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Appropriatezza della richiesta di esami ed esiti clinici: il caso delle malattie renali, tiroidee e della celiachia
Appropriateness of test request and clinical outcome: the example of kidney, thyroid and coeliac disease

This document analyzes the topic of appropriateness of test request. It is organized in 4 parts. The first deals with the theme of appropriateness, the consequences of insufficient or excessive test request and the need to balance guideline indications with the clinical need of a single patient. The other 3 parts present the cases of thyroid, chronic kidney and coeliac disease. With regard to the thyroid function, population screening, excluding neonates, is not recommended; on the contrary, it is highly recommended to evaluate the thyroid function in any individual with even only a minimal clinical suspect. The thyrotropin (TSH) is the test of choice with reflex free T4 and free T3, according to specific algorithms. The contemporaneous measurement of free FT3, free FT4 and TSH, except for specific cases, should be discouraged due to the high frequency of unjustified abnormal findings. Anti-thyroperoxidase antibodies are the test of choice for autoimmune thyroid diseases. In chronic kidney disease (CKD), the estimated glomerular filtration rate (eGFR) based on serum creatinine in most cases is the best indicator of renal function, provided that creatinine is measured with the accurate enzymatic method. In borderline situations, a confirmatory eGFR calculation based on cystatin C is recommended. Urinary albumin, expressed as albumin/creatinine ratio, is an essential complement for CKD staging. The diagnosis of coeliac disease requires integration between clinical, histological and serological data. The anti-transglutaminase IgA is the test of choice; only when an IgA deficit is present, the test to be used is IgG antigliadin deamidate peptides. The genetic HLA DQ2/DQ8 test is indicated for screening of subjects at risk: if negative, coeliac disease can be excluded.

Biochimica Clinica
DOI: 10.19186/BC_2017.040
Pubblicato online il: 03.08.2017
Documenti - Documents
 
Espressione e valore prognostico del ciclo cellulare e delle aneuploidie nel mieloma multiplo e nella gammopatia monoclonale di significato indeterminato
Expression and prognostic value of cell cycle and aneuploidy in multiple myeloma (MM) and monoclonal gammopathy of undetermined significance (MGUS)

In this study, we used multiparameter flow cytometry (MFC) to investigate old and new plasma cell (PC) markers, such as the extrusion pumps of drugs, cluster of differentiation 243 (CD243) and citochemokine receptors (CD197, CD191, CD192, CD196, CD183, CD184, CD126) involved in cellular interactions, locomotion, adhesion and invasion. We studied the different expression of PC in 55 samples of bone marrow of patients affected by MM and MGUS, using MFC and immunomagnetic sorting. The incidence and prognostic significance of the analysis of the cell cycle and aneuploidy were evaluated in order to support the efficacy of MFC. By analysing the immunophenotypic receptor molecules expression and extrusion pumps, we found that CD243, CD192, CD183, CD191 and CD196 showed increased expression in cases of MM, whereas an increased expression of CD197, CD184 and CD126 emerged in MGUS samples. In comparing neoplastic and normal PC in MM samples, we found an increased expression of all receptors on the surface of neoplastic PC. Cell cycle and aneuploidy analysis of all samples showed a pseudodiploid condition with a more difficult prognosis, even considering the old age of patients.

TAG: mieloma multiplo   aneuploidie   ciclo cellulare   MGUS  
Biochimica Clinica
DOI: 10.19186/BC_2017.038
Pubblicato online il: 02.08.2017
Contributi scientifici - Scientific papers
 
Un caso di mieloma multiplo IgG kappa in cui la misura delle catene leggere libere ha evidenziato precocemente una ripresa di malattia di tipo “light chain escape”
A case of IgG kappa multiple myeloma where the measurement of the free light chains was an early marker of a “light chain escape” relapse

Light chain escape (LCE) is a type of relapse where a serum free light chains (FLC) increase is observed, in the absence of a parallel increase of the original monoclonal component; this particular kind of relapse seems to be influenced by new therapeutic regimens. We present a case of a 55-years old man with a IgG kappa multiple myeloma (MM), who underwent double autologous bone marrow transplantation as first line therapy; after relapse, the patient was treated with lenalidomide/dexamethasone (LD). After more than three years of LD treatment, in September 2014, an increase of FLCs was observed, while serum and urine immunofixations remained negative until January and February 2015 respectively, when a LCE was diagnosed. Despite the new treatment, the patient died in June 2016. The FLCs measurement, although not reaching the IMWG criteria, detected relapse earlier than immunofixation. This case indicates that FLCs should be routinely performed during follow up of MM patients to ensure that LCE is not missed.

Biochimica Clinica
DOI: 10.19186/BC_2017.034
Pubblicato online il: 01.08.2017
Casi clinici - Case report
 
Il laboratorio clinico nelle indagini tossicologiche
The role of clinical laboratory in toxicological investigations

Clinical toxicology laboratory activities are carried out both for clinical purposes, providing support to the diagnosis and treatment of intoxicated patients, and for medico-legal aspects, providing data with value of judicial proof. The new Italian law (no. 41, March 23, 2016) considers vehicular homicide and road traffic injuries criminal offences to be severely punished, especially if the driver is under the influence of alcohol or psychotropic substances. Since toxicology results have an impact on administrative and legal decisions, analytical reliability and traceability of data, including the implementation of a chain of custody of samples, are crucial. Forensic toxicological analyses use conventional matrices (blood and urine) and alternative matrices (hair, saliva, sweat). To assess the current use of illicit drugs, blood is the matrix of choice because substance concentrations correlate with subject’s physical and mental status at the time of collection. On the other hand, urine testing is simple, rapid and non-invasive. A positive result indicates that the substance assumption was from several hours to a few days prior to sampling. The hair matrix is suitable to identify past use or abuse and segmental hair analysis allows the reconstruction of the history of abuse. Analytical methods for alcohol and drugs of abuse include qualitative screening tests and quantitative confirmatory tests. A negative result of the screening test does not require further investigation, while a positive result cannot assume forensic value without confirmatory analysis. The use of mass spectrometry in combination with chromatographic or electrophoretic separation techniques for confirmatory tests has found the consensus of the international scientific community.

Biochimica Clinica
DOI: 10.19186/BC_2017.039
Pubblicato online il: 02.08.2017
Rassegne - Reviews
 
Mieloma multiplo IgD lambda: “switch” isotipico immunoglobulinico dopo trapianto autologo
IgD lambda multiple myeloma: immunoglobulin isotype switch after autologous stem cell transplantation

IgD multiple myeloma (MM) is a rare disease affecting less than 2% of patients with MM, and it is frequently characterized by an aggressive course. It is usually associated with low monoclonal protein levels, so adequate diagnostic procedures have to be performed in order to identify the involved monoclonal component (MC). We present a case of a 38-year-old man with acute kidney disease caused by an IgD lambda MM. Diagnosis was achieved by serum protein electrophoresis and immunofixation with anti IgD and IgE antisera. After autologous stem cell transplantations (ASCT) the patient developed a MC different from the original isotype, followed by an oligoclonal bands (OB) pattern. Recently, the occurrence of MC and OB unrelated to the original clone has been proven to be an important favorable prognostic factor in patients with MM who undergo ASCT. The role of the protein laboratory at diagnosis and during follow up of MM patients is highlighted.

Biochimica Clinica
DOI: 10.19186/BC_2017.036
Pubblicato online il: 01.08.2017
Casi clinici - Case report
 
Incremento acuto di troponina I in assenza di malattia coronarica ostruttiva: un caso di sindrome di Takotsubo
Acute troponin I increase in absence of obstructive coronary disease: a case of Takotsubo syndrome
C. Bellia  |  B. Lo Sasso  |  L. Agnello  |  G. Bivona  |  G. Novo  |  M. Ciaccio  | 

A 66-year-old woman was admitted to the Emergency Department of Policlinico P. Giaccone, in Palermo, for nonradiating chest pain that occurred after an emotional stress. Her medical history included a positive family history for cardiovascular disease, arterial hypertension, gastro-esophageal reflux disease, and anxiety-depressive syndrome. Upon admission, the electrocardiogram showed diffuse ST-T abnormalities with an elevation of the ST segment; Troponin I was 3790 ng/L, creatine phosphokinase was 374 U/L, which became normal within 48 hours. No evidence of significant coronary artery stenosis was detected on the angiography. The echocardiogram showed apical akinesia and hyperkinesia of the basal segments of left ventricle, with moderately impaired ventricular function (Left Ventricular Ejection Fraction, LVEF=43%). Cardiac magnetic resonance imaging ruled out myocarditis and confirmed the diagnosis of Takotsubo cardiomyopathy. Supportive therapy with Angiotensin Converting Enzyme inhibitors, spironolactone and acetylsalicylic acid was initiated. After 30 days, the echocardiogram showed a complete recovery of left ventricular function. Takotsubo syndrome was diagnosed based on instrumental, clinical and biochemical findings.

Biochimica Clinica
DOI: 10.19186/BC_2017.033
Pubblicato online il: 31.07.2017
Casi clinici - Case report
 
Verso l’armonizzazione dell’analisi delle urine con striscia reattiva: il ruolo di un programma di VEQ
Towards harmonization in dipstick urinalysis: the role of EQAS

We reviewed the results of our 2013 to 2016 EQAS to evaluate the performance of the most used dipstick urinalysis methods in Italy. 67,450 results from 32 control samples were analyzed by using a normalized scale. For pH, the mean of the most frequent results was 72.1%±15.6. For specific gravity, the mean for values <1.020 Kg/L was 77.9%±9.5. For glucose detection, in negative samples 97.4%±3.1 of dipsticks provided correct results, while for samples with 300-500 mg/L, 10.8%±6.2 provided negative results, mainly Siemens dipsticks. For proteins, in negative samples 99.7%±0.2 of dipsticks supplied correct results, but for samples with 100-250 mg/L of proteins 25.6%±10.7 still resulted negative. For hemoglobin, in negative samples 94.8%±5.5 of dipsticks provided correct results; for samples with 0.1-0.3 mg/L 10.0%±0.8 of dipsticks resulted negative. For ketones, in negative samples 99.8%±0.2 of dipsticks provided correct results; however, Uropaper Alpha3-9L never revealed their presence in positive controls. For leucocyte esterase, in negative samples 97.6%±0.9 of dipsticks provided correct results. For nitrites, results were consistent both with negative and positive controls (99.3%±0.6). For protein/creatinine ratio, in samples with ~150 mg/g 14.3%±5.3 of dipsticks provided a normal ratio. The study demonstrates the importance of an EQAS in providing to participants an evaluation of their performance and a reliable view of the degree of harmonization among results of different types of dipsticks.

TAG: striscia reattiva   urine   VEQ   dipstick  
Biochimica Clinica
DOI: DOI: 10.19186/BC_2017.037
Pubblicato online il: 01.08.2017
Contributi scientifici - Scientific papers
 
Il microRNA-135b nella caratterizzazione molecolare del carcinoma della mammella “triplo negativo”
miRNA-135b in molecular characterization of triple-negative breast cancer (TNBC)
G. Pira  |  L. Murgia  |  F. Sanges  |  P. Uva  |  P. Cossu-Rocca  |  F. Loi  |  S. Orrù  |  M.R. Muroni  |  C. Carru  |  A. Angius  |  M.R. De Miglio  | 

TNBC accounts for 12-24% of all mammary cancers (BC). Its clinical and genetic heterogeneity and the lack of unambiguous molecular targets contribute to the scarcity of therapeutic options for this BC variant. Recently, the BC molecular biology has entered in the era of microRNAs (miRNA), a class of small highly conserved regulatory endogenous non-coding RNAs, which control complicated signaling pathways, governing cell cycle, proliferation, differentiation, apoptosis, etc., and whose deregulation contributes to the tumour development. Our goal was to improve the knowledge of TNBC biology analyzing the miRNA expression profile and to identify new potential prognostic and predictive biomarkers. We conducted a human miRNome analysis by TaqMan Low Density Array comparing different TNBC subtypes, defined by immunohistochemical basal markers, such as epidermal growth factor receptor and cytokeratin 5/6. Quantitative reverse transcription polymerase chain reaction confirmed differential expression of miRNA. We identified a single miRNA signature given by miR-135b expression levels, which allowed the distinction of TNBC with and without basal-like phenotype. Our study sheds light on the molecular complexity of TNBC and shows for the first time that miR-135b expression is strictly related to TNBC basal-like molecular subtype, acting as an oncogene in the tumor pathogenesis.

TAG: miRNA   miRNA-135b   triple negative   breast cancer  
Biochimica Clinica
DOI: 10.19186/BC_2017.035
Pubblicato online il: 01.08.2017
Contributi scientifici - Scientific papers
 
Durata della fibrinolisi post-operatoria e rischio trombotico dopo somministrazione di acido tranexamico negli interventi di protesi d’anca e ginocchio
Duration of post-operative fibrinolysis and thrombotic risk after tranexamic acid administration in hip and knee prosthesis interventions

Strong evidence indicates that TXA reduces blood loss and blood transfusion requirement in orthopedic surgery. However, drug safety and side effects are still a controversial issue, because TXA may increase thromboembolic risk. Aim of our study was to quantify the duration of postoperative fibrinolysis and to assess the impact of TXA administration after total hip (THR) and total knee replacement (TKR). Fifteen patients undergoing THR and 10 undergoing TKR were included in the study. Among these patients, 14 THR and 8 TKR received TXA, while 3 (one THR and 2 TKR) were employed as controls (i.e., no TXA administration). D-dimer and thrombin generation time were measured prior to surgery as well as 3, 6, 24 and 72 h after. No statistically significant difference in D-dimer was observed between patients treated and not treated with TXA, even if D-dimer increased postoperatively (6 h) more in patients not treated with TXA than in patients receiving TXA. Thrombin peak was lower in patients treated with TXA than in patients not receiving it. Our study shown that TXA limits postoperative fibrinolysis after THR and TKR, as evidenced by a lesser increase in D-dimer in patients receiving TXA, with no increase in prothrombotic risk.

Biochimica Clinica
DOI: 10.19186/BC_2017.032
Pubblicato online il: 31.07.2017
Contributi scientifici - Scientific papers
 
Ruolo e finalità dei laboratori di farmacotossicologia forense
Role and objectives of forensic pharmacotoxicology laboratories

The forensic toxicology laboratories produce analytical data on toxic or pharmacological compounds for forensic or administrative aims at the request of public offices, private companies or, less frequently, individuals. Although this definition includes a wide range of applications, the common aspect is to identify and measure analytes in biological samples, collected from a living or deceased person, or in non-biological samples. In forensic toxicology, the detection of xenobiotics in cases of driving under the influence of drugs is the most common investigation. Less frequently, the forensic toxicology laboratory deals with quantitative analysis of drugs in non-biological material. The toxicological investigations of cadaveric specimens are finalized to the detection of toxics or legal and illegal substances in case of fatal intoxication/poisoning or in case of traffic accidents, evaluating if these xenobiotics are the determinant or contributory factors in the cause and manner of death. In this field, where the consequences of an analytical error or misinterpretation of the data can have direct legal and social implications for the person involved in the investigation, the result of toxicological analysis must be particularly characterized by accuracy and reliability. Standards of quality must be applied and scientific and technological skills are mandatory. If not, professionals involved in this activity may incur in liability or criminal prosecution.

TAG: Tossicologia forense   guida   xenobiotici  
Biochimica Clinica
DOI: 10.19186/BC_2017.031
Pubblicato online il: 31.07.2017
Opinioni - Opinions
 
Un caso camaleontico di porpora trombotica trombocitopenica (sindrome di Moschcowitz)
A chamaleonic case of Moschcowitz syndrome (thrombotic thrombocytopenic purpura)
G. Lobreglio  |  F. Guerra  |  P. Forese  | 

A 51-year-old woman was admitted to the hospital because of fatigue, high temperature (39.5 °C), focal neurologic abnormalities and purpura. Her medical history included poorly controlled type 1 diabetes mellitus, hypertension, intermittent headache and occasional diarrhea with stools contaminated with blood. Laboratory data showed anemia, thrombocytopenia, leukocytosis and elevated lactate dehydrogenase, bilirubin and glucose, while creatinine and other test results were normal. Although medical history and laboratory studies supported several causes for the patient symptoms (sepsis, systemic cancer, severe hypertension, autoimmune disorders, disseminated intravascular coagulation), an elevated schistocyte count on the blood smear strongly suggested a diagnosis of a thrombotic microangiopathy syndrome. The von Willebrand factor-cleaving protease level below 5%, associated with its autoantibody inhibitor supported the clinical diagnosis of Moschcowitz syndrome. This case demonstrates the importance of laboratory tests in the diagnosis of rare disease in patients with symptoms that may be attributable to more frequent causes.

Biochimica Clinica
DOI: 10.19186/BC_2017.030
Pubblicato online il: 28.07.2017
Casi clinici - Case report
 
Utilità dell’elettroforesi urinaria come metodo di screening per la ricerca della proteina di Bence Jones
Utility of the urine electrophoresis as screening test for the detection of Bence Jones protein

Urine immunofixation (uIFE) is the gold standard method to detect the Bence Jones protein (BJP), but is time consuming. We investigated if the urine protein electrophoresis (uEF) can be used to select samples to be immunofixed, verifying its diagnostic accuracy. During a 5-month period, we analyzed 993 urinary samples performing both uEF and uIFE on agarose gels. Two trained operators evaluated independently the gels comparing results of the two techniques. uEF was considered negative when no protein or only the albumin band were visible; any other pattern was classified as positive. 528 samples were negative and 272 were positive with both methods; 12 false negative results were observed with uEF, but only one of these showed a BJP quantification methods >10 mg/L (the recommended sensitivity threshold). A positive predictive value of 60% and a negative predictive value of 97% were calculated for uEF. In order to evaluate the concordance with the uIFE, we calculated the Cohen’s k coefficient: the results showed a moderate agreement with a Cohen’s k coefficient of 0,594. uEF could be an alternative tool to facilitate the diagnostic pathway for the PBJ detection, provided that the technique is at high resolution and sensitive. In particular, uEF could be used as a first step test to select the samples to be immunofixed.

Biochimica Clinica
DOI: 10.19186/BC_2017.029
Pubblicato online il: 28.07.2017
Contributi scientifici - Scientific papers
 
Obesità, microbiota e stress ossidativo
Obesity, microbiota and oxidative stress
A. Vanzo  |  A. Bolner  |  G. Nordera  |  O. Bosello  | 

Only in recent years, scientific societies and governments of many countries have considered obesity and its precursors, namely overweight, such as a disease that causes other diseases and reduces life quality and expectancy. According to the latest researches, obesity is a complex disease, with multifactorial etiology, not exclusively linked to eating disorders and lifestyle, which contribute inflammatory, infectious, toxic and also mental phenomena. Among many pathogenetic and pathophysiological invoked mechanisms, the effects of oxidative stress have recently received special attention. The imbalance between the production of free oxygen and nitrogen radicals and the physiological contrast mechanisms could actually play a causal role in the development of obesity by stimulating the deposition of white adipose tissue and altering the assumption of food. Oxidative stress and systemic inflammation are also key factors in the pathogenesis of obesity-related diseases, including atherosclerosis, insulin resistance, type 2 diabetes and cancer. Despite the correlation between obesity and oxidative stress, none of the biochemical markers of oxidative damage can be considered predictive of obesity; on the contrary, some markers seem to predict the development and progression of cardiovascular and metabolic disease in overweight and obese subjects. Recent observations also demonstrate the existence of quantitative and qualitative differences in the intestinal microbiota between individuals at high and low risk of development of obesity and related complications. Therefore, the intestinal microbiota might play a key role in the pathogenesis of obesity.

TAG: Stress   ossidativo   obesità   microbiota  
Biochimica Clinica
DOI: 10.19186/BC_2017.028
Pubblicato online il: 26.07.2017
Rassegne - Reviews
 
Anemia acquisita da ospedalizzazione: il ruolo delle perdite di sangue a scopo diagnostico
Hospital-acquired anemia: the role of diagnostic blood loss

Hospital-acquired anemia (HAA) is defined by a reduction of blood hemoglobin concentrations in hospitalized patients, in absence of bleeding episodes occurring during the hospital stay. One of the most important causes of HAA is the considerable amount of blood drawn for diagnostic purposes, which mainly affects critical patients in the intensive care units. Although usually underestimated by healthcare providers, HAA can be a significant problem, because it may increase the necessity of allogenic transfusions, the morbidity and mortality rates and healthcare costs. Strategies to minimize diagnostic blood loss should be implemented by both clinical wards and laboratories within wider patient blood management programs, with the aim of improving patient clinical outcome. These should include using small-volume test tubes, reduction of sample waste, optimization of testing frequency, early removal of central catheters and healthcare professional education.

TAG: costi sanitari   anemia iatrogena   emoglobina  
Biochimica Clinica
DOI: 10.19186/BC_2017.027
Pubblicato online il: 13.07.2017
Rassegne - Reviews