Articoli in pubblicazione

The finding of a monoclonal gammopathy both by chance and upon clinical suspicion is becoming more and more frequent and requires in-depth clinical, laboratory and instrumental analyses in order to establish the underlying disease, if any. In the last two decades the improvement of the diagnostic tools has led to the identification and precise definition of several clinical entities pathogenetically linked to the monoclonal gammopathy, thus shrinking the field of the "monoclonal gammopathy of undetermined significance". Such a striking improvement relies on the increasing sensitivity and accuracy of old analyses and availability of new ones (such as the serum Free Light Chain assay). Currently, data from the clinical biochemistry laboratory provide important clues to the diagnosis and prognosis, and are also crucial for monitoring the therapy. These new achievements, along with the availability of new therapeutic options, allowed a significant, sometimes dramatic improvement of the prognosis of many of the gammopathy-related diseases. In this review the main clinical pictures are described along with the contribution of the clinical biochemistry laboratory to the definition of the diagnosis, the risk profile and the monitoring of the specific diseases.

Reverse-transcriptase quantitative Polymerase Chain Reaction (RT-qPCR) is a well-established technique to quantify gene expression levels and critically depends on reference genes for data normalization.
We performed a review of biomedical literature to analyse the usage of RT-qPCR in relation to other techniques for transcriptional analyses and to describe practices for the identification of suitable reference genes for RT-qPCR.
In the 81 analysed studies, 3 genes (GAPD, ACTB, B2M) were included in ≥70% of cases, but ranked among the most stable genes in ≤1/3 of cases. The most frequently used normalizing algorithm was geNorm(83%), followed by NormFinder(73%) and BestKeeper(32%).
We also analysed transparency and good laboratory practices based on adherence to the Minimum Information for Publication of Quantitative Real-Time PCR Experiments (MIQE) guidelines, using selected validated evaluation criteria. Overall, key MIQE criteria were satisfied in ≥50% of analyzed studies, but only four criteria (details of employed kit/enzyme for reverse transcription, priming method, primers/probes and DNA polymerase) were satisfied in ≥90% of cases. Data on assay repeatability were reported only in 15% of studies. The presence of pseudogenes as a potential confounder of assay specificity was evaluated only in 13% of studies. Finally, as few as 6% of studies accounted for the presence of known mutations of singly nucleotide polymorphisms when designing assay primers/probes.
Better adherence to the MIQE guidelines should be encouraged. Publicly available transcriptomic and genomic data sets could be employed to refine the identification of suitable normalizing genes and to assist assay design.

Introduction: this study compares the cardiac troponin I (cTnI) values measured with three high-sensitivity (hs) different methods in apparently healthy volunteers enrolled in a multicenter study.
Methods: heparinized plasma samples were collected from 1511 volunteers in 8 Italian clinical institutions (mean age 51.5 years, SD 14.2, range 18-86, female to male ratio 0.94). All volunteers denied chronic or acute diseases and had normal values of routine laboratory tests and ECG. The reference laboratory of the study (Laboratorio Fondazione CNR Regione Toscana G. Monasterio, Pisa, Italy) assayed all plasma samples with three hs-methods: Architect hs-cTnI, Access hs-cTnIand ADVIA Centaur XPT hs-cTnI. After the exclusion of outlier values, calculation of 99th percentile (Upper Reference Limit, URL) values was performed using both robust nonparametric and bias corrected and accelerated bootstrap methods.
Results: large between-method differences were found. ADVIA Centaur measured higher cTnI values (up to 2-fold) than the two other methods. cTnI values were significantly higher in men than in women, and progressively increased with age over 55 years. Moreover, 99th percentile URL values also depended on the statistical approach used for calculation (robust non-parametric versusbootstrap). All 99th percentile URL values calculated with non-parametric robust method were on average slightly lower than those suggested by manufacturers (mean difference 4.2 ng/L, standard error 1.7, p=0.0273).
Conclusion: clinicians should be advised that plasma samples from the same patient should be measured for hs-cTnI in the same laboratory. Specific clinical studies are needed to establish the most appropriate statistical approach to calculate 99th percentile URL values for hs-cTnI methods.

Introduction: the Working Groups “Hematology” and “Extra-Analytical Variability” of the Italian Society of Clinical Biochemistry (SIBioC) promoted a survey investigating the quality of the complete blood count reporting among Italian Laboratories.
Methods: the survey included 36 questions and was sent to all the SIBioC members. 251 laboratories participated in the survey.
Results: there is a full concordance in reporting the traditional parameters (leukocytes, erythrocytes and platelet count, hemoglobin, hematocrit and the calculated indices, plus the leukocytes differential count), while other relatively new parameters, like the mean platelet volume (MPV) and the platelet distribution width (PDW) are reported by 70% of the laboratories. A low percentage of laboratories (20-30%) do not report the presence of abnormal cell populations, if detected (blasts, immature granulocytes, plasma cells, prolymphocytes and erythroblasts). 70% of laboratories do not report the erythrocyte and leukocyte related parameters available on the new analyzers. Specific reference intervals for gender and age are adopted by 68% of the laboratories, but only 50% have instrument-specific intervals. 83% of the laboratories include interpretative comments in the report, but only in less than half of them these are harmonized according to the recent available recommendations. 83% of the laboratories have a shared document to manage critical values, that are communicated to the requesting physician by 90% of the laboratories.
Discussion: activities promoted by the SIBioC Hematology working group to harmonize the hematological report have been effective on traditional parameters reporting with a substantial improvement compared to the 2014 survey. Two issues remain however unresolved: the inclusion of interpretative comments and of the recent available parameters in the report.

Introduction: oncololytic adenoviruses (OAds), viruses constructed to replicate in tumor cells, improve the outcome of cancer therapy in some cases, such as sarcomas. However, the molecular heterogeneity of tumors requires specific and personalized cancer treatments in order to set up more adequate and effective therapies.
Methods: by using the array Comparative Genomic Hybridization (array-CGH), a molecular approach method, we aimed to identify chromosomal aberrations or Copy Number Variants (CNVs) in three different tumor cell lines: HCT116, SW872 and A2058 selected for their Coxsackievirus and Adenovirus receptor (CAR) expression profile.
Results: the cells showed several duplications of genes involved in replicative Adenovirus cycle (binding, internalization, escape) in the core transport, and in the escape of the viral DNA from the capsid.
Conclusion: in this study, our aim was to identify chromosomal alterations in genes involved in the OAd replication cycle process. Array-CGH method could be useful to design a platform for a screening analysis in order to identify mutations that can contribute to oncolytic virotherapy approach generating a personalized strategy for tumor suppression.

Introduction: immune-checkpoint inhibition using programmed cell death-1 and its ligand drug inhibitors have improved survival, among patients with advanced non-small-cell lung cancer (NSCLC): nivolumab is one of the last approved. Vitamin D deficiency (<20 ng/mL) is frequent in lung cancer patients and studies showed this pre-hormone modulates the expression of genes involved in drug pathway and in the immune system regulation. Furthermore, not many biomarkers related to nivolumab therapy are present in literature. The aim of this study was to understand which factors were able to predict nivolumab concentrations and its anti-antibody levels in patients’ plasma at 15, 45 and 60 days of therapy.
Methods: forty-five patients with advanced NSCLC were enrolled to receive nivolumab. Enzyme-linked immunosorbent assay was used for drug and vitamin D quantification.
Results: Median nivolumab plasma levels were 12.5, 22.3 and 27.1 μg/mL respectively at 15, 45 and 60 days (p<0.001). No anti-nivolumab antibodies have been detected. 25-hydroxyvitamin D median concentrations were 12.8 ng/mL at baseline, 13.6 ng/mL at 15 days, 11.8 ng/mL at 45 days and 12.9 ng/mL at 60 days. Gender significantly affected nivolumab concentrations (p=0.010 at 15 days, p=0.033 at 45 days and p=0.006 at 60 days). In linear regression analyses, 25-hydroxyvitamin D <20 ng/mL before starting therapy, gender and 25-hydroxyvitamin D <20 ng/mL at 15 days were able to predict nivolumab concentrations respectively at 15, 45 and 60 days of treatment.
Conclusions: for the first time, this study shows factors able to predict nivolumab exposure at different timings, but further, studies in bigger and different cohorts are needed to clarify these data.

Insuline-Naaïve type 2 diabetic patients: a multidimensional evaluation on the role of glycated albumin Introduction: glycated Albumin (GA) is an innovative glycemic marker, that could be used in the clinical practice, as an add-on strategy, to the traditional glycemic monitoring systems, such as glycated haemoglobin (Hb1Ac) and fasting plasma glucose (FPG). The study aims at presenting the results of a multidimensional analysis conducted in Italy, exploring the main clinical, economic, ethical, social and organizational implications, related to the introduction of GA. Methods: an Health Technology Assessment (HTA) approach was implemented. The analysis considered the Italian National Healthcare Service (NHS) perspective, and assumed a 12-month time horizon, focusing on type 2 diabetes patients insulin-naïve, assuming oral therapy. The 9 HTA dimensions (derived from the Core Model developed by the European Network of HTA – EUnetHTA) were deployed, considering scientific evidence, health economics tools and qualitative approaches, through the administration of specific questionnaires to 15 diabetes experts. Results: literature reported better GA safety and efficacy profiles, thus being a predictor of the relative risk for diabetes complications development, and increasing the therapeutic success after 3 months of therapy (97.0% versus71.6%). From an economic point of view, GA introduction resulted in an economic advantage of 1.06% and in a better trade-off between costs sustained and efficacy gained. Considering a 7-item Likert Scale (ranging from -3 to +3), negative perceptions emerged with regard to equity aspects (0.13 versus0.72) due to GA limited accessibility, whereas it would improve both patients (2.17 versus1.33) and care givers (1.50 versus0.83) quality of life. In the short term, GA required training courses and equipment update, whereas, in the long term, it could be considered the preferable solution from an organizational perspective (0.30 versus0.01). Conclusions: the results of this study demonstrated GA strategic relevance, its economic sustainability and feasibility, as well as the potential clinical pathway improvement.

Introduction: the study of the human microbiome is one of the most dynamic current topics in biomedical research. A significant challenge in this field is the development of cost effective method for a robust interrogation of microbiota composition. Advances in next-generation sequencing (NGS) technologies have allowed for efficient and molecular-based analysisof microbial communities. Association between diseases and imbalance of the microbial populationsare today wellinvestigated.
Methods: Pemphigus Vulgaris (PV) and Bullous Pemphigoid (BP) are two rare autoantibody-mediated blisteringskin diseases. In this pilot study, we characterized the intestinal, cutaneous and oral mucosal microbiota compositionsin PV/BP patients, in order to evaluate the potential role of the bacterial composition in these dermatologicaldisorders. Particularly, we performed a high-throughput sequencing analysis of the V3-V4 hypervariable regions of16S rRNA for the evaluation of bacterial composition of stool, skin and oral mucosa samples in PV (n=12) and BP(n=8) patients.
Results: a similar composition of the intestinal microbiota was observed in PV and BP patients. The evaluation of skin lesions revealed a prevalence of Firmicutes phylum in both patients’ groups. In the cutaneous microbiota, we identified a significant decreased abundance of Bacteroidetes phylum compared to healthy controls.
Conclusions: the results obtained from our standardized NGS pipeline, reinforced by correlation with other clinical and biochemicalparameters, will contribute to clarify the mechanisms of these rare diseases.

Introduction: the development of new technologies in the era of information technology and digitization has certainly influenced the clinical laboratory and quality management system. The aim of this work is to verify the utility of a dedicated software (SNCS - Sysmex, Inc. Kobe, Japan) for the improvement of quality control management procedures of quantitative parameters obtained by the automated cell counting in biological liquids.
Methods: the measurements were performed on the XN "Body Fluid Mode" (XN-BF) analytical system (Sysmex, Inc. Kobe, Japan) according to the manufacturer's specifications. The parameters that can be included in the report using this mode are the total nucleated elements count, the leukocyte count, the differentiation of mononuclear from polymorphonuclear cells and the erythrocyte count.
Results: our study included: a comparative evaluation between the laboratory CVs and the CV of an international homogeneous group; a retroactive evaluation from the SNCS software using the standard deviation index and the precision index used as accuracy and precision measurements. Finally, a daily comparison was made between the Levi-Jennings cards of the instrument and the SNCS intra-day report, to improve the timely evaluation of the random error.
Conclusion: using the SNCS software, the performance of the analyzers can be precisely monitored and compared on an internaional basis. Its utility lies in the possibility of comparing internal performances with those of a group of laboratories using the same instruments and the same controls, allowing the quantification of the analytical bias.

Introduction: aging is regulated by a number of aging genes including sirtuins, linked to redox status and epigenetically controlled. Physical exercise, depending on intensity, type of training and duration, seems to modulate positively the redox state in aging. It was demonstrated an increase in susceptibility to oxidative stress by the depletion of intracellular glutathione (GSH) and total glutathione (tGSH) levels in the muscles of aged animals. Moreover, physical activity, especially if moderate and regular, seems to activate adaptive mechanisms, reducing body's vulnerability to oxidative stress and improving systemic metabolic activities.
Methods: this study is aimed to evaluate the effects of regular exercise (3 times/week for 2 months) on the levels of radical species (d-ROM test), thiol groups (SHp test), plasma antioxidant capacity (BAPtest), 8-OH-guanosine (COMET test) and some redox-related proteins (HSP27, HSP70, Sirt1 and 2) in 40 healthy elderly subjects, aged from 65 to 74 years. In addition, plasma enzymatic activities of superoxide dismutase (SOD), glutathione peroxidase (GPx) and glutathione reductase (GR) were evaluated.
Results: the enrolled subjects showed oxidative stress before exercise with the presence of radical species, oxidation of purine bases and reduced antioxidant capacity. After the scheduled training, a global improvement of oxidative stress markers was observed with an upregulation of HSP27, HSP70, Sirt1 and Sirt2 expression, as adaptive response.
Conclusion: our results underline the importance of these biochemical parameters to monitor oxidative stress in aging and the adaptive redox response to physical exercise in elderly.Therefore, these biomarkers may be routinely used in order to identify individuals at risk for developing oxidative stress related pathologies as well as in personalized physical therapy.

Introduction: heart failure (HF) has been defined a modern pandemic. The complex array of physiologic, psychological, social and health care issues makes it a challenging chronic disease to diagnose and manage. Our study is aimed to evaluate a multi-markers approach in diagnosis of HF in aged males.
Methods: 68 Italian males aged >65 years have been enrolled; 25 were patients with heart failure (HF) and 43 were healthy controls. In all the subjects, measurements of high sensitivity troponin I (TNI), galectin-3 (GAL), cystatin C (CYS) and brain natriuretic peptide (BNP) were performed using routine methods.
Results: in patients with HF, mean concentrations of TNI, GAL, CYS and BNP were significantly higher (p<0.001) than values observed in controls subjects. Only BNP and GAL showed a correlation with NHYA stage of HF. In this study, GAL and BNP demonstrated better diagnostic perfomamces to differentiate of HF patients from controls subjects.
Conclusions: our study showed the usefulness of a strategy involving multiple biomarkers determination in laboratory diagnosis of HF in elderly males.

Introduction: the increasing worldwide spread of multidrug resistant bacteria, in particular of carbapenemase-producing Enterobacteriaceae(CPE), represents a serious clinical and public health concern. An accurate and fast detection of infected patients or colonized carriers is thus mandatory.
Aim of this study was to assess the performance of a multiplex immunochromatographic assay (NG-Test CARBA 5, NG Biotech, Guipry, France) for the rapid detection of carbapenemases directly from pure bacterial colonies.
Methods: seventy-five non-replicated Enterobacteralesisolates with decreased susceptibility to carbapenems, including 71 Klebsiella pneumoniae, 3Escherichia coli and1Enterobacter cloacae, were analysed with NG-Test CARBA 5. At the same time the combination disk test (CDT) was performed according to the European Committee on Antimicrobial Susceptibility Testing (EUCAST) indications, while confirmation of carbapenemase production was achieved by polymerase chain reaction (PCR).
Results: PCR assay could find 66 CPE strains, including 64 Klebsiella pneumoniae[53 producing Klebsiella pneumoniae carbapenemase (KPC), 5 New Delhi metallo-β-lactamase (NDM), 2 class D oxacillinases (OXA-48), 1 Verona integron-encoded metallo-β-lactamase (VIM) and 3 co-producing NDM and OXA-48] and 2 Escherichia coli (2 NDM+OXA-48) while 9 isolates were found as non-carbapenemase producing: 7 Klebsiella pneumoniae, 1 Escherichia coli, 1 Enterobacter cloacae. CDT allowed us to consider those 9 strains as extended spectrum β-lactamase (ESBL) or AmpC β-lactamase producers. NG-Test CARBA 5 successfully identified 66/66 CPE showing 100% sensitivity and 100% specificity. Unlike NG-Test CARBA 5, CDT was not able to correctly identify 5 strains co-producing NDM and OXA-48 carbapenemases.
Conclusion: NG-Test CARBA 5 is a reliable assay that can be useful in settings requiring a rapid identification of CPE directly from culture colonies. Moreover, this test is an easy-to-use option that could avoid misidentification of carbapenemases co-producers strains.

Background: the complete blood count (CBC) is the test more frequently requested in clinical practice. Therefore, estimating the biological variation (BV) of CBC parameters is essential for assessing the analytical performance of hematological analyzers and for enabling accurate data interpretation and appropriate clinical management. This study was aimed to define BV estimates and reference change value (RCV) of CBC parameters.
Methods: the study population consisted of 21 healthy volunteers, who had BV of CBC parameters assessed with Sysmex XN. The study protocol, the analytical measurements and the statistical analysis were carried out according to current recommendations of the European Federation for Clinical Chemistry and Laboratory Medicine (EFLM).
Results: Within-subject BV ranged between 0,3% for mean cell hemoglobin (MCH) and 19,7% for immature granulocytes (IG), whilst between-subjects BVs ranged between 0,9% for mean corpuscolar haemoglobin concentration (MCHC) and 66,6% for microcytic red blood cells (Micro-R). The RCV ranged between 2,3% for MCH and 73,5% for IG.
Conclusion: This study has allowed the estimation of BV of many CBC parameters, some of which have not been currently explored, thus leading the way to use RCV calculated according to time of monitoring and/or differentiated by sex.

This Opinion is aimed to comment and emphazise the main points raised in a seminal paper published in 2018 inBlood. The paper deals with a number of severe diseases caused by small lymphoid/plasma cell clones. Theseclones affect different organs by means of the biological properties of the clonal cells themselves and/or of their secretion products such as monoclonal immunoglobulins, cytokines and other molecules. More importantly, the paper also deals with the pathogenetic mechanisms involved in the organ damage and sheds light on most of them. The present comment aims to bring attention to these diseases, but it does not encompass the whole matter. We suggest that the readers involved in this matter refer to the paper in its original version.

DNA methylation is the most known and studied among the epigenetic modifications; these are chemical modifications occurring on DNA or histone proteins, able at modifying the transcriptional efficiency of genes. DNA methylation consists in the binding of a methyl group (-CH3) on the carbon n. 5 of a cytosine moiety. Recently, it has been demonstrated that methylated cytosines can be further modified to hydroy-methyl-cytosines, but it is still unclear whether this transformation is just a demethylation intermediate or it canretain the functional role of an independent epigenetic modification. At first, DNA methylation has been studied for itsphysiological role in the regulation of one expression during the different stages of the cell life, particularly duringdifferential and embryogenesis. Then, during the last thirty year, it has been shown that the epigenetic modifications,particularly DNA methylation, are involved in the onset and progression processes of some pathologies. The role of DNA methylation in cancer processes is known since a long time, whereas only recently it becomes evident that this epigenetic modification is a component of some degenerative and aging-associated pathologies, particularly in neurodegenerative and inflammatory processes. Due to the incredible technical advances developed in the last years, it is now possible to study in detail the methylation pattern of a gene sequence with single cytosine resolution, rapidly and with high accuracy and precision. Besides allowing the rapid evolution of our knowledge of the physio-pathological states in which DNA methylation has a functional role, this favourable condition also allows us to consider the possible use of DNA methylation as diagnostic biomarker in different pathologies.

The evolution of the biochemical diagnosis of cardiac diseases, represents a paradigm of the laboratory medicine evolution in the recent years.
Starting from the use of poor specific and sensitive biomarkers, the “so-called” cardiac enzymes (aspartate aminotransferase; lactate dehydrogenase; creatine kinase) recommended by World Health Organization for the acute myocardial infarction (AMI) diagnosis, a fundamental development in biochemical knowledge has been obtained, providing new biomarkers (CK-MB, myoglobin) for a more specific and early diagnosis according to the clinical and therapeutic needs. However, the revolutionary biochemical issue has been represented by the discovery of cardiac troponins and by the implementation of methods allowing their measurement in emergency setting in patients with acute chest pain. Cardiac troponins, are characterized by an absolute cardiac specificity and by a high sensitivity that allow to carry out a timely and safe diagnosis of AMI, being recognized as “gold standard” in all clinical and biochemical guidelines. In patients with acute chest pain and in ischemic clinical setting, a typical kinetic release of biomarker concentration may be suggestive of AMI even if ECG typical patterns are lacking. The actual improvement in analytical performance of troponins methods, particularly in the analytical sensitivity, allows to extend the measurement also in diagnosis of minor myocardial damage in patients suffering from different cardiac disease, to monitor the efficacy of therapy, the progression of the disease and to provide prognostic information and risk-stratification in addition to the clinical pathway.

Von Willebrand disease (VWD) is the most common inherited bleeding disorder. Clinically, VWD induces mucosal bleeding caused by a decreased quantity or quality of von Willebrand factor (VWF). Diagnosis of VWD requires careful consideration of patient specific factors, bleeding symptoms, and laboratory results. There is no single diagnostic test for VWD; laboratory diagnosis requires a number of assays of VWF amount and function, and factor VIII activity, with no single straightforward diagnostic test available up to know to either confirm or exclude the diagnosis. The currently available laboratory testing for VWD is imperfect, but if accompanied by an attentive and careful interpretation provides significant clinical utility by categorizing affected patients by type of VWD. As the diagnosis of VWD variants has implications fort reatment, laboratory testing is therefore critical for optimising patient care. Newer assays of VWF function are becoming available and will be of great help in establishing the laboratory diagnosis of VWD.

This document represents the second part of a glossary on molecular biology. In particular, the main laboratory techniques for molecular biology are be described. Indeed, recent technological advances made available a number of technologies featured by higher accuracy and sensitivity that are becoming commonly used in routine molecular diagnostics. Aiming to support less experienced readers, the terms related to the main molecular biology techniques are listed herein. For each term the corresponding English version is reported (see also the complete list, both in Italian and in English alphabetical order, reported in the Appendix). In addition, for some of the terms, a link to articles published in Biochimica Clinica, where they have been used, is reported.

Laboratory Medicine rides the wave of technological progress, the metamorphosis of information systems and data management. The Young Specialist is not a mere observer, but rather takes a leading role in this change, taking advantage of the opportunities offered by “omics” technologies, capturing new ideas and innovative stimuli that lead to a new concept of work and research oriented to health and prevention. Thanks to the support of international web platforms, training and exchange programs supported by the International Scientific Societies and Federations that favor professional and scientific growth, Young Scientists work in a global context. In this scenario, the SIBioC Young Scientists Study Group, with the auspices of SIBioC, EFLM and IFCC, organized a meeting on "Laboratory Medicine: Specialists of tomorrow" with the aim of discussing and highlighting some of the most important challenges, such as technological progress, training and internationalization of young people. Finally, the future of laboratory medicine looks at a multidisciplinary approach that leads to integrated diagnosis, identification of the frail patient, the use of the Point of Care Testing as an indispensable tool in crisis areas, making the dialogue between physician and laboratory specialist a fundamental step for the diagnosis and treatment with the final aim of a better outcome for the patient.

The greatest workload for the laboratories performing pharmacotoxicological tests remains the routine activity for detection and measurement, in different biological matrices, 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 the pharmacotoxicological laboratories may also include medico-legal investigations, whose variety and complexity contributed to the adoption of personalized and extremely diverse operating modalities implemented in the Italian laboratories. The purpose of this document is to provide the Laboratories of the National Health Service in Italy that are planning to carry out or that already perform determination of drugs of abuse for medico-legal purposes, with recommendations at national level that take into account the “good laboratory practices” recognized at the international level in order to perform accurate and precise analytical tests so that they can meet the requirements necessary to provide a high quality and legally unassailable service.

The human parechoviruses (HPeV) have recently been recognized as emerging pathogenic microorganisms causing a broad pattern of diseases including sepsis and meningitis in children. A born-at-term, 33-day-old child, was admitted to the hospital with fever, irritability, and loss of appetite. Results of physical examination and routine blood chemistry were unremarkable (no lung rales or skin rashes; normal hemoglobin and leukocyte and platelets counts) with the only exception of an elevated procalcitonin serum level. Examination of the patient’s cerebrospinal fluid (CSF) showed pleocytosis, normal glycorrhachia and a mild increase of proteins. Blood and CSF cultures were negative. When tested with a commercial multiplex PCR technology (FILMARRAY®- Biomerieux), CSF turned out positive for the HPeV. Rapid identification of HPeV may contribute to reduce the laboratory turnaround time and improve clinical management. HPeV should be included in the differential diagnosis of young children with central nervous system symptoms and sepsis-like illness.

Persistent Polyclonal Binucleated B-cell Lymphocytosis (PPBL) is a rare, benign hematological disorder characterized by a chronic polyclonal B-cell lymphocytosis with binucleated lymphocytes. We report the clinical case of a young woman with lymphocytosis who presented binucleate lymphocytes at the morphological examination of the peripheral venous blood smear. Flow cytometry immunophenotyping performed in peripheral blood showed a polyclonal lymphocyte B subpopulation. Serological tests were negative for viral infections. Because of its benign and indolent course, the diagnoses of PPBL is important in order to avoid unnecessary diagnostic procedures and therapies.

Growth hormone deficiency (GHD) is a disorder characterized by the inadequate secretion of GH, which results in short stature reflected by the delay in the bone lengthening, that is inappropriate to the chronological age of the child. Laboratory tests are very important to determine whether the growth-delayed child actually has GHD. These tests are intended to stimulate the pituitary gland to secrete GH, allowing the measuring of its levels in blood at timed intervals. In a 7-year-old child arrived at our attention for deceleration of growth rate, laboratory tests excluded other causes of short stature and the GH measurement confirmed the deficit of this hormone. The patient started the therapy using the recombinant human growth hormone (rhGH). Serum insulin-like growth factor-1 (IGF-1) concentration was monitored during the treatment to help with dose adjustment and to determine the adherence to therapy by the child.

Multiple myeloma (MM) represents 10% of all hematologic malignancies; in 15% of MM the monoclonal component consists of only free light chains. A 53 year-old patient performs at the Corelab laboratory (AOU-AUSL Modena) blood tests for bone pain. Serum electrophoresis shows hypogammaglobulinemia (5,5 g/L). The laboratory professional decides to carry on further studies: a serum immunofixation that highlighted the presence of kappa free light chains not traceable to any heavy chain and the measure of the serum free light chains (sFLC) with the following results: FLC-κ 26 777 mg/L (i.r. 3.3-19.4); FLC-λ 6.15 mg/L (i.r. 5.7-26.3); ratio FLC (rFLC), 435.31 (i.r. 0.26-1.65). The light chain MM is a type of MM difficult to recognize. The laboratory professional's own initiative defines a procedure of "personalized medicine" oriented to to the patient's needs. The expertise of the laboratory professional is crucial in assuring the patient the best outcome when carried out on the basis of the available guidelines.