
Laperche S.
EW101
Lapolla A.
T207
Lapovets L.
T152
Larcher A.
M153
Lari R.
M096, M114, T300
Larosa D.
T315
Laserna-Mendieta E.J.
M031,
T156, T264
Laskaj R.
M111
Laskovets A.
T170, W327
Lastusaari M.
T358
Latawiec A.
M360
Latini R.
OC32
Latten M.
M200
Laudadio M.A.
W237
Lauren H.
W233
Laurent T.
M152
Lavarda F.
M303
Lavarini V.
W068
Lavatelli F.
W270
Laville M.
W165
Ławicki S.
M183, M184, M223
Lawrie A.S.
W315
Lázaro de la Osa J.J. W249, W274
Lazarovska S.
W176
Lazzaroni M.
M159, T137
Lazzarotto T.
EW027
Lazzeri M.
OC17, EW024, M153
Le Bris C.
W008
Le Carrer D.
M256, W037
Le Corvoisier P.
OC17
Le Goff C.
T049, T360, W101,
W102, W103
Leão J.R.B.
M017
Leclerc-Mercier S.
M054
Lecocq E.
M320
Lee D.H.
M076
Lamont J.V.
La Motta M.
Lamovšek N.
Lampertico P.
Lampinen H.
biochimica clinica, 2013, vol. 37, SS
S719
EuroMEdLab 2013 - IndEx of authors
Author
Lee J.H.
Lee M.Y.
Lee M.H.
Lee M.
Lee S.H.
Lee S.
Lee Y.
Lee W.
Lee W.I.
Lefebvre M.
Lefevre G.
Le Goff C.
Code
T346
T359
W265
T319
M076, T359
M076
M076
M319, M393,W092
M028
M256
W050, W104
M347, T360, W102,
W103
Leguizamon M.A.
M279, M280
W105
Lehmann S.
OC11
Lehmusvuori A.
M127, T361
Lehto T.
W391
Leiva-Salinas C.
OC34, T125
Lekkas P.
M363
Leli S.
M070
Lémery D.
T236
Lencioni P.
M114
Lennartz L.
W111
Lenters Westra E.
EW085
Leon A.
W135
León-Justel A.
T005, T006,
T007, T008,T020,
T144
Leoni V.
T157, T158
León-Martínez M.
M386, M408
Lepoutre T.
W078
Leslie D.
SY61
LeSourd S.
W242
Leto F.
W278
Letondel M.
T085
Lewandowska K.
W057
Lewis K.
T311
Lewis A.
W033
Ležajić V.
M287
Li Y.
M215, M328
Li P.
W335
Li Bergolis F.
W270
Lianidou E.
SY32, M079
Lianidou E.S.
M142
Libert F.
T382
Librero J.
M246
Lichtenegger W.
M212
Lichtinghagen R.
W350
Lidestri V.
M271
Ligabue G.
W223
Lighezan D.
W167
Liguori R.
W191
Liljenbring H.
OC03
Lillo J.A.
T108
Liloglou L.
SY11
Lim M.K.
W015
Lim S.K.
T362
S720
Author
Code
Lima A.D.S.
M090
Lima Oliveira G.
T086
Limongelli G. OC23, W051, W060
Lin M.
W364
Lin P.
T130
Lindahl B.
PL4
Lindberg S.
W392
Lindsay C.
OC19, W324
Link B.
EW103
Lino S.
T258
Lioi S.
W062
Lipowsky C.
W106
Lippa L.
M157
Lippi G.
EW037, EW108, M022,
T367, W207, W351
Lipunova A.
W327
Liquier A.
M054
Lird A.
M279, M280, W105
Lis K.
W017
Lisik W.
M343
Lista G.
M153
Liton M.F.K.
M186
Liu C.
M154
Liu S.Y.
M155
Liu Z.
M236
Ljesevic S.
M117
Ljubić S.
W226
Ljubisavljevic S.
T172
Lo Y.M.D.
SY64
Lo S.
M245
Lo Gioco P.
W278
Locci E.
OC28
Lodi S.
M318
Loef A.
T095
Logothetidis S.
W186
Loh T.P.
W194
Loh Tze P.
T025
Lojo Rocamonde S.A.
T397
Lombardi S.
M112
Lombardo B.
M071
Lombardo Grifol M.
M385
Longo G.
M113, W349
Longo F.
T334
Longoni S.
M377
Lopez C.
M374
López F.
W042
López-Baltar I.
M087
López-Díaz M.C.
T156
López-Fernandez T.
W039
Lopez-Garrigos M.
OC34, T117,
T125
López-Gómez E.
W276
López-Mingorance F.N.
W160
López-Sendon J.L.
W039
Lopez-Urrutia A.
W248
Lorec-Penet A.M.
T324
Lorence D.
M231
Lorenzini F.
T305
biochimica clinica, 2013, vol. 37, SS
Author
Code
Loric S.
M182
Los F.
M329
Lounici Y.
W268
Lourenço P.
W142
Lovero R.
OC04, W393
Lövgren T.
W385
Lövgren-Sandblom A.
W342
Lovrić M.
M244, T402
Lovrity Z.
M322
Löwe T.
M015
Lucarelli E.
M187
Lucarelli F.
W380
Lucarelli M.
M321
Lucchiari M.
T051
Luci N.
T324
Lucini R.
M113, W349
Luconi M.
M216
Ludany A.
T014,T016
Lueke A.J.
W136
Lughezzani G.
OC17, M153
Lugo J.
OC34, T125
Lukacin R.
T189
Lukas P.
OC29, M260, W009
Łukaszewicz-Zając M. M188, M198
Lukova S.
T277
Lum M.
W066
Lund J.
W138
Lundeen C.
W008
Lunghi G.
M035
Lupi A.
M379
Lupon J.
W073
Luporsi E.
M182
Lussu M.
OC28
Lutsyk B.
T152
Lutteri L.
M251, W264
Lysikov O.
W038
M.P. G.
W054
Maatouk F.
W033, W150
Maccarone P.
W125
Macciardi F.
W061
Maccora D.
OC09
Macharia M.
M283, W187
Macher H.
T008
Macher-Manzano H.
T027, T241
Machin S.J.
EW082, W315
Machnik G.
M066
Mackie I.J.
W315
Macolić Šarinić V.
M238
Madalena L.B.
M265
Madic S.
T015
Maeda C.
T363
Maekawa M.
T331, T345
Maenhout T.M.
M320
Maeno M.
M107, W011, W012,
W016, W022
Maggio A.
M278
Maggio M.
W265
Magni F.
M156, M298, OC01
EuroMEdLab 2013 - IndEx of authors
Author
Code
Mahesar A.
M382
Mahgub E.
W355
Mahmod M.
M194
Mahmoud A.
M194
Mahrooz A.
M339
Maiavacca R.
M035
Mailloux A.
T265
Maine G.
M115
Mainini V.
OC01, M156
Maiorana A.
M144
Majkic-Singh N. M290, M263, M380,
M397, T055, W087,
W147, W173, W240
Makarova Y.
W056
Makau P.
M119
Makedou A.
W186
Makedou K.
W186
Makris K.
EW052, M281
Maksić D.
M286
Maksimović Z.
M286
Makukh H.
M162
Malabaila A.
M317
Malagnino A.
T306
Malakhova A.
T190
Małek U.
W285
Malenica M.
W170, W195, W196
Malentacchi F.
T116, T266
Malešević .
T209
Malickova K.
M032, T003
Malinowska I.
W285
Malla B.
W130, W197
Mallika J.
W365
Malmi E.
T364
Maltezos C.
M281
Manaças M.
W246
Manaka S.
W011
Manaswiyangkoo J.
M391
Mancini R.
M381
Mandal S.
W195, W196
Mandelc-Mazaj M.J.
W277
Mandic D.
M330
Mandic S.
M174, M330
Mandic Havelka A.
W352, W353
Maneemaroj R.
M391, W405,
W406
Manganaro M.
W232
Mangione R.
M054
Maniecki M.B.
M398
Manieri G.
M318
Manitius J.
W034, W035, W127
Mankowska-Cyl A.
W108,W127
Mannelli M.
M216
Manninen J.
T357
Mannucci E.
W205
Manolov V.
M189, T159, T221,
W109, W110, W269, W354
Manov E.
W109, W110
Manuli E.
M298
Author
Manysiak S.
Manzano-Fernández S.
Code
W017
W154,
W156
Manzoni C.
T234
Maquart F.
W284
Mar M.C.
W135
Marangi G.
T192, W290
Marano G.
W070
Marasinghe E.
M348
Marc J.
W019, W195
Marcaida G.
T117
Marcato C.
T274
Marcelli G.
T037
Marchei E.
OC05
Marchese A. E.
M073
Marchese C.
W232, W317
Marcheselli L.
W321
Marchetti C.
M352
Marcialis M. A.
OC28
Marcos Corona L.
M026, T043,
T080
Marczi S.
M174
Marenzana A.
T292
Marevic S.
M111
Mari D.
T145
Mariak Z.
M177, T155
Marie Y.
T128
Marijancevic D.
W372
Marín F.
W154, W155, W156
Marin M.G.
M190
Marín Patón M.
M255
Marinkovic A.
M282, M307
Marinov B.
T221
Marinov M.
W119
Marinova M.
T032, T365
Marín-Patón M.
T177
Markova V.
W058, W316
Marković M.
T055
Marković Z.
T050
Marković-Sovtić G.
T202
Marlet J.
M191, T337
Marmo M.
M317
Marmur J.
T347
Marotta G.
M047
Maroz-Vadalazhskaya N.
W112
Marques V.
M094
Marranca D.
T376
Marsiliani D.
M297
Martens F.
M274
Martín E.
T017, W075
Martin P.
M182
Martinefki M.
W340
Martinelli Boneschi F.
W061
Martínez A
M077, T108
Martínez A.B.
M139
Martinez E.
M139
Martínez L.
T017
Martinez O.
T235
Author
Code
Martinez P.
W042
Martínez R.
T092
Martinetz T.
T104
Martinez Bugallo A.
W214
Martinez Fernandez J.
M128
Martínez-Fernández C. T005, T008
Martínez-Gago M.D.
M383
Martínez-Hernández P.
OC30,
M097, M098, T179, T222, T223,
T224, W006, W013, W154, W155,
W156, W250, W273, W382
Martínez-López-de-Castro A. W273,
W382
Martínez-Ruiz A.
M098, M097,
T179, T222, T223, T224, W006,
W155, W250, W382
Martínez-Sánchez E.
T204
Martínez-Villanueva M.
OC30
M097, M098, T018, T204, T222,
T223, T224, W006, W013, W250,
W273, W382
Martinic-Popovic I.
T142
Martinovic J.
M010, M054
Martinovic V.
W183
Martin P.M.
M182
Martins S.
W142
Martorana G.E.
M379
Marutpong D.
W094
Marziali A.
M268
Mascolo E.
OC04, W393
Mashek O.
W064
Masi L.
T293
Masini L.
T234
Masliah J.
M054
Mason D.
T267
Masotti S.
W113
Masri W.
M315, M316, M327,
M333
Massaccesi L.
W014
Massi D.
M220
Masson S.
OC32
Mastorakos G.
T233
Mastrantonio F.
W380
Masullo M.
T146
Matějka M.V.
M300
Matek J.
T023, T024
Mateos D.
W235
Mateva N.
W215
Mathe P.
T388
Mathieu R.
M146
Mathijssen R.
M248
Matica J.
T295
Matinato C.
M035
Matsha T.
M266, M283, T148,
W198
Matsha T.E.
W080, W187
Matters D.
T390
Matters D.J.
T304, T312, T314
biochimica clinica, 2013, vol. 37, SS
S721
EuroMEdLab 2013 - IndEx of authors
Author
Matthijs G.
Mattsson L.
Code
OC06
T296, T358, T386,
W114
Matveeva E.
T218, T225
Mauri G.
M156
Maurizi P.
M041
Mauro A.
T082
Mavsar N.
M252
Maximova I.
W038
Mayanskiy N.
T190, T191
Mazeikiene A.
W199
Mazigh C.
W029, W030, W204
Mazur A.
M392, W306, W329
Mazur B.
W285, W306, W329
Mazza E.
W178
Mazzaccara C.
T146, W060
Mazzolini S.
T039, W169
Mazzon G.
T039
Mc Naughton D.
M310
McAleer D.
W021
McCann K.
T298, T311
McClure E.
M361, T047
McConnell R.
W020, W021
McEntee D.G.
T312
McErlean N.
M125
McGivern P.
M063, M273, W081,
W082
McGrath N.
M125
McKenna J.
M110, M125
McKeown D.
T267
McLean R.
W395
McNicholas T.
OC17
McNulty H.
M364
McSorley E.
M364
Mebazaa A.
W028
Mechtler T.P.
T189
Medigovic I.
T036
Medina E.
M301
Medina P.
M370, M371
Medina Escobar P.
M372
Medrado R.S.D.O.
M089
Meemaew P.
T366, T401
Meex S.
W093
Megia M.d.P.
T117
Méhes G.
M201
Mehrotra V.
M192
Meigas K.
W410
Meijer P.
OC33, T244
Melchionno P.
W008
Melegari A.
M022, T160, T367
Melis E.
T294
Melli F.
T124
Mello E.
M075
Melloni N.
M002
Melnichuk O.
T190, T191
Melo Cristino J.A.
W246
Melon P.
W101, W102, W103
Melzi S.
T305
S722
Author
Code
Melzi d'Eril G.
M166
Mema A.
W302
Memon L.
M284
Menacho Roman M.
M365, T050
Menao-Guillen S.
M084
Mendes M.A.
T317
Méndez Fernández A.B.
W118
Menéndez Valladares P.
T136
Mengozzi G.
T051, W317
Mengozzi S.
M317
Mercade I.
M044
Mereb C.
M092
Mereuta O.M.
W232
Mergalska K.
W267
Merino-Fernandez S.
W248
Merk M.
T189
Merlini G.
PL2, T307, W270,
W328
Meroni P.
SY13, M036
Messaoud T.
M074, T132
Messerli F.H.
W088
Messineo S.
W178
Mèta D.
M275
Metz T.F.
T189
Metzmann E.
T388
Meuleman C.
W032
Meunier V.
M366
Mezei Z.A.
T169
Mhenni H.
W346
Mialon A.
W337
Mian M.
W282
Micali S.
M144
Micca G.
M317
Michaud L.
W008
Michelazzo C.
M168
Michienzi S.
T334
Micle L.
M285
Micle O.
M285, T226
Mielgo D.
W320
Migała M.
W159
Migliardi M.
T001, T368, T376,
W318
Mihaescu R.
W167
Mihaljević-Peleš A.
M244
Mihmanli V.
T243
Mijuskovic Z.
M101, M117, M286
Mikulova V.
M176
Milanesi B.
M190
Milani A.
W255
Milani P.
W270
Milatos G.
M295
Milatovic Jezdic V.
T268
Miled A.
M039, W025, W033,
W115, W116
Mileti A.
W393
Milivojevic M.
M193
Miljanovic F.
W228
Miljuš .
T209
biochimica clinica, 2013, vol. 37, SS
Author
Code
Milki M.V.
M089, M090, M091
Miller G.
EW087
Miller K.
M200
Miller V.
T297
Miller W.L.
W136
Miloševic V.
T036, T051, T055
Milosevic-Tosic M.
T227, T161
Milot A.
OC19, W324
Min W.
M319, M393, W092
Min S.
W117
Minami H.
OC31
Minciu R.
M412
Minet-Quinard R.
T236
Mingels A.
W043
Mino L.
M022
Minucci A.
M041, M042,
M043, M075
Mion M.M.
T404, W044, W161
Miotto E.
T376
Miralles A.
T117
Miralles F.
T117
Mirandola R.
M002
Mirjanić-Azarić .
T209
Mirković D.
M287
Mironkov B.
W140, W141
Mirošević S.
M238
Misra S.
T118
Missale G.
W334
Mistraletti G.
T009
Mitev V.
M241, M247, W119
Mitev L.
W241
Miteva-Toncheva D.
W296
Mitevska E.
T399
Mitkov M.
W215
Mitrovic J.
T268
Mitsuse K.
T363
Mittel K.
W271
Mizrack S.
T330
Mizunoe S.
W312
Mlinar B.
W195
Moesender-Frajria C.
W321
Moiana A.
T343
Mokthar N.
M226
Molina J.
T117
Molina R.
M169
Molina-Arrebola M.A.
M128
Molina-Hernández O.R. T200, T213
Molinié V.
M182
Molino A.
M157
Molinos J. I.
T117
Mollee P.
W286
Møller H.J.
M398
Mollineda-Trujillo A.
T213
Molloy A.
M364
Molotov-Luchanskiy V.
M394
Momirovska A.
T203
Monaghan P.
M165
Monari M.N.
M033
EuroMEdLab 2013 - IndEx of authors
Author
Monari E.
Code
M144, M259, M288,
W223
Monari M.
T369
Mondola P.
W052
Mongelli A.
M050
Mongkolwongroj P.
W094
Monguzzi A.
T211
Monneret G.
SY71
Monreal-Marquiegui I.
W006,
W013
Monsalve-Naharro J.
M104
Montagnana M.
W207
Montalcini T.
W178
Montalvão E.R.
M092
Montanaro D.
W180
Montanelli A.
M033, T071, T369,
W245
Montaruli B.
W317, W318
Montes A.
W272
Moon H.
M108, M276,
M311
Moon H.W.
W264, W265
Moon S.Y.
W015
Mora C.
W105, W235
Mora Brugués J.
W118
Morales A.
T110
Moranne O.
M264
Mora-Vallellano J.
M335
Moreau E.
M366
Morelli R.
W386
Moreno A.
W075
Moreno F.
W073
Moresco R.N.
M205, W120
Morgan S.L.
T270
Morganti A.
EW069
Mori M.
OC31
Morin V.
T235
Morin C.
W104
Morini L.
SY08
Morito Aguilar M.
M006, M007,
T259, T338
Moro-Ortiz A.
W249, W274
Morris H.
SY69
Mosa T.
M194, M195
Mosca A.
SY62, EW066, W207,
W208, W380
Moscardin R.
M271
Moscarella V.
T089, T090
Moschou M.
M067
Mosquera A.
M052, M053,
M086, M087
Mosquera M.
W200
Mostapha N.
M323
Mota M.
W220
Motallebi S.
M339
Motoc M.
M412
Motta R.
W237
Mouhoub A.
W268
Author
Code
Moulasserdoun K.
W304
Mourtzikou A.
W363
Moz S.
OC20, M148, M149,
M173, M196, M249,
T194, T373
Mozzi S.
M168
Mozzi R.
M197, T087, W343
Mrabet A.
T132
Mrhar A.
M252
Mroczko B.
M188, M198
Mrozek B.
M199
Mtaoua H.
W025
Muchová J.
W143
Muchova L.
T242
Mücke M.
T356
Mueller C.
EW014
Müftüoğlu T.
OC12, T134, T140,
T162
Muhl D.
T014, T016
Mulaomerovic S.
T167, T168
Müller C.
EW054
Müller H.
M095
Mulliqi-Kotori V.
T219
Mumtaz N.
T208
Munch Jensen C.
T119
Muñoz A.
T110
Muñoz-Colmenero A.U.
T271
Muravluyova L.
M394
Muravska A.
OC02
Muresan M.E.
M285, T226
Murgia F.
OC28
Murillo-Cabezas F.
T005, T006,
T007, T008, T020,
T144
Murillo-Florez I.
W272
Murphy C.
W321
Murphy F.
T313, T394
Murphy W.
W321
Murray H.
M200
Murray P.
EW056
Musa R.
W351
Musaraj A.
W201
Muscaridola N.
M242
Musetescu A.
M203
Mushtaq A.
T332
Musolino G.
W208
Musolino S.
T001
Mussell C.
T267
Mustafa G.
W220
Muszyńska-Rosłan K.
W285
Mutta I.
W208
Nachev G.
M241, M247, W119
Naegelen J.
EW047
Nagtalon D.
T311
Nagy Jr B.
M201
Naidu Kamatham S. W090, W322
Najjar M.F.
M332, W150, W346
Nakagawa S.
W202, W227
Author
Code
Nakahara K.
W312
Nakai K.
W016, W022
Naklicki M.
W338
Nakstad B.
T201
Namuslu M.
W171
Nancey S.
W337
Nancheva K.
T277
Nania C.
M131
Nannavecchia V.
T376
Nante G.
M249
Naotomo Y.
T128
Napoli P.
W232, W317
Napoli Z.
M096, M114, T300
Nardelli C.
W180
Nasrallah F.
M062
Nauti A.
T157, T158
Navaglia F.
M148, M173, M196,
T194, T288, T373
Navarro L.
M139, T117, T138
Navarro-Casado L.
M104
Naydenova G.
M247, W119
NayelL O.
M243
Ndreu R.
T248
Neamtu C.
T038
Nedeljkovic I.I.
M117
Nedeljkovic T.
M117, M202
Nedovic J.
M202
Nedzvetsky V.S.
T135
Neffati F.
M332, W150, W346
Negash H.
W389
Negri G.
T230, W282
Negru S.
M163
Nelovkov A.
M118
Nelson S.
EW023
Nesi G.
M216
Ness K.
T034
Nessim I.
W355
Nesterova N.
W098, W099
Netchacovitch M.
T048, T360
Neugebauer J.
M212
Nexø E.
M398
Ng E.K.
M155
Ng H.X.
T359
Niccolai M.
T300
Nicola L.
W014
Nicolae C.
M203, M204
Nicolae I.
M203, M204
Nicolardi S.
M156
Nicolescu A.
W220
Nicolo' C.
W317
Niedzielska E.
W285
Niedźwiecki M.
W285
Nieuweboer A.
M248
Nieuwenhuis J.
EW076
Niimi H.
OC31
Nikiforov Y.
SY21
Nikolac N.
OC26
Nikolić A.
T161, T227
biochimica clinica, 2013, vol. 37, SS
S723
EuroMEdLab 2013 - IndEx of authors
Author
Code
Nikolić T.
T165
Nikolov G.
M257, M258, M289
Nilsson S.
OC03
Ninkovic M.
T172
Nix B.
T208
Niyomtham S.
M391
Noah C.
M095
Nocca G.
M379
Nock C.
M371
Nock S.
M301
Nogara A.
T044
Noguera Velasco J.A. OC30, M097,
M098, T018, T179, W006, W013,
W250, W273, W382
Nogues D.
T333
Noh W.
W265
Noia G.
T234
Nõmm K.
W387
Nonnato A.
T052
Noorazmi M.
M226
Noordegraaf M.
M034
Nordber A.
SY26
Nordin G.
OC03
Norlund L.
OC03
Norlund P.
OC03
Norman S.
M118
Noto A.
OC28
Nouioui M.A.
M315, M316,
M327, M333
Novak-Jankovič V.
T012
Novembrino C.
M035, W203
Nowacki W.
W017
Nowak-Łos L.
T228
Nowak-Sadzikowska J.
M214
Nozzoli C.
W288
Nshimyumukiza L.
OC19, T235,
W324
Nsiri B.
W204
Ntola V.
T064
Nunes Á.
W126
Nurmi M.
OC18, M141
Nusier M.
W164
Nwachukwu C.
M206, W275
Nydegger U.E. M301, M370, M371,
M372
Nýdlová E.
M337, W356
Oakervee H.
W239
Obermayer-Pietsch B.
SY68
Obermeier M.
M095, M254
Obradovic I.
M402, W173
Obrenovic R.
M290
Obriadina A.
T206, T218, T225,
T232
Obtulowicz K.
M008
Ocaña E.
T108
Ocaña Lopez S. M006, M007, T338
Oddoze C.
EW35, T085
Odrowaz-Sypniewska G.
T228
S724
Author
Code
Oesinghaus U.
EW034
Ognibene A.
M207, M291, T124,
W205
O'Gorman P.
W004
Ogorodova L.
W069
Oguntunde O.
T120
Oh S.
M393
Ohta Y.
W188
Ojengbede O.
W121
Ojwang P.
T088
Okinda n.
T084
Oksala T.
M127
Okunola M.
T378
Oladele F.C.
W121
Oladoyinbo S.
M206, W275
Oláh A.V.
M088
Olaniran I.O.
W229
Olczyk P.
M390
Olczyk K.
M390, T197
Olender K.
M345
Olivani A.
W334
Oliveira J.C.
T063
Oliveira R. T. D.
OC15
Oliveira S.C.
M058, M067
Oliveira Rodríguez M. M367, W276
Olivieri G.
M303
Olorunsogo O.
OC08
Omar S.
M062, W027
Ombrone D.
M083
Omodei D.
M395
Omuse G.
M119
Onalan E.
T135
Ondrkalová M.
T163
Ondrova D.
T239
O'Neill J.
M110
Onelöv L.
W352
Oner-Iyidogan Y.
M362, M368
Ong L.
T026
Ong S.K.
T269
Onsongo S.
M106, T088
Ontanon J.
M139
Oosterhuis W.
T285
Opančina B.
T202
Opurum H.C.
M334
Orbetzova M.
W215
Ordonez J.
EW013
Ordóñez-Llanos J.
W118
Oremus M.
W091
Orenes-Piñero E.
W154, W155,
W156
Orlando C.
M216, M217, M220,
T116
Orlova O.
W140, W141
Oronsaye P.
M120
Oros J.
T227
Orr R.K.
T127
Ortmann U.
M212
Ortola J.
T117
biochimica clinica, 2013, vol. 37, SS
Author
Code
Orts-Costa J.A.
T183, T184
Ortuño M.
T117
Orywal K.
M177, M208, M209
T155
Osadolor H.
M325, W083
Osegbe I.
T120, W122, W206
Osei-Bimpong A.
W395
Ospino L.
W200
Osredkar J.
M221, M341, M396,
T229, W344, W347,
W357, W358, W359
Ostanek B.
W195
Osther P.J.
M150
Ostrovski I.
W112
Otero M.F.
W396
Otero de Becerra J.
M018, T113
Otero-Durán M.O.
M025
Otheitis I.
M403
Ottaviano R.
T089, T090, T258,
T370, T371
Ottomano C.
EW111
Oueslati S.
M074
Ouikhlef N.
M080
Oyaert M.
T372
Oyedele O.
T378, W211, W398
Ozarda Y.
T121
Ozbanazi Y.G.
T243
Ozben S.
T139, T147
Ozben T.
M144, M210, M288,
M292, T139, T147, W223
Ozcan O.
OC12, T134, T162
Ozdem S.
M293, M294, T139,
T147, W024
Özderya A.
T067
Ozgurtas T.
M357, M358
Ozkol H.
W139
Oztekin G.
M134
Ozturk G.
W370, W371
Paas L.
W410
Pacarizi H.
T175
Pacheco-Sánchez M. T005, T008
Pachmann K.
OC07, M213
Pachmann U.
OC07, M213
Pacifici R.
OC05
Pacileo G.
OC23
Pacquola E.
W321
Padoan A.
OC20, M143, M148,
M149, M173, M196, T093,
T194, T288, T373
Padrini R.
OC20, M249
Padró-Miquel A.
W041
Pagliari C.
M190
Pagni F.
OC01
Pagotto U.
T060
Pailahuque J.
T061
Pajič T.
W277, W319
Pajula S.
M126
Päkkilä H.
T364
EuroMEdLab 2013 - IndEx of authors
Author
Code
Paleari R.
W207, W208
Paleologos E.
M363
Palladini G.
W270
Palladino G.
M259, M288
Palmieri A.
M048
Palomino-Muñoz T.J.
T271
Paludetti G.
M003
Panagiotakos D.
W067
Panagiotopoulos K.
M295
Panagiotou I.
M037
Panasiuk A.
W336, W338, W345
Pandolfo M.S.
M265, T230
Panek A.
M346
Panek J.
W348
Panella R.
W123
Paniagua E.
M231
Panjeta M.
M158
Pannarong P.
W406
Panoulis K.
T233
Pansini N.
W305
Pantano G.
T192, W290
Panteghini M. M168, M197, T087,
T182, T257, T260, T282, T350,
W070, W071, W244, W343,
W366
Pantelic J.
T036
Pantović M.
T165
Paolella G.
OC23, M049
Paoletti E.A.
W308, W320
Paoletti M.
W308
Paoletti M.E.
W320
Pap D.
W173
Papa S.
T146
Papageorgiou G.
W186
Paparella M.
M303
Papasteriades C.
W252
Papay-Ramirez L.
M057, M100,
M331, M335,
M336, T254, W209
Pape M.
T053, T054
Pape-Medvidović E.
W166
Papillo T.P.
W237
Pappone C.
W061
Paradossi U.
OC10, W074
Paradowski M.
W158, W159
Parent M.
OC19, W324
Parenti G.
M056, M082, M083
Park C.M.
M276, M311
Park H.
M076
Park K.U.
T346, W219
Park W.
M076
Parodi F.
T315
Paroni R.
M170, T009
Parra-Pallarés S.
W154
Parri M.S.
OC10, W074
Pasalic D.
T164
Pasanisi F.
M395, W191
Pascale E.
M321
Author
Pascar N.
Pasini A.
Paskalev E.
Paskaleva I.
Pašková Ľ.
Pasquali C.
Passarello C.
Passino C.
Pastore L.
Pastori S.
Code
W064
W068
M350
M296, T325
W143
M148, M196
W278
W113
M071
T089, T090, T258,
T370, T371
Patani S.
T122, W124
Patel P.S.
T313
Patellongi I.
W184
Pater A.
W017
Paterna L.
M303
Pathak J.L.
T322
Patibandla S.
M121
Patokova Y.
M241, M247
Patrucco G.
W232
Pätzold S.
W148
Pauliková I.
W143
Paun D.
T038
Pavanello G.
T373
Pavlov P.
W058, W316
Pawlica D.
M008, T215, W177,
W360, W403
Pawlicki L.
W158,W159
Pawlowski W.
W279, W280
Paz J.M.
W396
Pazzagli M.
M216, M217, M220,
T116, T266
Pecoraro G.
M245
Pedrazzoli S.
M149
Pedretti M.
T369
Pedrola L.
M045, M060, M065,
M077
Peela J.R.
M211, M219
Peeters S.
T048, T360
Pejnović L.
M238
Pejović J.
M101, M286, W341,
Pelanti J.
T279
Pelc E.
M066
Pelinkova K.
T003
Pellegrini M.
OC05
Pellegrino M.
T234
Pelliccia A.
W060
Pelloso M.
OC20, M148, M196,
M249, T194, T288
Peltola M.T.
OC18, M186
Peña-Monje A.
M099
Penco M.
W060
Penders J.
M308
Pengo V.
OC20, M249
Penitente R.
M003, M041, M297
Pennemans V.
M308
Penzo L.
T341
Pepi M.
M220
Author
Code
Perazzi B.
T230
Perbellini O.
W321
Perea J.E.
W125
Perea S.M.
W125
Peredo-Lopez B.
T043
Pereyra A.
W320
Perez M.S.
M078, M122
Pérez C.
T011
Pérez F.
T109
Pérez M.J.
T108
Perez S.
M231, W255
Pérez-de-Alejo-Rodríguez L. T200,
T213
Perez Gamir E.
T079, T123,
T329, T342, T374
Perez Garay R.
W248
Perez Gonzalez E.
M255
Pérez-Fornieles J.
T179, T222,
T223, T224
Perez-Gonzalez E.
T177
Perez-Lopez G.
T050
Perez-Parra S.
M099
Peréz-Suaréz L.
W247
Pérez-Valero V.
OC27, T198
Pergolini R.
T037
Perini R.
T367
Perlangeli M.V. M275, T074, T082
Perlangeli V.
T305
Perna Rodríguez M.V. M255, T136,
T177
Pernet P.
T362, W377
Perovic A.
T251
Perovic M.
W210
Perovic-Blagojevic I. W236, T055
Perret T.
W050
Perrin P.
M182
Perrone F.
W232
Persichilli S.
T340, T375
Peruzzi B.
T255
Pesenti A.
OC32
Pešić V.
T056, T057
Pestka A.
M212
Pesudo S.
T117
Pesut M.
W236
Peteiro-Cartelle J.
M013
Petera J.
T299
Petermann L.J.
M306
Peters F.T.
SY07
Peters F.
M034
Petersen M.B.
M058, M067
Petrarulo M.
T376
Petrillo G.
T185
Petrone L.
M217
Petronijevic N.
M193, T165
Petrov G.
W157
Petrova I.
M241, M247, M296,
T159, W069
Petrovic D.
M290
biochimica clinica, 2013, vol. 37, SS
S725
EuroMEdLab 2013 - IndEx of authors
Author
Code
Petrovic J.
T231
Petrovska G.
M136
Petrovska T.
W176
Petruzzelli M.F.
W059
Pettersson K. OC18, M141, M186,
W100, W137, W138,
W385, W401
Pezzilli R.
M166
Pfeffer J.
M123, M124
Pfeiffer T.
M069
Phillipov J.
M350
Pi G.
M045, M065, M077
Piaserico G.
T287
Picard P.
T047
Picarelli L.
T185, T186
Piccin A.
W321
Piccoli M.
OC14
Picheth G.
T086, W185
Pichini S.
OC05
Piciocchi A.
T185
Pierini M.
T248
Pierucci I.
T146
Pieske B.
W148
Pietilä P.
W100
Pietrelli A.
OC24
Piffret J.
M182
Pignata S.
M253
Pilka R.
T239
Pillay N.
W407
Pilli M.
W334
Pilone V.
W180
Pimenta J.
T317
Pinar E.
W155
Pineda-Tenor D.
M031, T264
Pineiro D.J.
W125
Pinika P.
W233
Pinney J.H.
W299
Pintó-Sala X.
W040, W041
Pintus M. C.
OC28
Pinzani P.
M216, M217, M220
Pires D.
W246
Pirgakis K.
M281
Pirola D.A.
M122
Pirolini L.
W270
Piromkit N.
W281
Pisa S.
T306
Piscitelli R.
T293
Pitarch Castellano I.
T183, T184
Pitkänen P.
T355
Pitkin J.
T214
Pittalis S.
T074, T082, T305
Pitto M.
M298
Pivetti A.
M245
Piwowarczyk A.
M346
Pizon M.
OC07, M213
Pizza S.
T185
Pizzamiglio S.
T116, T266
Pizzileo G.
M278
S726
Author
Code
Pizzo M.
T185, T186
Pizzolo G.
W321
Plácido Raposo R.
T270, W126
Plebani M.
OC20, SY74, EW067,
EW105, M061, M143, M148, M149,
M173, M196, M249, M317, T032,
T068, T093, T192, T194, T207,
T273, T274, T275, T288, T365,
T373, T404, W044, W161, W230,
W290, W321
Plećaš B.
T056, T057
Plokhoy E.
W397
Plouvier E.
W018
Plushch M.
M299, W399
Plyushch M.
T029
Pobigailo L.
T379
Pocino K.
M041, T100, T377
Podschekoldina O.
W399
Podsosova E.
T191
Poffe R.
W068
Pohjola J.
T398
Poledne R.
W072
Poli G.
M216
Poll A.
M320
Pollak J.
M345, W017, W127
Pollock C.
M110
Polverini F.
W384
Pompeo D.B.
W243
Poncela M.
T117
Pongrácz E.
T169
Ponomarenko E.
T191
Pons-Rejraji H.
T220
Pontillo M.
OC17, M153
Ponzini D.
T293, T294
Poór M.
M328
Popa A.
M285, T226
Popa S.G.
W220
Popat R.
W239
Popescu S.
M163
Popoola O.
T378, W211, W394,
W398
Popov D.
T029
Popov I.
M247
Popovac S.
T231
Popovic D.
T091
Popovic M.
T091
Poppi B.
T306
Porela P.
W138
Porini A.
M159
Portaluri M.
W059
Portugal H.
T085, T324
Posta J.
M021
Postiglione L.
M187, W052
Postigo R.
T092
Potočnik I.
T012
Pottel H.
M274
Pouly J.
T220
Poumpouridou N.
M079
biochimica clinica, 2013, vol. 37, SS
Author
Poyatos-Andujar A.
Code
M100, M335,
M057
Pozzi P.L.
M298
Pradhan P.
W197
Pradier O.
EW048
Prah Krumpak M.
M396
Prante C.
T352, W128
Prasad K.
M369
Pratap S.
W322
Prayer-Galetti T.
M143
Precone V.
OC23, M024, M161
Predrag V.
W132
Pregnolato F.
M036
Premaor M.O.
W120
Pretorius C.J.
W286
Price C.P.
SY53
Prieto B.
T217
Primiano A.
M297, T340, W402
Printzen G.
W408
Prinzen F.
W043
Pristovšek N.
W019
Prnjavorac B. W170, W195, W196
Prontera C.
T404, W036, W113
Proungvitaya S.
M404
Pruijn G.
SY15
Prunk M.
W019
Prusa R.
M185, M269, T023,
T024
Pruszczyk P.
W057
Prylutskyy Y.
T379
Psarra K.
W252
Ptasiński M.
M346
Ptitsyna Y.
T232
Puc N.
T251
Pucci F.V.C.
M017, M092
Puccinelli M.P.
T052
Puche-Morenilla C.M. M097, M098,
T018, T204
Puddu M.
OC28
Pudil R.
W151, W152, W373
Puerta A.
M139
Puertas Cuesta F.J.
T183, T184
Pueyo Mateo M.P.
M383
Pugin J.
SY72
Puigdemont P.
W404
Pulk R.
M126
Pulkki K.
M138, W295
Pulvirenti M.
M125
Puncheva E.
M180
Puntumetakul M.
W094, W281
Punzi L.
M061
Pupilli C.
M217
Purhonen A.
M138, W295
Pusceddu I.
W282, W321
Putnoky S.
M163
Putti M.C.
T192, W290
Puzianowska-Kuznicka M.
M343
Quaglia A.
T186
EuroMEdLab 2013 - IndEx of authors
Author
Quarone M.F.
Quattrocchi A.
Queraltó J.M.
Quercioli M.
Quirion R.
Quiroga S.
Code
T376
M073
W301
T255
SY24
M374, M375, T278,
T315
Raaf N.B.
M080
Rabadan L.
T117
Racek J.
M300, W143
Rachok L.
W089
Rack B.
M212
Radakovic L.
T231
Radgowska A.
W267
Radišić Biljak V.
W166, W226
Radivojević D.
M287
Radko I.
W279, W280
Radojkovic M.
W236
Radonjić N.
T165
Radosavljevic A.
M380
Radosavljević B.
M397
Radovanovic D.
M010
Raffaelli M.
OC09
Raffi H.
W032
Rafique A.
M398
Ragolta D.
W235
Rahal M.
W304
Raimondi F.
EW049
Raimondo F.
M298
Raimondo M.
M132
Raita R.
T355
Rajakaruna G.
M310
Rajdl D.
M300, W143
Rajewski P.
W108
Rajindrajith S.
M348
Ramadan A.
M195, W164
Ramasamy I.
W129
Rami N.
T196
Ramila P.
W135
Ramirez E.
W039
Ramírez D.A.
T110
Ramírez Ruiz C.
W273, W382
Rammeh S.
W330
Ramondetta M.
M035
Ramos Corral R.
M031
Rampazzo A.
M061
Rampoldi B.
W123
Ramshev K.
T019
Ramsheva Z.
T019, T058
Ranchin B.
M274
Ransilhac C.
W008
Rantakokko Jalava K.
M127
Ranucci M.
W123
Rapi B.
W205
Rapi S.
M227, M291, T124,
W205
Ratiu I.
M285
Rattazzi M.
T129
Author
Code
Rattei T.
SY51
Rautela A.
T380
Ravn T.
W388
Rawa T.
OC22
Ray P.C.
W054, W104
Razic S.
M193
Re L.
T089, T090
Real C.
T109
Reamer R.
M121
Rebillard X.
M182
Rebolido M.M.
W247
Redorta J. P.
OC17
Refatllari E.
M070, W302
Reggiani C.
M148
Reggiani Bonetti L.
M144
Regina M.G.
T074
Reginashvili D.
M020
Regine V.
M132
Regmi P.
W130
Rego F.G.M.
W185
Reiertsen O.
W260
Reignier A.
W037
Reinharz D.
OC19, T235, W324
Reinhold D.
OC21
Reis J.
W323
Reixach A.
W404
Rejc B.
T229
Remacha A.
W301, W259
Renda A.
W180
Renesto A.
M081
Renna L.
W305
Rensburg M.
M266
Renz P. B.
OC25
Renzi N.
W318
Repetti I.
W270
Reshetnyak M.
W212
Restituto-Aranguren P.
W006,
W013
Reverendo M.A.
M375
Revuelto-Rey J.
T006, T007,
T020,T144
Rey J.
W153
Rezzani R.
M170
Riaukaite L.
W283
Ribeiro R.
T031 ,T237
Ribelles M.
T117
Riboldi L.
W221
Ricciardone M.
W052
Rice B.
T381, T385
Richard D.
T382
Richard M.
M366
Richardson C.
EW053, W020,
W021
Richetta E.
W384
Ricotta D.
EW059
Ridefelt P.
T193
Rieusset J.
W165
Rigo J.
M308
Author
Code
Rigolini R.
Riistama-Laari S.
W123
T353, T354,
T355, T383, T384
Riquelme B.
T292, W255
Risch C.
M370, M372
Risch L.
M301, M370, M371,
M372
Risch M.
M301, M370, M371,
M372
Rise F.
T201
Ristić N.
T036, T050
Ristić S.
W236
Ristić T.
M051, T015, T141,
W132, W133
Ristiniemi N.
W385
Ritchie J. C.
EW073
Ritrovato D.
W384
Ritter U.
T379
Rivas Lombardero M.D.
M401
Rivas Lombardero D.
W214
Rivers E.J.
T381, T385
Riyat M.
T084
Rizk M.M.
M302, W213, W361
Rizos D.
T233
Rizou M.
T233
Rizza V.
M303
Robaina J.
M265
Robledo-Aguilar M.N.
T284
Robles-Garcia M.
M100, M336,
M057, M331, T254, W209
Rocca R.
T368
Roccatello D.
W232
Rocejanasaroj A.
W216
Rocha Bogas M.J.
M031, T156
Rochanawutanon M.
T308, T366
T401
Roche L.
T382
Rödel A.P.P.
W120
Rodella A.
M132
Rødgaard-Hansen S.
M398
Rodríguez A.
M231
Rodrigues B.M.
W231
Rodríguez F.
T108
Rodríguez J.
W168
Rodríguez M.
T108
Rodríguez-Conde-Salazar L. M331
Rodriguez-Espinosa M.
OC27
Rodriguez-Fraga O.
W039
Rodríguez-García E.
T151
Rodríguez-Pedreira M.
M052,
M053, M086, M087
Rodríguez-Pérez M.
T213
Rodríguez-Rodríguez A.
T005,
T006, T007, T008, T020, T027,
T144, T284
Rodríguez-Sánchez B.
M053
Rodríguez Segade S.
W168
Rodríguez Vázquez P. M025, W214
biochimica clinica, 2013, vol. 37, SS
S727
EuroMEdLab 2013 - IndEx of authors
Author
Code
Roelens M.
T004
Rogalskaya E.
T029, W399
Rogers J.
W106
Rogers L.
T059
Roggenbuck D.
OC21, M036
Rogic D.
OC33, T010, T244
Rognoni A.
W343
Rohwäder E.
T104
Roig-Minguell E.
W118
Roitman A.
W038
Rojas L.
M246
Rojas Rodríguez E.
W259
Roldán V.
W154, W156
Roli L.
T060, T069, W134
Romanelli R.
M082
Romanelo M.
M003
Romanielo M.A.R.d.M.
M092
Romanò C.L.
W014
Romano S.C.
T086, W060
Romeo G.
T301
Romero C.
W135
Romero M.A.
OC32, T110
Romero Aniorte A.I.
W155
Romero García Y.
T213
Romeu E.
W008
Romic Z.
W372
Romito A.
W317
Ronchev Y.
W215
Ronchi M.
M035
Ropero P.
W289
Rosa R.
W397
Rosales M.
W106
Rosenberg W.
EW046
Rosillo-Coronado M.
M365
Rossi C.
T234
Rossi E. M148, M196, T194, T288
Rossi L.
W400
Rossi P.D.
T145
Rossi W.
T074, T082
Rostirolla M.J.A.
M306
Rota C.
M399, W334
Rotolo M.C.
OC05
Rotundo S.
W178
Rotzen Östlund M.
OC03
Roušar T.
M337, W356
Rousseau F.
OC19, T235, W324
Rousseau M.
W078
Rousselle O. OC29, M152, M347
Rowe M.
M373
Rozenberg O.
M020, M093
Ruamsuk S.
M404
Ruano Y.
T217
Rubba P.
M047
Rubeca T.
M227
Rubinstein M.
T180
Rubio A.
T008, T027
Rubio-López-de-la-Oliva A. M057
Rubio-Ruíz-de-la-Oliva A.
T254
S728
Author
Code
Ruda Vega H.
T230
Rueda I.
OC27, T198
Ruggiero A.
M041
Rugiene R.
M019
Ruiz F.
W042
Ruiz De Azúa-López Z.
T005,
T008, T020
Ruiz-Budría J.
M344
Ruiz-Escalera J. F.
OC27
Rukin K.
W069
Runzo C.
T001
Ruoppolo M.
M056, M082, M083
Ruotolo A.
M047
Russkikh I.
W089, W112
Russo A.
M022, T367
Russo C.
EW026
Russo I.
M041
Rutkowski R.
M177, T155
Rychlik U.
M214, M233, M234
Saadaoui M.H.
M332
Sabatino P.
T185, T186
Sacchetti L.
M023, M024, M395,
T146, W180, W191
Sachse D.
T201
Sacks D.
EW064
Saenger A.K.
W136
Sáenz Mateos L.F.
T271
Saffar H.
W346
Safka V.
W151, W152, W373
Sagach V.
T379
Sagol O.
T072, T073
Sahli C.
M074
Saint-Marcoux F.
T382
Sainz Guerra M.
W111
Saito S.
OC31
Sakem B.
M371
Sakulhong A.
W406
Sala S.
OC24, M050, W061
Saladino R.E.
T301
Salamone S.J. M215, T166, T171
Salazar L.A.
M400, T061, T272
Salazar-García S.
T284
Salazar-Torres L.
T200, T213
Salemme N.
M056, M083
Salgó L.
M147, M222, T195
Salinas M.
OC34, T117, T125,
W225, W293
Salman A.
T330
Salmen J.
M212
Salminen T.
W401
Salovaara O.
T296, T386
Salti S.
T124
Salvadori B.
M291, W205
Salvagno G.L.
T086
Salvati M.
W008
Salvatoni A.
W208
Salvatore F.
OC23, M024, M046,
M048, M049, M056, M072,
biochimica clinica, 2013, vol. 37, SS
Author
Code
M082, M083, M161, M172,
M395, T146, W051, W060
Salvayre R.
W045
Salvi E.
W061
Salvianti F.
M216, M217
Samaja M.
M170
Samal F.
M185, T023
Samouilidou E.
M304
Samson L.
T382
Samsonova N.
W399
Sánchez M.E.
W075
Sánchez-Alarcón J.
T198
Sánchez-Bermudez A.
T018
Sánchez-Navarro R. M057, M335,
T254
Sanchis A.
M077
Sancho-Rodríguez N. M097, M098,
T179, T222, T223,
T224, W156, W250
Sandager P.
T216
Sandahl T.
M398
Sandberg S.
SY04, OC33, T244
Sanfeliu E.
W404
Sangkitikomol W.
W216
Sangoi M.B.
W120
Sanhaji H.
M062, W027
Sanhueza J.
M400
Santa Cruz G.
T230
Santacruz-Lomarquis K.
T178
Santamaria Gonzalez M.
M084
Santangelo M.
W180
Santarsia G.
M242
Santoni F.
M096
Santonocito C.
M075
Santo-Quiles A. OC34, T117, T125
Santos M.
OC15
Santosh K.
T181
Santucci M.
M220
Sanzari M.C.
T192, W290
Sanz-Casla M.
W289
Sapan M.
M292
Sapin V.
T236
Sarabia A.
W042
Sarabia-Meseguer M.D.
T222,
T223, T224
Saracevic A.
OC26
Saraci B.
W201
Saracino A.
M242
Sardà M.P.
W301
Sarić I.
M330
Sarioglu S.
T245
Sarra O.
T294
Sarraß C.
M015
Sarrazin C.
EW045
Saschenbrecker S.
T104
Sastre J.
T117
Sastre-Gómez A.
T271
Sauceda M.
M231
EuroMEdLab 2013 - IndEx of authors
Author
Code
Sauchelli G.
M049
Savić M.
W002
Savukoski T.
W137, W138
Saw S.
T025, T026
Sayed M.
M011
Scacchetti A.T.
M012
Scapaticci M.
M075
Scarcella C.
M324
Scarlini S.
W134
Scatena C.
M216, M220
Scattoni V.
OC17
Schalij M.
W048
Schallenberg U.
T344
Scharff P.
T379
Scharnagl H.
W148
Schiattarella A.
W402
Schiatti C.
M317
Schilling K.
W300
Schipor S.
M204, T038
Schleck M.
M152
Schlicht K.
T297
Schlueter K.
T099, T253
Schlumberger W.
M015
Schmitt S.
M054
Schmitz G.
W063, W065
Schmoz B.
T105, T106, T256
Schneider N.
W284
Schoen K.
W185
Schönenberger A.
W157
Schoorl M.
W273
Schroeder A.D.
T387
Schu P.
T388
Schuetz P.
EW091
Sciacca M.
M073
Sciacovelli L.
EW039, T093,
T273, T275
Sciascia S.
W232
Scolamiero E.
M082, M083
Scopacasa F.
W257
Scorza M.
M055, M059, M085
Scorzeto M.
M148
Scraba K.
T099
Scribano D.
W386, W402
Scudeller L.
T307
Sebastiani C.
T300
Secchiero S.
T273, T274, T275
Secco S.
M143, M317
Sędek Ł.
W285
Seger C.
SY29, T389
Seghier F.
W304
Segovia M.J.
M102
Segura T.
T138
Seguso M.
T273, W230
Seia M.
OC16, M059, T211
Seidlova A.
M176
Sekeroglu M.R.
W139
Sekino K.
W227
Selistre L.
M274
Author
Code
Selva P.
W237
Semenzato G.
M173
Semikina E.
T191
Semiz S.
W170, W195, W196
Semjonow A. SY43, M145, M150
Sen N.
W024
Senna G.E.
M002
Sepp M.
M126
Serban C.
W167
Serdar M.A.
M229, M305, M357,
M358
Serdar T.
W372
Serdarevic N.
M218, T167, T168
Seric V.
M330, M384
Serra C.E.
W340
Serrano-Heras G.
T138
Serrano-Olmedo M.G.
T259
Sertoglu E.
M229, M305, W368
Sethi S.K.
T025, T026, W194
Sethom A.
W204
Settanni F.
T051
Settasatian N.
M404
Setti M.
T126
Seven A.
W003
Seyidhanoglu M.
M362, M368
Sezer S.
W370
Sezgin F.
T243
Sfriso P.
M061
Shaban G.
W079
Shabani S.
M339
Shafi T.
EW100
Shah D.S.
W130
Shakila S.
M211, M219
Shakya P.R.
T040, W217
Shalaby S.
M011
Shams K.
M342
Shannan G.
SY75
Shapoval L.
T379
Sharafutdinov V.
W077
Sharif E.
T062
Sharma H.
T122, W124
Sharma S.
T181
Sharrod-Cole H. T390, T391, T392
Shehu A.
W302
Sheldon J.
SY16
Shemirani A.
T169
Sheshurina T.
W064
Shevchenko A.
W141
Shevchenko O.
W140, W141
Shiesh S.
T130, T276, W375
Shim H.S.
M108
Shimizu N.
W011
Shinya K.
T128
Shionome C.
W011
Shishenkov M.
T277
Showell P.J.
T312, T313, T314,
T332, T390, T391, T392, T393,
T394, T395
Author
Code
Shrestha R.L.
T322
Shukla K.
W218
ShuklaA R.
W218
Shumka L.
M070
Siala H.
M074, T132
Sichinava L.
W098
Siddiqui I.
W086
Sideri M.
EW042
Siergiejko E.
M164
Sigdel M.
W130
Sighinolfi M.C.
M144
Signorini S.
M156
Silva C.
W323
Silva N.
W142
Silva N.A.D.
M017
Silvani A.
M159
Silveira R.A.
M205
Silveiro S.P.
OC25, M250, M306
Silvera S.K.I.
T391
Simão L.
W323
Simi L.
M220, T116
Simic-Ogrizovic S.
M284
Simon D.
W362
Simon S.
W233
Simonato F.
M149
Simonelli F.
M072
Simonetti S.
T124
Simon-Gordo M.
W259
Simoni M.
T060
Simtong P.
W094
Simundic A.
OC26, T142
Šimunović D.
M174
Singh R.
T280
Sirigibattina S.
W322
Sirotkina O.
T170, W327
Šišková K.
W143
Sisowath C.
W253, W352
Sivera P.
W318
Siwicka M.
W057
Skalidakis I.
M067
Skitek M.
T012
Skliris A.
M037, M410, W363
Skoczen S.
M199
Skolskaya O.
W297
Skov-Poulsen K.
OC03
Skrodeniene E.
W283
Skulj T.M.
W125
Sletner L.
T201
Slingerland R.
SY05
Slowinska-Solnica K. M008, W177,
W403
Smagadi A.
T053, T054
Smirnova L.
W266
Smit N.
W047
Smith V.
M373
Smrkolj T.
M221
Snezana M.
W107
Snozek C.
T127
biochimica clinica, 2013, vol. 37, SS
S729
EuroMEdLab 2013 - IndEx of authors
Author
Code
Soares A.A.
M250, M306
Soares H.
T166, T171
Sobhy M.
M243
Sobki S.
T094, W144
Sobol G.
W285
Sodnomtseren B.
M405
Soffiati G.
M352
Sogno I.
M167
Soikkeli M.
M127
Soita D.
W198
Sokolic B.
M111
Sola P.
T160
Solari M.
W008
Solarova T.
M241, M247
Šolcová M.
M300
Soldevila F.
W235, W404
Solesio-Torregrosa M.E.
M386
Soliman I.
T369
Solnica B.
M008, T215, W177,
W348, W360, W403
Soman R.
M237
Somen E.
T244
Somma V.
M036
Sommariva E.
W061
Sonati M.F.
OC15
Song J.
M076, T346, W015,
W219
Song S.H.
T346, W015, W219
Sonsala A.
W285
Soragna A.
T001
Sorda J.A.
W340
Soriani N.
T211
Soriano P.
W235
Sorribas-Alejaldre V.
M084
Sosa Moncayo D.
M128
Šošić-Jurjević B.
T050
Sotirova K.
W316
Soto J.
W308, W320
Soto Fernández S.
T397
Souberbielle J.
EW051, M347,
T280
Soukka T.
M127, T296, T357,
T358, T361, T364, T386, T398,
T403, W114
Soukup V.
M176
Sousa G.
T031, T237
Sousa J.G.
T031, T237
Sousa M.J.
T031, T237
Southan L.D.
T395
Souto-Fernández R. M013, M025,
M052, M053, M086, M087,
M401, T327
Souza M.I.
W243
Soylemezoglu T.
M314
So-Young K.
W092
Sozer V.
M277
Sozmen E.
OC33
Spanuth E.
OC32, M129, T021,
S730
Author
Code
T022, W046, W145
Spasic S.
M284, M312, M313
Spasic-Obradovic G. T238, W084
Spasojevic-Kalimanovska V. M284
Spasova M.
W316
Spatuzza C.
W052
Spencer K.
SY66
Sperti C.
M148, M196
Spessatto D.
W193
Speziani F.
M317, M324
Spiess B.E.
EW025
Sprague S.
T280
Springer D.
M185, T023, T024
Spyropoulos B. T102, T103, W383
Srisawasdi P. M130, W146, W146
Srisunthornharuthai K.
W172
St. John S.
W106
Štabuc B.
W357
Stach Z.
T003
Stagnitto A.
M271
Staiti R.M.
M131
Stål P.
T347
Stallone G.
M242
Stamouli M.
M037, M410, W363
Stanbouli N.
W029, W030
Stanchev N.
M189, W354
Standowicz S.
W306, W329
Stanek L.
M185, T023
Stanga Z.
M301, M370, M371,
M372
Stanger O.
EW061
Stankic V.
T231
Stankovic A.
W397
Stanković S.
M287, W147
Stankovic-Ferlez D.
M038
Stanojkovic M.
M282, M307,
W303, W325
Stanojkovic Z.
W303, W325
Starkie V.
T309
Stasik Z.
M214, M233, M234
Stea F.
OC04
Stefan C.
T319
Stefan L.I.
W220
Stefaniotou M.
M067
Štefanović M.
M239, M240
Steiber Z.
M201
Stejskal D.
T239
Stel G.
T039, W169
Stella S.
W317
Steller U.
M068, M069
Stepan H.
EW041
Stepanenko L.
T379
Štěpánková Š.
T174
Stepanov G.
W002
Stephan C.
M145
Stephen D.
T328
Stepman H.
T279
Steuten L.
M388
biochimica clinica, 2013, vol. 37, SS
Author
Code
Stevanovic I.
T172
Stewart P.
W020, W021
Sticha M.
T242
Stöcker W.
M015, T104
Stöckl D.
T279
Stojakovic T.
W148
Stojanovic I.
M051, T172
Stojanovic J.
M117
Stojiljkovic S.
M181
Stojimirovic B.
M263, M290
Stojkovski V.
M136, T399
Stojnic A.
M014, T246
Stone S.L.
T392
Storti S.
OC10, W074, W113
Stosic G.
M402
Støtterud S.
W256
Strain J.
M364
Štramová X.
T174, T240
Strangio S.
M131
Strani G.
W232
Straube B.
T105, T256
Stricker R.
M115
Strom R.
M321
Strozecki P.
W127
Stupka E.
SY50
Sturgeon C.
SY42, T280, T281
Stürmer M.
M095
Su C.
W364
Subota V.
W341
Subramaniyam S.
W222
Suceava I.
W167
Sudarević B.
M174
Suer W.
M015
Suhadolc K.
W344, W358
Sukasem C.
M130
Sukhachev D.
W279, W280
Sukhacheva E.
W279, W280
Sukhova I.
W064
Sulaieva O.
W326
Suleymanlar G.
M292, T290
Suligoi B.
M132
Sults A.
W410
Suomalainen A.
T149
Supak S.
T251
Supak Smolcic V.
T396, W271
Suppressa S.
T037
Surapaneni K.M.
W365
Surtihadi J.
M105
Suša S.
M286
Sust Martinez M.
W259
Suwalak T.
M130
Suzuki N.
W011, W022
Svaldi M.
W282
Svestak M.
T239
Svinarov D.
M350
Svoboda M.
M377
Sweat K.
W242
Swennen Q.
M308
EuroMEdLab 2013 - IndEx of authors
Author
Code
Syam M.
W355
Syme N.
T281
Sypniewska G.
M345, W017,
W034, W035, W108, W127
Syrjänpää M.
T403
Szabó G.
M088
Szabó M.
W362
Szadkowska I.
W158, W159
Szalai A.
M322
Szalay I.
M147, M222
Szczepański T.
W285
Szilasi M.
M201
Sziráki-Kiss V.
W263
Szmitkowski M.
M160, M177,
M183, M184, M188, M198,
M208, M209, M223, T155,
W336, W338, W345
Szőke D.
T282, W366
Sztefko K.
M199, M224, M225
Taar J.P.
M123, M124
Tabak O.
M277
Tabata H.
OC31
Taddei A.
OC10, W074
Tae-Dong J.
W092
Taemthong N.
M391
Taghzouti K.
T196
Tagliavini S.
T069
Tahiraj-Lokaj S.
M133
Tai J.
W086
Taibi L.
T173, W367, W377
Taibon J.
T389
Taimen P.
M141
Taklewold A.
T283
Tamang M.K.
W217
Tamanini A.
M081
Tamimi W.
M376
Tamuliene I.
M228
Tan K.
T025, T026
Tan S.Y.
T359
Tan T.
T118
Tanabe N.
W011, W016, W022
Tanaka H.
M107, W022
Tanaka K.
OL, W314
Tanaka T.
W202
Tandurella I.C.M.
M049, M072
Tani M.
W314
Tank A.
M215
Tanrikulu-Kucuk S.
M134
Tansan S.
M151
Tapan S.
M305, W368
Tapia-Ruano C.
T156
Tarapacz J.
M214, M233, M234
Tarassova L.
W297
Taroni F.
T137
Tarr T.
M021
Tarrega-Roig E.
T184
Tarsitano M.
M071
Tataru M. V.
M403
Author
Code
Tate J.
W286
Tau C.
T180
Tauber M.
W282
Tavella K.
M207
Tedeschi S.
M298
Tedone E.
T145
Teerajetgul Y.
M404
Teerakarnjana N.
T401
Tehvre M.
M411
Teles M.J.
W142
Telese A.
M048
Temporiti R.
T071, W245
Tencomnao T.
W216
Teolato S.
M173
Ter-Laak M.
T095
Terraneo L.
M170
Terreni A.
M207, W287, W288
Terrijärvi J.
T398
Terrin G.
M055
Terzieva D.
W215
Tesar V.
OC02
Tessari A.
EW019, T194
Tessarolo A.
T098, T129
Testa R.
M268
Teti M.
T100, T375
Teyeb H.
M135
Thapliyal R.
M110
Theansun W.
W405, W406
Thelen M.
T285
Thevarajah T.M.
M226
Thibeault D.
T326
Thiele R.
T286
Thielen A.
M095
Thienpont L.
T279
Thirunavukkarasu r.
W222
Thoenges D.
T388
Thomae R.
OC32
Thomson Y.
M165
Thonat C.
T236
Thuillier F.
M182, W018
Tichopad A.
T116, T266
Tiers L.
OC11
Tiikkainen U.
T279
Tikanoja S.
T355, T383, T384
Timms P.
M373, W117, W369
Timón-Zapata J.
M031, T264
Timur M.
M210
Ting K.R.
W004
Tinto N.
M023
Tiozzo A.
W309
Tirabassi G.
T037
Tiranti V.
T158
Tirelli A.S.
W203, W221
Tišler-Štuflek J.
W347
Tiso E.
M249
Titonel S.
T063
Tobolczyk J.
W336
Tocchini M.
T037
Author
Code
Todorova K.
Toerring N.
Tognoni G.
Toker A.
Tolaini J.
Toly-Ndour C.
Tomaiuolo R.
T212
EW040
OC32
M175
T381, T385
T265
OC16, M055,
M059, M085
Tomasi A.
M144, M259, M288,
T306, W223
Tomasik P.
M199
Tomic A.
M312, M313
Tomova L.
M377
Tomova N.
W354
Tonozzi D.
M318
Tonutti E.
EW081
Topciu V.
T175
Topçiu Shufta V.
M309
Toprak B.
M349
Topuzova M.
T170, W327
Tormo C.
T117
Torregrosa-Benavent A.
T259
Torrejon M.J.
W289
Torres M.
M375, T278
Torresani E.
M035, W221
Torretta E.
OC14, M167
Tosato F.
T192, W290
Tosheska-Trajkovska K.
W149,
W190
Tóth G.
W362
Totos G.
M037, M410
Touchon J.
OC11
Touzani A.
T196
Tovar I.
W042
Tovar-Zapata I.
OC30
Trabattoni E.
T004
Trabelsi M.
W330
Trabuio E.
M271, T044, W310
Trajkoska E.
T046
Tran N.
T013
Traylor L.
W242
Treebuphachatsakul W.B.
M391,
W405, W406
Trefil J.
M300
Tregnaghi A.
W309
Trelińska J.
W285
Trementino L.
T037
Treneska T.
T046
Trenti T.
EW009, M012, M022,
M318, M399, T060, T069, T126,
T160, T367, W134, W334
Trifunovic D.
W147
Trifunović S.
T036, T050
Triki S.
W150
Trimech T.
W033
Tripodi A.
EW031
Tripodi V.P.
W340
Trokthi R.
W201
biochimica clinica, 2013, vol. 37, SS
S731
EuroMEdLab 2013 - IndEx of authors
Author
Code
Trombetta C.
T039
Trombouki S.
M295
Trouvé C.
T372
Trujillo Arribas E.
T027, T241
Trzpil R.
T030
Tsai C.
M154
Tsai W. L.
T130, T276
Tsarfati E.
W117
Tsaroucha E.G.
M142
Tseng K.
W364
Tserennadmid E.
M405
Tsionou C.
M079
Tsoneva V.
T028
Tudini S.
T334
Tudor A.
M163
Tulaci K.G.
M406
Tuladhar e.
W224
Tuli A.
T210
Tuomisto M.
T358
Turčáni P.
T154, T163
Turiano F.
T301
Turksoy V.A.
M314
Turner H.
T078
Turner L.J.
T343
Turner S.
T208
Turpeinen U.
T149
Turrini R.
T287
Turrini F.
W134
Turzyniecka M.J.
T064, W407
Tuteska J.
M136, T399
Tutkun E.
M314
Tuunainen E.
M127
Tuya E.
M405
Tuzcu M.
T135
Tuzuner A.
M406
Twardoch M.
W285
Tyagi S.
W131
Tykhomyrov A.A.
T135
Tyrkus M.
M162
Tzatchev K.
T212, W269
Tzavaras A.
T102, W383
Tzika K.
M058
Tzontcheva A.
T065
Tzveova R.
M241, M247, W119
Ucar F.
M406, T262, W370,
W371
Udalova O.
T206, T232
Udristioiu A.
T400
Udvardy M.
W263
Ueno T.
OC31
Ughetto S.
T236
Uhelly C.
T315
Uldbjerg N.
T216
Ulenkate H.
W291
Ulutas P.A.
M137
Umahoin K.
W023
Ünal S.
T330
Ünal Z.N.
W007
S732
Author
Code
Unanue U.
W225, W292, W294
Unceta-Suarez M.
W248
Unic A.
W372
Unlu A.
W171
Ural M.
M137
Urasiński T.
W285
Urbano M.M.
T110
Urbonas V.
M228
Urboniene D.
W283
Urrechaga E. W225, W292, W294
Urso C.
M220
Urso M.
M271
Usmani S.
W242
Üstüner F.
M349
Uy J.
T127
Uyanik M.
M229, M305
Uysal M.
M351, M362, M368,
T067
Uysal S.
W007
Uzun G.
M293, M294, W024
Uzun H.
M277
Väänänen R.
M141
Väisänen V.
OC18
Vajtr D.
M185, T023, T024
Valaperta S.
W328
Valdazo-Revenga M.V.
M385
Valdés M.
W154, W155, W156
Valdés P.
T061
Valdes Socin H.G.
T066
Vale M.A.A.B.d.V.
W231
Valenta J.
T003
Valente C.
M197, T087, T282,
W366
Valentim D.
T086
Valentin O.
W032, W377
Valentini V.
W270
Valerio L.
T069
Valgimigli F.
W380
Valido F.
W323
Valinotto R.
M317
Valldecabres-Órtiz C.
T329
Vallée M.
T110, T235
Valle-García M.T.
T284
Valle-Muñoz J.
M031
Vallianou N.
W067
Valverde S.
M271, T044, T341,
W309, W310
Vamanu E.
M407
Van der Burgt Y.E.M. M156, W047
Van der Laarse A.
W047, W048
Van Dieijen-Visser M.
SY59,
W043, W093
Van Dijk J.
W093
Van Hasselt C.A.
M155
Van Schaik R.
M248
Van Vlierberghe H.
M320
van Wijk E.
T095
Vanavanan S.
T308, T366, T401,
biochimica clinica, 2013, vol. 37, SS
Author
Code
W146
T242
W093
T248, W036
T372
W043
W389
M138, W295
M388
W230
T243
T284
M104, M139,
M386, M408
Varo Cenarruzabeitia N.
W006,
W013
Varona López W.
M344
Varo Sánchez G.
M104
Varraso L.
OC04, W393
Varriale G.
M187
Vasatova M.
M230, W151, W152,
W373
Vasilev V.
M189,T159,T221,
W109, W110, W269, W354
Vasiljević Z.
M397, W147
Vaskivuo T.
W391
Vassalle C.
T248, W036
Vasso M.
OC14, T145
Vaubourdolle M.
T173, T362,
W032, W367, W377
Vavilova T.
T170, W098, W327
Vázquez C.
T109
Vazquez M.
T230
Vázquez-Blanco M.
W160
Vázquez-Zaragoza M.A.
M027
Vcev A.
M384
Veeraraghavan V.P.
W374
Veervart P.
SY40
Vehniäinen M. M186, T291, T348
Vejar B.
T061
Velasco L.
M094
Velija-Asimi Z.
W170
Velissari A.
M067
Velizarova M.
W296
Velkeniers B.
SY22
Veltri D.
T185, T186
Veneri D.
W321
Venero J.
M231
Venge P.
EW074
Venner C.P.
W299
Venta-Obaya R.
M367, W276
Venton T.
M373, W369
Ventura L.
T343
Venturelli B.
T367
Verboeket-van de Venne W. T285
Verderio P.
T116, T266
Vergara P.
W061
Verhoye E.
W095
Vanikova J.
Van-Loon L.
Vannucci A.
Vanpoucke H.
Van Rooij T.
Vansith K.
Vänskä M.
Van'T Sant P.
Varagnolo M.
Vardar M.
Vargas Morales J.M.
Varo Sánchez G.M.
EuroMEdLab 2013 - IndEx of authors
Author
Code
Vermeer H.
T285
Vernet M.
W153
Vernic C.
M412
Veroni F.
M291, T124, W205
Versluys C.
W291
Veseli S.
M309
Vesper H.
T249, T280
Vetoshkin A.
W010
Vezyraki P.
M363
Vialaret J.
OC11
Vianello E.
W063, W065
Vianey Saban C.
M039
Vianna Crabal F.
M017
Viarengo M.
M317
Vicas S.
M285, T226
Vicente V.
W154, W156
Vicente Saiz M.
M018
Vickovic S.
W173
Vidal B.
T324
Vidal H.
W165
Vidali M.
M317
Vidosava D.
T141
Vidranski V.
M111
Viegas C.
W126
Viggiani V.
T334
Vígh E.
T195
Vigna L.
W203, W221
Viikant N.
M411
Vilaverde J.
T063
Vilches-Arenas Á.
T005, T006,
T007, T020, T144
Vílchez J.A.
W075, W154, W155,
W156
Vílchez Aguilera J.A. M097, M098,
T222, T223, T224,
T179, W250
Villafruela-Sanz J.J.
M365
Villanucci A.
M207
Villanueva S.
M231
Villard C.
M366
Villarreal-Ortega A.
M027
Villar-Valdés M.
T213
Villegas M.
W075
Villeneuve S.
W008
Vincendeau S.
M145, M146
Vincent J. L.
SY70
Vinciguerra M.
W278
Vincze Á.
W362
Viniegra J.
M265
Vinuesa C.
T117
Viollier E.H.
M377
Viqueira M.
T011, T017
Virág K.
T195
Virgili E.
M170
Virgilio M.
W305
Visentin I.
T129
Visentin S.
T207
Visvikis Siest S.
EW005
Author
Code
Vitek L.
T242
Viterbo G.
T180
Vitkauskiene A.
W283
Vitkus D.
M178, M359
Vitoratos N.
T233
Vitorovic M.
M117
Vitullo E.
M242
Vizzini M.
T368
Vlad D.C.
T187
Vladimirova S.
W297
Vladimirova-Kitova L.
W058
Vlahovic P.
M038
Vlantis A.C.
M155
Vlašić T.
T112
Vlassopoulos D.
M295
Vogeser M.
SY27
Vogiatzakis E.
W067
Vogrinc Z.
T010, T402
Voigt J.
T104
Vøllestad N.
W254
Volynec A.
M019
Von L.
M127
Vorčáková K.
T174, T240
Voss J.
M068
Vranken L.
T066
Vrbová M.
M337
Vučić-Lovrenčić M.
W166, W226
Vuckovic Z.
M117
Vujanić S.
M101, W341
Vujosevic I.
M290
Vujotic L.
M402
Vukasovic I.
T251
Vukovic-Dejanovic V.
M338
Vuojola J.
T403
Vural P.
T067
Wafula B.B.N.
T096
Wagner C.
M105
Wahlroos V.
W100
Wallace J.
M364
Wallemacq P.
SY28, T297
Walter H.
M095
Walz B.
W157, W408, W409
Wanderlich B.
T195
Wang B.
W375
Wang C.
W335
Wang E.
T319
Wang Y.
T047
Ward M.
M364
Wassef N.L.
W298, W299
Watanabe M.
W202
Watine J.
OC33, T244
Watson I.
SY06, T097
Weber B.H.
SY52
Weber F.
T286
Weber K.
T256
Wechalekar A.
EW088, W299
Weimann A.
M015
Weinert L.S.
OC25, M250
Author
Code
Weinstock M.
T150
Werdan K.
M129, T021
Wereszczyńska-Siemiątkowska U.
M188, M198
West P.
M232, M310, M409,
T131
Westgard J.
EW022
Wex T.
OC21
Wieczorek M.
W285
Wienbreyer A.
M254
Wieringa G.
SY17
Wiesgigl M.
W300
Wiesner D.
W106
Wiewiorka O.
T077
Wiik A.
EW080
Wijaya A.
W184
Wilke M.
EW093
Wille S.M.
SY09
Williams C.
W239
Wilson D.
M314
Winsz-Szczotka K.
M390, T197
Wisplinghoff F.
EW010, T344
Wittfooth S.
M127, W100, W137,
W138
Wlazel R.N.
W158, W159
Wojcik E.
M214, M233, M234
Wojtukiewicz M.
M223
Wolf E.
M095
Wolf M.
EW050
Wolthuis A.
M034
Wong C.
M105
Wood J.
EW008
Woo H.I.
M076
Woollatt L.
T304
Wootton A.
T097
Workman R.
W106
Worster A.
W091
Woth G.
T014, T016
Wuyts B.
M320
Wynckel A.
W284
Wyrich R.
T116, T266
Wysocki M.
W285
Wysocki W.
M233
Xadjiyannakos D.
M295
Yadav S.
T114
Yago M.
T117
Yahyaoui R.
OC27, T198
Yako Y.
M266, M283
Yakupoglu G.
M292
Yalcin F.
M134
Yamato S.
W202, W227
Yancey S.
W008
Yang D.
T310
Yang J.J.
M028
Yang Z.
W194
Yapur V.M.
W160
Yaqub S.
W260
Yaroustovsky M.
M299, T029,
biochimica clinica, 2013, vol. 37, SS
S733
EuroMEdLab 2013 - IndEx of authors
Author
Code
W399
Yasushi K.
T128
Yavuz T.
M406
Yavuz Tasplinar M.
T262
Yavuzer H.
W003
Yazici C.
W174
Yigitoglu R.
W171
Yiğitoğlu M.R.
W007
Yildirim F.
M368
Yildirmak S.
T243
Yilmaz B.
W371
Yilmaz F.M.
M314, W171
Yilmaz H.
M314, W171
Yilmaz V.T.
M293, M294
Yordanova–Laleva P.
W119
You J.J.
W091
Young L.
M273, W081
Young P.
W299
Yu T.
M154
Yu W.
T276
Yuce D.
M314
Yucel G.
T289, T290
Yuksel O.
W370
Yun Y.M.
M108, M276, M311,
W264, W265
Yussef M.
W213
Zaccariotto T.R.
OC15
Zacharin M.
T214
Zaciragic A.
W228
Zahran F.
M011
Zahzeh M.R.
M235
Zahzeh T.
M235
Zak P.
M230
Zaka A.
W302
Zalewska-Zacharek M.
T228
Zambon C.F. OC20, M143, M148,
M173, M196, M249, T194,
T288, T373
Zammaretti P.S.
SY34
Zampieri C.
M081
Zamurovic M.
T231
Zanelli P.
W334
Zanetti A.
W334
Zaninotto M. EW096, M317, T032,
T207, T365, T404, W044, W161,
W230
Zanotta S.
W051
Zapała M.
M066
Zapico-Muñiz E.
W259, W301
Zappacosta B.
T375
Zardo L.
T273, T287
Zargari M.
M339
Žarkov M.
T161
Zarrilli F.
OC16, M059
Zatezalo L.
T202
Zattoni F.
M143
Zayani Y.
W027, W028
Zaytseva N.
T170
S734
Author
Code
Zazulak W.
M121
Zborowska H.
T030
Zdrodowski M.
M208, M209
Zdunek D.
M254
Zeccolella R.
M395
Zegarska J.
T228
Zeher M.
M021
Zei D.
T293, T294
Zelioli N.
M318
Zemtsovskaja G.
W410
Zeneli D.
W302
Zeqiraj E.
W302
Zerah S.
SY18, M123, M124
Zerbini A.
W334
Zermeni R.
W330
Zetterberg H.
T166, T171
Zhang H.
M215
Zhang L.
M236
Zhang R.
T351
Zhubi B.
T175
Zhuri M.
T219
Zibar L.
M238
Zidi W.
W027, W028
Zidi Y.
W330
Zielinska M.
W158, W159
Zilinskaite R.
M359
Zima T.
OC02, M032, M176,
M185, M329, T003,T023, T024,
T263
Zimon D.
OC07, M213
Zingaro L.
M399
Zivanovic S.
M117
Živković M.
M244
Zlatkov B.
M350
Zneidi N.
W330
Zoga J.
W302
Zogović D.
T056, T057
Zoppis I.
M156
Zoraqi G.
M070
Zorbas G.
M037
Zorbozan N.
T261
Zoric L.
M380
Zorič P.
T174
Zorzo P.
W120
Zoumbouloglou F.
M281
Zsuzsanna B.
T169
Zucchelli G.
W113
Zuccotti G.V.
T182
Zuga Z.
M218
Žula Š.
W277
Zunic G.
M312, M313
Zúñiga Á.
M045, M060, M065,
M077
Zupan J.
W019
Zupan M.
M341
Županić D.
T112
Zuppi C.
OC09, M003, M041,
M042, M043, M075, M297, T100,
biochimica clinica, 2013, vol. 37, SS
Author
Code
T234, T340, T375, T377, W386,
W402
Zvezdanovic L.
M181, T015
Zvezdanovic Celebic L.
M038
Zwingers T.
M212
Zybina N.
W212
Zych W.
OC22
Żyła J.
M392