Articoli in pubblicazione

Haematological laboratory diagnostics couldbenefit widely from telematics, but some critical issues need to be addressed for a successful organization. Imagetransmission is probably the most critical item. In fact, specific competences are required for the selection of thesamples to be reviewed, preparing of the slides, choosing fields and cells to be examined, and so on. Thetransmission of the entire blood film could be a good solution, but it is not yet available for laboratory haematology,while expert automated systems are nowadays ready for high performance processes without the need of specificskills.
Digitization of laboratory haematology can harmonize the activities utilizing the same rules of selection of thepreparations to be reviewed, and for the control, verification and validation of the analysed samples and finally forreporting. It offers support for consultancy and training. When these needs involve different sites far from each other,the transmission of data and images effectively requires automation technologies for preparing and reading thepreparations, information technologies for an integrated management of all the necessary data helpful for thediagnosis and a suitable network to make communications travel in suitable quantities and speeds.
The new frontiers of artificial intelligence will probably have a greater role both in the management of process, in theverification of automatic validations, and finally in the recognition of pathological morphological patterns. All this toolscannot replace the specialized expertise in the final supervision of haematological diagnoses, but will allow simpler,faster and safer management of haematological analyses and revisions, meeting the changing needs of modernlaboratory medicine.

Background: the pre-analytical phase of the stat tests requested by the Emergency Department (ED) has been rarelystudied in relation to the containment of the laboratory turnaround time (TAT).
Methods: through a pre-analytical workflow analysis in a large ED with "Lean" methodology, some improvementshave been activated, including the installation of a pneumatic tube system (PTS).
Results: significant improvement of TATs (23 minutes at 90th percentile) and also of length of stay (LOS) of EDpatients (53 minutes at 90th percentile) has been documented. The plasma concentrations of a number of analytesmeasured in samples transported manually and by PTS were very similar (lactic dehydrogenase excluded),demonstrating that PTS does not alter the integrity of the samples.
Conclusions: compared to manual transportation, the use of this PTS significantly reduced transport time and alsoimproved some pre-analytical flow phases within the ED. The system is suitable for the measurement of most of theanalytes commonly requested for ED patients.

For many yearslaboratory medicine services have been focused on reorganization interventions aimed at improving efficiency, inorder to respond to new care needs and to reduce costs. In some situations, when the centralized laboratory is notable to guarantee the service with an adequate timeliness, a Point-Of-Care Testing system designed for the clinicalmanagement of critically ill patients could be the solution. These systems can guarantee the immediate availability ofdiagnostic tests for diagnosis, monitoring and therapy, both for critical ill patients and for the continuity of health-care.
In this paper a six years’ experience of a Point-of-Care Testing implementation and management is described in aFirst Aid point service, in a particular territorial health-network created to guarantee continuity between the referencelaboratory and the local hospitals.

Background: procalcitonin (PCT) is a polypeptide secreted as a response a bacterial stimulus. PCT serumconcentrations are increased also in some autoimmune diseases. At the best of our knowledge, there is no study inliterature that evaluated PCT values in patients with primary Sjögren’s syndrome (pSS). The aim of this paper is tomeasure PCT values in pSS and to determine if these are related to the disease activity.
Methods: this is a case-control study. Two groups of subjects were included: 48 patients with pSS, who met AmericanCollege of Rheumatology 2012 Classification Criteria for Sjögren's syndrome and 53 healthy subjects as controlgroup (without any acute or chronic disease). The subjects with possible infectious disease were excluded on thebasis of their clinical evaluation and laboratory data. Serum PCT values were measured by electrochemiluminometricmethod. PCT values have been compared between the groups; the correlation between disease activity, measuredby Sjögren’s syndrome disease activity index (SSDAI) and PCT levels was evaluated.
Results: PCT values in pSS group were within the reference range, but significantly higher than those measured inthe control group [median (interquartile range) values were 0.036 ng/mL (0.031-0.044) and 0.020 ng/mL (0.020-0.020) respectively], (p<0.001). No correlation was found between disease activity and PCT values (p=0.63).
Conclusions: on the basis of the presented results, PCT could be a candidate marker for differentiating diseaseactivity from the presence of an infection in pSS patients. Future studies in pSS patients with infectious diseasescould possibly demonstrate the role of PCT in this context.

Background: telomerase activity and telomere length (TL) have important implications in several human diseases.Telomere shortening is associated with colorectal carcinogenesis. Recent studies also showed that protocadherin 10(PCDH10) plays a critical role in cancer cell growth, by negatively regulating telomerase activity. PCDH10isfrequently downregulated by promoter DNA methylation. The aim of this study was to investigate whether PCDH10promoter methylation was associated with TL in colorectal cancer (CRC).
Methods: DNA was extracted from 35 CRC and 35 adjacent normal tissues with Gentra Purgene Kit (Qiagen, Hilden,Germany). A quantitative methylation-specific PCR (MSP) based method was used to analyze a selected CpG site inPCDH10promoter. TL was evaluated with qPCR and expressed as telomere to single copy gene (T/S) ratio.Differences were assessed with Mann-Whitney test or Wilcoxon signed-ranks test when appropriate, whilstcorrelation analyses were performed with Spearman’s test. Diagnostic performance was calculated with receiveroperating characteristics (ROC) curve analysis. The level of statistical significance was set at p <0.05.
Results: we found that TL was significantly lower in CRC than in adjacent non-cancerous tissues (p=0.0005). Thearea under the ROC curve (AUC) for TL was 0.759 (95% Confidence Interval: 0.643-0.875, p=0.0002). AberrantPCDH10promoter methylation was detected in 100% of CRC tissues but in none of paired non-cancerous tissues.The median methylation rate in CRC tissues was 55.7% (range: 6.1-97.8%). TL was negatively correlated withPCDH10promoter methylation (r=-0.42, p=0.0002).
Conclusions: these results suggest a pivotal role of telomere shortening and PCDH10methylation in CRC tissues.TL may be seen as a potential biomarker in CRC diagnostics.

Medical laboratories are responsible for the qualityof test results, also when the same patient sample is evaluated using different analytical systems within the same lab.Indeed, as stated by ISO 15189:2012, laboratories should define means to compare procedures for evaluating thecomparability of patients’ samples results within the same healthcare system. In this study we report the approachused to define a procedure for assessing results comparability, developed in our laboratory before the ISO15189:2012 accreditation in 2016. Firstly, the approach was focused on the identification of all the different situationsthat may potentially require alignment of test results within the laboratory. Therefore, after evaluating guidelines anddocuments available in the literature, we defined a workflow applicable both to quantitative and qualitative methods.For quantitative methods, bias was estimated by means of statistical analyses such as Bland Altman and PassingBablok. For qualitative methods, results comparability was assessed by concordance. Criteria for defining theacceptability of systematic errors were also included in the procedure.

Insulin is a polypeptide hormone, secretedfrom pancreatic β-cell, involved in the regulation of glucose and lipid metabolism. Insulin measurement is a useful toolto identify some clinical conditions, such as fasting hypoglycemia, some types of diabetes, the presence of insulinresistance. An important pre-analytical aspect that influences the determination of insulin serum concentration is thepresence of hemolysis. In fact, it is well known that insulin is degraded by a protease released by red blood cells afterhemolysis. The aim of this study is to evaluate the interference of hemolysis on insulin measurements performed bya chemiluminescence method. To study the effect of hemolysis on insulin degradation, we added increasingconcentrations of red blood cell hemolysate to a serum pool with known insulin concentration. The reduction of insulinlevels was affected by the degree of hemolysis, by the time elapsed before the assay and by the temperature ofsamples storage. Our results show that insulin values do not decrease significantly (<10%) when hemolysis is <2.0g/L of free hemoglobin (corresponding to H-index=200) if samples are maintained at low temperatures (i.e. in an ice-water slurry) until the assay is performed.

Consolidation is a modern phenomenonthat is heavily affecting all economic segments and healthcare as well, where the mergers and acquisitions carriedout by the big pharma vendors are followed by care providers that are consolidating into big groups. As part ofhospitals and institutions, clinical laboratories are impacted by this trend and must deliver more results with fewerresources. On this scenario, automation is a tremendous booster for clinical laboratories, since it can speed up thewhole process, offering shorter turnaround times, improving staff motivation, increasing workflow control, reducingfootprint. This opinion paper offers a summary of the many advantages provided by the automation of processes inthe different steps of the specimen workflow inside the laboratory.

The Italian accreditation body, Accredia, requires that clinical laboratories obtained positiveanalytical performances in the last four External Quality Assessment (EQA) surveys in order to undertake theaccreditation with flexible scope (document RT-26).
In addition to the choice of acceptability limits (AL), other factors contribute to define the analytical performance:nature and commutability of control materials, definition of target value (TV), homogeneous group classification, dataelaboration, procedures for outliers exclusion.
In this study, the creatinine performances of 106 participants, obtained in the last four surveys of the year 2017 ofthe Centre of Biomedical Research (CRB) EQA program, have been evaluated using two different AL and TV: the ALproposed by the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) and by the RegionalReference Centre of the Azienda Ospedaliera Universitaria “Careggi” of Firenze (Italy) (CRRVEQ); the TV assignedwith the reference method (RV) and as consensus value, i.e. median of the results obtained with the same method(AV).
The percentage of laboratories satisfying the RT-26 requisite was different on the basis of the AL and TV considered:with the EFLM-AL, 68.8 % laboratories complied the requisite if AV was used and 60.4% if RV was applied; with theCRRVEQ-AL, 50.0% and 48.1%, respectively.
These data demonstrate that harmonized criteria and procedures for evaluation of EQA results are needed to obtainhomogeneous classification of laboratories’ performance.
In order to support the laboratory professionals in accreditation processes and, above all, to guarantee theirperformance reliability, time has come that the Scientific Societies of Laboratory Medicine promote the merging of thedifferent Italian EQA schemes in a consolidated network of EQA providers.

Urgenttests requesting is variable across different institutions in the same country and at international level. The percentageof urgent testing has been found to be about 33% in Italy, but only some of these tests are really related to clinicalneeds. Various reports are available to document the growth of extra-laboratory testing, otherwise referred to as nearpatient, bedside or Point-of-Care testing (POCT). The key objective of extra-laboratory testing, particularly POCT, isto generate a result quickly so that appropriate treatment can be implemented rapidly, but few data are available todemonstrate an effective improvement in operational and clinical outcomes. This paper sets out the requirements fordelivering an effective extra-laboratory testing by reviewing the data of the literature as well as the performancespecifications for assuring quality and patient safety.

Laboratory services are undergoing substantial consolidation and changes through mechanisms ranging from mergers, acquisitions and outsourcing, primarily based on the expectation towards increasing volumes, improving efficiency, and reducing cost per test. However, in laboratory medicine the relationship between volume and costs is not linear, as numerous variables may influence the comprehensive costs. In particular, the relationship between volumes and costs does not span the entire pattern of clinical laboratories: high costs are associated with low volumes up to a threshold of about one million test per year. Over this threshold, there is no linear association between volumes and costs, as the laboratory organization rather than test volumes affects the final costs more significantly. Available evidence collected in the last decades, namely data on laboratory errors and associated diagnostic errors and risk for patient harm emphasizes the need for a paradigmatic shift: from a focus on volumes and efficiency to a patient-centered vision restoring the nature of laboratory services as an integral part of the diagnostic and therapy process. In particular, the vulnerability of extraanalytical phases and the lack of reliable quality specifications in pre- and post-analytical steps do not allow an improvement in the ultimate laboratory information. Process and outcome quality indicators have been proposed as effective tools to measure and improve laboratory services by stimulating a competition based on intra- and extraanalytical performance specifications, intermediate outcomes and customer satisfaction. Rather than competing with economic value, clinical laboratories should adopt a strategy based on a set of harmonized quality indicators and performance specifications, active laboratory stewardship, and improved patient safety.

The essential goals that laboratorymedicine shall pursue to adequately fulfill clinical needs can be summarized in delivering high quality information,availability of clinically usable tests and turnaround time. The governance of urgent laboratory testing encompassesa harmonious integration of clinical needs and laboratory organization. Clinical laboratories shall hence be morefocused on the pre-preanalytical phase, be involved in proactive efforts for standardizing pre-analytical and analyticalprocedures, optimize the post-analytical and post-post-analytical phases, thus providing a complete information andallowing the achievement of favorable outcomes. Throughout this ample and multifaceted process, the strictcooperation between laboratory professionals and emergency physicians is pivotal. As rationale follow-up of thecollective article published concomitantly with the first joint Academy of Emergency Medicine and Care (AcEMC) -Italian Society of Clinical Biochemistry and Clinical Molecular Biology (SIBioC) meeting, this new collective paperaims to summarize the topics discussed during the second joint event “Laboratory Medicine and EmergencyMedicine: a resumed link”, specifically including the governance of urgent tests, acid-base disorders, venousthromboembolism, acute heart failure, trauma, acute intoxications, viral diseases and other emerging infections.

There is a continual debate on what type of sample a clinical laboratory should use. While serum is still considered the gold standard and remains the required sample matrix for some assays, laboratories must consider turn-around time, which is an important metric for laboratory performance and, more importantly, plays a critical role in patient care. In addition, a body of evidence emphasize the choice of plasma samples in order to prevent modifications of some measurands due to the coagulation process and related interferences. Advantages and disadvantages of serum and plasma are discussed on the basis of current literature and evidence. In addition, data are provided on the current utilization of the matrix (serum or plasma) in Italy and in other Countries. Finally, a rational for a possible shift from serum to plasma is provided.

With the growth and merging of clinical laboratories, very frequently analytical tests are performed onmultiple instruments within one or multiple locations. In these situations, there is the need of verifying thecomparability of patient results obtained with different analysers and/or different measurement procedures. Theimportance of this verification is further emphasised when considering that it is included into the ISO 15189specifications. This protocol provides step-by-step guidance on how to assess results comparability in differentscenarios. Up to four experimental designs are presented to meet laboratories’ needs, with details and examples onfrequency of testing, definition of acceptability criteria, samples selection, sample size calculation, statistical analysisand reporting.

Poor standardization of preanalytic variables influences greatly thereliability of coagulation testing, consuming health care resources and compromising patient outcomes. Thesevariables include patient preparation, sample collection, handling, transportation, processing, and storage until timeof analysis: lack of standardized procedures for sample collection accounts for most of the errors encountered withinthe total testing process. Most pre-analytical problems may arise from system faults and insufficient audit of theoperators involved in specimen collection and handling, leading to unsuitable specimens due to misidentification,hemolysis, clotting, inappropriate volume, wrong container, contamination from the infusive route. Detection,acknowledgement and management of pre-analytical variables, is mandatory for delivering accurate laboratoryresults. The present document, issued by the Study Group on Haemostasis of the Italian Society of LaboratoryMedicine, is a summary of the recommendations for standardisation of the pre-analytical phase of the coagulationtesting, related to sample collection, transportation, and storage and provides guidance to reduce the effects of pre-analytical issues that can have a significant impact on patient care.

Since the approval of the first polyadenosine diphosphate (ADP) ribose polymerase inhibitor (PARPi), olaparib for platinum-sensitive relapsed highgrade ovarian cancer, with either germline or somatic BRCA1/2deleterious variants, the strategies for BRCA1/2testing are dynamically changing. In fact, along with germline assay, patients are now tested for tumor BRCA1/2alsoabove all for treatment decisions. In fact, it is reported as by tumor BRCA analysis we can identify 3–9% moremutated women which can therefore benefit from PARPi therapy. Although this new type of approach looks likechallenging, in particular due to the technical and analytical difficulties regarding low quality DNA deriving fromformalin-fixed paraffin-embedded specimens, the new CE-IVD on NGS-based pipelines, can overcome these issues,allowing specialized molecular laboratories to ensure high quality results and perform the best test settings.Nevertheless, each new NGS pipeline (CE-IVD or in house) should be validated using peculiar samples along withcommercially available reference and certified materials, before being introduced in routine settings. The validationset should be appropriately chosen in order to provide unequivocal data regarding robustness of each NGStBRCApipeline. Therefore, in order to harmonize the patient and laboratory path, a group of Italian Scientific Societies[Italian Society of Clinical Chemistry (SIBioC), Italian Association of Medical Oncology (AIOM), Italian Association ofClinical Pathology (SIAPEC), Italian Society of Human Genetics (SIGU)] provided the present recommendationswhich are aimed to guide all professionals (oncologists, gynaecologists, clinical and laboratory geneticists, clinicalmolecular biologists and pathologists). The intersociety group is confident that the present paper can offer all ovariancancer women a well-organized pathway of diagnosis and treatment.

The greatest workload for the laboratories performingpharmacotoxicological tests remains the routine activity for detection and measurement, in different biologicalmatrices, of psychotropic substances such as opiates, cocaine, cannabinoids, amphetamines, methadone,buprenorphine and ethyl alcohol. In addition to the investigations requested for clinical reasons, the requests to thepharmacotoxicological laboratories may also include medico-legal investigations, whose variety and complexitycontributed to the adoption of personalized and extremely diverse operating modalities implemented in the Italianlaboratories. The purpose of this document is to provide the Laboratories of the National Health Service in Italy thatare planning to carry out or that already perform determination of drugs of abuse for medico-legal purposes, withrecommendations at national level that take into account the “good laboratory practices” recognized at theinternational level in order to perform accurate and precise analytical tests so that they can meet the requirementsnecessary to provide a high quality and legally unassailable service.

This document provides a joint recommendation for venous blood sampling of the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) Working Group for Preanalytical Phase (WG-PRE) and Latin American Working Group for Preanalytical Phase (WG-PRE-LATAM) of the Latin America Confederation of Clinical Biochemistry (COLABIOCLI). It offers guidance on the requirements for ensuring that blood collection is a safe and patient-centered procedure and provides practical guidance on how to successfully overcome potential barriers and obstacles to its widespread implementation. The target audience for this recommendation are healthcare staff members directly involved in blood collection. This recommendation applies to the use of a closed blood collection system and does not provide guidance for the blood collection with an open needle and syringe and catheter collections. Moreover, this document neither addresses patient consent, test ordering, sample handling and transport nor collection from children and unconscious patients. The recommended procedure is based on the best available evidence. Each step was graded using a system that scores the quality of the evidence and the strength of the recommendation. The process of grading was done at several face-to-face meetings involving the same mixture of stakeholders stated previously. The main parts of this recommendation are: 1) Pre-sampling procedures, 2) Sampling procedure, 3) Postsampling procedures and 4) Implementation. A first draft of the recommendation was circulated to EFLM members for public consultation. WG-PRE-LATAM was also invited to comment the document. A revised version has been sent for voting on to all EFLM and COLABIOCLI members and has been officially endorsed by 33/40 EFLM and 21/21 COLABIOCLI members. We encourage professionals throughout Europe and Latin America to adopt and implement this recommendation to improve the quality of blood collection practices and increase patient and workers safety.

The issue of the appropriateness in laboratory medicine has been discussed from several years in association to theparallel onset of two aspects: 1) the significant increase in tests demand and utilization, thanks to the developmentof laboratory automation and information laboratory systems (LIS), that allow to provide timely and reliable results toclinicians; 2) the opportunity, thanks to new pathophysiological knowledge and new technologies to introduce newand more sophisticated tests in clinical practice, providing a relevant support to the clinician in the management ofpatients, according to the improved vision of personalized medicine. As a consequence, the potentialinappropriateness in test utilization and the need to manage demand and to reduce the redundant testing havereceived increasing concern. Several papers, in the recent literature, demonstrated that the inappropriateness inlaboratory test utilization may represent a potential source of errors, and interesting strategies have been proposedand progressively adopted in order to limit this problematic outcome. An essential issue is to assure appropriatenessnot only in test request, but in all steps of the testing cycle. In particular, some of the more relevant issues has beenlinked to: rationalization of laboratory test ordering prescription, thanks to development of a computerized clinicaldecision support systems; implementation of the reflexing tests rule; definition of the minimum retesting intervalaccording to the clinical and pathophysiological criteria; timely revision of the available panel tests in order to deletethose considered obsolete from clinical and analytical point-of-view and, finally, improving the education in demandmanagement. The “clinical laboratory stewardship” seems to be the new and shared strategy, that guarantees notonly the appropriate utilization and interpretation of laboratory tests improving efficacy and providing efficiency but,more importantly, the future of the discipline and the role of laboratory professionals in the context of new and morecomplicated clinical and economical scenarios.

Italian Federation of Laboratory Medicine Societies (FISMeLab) recommendations for biological samples transportation. In recent years the transport of biological samples has become a strategic issue and a frequent practice, due to the tendency of public laboratories to move towards consistent consolidations and of private laboratories to join other, bigger or more equipped ones (hub and spoke model), to process a substantial part of the analytical repertoire. Moreover, the sampling centers have become more numerous and more widespread to improve the service to the citizens. The time and the way of remote transport of biological samples is a source of potential corruption of the matrix that can generates preanalytical errors of various kinds and severity. The lack of unequivocal national indications in Italy has prompted the Italian Federation of Laboratory Medicine Societies (FISMeLab) to set up a working group that includes representatives from the scientific societies members of the Federation, with the aim of assembling a practical recommendation on transport requirements of biological samples. In order to enable the users to consult the document quickly and effectively, the recommendation lists the single measurands from different areas of laboratory medicine and reports for each of them the ideal transportation modalities. These are based on the time elapsed from the blood collection: less or more than three hours; it is however recommended that the time from the blood collection to the transport be as short as possible.

The case reports about a patient who underwenta kidney transplantation for chronic disease of unknown cause. The clinical course showed a delayed graft functionand acute tubular necrosis. Urine microscopy confirmed a tubular disfunction: presence of renal epithelial cells,cylindruria and crystals. The microscopy images showed brownish-colored crystals that, under polarized light,suggested a 2.8-dihydroxyadenine (DHA) urolithiasis, rare and underdiagnosed pathology, due to the deficiency ofadenine-phosphoribosyltransferase (APRT). The specific analysis, i.e. the determination of the enzyme activity onerythrocyte lysate, did not confirm our initial hypothesis, excluding de facto a DHA urolithiasis. Analysis of purine andpyrimidine profile confirmed the presence of a purine dysmetabolism. The patient was treated with allopurinol, whichimproved the clinical picture. This case underlines the need for more extensive studies of crystal and/or metabolicnephropathies before renal transplantation. The microscopy study was however useful to trigger investigations thathave then influenced the therapy and the clinical progress of the patient.

Automated urinalysis instruments image-based for cell analysis can identify non-squamousepithelial cells (NSE). Among these elements, expert pathologists can distinguish the so called Decoy Cells (DC),Polyomavirus BK (BKV)-infected elements primarily seen in immunocompromised patients. Epstein-Barr virus (EBV)infection can induce a transient immunosuppression in immunocompetent patients, and this could lead to areactivation of a latent BKV infection in urothelial cells: this is a rare event in pediatric patients. This study reports thecase of a 4 year-old child with lateral lymphadenopathy, fever and oliguria. Automated urinary sediment analysisevidenced the presence of many NSEs identifed as DC, generating a subsequent virological investigation with a finaldiagnosis of concomitant BKV and EBV infection. The combination of an automated technology, an efficientmiddleware and the expertise of the laboratory professionals , allowed the proper identification of these peculiarreactive elements, which could easily be mistaken for malignant atypical cells.

Cerebrospinal fluid (CSF) of a 64 year old malepatient was sent from the hematology unit to laboratory for cell count and morphology and chemical-physicalexamination. CSF was clear, colourless and with increased total protein concentration. Cell count was first performedin Burker camera with a result of 40/μL; some of the cells showed an abnormal morphology. Our laboratory workflowincludes the CSF examination utilizing an automatic cell counter: it showed a few white blood cells (3/μL), but a highnumber of total cells (64/μL). The morphological evaluation, with cytocentrifugation and May-Grunwald Giemsa stain,identified the elements as mature plasma cells; the result was then confirmed by immunophenotyping.
These findings suggest a neurological localization of a multiple myeloma (MM). Actually, the patient had beendiagnosed as IgA lambda MM, with bone involvement that caused progressive loss of walk. Positron EmissionTomography revealed hyperdense areas, but it wasn’t able to distinguish between lymphoproliferative disease andthrombotic phlogosis. In spite of the therapy, patient neurological conditions worsened till irreversible coma. He dieda few days later.

Methylenetetrahydrofolate Reductase (MTHFR) deficiency, is avery rare congenital defect of folate metabolism, inherited in an autosomal recessive pattern included in newbornscreening (NBS) programs in Italy. It is caused by mutations in the MTHFRgene and is characterized by elevatedplasma homocysteine and borderline-low or normal methionine levels, causing severe neurological signs, recurrentapnoea, microcephaly and convulsions, generally during the neonatal period. An early treatment may prevent theclinical manifestations with a positive impact on patient’s health.
We report a new case of MTHFRdeficiency, identified during NBS that showed hypomethioninemia 4.6 μmol/L (r.i.6-20). The second level-test revealed hyperhomocysteinemia (106.7 μM, r.i. 5-15). The whole sequencing of theMTHFRgene showed two missense mutation: c.176G>C (p.Trp59Ser), reported as disease causing and the novelc.1769T>G (p.Leu590Arg), classified as likely pathogenetic. The baby was immediately treated with vitamin B12,folate and betaine; after 12 months of follow-up he has no signs or symptoms of the disease.
In conclusion, this case report highlights the importance of NBS for inborn errors of metabolism and genetic analysis,that can prevent the establishment of a serious disorder of folate metabolism.

Autoimmune hemolyticanemia (AIHA) is a relatively rare disease where red blood cells are selectively destroyed by auto-antibodies. Ingeneral, direct antiglobulin test (DAT) is the test used for confirmation even if there are other markers to guide thedifferential diagnosis and to evaluate the degree of hemolysis. We present a case of severe warm-type AIHA occurredin a thirty-six year old man with initial symptoms of asthenia and dark urine. The case shows how specialists inlaboratory medicine can play a fundamental role in the diagnostic process through an appropriate use of the tests,speeding up the management of the patient, improving thus the prognosis.

Il volume APPROCCIO ALLA CHIMICA CLINICA di Lorenzo Prencipe si presenta nella forma di un trattato,con l’intento quindi di toccare tutti gli argomenti inerentila disciplina della Chimica Clinica anche se in formato necessariamente compatto.