Volume 41, Issue 3

The absence or deficiency of specific platelet glycoprotein receptors has a well-defined role in causing several rare bleeding disorders such as Bernard-Soulier syndrome or Glanzmann's thrombasthenia. Several new rare disorders caused by defects in other receptors or their signalling pathways have recently been described. Platelet receptors are also often targets for antibodies in pathological conditions. The roles of platelet receptors or their polymorphism variants in diseases such as cardiovascular disorders have started to be intensively investigated over the last 5 years. Many of these findings still remain controversial. Recent evidence points to a fundamental role for platelets and their receptors in the origins of atherosclerosis. Studies on the role of platelet receptors in diseases such as asthma, diabetes and HIV are still at an early stage.

Since PSA is supposed to play an active role in the progression of prostate cancer, we applied a quantitative RT-PCR to measure the absolute levels of prostate-specific antigen (PSA) mRNA expression in benign and malignant prostatic tissue. Consecutive fine needle prostate biopsy material from 59 patients (43 with prostate adenocarcinoma and 16 with benign prostatic hyperptrophy; BPH) was used for the measurement of PSA mRNA expression. In addition, we evaluated the correlation between PSA synthesis and PSA circulating levels in the same patients. The relationship between PSA mRNA expression and histological grade was also evaluated. PSA mRNA was measured with a quantitative RT-PCR, based on the use of fluorogenic probes, according to the TaqMan reaction system. The mRNA expression for PSA in prostate adenocarcinoma biopsies was highly variable, ranging from 2×10 4 to 2.1×10 8 molecules/μg total RNA with a mean value of 2.5×10 7 and significantly higher (p = 0.006) than that found in BPH patients (mean: 1.3×10 6 and range: 6.9×10 2 to 8×10 6 ). The mRNA PSA expression in needle biopsy material did not seem to be related to PSA circulating levels in prostate cancer patients (r = 0.281), whereas in BPH patients the two parameters correlated significantly (r = 0.667, p < 0.01). A reduction of PSA mRNA expression in samples with a lower grade of differentiation (Gleason score 9–10) was also observed. Even though a mean increase of PSA expression was demonstrated in cancer samples, this small difference does not confirm a significant role of PSA proteolytic activity in prostate cancer progression. In conclusion, the assay procedure we proposed represents a reliable basis for more extensive study of PSA physiopathology in prostate cancer.

Familial hypercholesterolemia (FH) is an autosomal dominant disease which results in 2-3-fold elevated cholesterol levels and in accelerated atherosclerosis. FH is caused by small mutations or larger rearrangements in the low-density lipoprotein receptor (LDLR). Here, we report that screening the LDLR gene in a Swiss family (n = 15) with clinical symptoms of FH by combined single strand conformation polymorphism and long-distance PCR identified a novel 1.3 kb deletion in the LDLR. The deletion eliminated exon 4 of the LDLR presumably by recombination between two identical 25 bp repeats present in intron 3 and 4. The 25 bp sequence in intron 3 is part of an Alu repeat, whereas no homology to Alu repeats was found for the intron 4 region. This 1.3 kb LDLR deletion allele cosegregated with elevated cholesterol levels over three generations. Even on high-dose statin therapy, carriers of the deletion averaged 1.6 times higher cholesterol levels and 1.9 times higher apolipoprotein B-100 (apoB-100) levels than non-carriers who had lipid and apoB-100 levels within the range of the Swiss population. Most affected members of the first and second generation of this family had experienced a first myocardial infarction (MI) before the age of 55 years and most LDLR gene deletion carriers older than 40 years showed severe coronary artery disease (CAD). Hence, we conclude that deletion of exon 4 in the LDLR gene drastically decreases low-density lipoprotein binding leading to severe hypercholesterolemia.

Mutations in the gene CACNA1A have been known to cause familial hemiplegic migraine (FHM); it has been suggested, based on indirect genetic studies, that this gene may also be involved in common forms of migraine. To obtain data from direct gene analysis to test this hypothesis, we investigated 143 patients with common migraine, irrespective of their family history, for the presence of mutations known to result in the FHM phenotype; the mutations V714A, R192Q, R583Q, T666M, V1457L, and I1811L were absent in our patient sample. Furthermore, exons 4, 16, 17, and 36 were completely screened by single-strand conformation polymorphism (SSCP), and no other, hitherto unknown, mutations were detected. Bearing in mind that, in particular, the T666M mutation contributes to a large proportion of FHM linked to chromosome 19, we conclude that common migraine is distinct from FHM in its molecular basis and, therefore, most likely also in its pathophysiology. The possibility, however, of the existence of allelic disorders, with mutations located in other regions of the CACNA1A gene, cannot be ruled out. Molecular testing, therefore, is at present not a feasible option for the diagnosis and classification of migraine.

Reports related some polymorphisms of the 5,10-methylenetetrahydrofolate reductase (MTHFR) to folate-dependent neural tube defects. In view of the common origin of the cells involved both in neural tube closure and heart septation, we analyzed the MTHFR C677T and A1298C polymorphisms in mothers of children with conotruncal heart defect (CD) and in their offspring to evaluate the association between the MTHFR genotype and the risk of CD. We genotyped 103 Italian mothers with CD offspring, 200 control mothers, 103 affected children and their fathers by restriction fragment length polymorphism analysis. No increased risk was observed for the prevalence of the 677TT genotype by itself in affected children and in their mothers. The combined maternal 677TT/1298AA and 677CC/1298CC genotypes have odds ratio of 1.73 and 1.85, respectively. The prevalence of 1298CC genotype in the affected children gives odds ratio of 1.90, that becomes 2.31 for the 677CC/1298CC genotype. However, none of the odds ratios was statistically significant. We observed a higher frequency of the 677T allele in Italy than in other European countries. No association has been demonstrated between the 677TT MTHFR genotype and CD.

Bradykinin is not only a mediator of pain and inflammation but also a potent vasodilator and is likely to contribute to the cardioprotective effects of angiotensin-converting enzyme inhibitors. The B 2 receptor (B 2 -R) mediating most of the inflammatory and cardiovascular effects of bradykinin represents a candidate gene likely involved in the complex genetic causes of common chronic disorders such as hypertension. The C 181 T polymorphism of the B 2 -R gene influences the potency of bradykinin and there is evidence of a possible role of this polymorphism in the development of hypertension and end-stage renal disease. We developed and validated a new, rapid, and reliable method for the detection of the C 181 T polymorphism based on the hybridization probes format on the LightCycler™, which is superior to the conventional PCR-RFLP method commonly used to detect this polymorphism. It allows the solid evaluation of large patient populations with the best time.

Laboratory markers of thyroid function, selected steroid hormones, sex hormone-binding globulin (SHBG), homocysteine, prolactin, major markers of lipid- and glucose metabolism and of insular-growth hormone axes were investigated in fasting sera from 16 female patients with severe hypothyroidism after thyroidectomy because of thyroid cancer. The results obtained in severe hypothyroidism within 5–6 weeks after withdrawal of thyroid substitution therapy before control scintigraphy were compared with those obtained after correction of thyroid function. Elevated levels of homocysteine and prolactin in hypothyroidism significantly decreased after correction, while SHBG concentration increased. Correction of thyroid function led to significant changes of growth hormone and immunoglobulin F1 (decrease and increase, respectively), while insulin and proinsulin increased only insignificantly. Elevated levels of total cholesterol and triglycerides in hypothyroidism were normalized, along with a significant increase in high density lipoprotein (HDL)-cholesterol. As revealed by correlation and factor analyses, different relationships characterizing both states were found in hypothyroidism and after correction of thyroid function. A strong inverse relationship between homocysteine and free thyroid hormones confirms the effect of thyroid hormones on homocysteine metabolism. No such inverse relation was found in euthyroid state, however. Similarly, in hypothyroidism only, dehydroepiandrosterone sulfate correlated positively with immunoglobulin F1 and homocysteine and negatively with thyroid hormones and SHBG.

The anaerobic blood culture (AN) bottle is routinely used in Japan with little discussion as to its justification or validity. We retrospectively studied the AN bottle yield of obligate anaerobes and the characteristics of, and potential risk factors in, patients with anaerobic bacteremia during a 2-year period (1999–2000) at four university hospitals and one community hospital. Thirty-four of 18310 aerobic and anaerobic blood culture sets from 6215 patients taken at the university hospitals, and 35 of 2464 samples taken from 838 patients at the community hospital, yielded obligate anaerobes. Bacteroides species and Clostridium species accounted for 60% of the isolates. Fifty-seven patients from 69 blood culture sets containing anaerobes had clinically significant anaerobic bacteremia. Among these 57 patients, 24 (49%) were oncology patients, 40 (70%) had an obvious source of anaerobic infection, 15 (26%) had recent surgery and/or were in an immunosuppressed state. We concluded that the recovery rate of obligate anaerobes isolated from AN bottles was low, and the patients with anaerobic bacteremia had limited number of underlying diseases or potential risk factors for anaerobic infections. Therefore, anaerobic blood cultures may be selectively used according to the potential risk for anaerobic infections.

Genetic polymorphisms in the alcohol dehydrogenase genes, ADH2 and ADH3 , have been shown to affect individual susceptibility to diseases such as alcoholism and oesophageal cancer. Although several PCR-based methods for genotyping these enzymes have been previously developed, the two-buffer polyacrylamide gel electrophoresis system has the ability to rapidly resolve all classes of point mutations within 2–3 hours instead of the conventional overnight separation. The success of this technique is partly attributable to a discontinuous two-phase buffer system and horizontal flatbed gel electrophoresis rather than conventional vertical gels. Using a modification of this system, we were able to detect all of the known polymorphisms within ADH2 exons 3 and 9 and ADH3 exon 8, as well as a rare variant within ADH2 exon 9. This method is rapid, cost-effective, and is ideal for large scale screening programmes.

Using 3,3′-diclorophenolsulfoftaleinil N-acetyl-β-D-glucosaminide as a substrate, the apparent activation energy of β-N-acetylhexosaminidase (Hex) was determined in samples of plasma and urine, as well as in leukocyte and platelet lysates. Incubation with papain produced an increase in this thermodynamic variable for plasma Hex (precursor forms with high molecular mass) that would be caused by the proteolytic action of papain on the Hex A isoenzyme. However, digestion with papain did not significantly modify the activation energy of Hex in leukocyte and platelet lysates (mature enzymatic forms). In 11 healthy subjects and 28 patients with different renal diseases, no statistically significant differences were found with regard to the values obtained in cellular lysates for variations in the activation energy of urinary Hex, regardless of whether they presented normoalbuminuria, microalbuminuria or macroalbuminuria. These results support the hypothesis that even in patients with proteinuria, no significant amounts of plasma Hex precursor forms are found in urine samples, and the source of the enzyme activity is the kidney itself.

The aim of this study was to evaluate the diagnostic and prognostic values of serum angiogenin concentration in cases with gestational trophoblastic diseases (GTDs). Seventy-two patients with GTDs and 20 first trimester healthy pregnant women (controls) participated in this study. According to the WHO scoring system, GTDs were subgrouped into 24 hydatiform mole spontaneous regression (HMSR), 18 postmolar gestational trophoblastic tumors of high risk (PMHR), 16 low-risk choriocarcinoma, and 14 high-risk choriocarcinoma. Before treatment, a blood sample from each case was assayed for human chorionic gonadotrophin β subunit (hCGb) by radioimmunoassay and angiogenin by enzyme immunoassay. Follow-up hCGb and angiogenin assays were carried out for 1 year after treatment. Pretreatment of abnormal values of serum angiogenin (> 711 ng/ml, upper 95% confidence interval of controls) was encountered in 100% of PMHR cases compared to no single case of HMSR. Serum angiogenin levels in low- and high-risk cases with choriocarcinoma were significantly higher than in controls. Abnormal high values were encountered in 25% and 86% of cases, respectively. None of the low-risk cases exceeded 920 ng/ml, while 72% of high-risk cases exceeded this value. Serial angiogenin assays were correlated with disease progression and were positively correlated with serum hCGb (r = 0.75, p < 0.01). In conclusion, serum angiogenin may be a valuable marker of differential diagnosis of GTDs and its serial measurements are suggestive of remission and effective therapeutic intervention or disease progression.

Serum concentration of carbohydrate 19-9 antigen (CA 19-9), a sensitive marker of pancreatic cancer and cholangiocarcinoma, increases in a variety of liver diseases due to higher production and release by bile duct cells. Biliary epithelial cells are primarily affected in liver disease associated with cystic fibrosis (CF), which develops in up to 30% of CF patients. Our aim was to evaluate the usefulness of serum CA 19-9 concentration as a test of liver involvement in CF. Serum concentration of CA 19-9, liver enzymes, bile acids, and total amylase was determined in 107 CF patients (49 with and 58 without liver disease) and 56 healthy subjects. Serum CA 19-9 concentration was significantly higher in CF patients (67 U/ml, 95% CI 53.5–80.5 U/ml) than in controls (11.8 U/ml, 95% CI 2.5–44 U/ml; p < 0.001) and in CF patients with liver disease (92.3 U/ml, 95% CI 75–109.5 U/ml) compared to CF patients without liver disease (46.6 U/ml, 95% CI 27.8–65.4 U/ml; p < 0.001). In CF patients, stepwise logistic regression analysis identified alanine aminotransferase, γ-glutamyltranspeptidase, amylase, and CA 19-9 as the most useful predictors of liver disease (p < 0.0001). Receiver-operating characteristic (ROC) curve analysis revealed γ-glutamyltranspeptidase and CA 19-9 as the best tests for identification of liver disease in CF patients; at a CA 19-9 cut-off arbitrarily fixed at 73 U/ml, positive and negative predictive value was 70% and 78%, respectively (sensitivity 57%, specificity 81%). To increase sensitivity to 94%, the cut-off had to be fixed at 31 U/ml, which corresponds to a specificity of only 36.2% (predictive value 33%). Our study indicates that measurement of the serum CA 19-9 concentration alone cannot be proposed as a reliable test of early hepatic involvement in CF.

No comparative information is available concerning the ability of various cholinesterase (ChE) methods to identify succinyldicholine-sensitive patients, purely on the basis of the enzyme activity recorded in serum. Here, we evaluated six different methods for the measurement of ChE activity; 131 subjects were subdivided according to ChE phenotype and, therefore, to succinyldicholine sensitivity. ChE phenotype was determined by measuring dibucaine and fluoride numbers. DNA analysis was also performed to confirm correlation between the phenotype classification used in the study and the ChE genotype. The tested methods were significantly different in their ability to discriminate between the subjects with and without succinyldicholine-sensitive phenotypes. The succinyldithiocholine/5,5′-dithio-bis(2-nitrobenzoate) (DTNB) method showed the highest accuracy (area under the receiver operating characteristic (ROC) curve 0.97) followed by the propionylthiocholine/DTNB method (area under the ROC curve 0.94). On the other hand, the two methods using butyrylthiocholine as substrate and that employing benzoylcholine showed limited clinical utility in discriminating subjects at risk of prolonged apnea (area under the ROC curve ≤ 0.9). Using the succinyldithiocholine method, a value ≤ 23 U/l was approximately five times as likely to occur in a sensitive individual as in a normal one.

In 2000, the Belgian Scientific Institute of Public Health introduced a voluntary external quality assessment scheme for lymphocyte immunophenotyping. This paper provides an analysis of the first six surveys. Specimens consisted of fresh EDTA-anticoagulated whole blood and were sent by overnight mail. The 41 participants were surveyed for methodology and were asked to report white blood cell count, percentage of lymphocytes, and percentages and absolute numbers of CD3+, CD4+, CD8+, and CD19+ cells. Median intralaboratory coefficients of variation were 1.0, 1.3, 1.7, and 3.2% for CD3+, CD4+, CD8+, and CD19+ cell percentages, respectively. Interlaboratory variability was consistently lower than 6.5% for CD3+ and CD4+CD3+ cell percentages, and lower than 9.5% for CD8+CD3+ cell percentages. Median coefficients of variation for the absolute values were higher, ranging from 10.1% for CD4+CD3+ cells to 16.5% for CD19+ cells. The percentage of CD4+CD3+ and CD8+ CD3+ cells was in several samples significantly lower than the percentage of total CD4+ and CD8+ cells. The number of laboratories measuring total CD4+ and CD8+ cells decreased by 30% during the programme. Between-laboratory variability remained stable over time. Analysis of individual laboratory performance indicated that some laboratories markedly improved their results.

A group of neurologists and clinical neurochemists representing twelve countries worked towards a consensus on laboratory techniques to improve the quality of analysis and interpretation of cerebrospinal fluid (CSF) proteins. Consensus was approached via a virtual Lotus Notes-based TeamRoom. This new approach respecting multicultural differences, common views, and minority opinions, is available in http://www.teamspace.net/CSF, presenting the implicit, complementary version of this explicit, printed consensus. Three key recommendations were made: CSF and (appropriately diluted) serum samples should be analyzed together in one analytical run, i.e. , with reference to the same calibration curve. Results are evaluated as CSF/serum quotients, taking into account the non-linear, hyperbolic relation between immunoglobulin (Ig)- and albumin-quotients rather than using the linear IgG index or IgG synthesis rate. Controls should include materials with values within the reference ranges (IgM: 0.5–1.5 mg/l; IgA: 1–3mg/l; IgG: 10–30 mg/l and albumin: 100–300 mg/l). The physiological, methodological and clinical significance of CSF/serum quotients is reviewed. We confirmed the previous consensus on oligoclonal IgG, in particular the usefulness of the five typical interpretation patterns. The group compared current external and internal quality assurance schemes and encouraged all members to maintain national or local traditions. Values for acceptable imprecision in the CSF quality assurance are proposed.

The detection and quantification of monoclonal free light chains in urine (Bence Jones protein, BJP) are thorny issues for the laboratorian. Immunoelectrophoretic techniques (immunofixation) allow the characterization of the two pathognomonic features of light chains: monoclonality and absence of heavy chains. Immunochemical methods such as nephelometry and turbidimetry are widely used in clinical practice to exclude the presence of BJP. However, these methods are limited by several metabolic and analytical problems. The accuracy of quantitative immunochemical methods is hampered by the heterogeneous molecular forms (fragments and polymers) of BJP and by the lack of reference materials, and the precision of the methods in clinically relevant regions of the dynamic range is poorly defined. Immunoelectrophoretic methods, especially immunofixation, are recommended because of their ability to demonstrate monoclonality and the absence of heavy chains. Immunofixation is also considered the best method to document the disappearance of the monoclonal protein (complete remission). The physiology of immunoglobulins and the clinical relevance of BJP are illustrated in the two appendices to this paper.

Method comparison studies are usually evaluated by several statistical tests ( e.g. , regression analysis) which sufficiently describe the analytical (dis)agreement between the results of two procedures. However, they do not provide any information how differences, if observed, influence diagnostic decision making. A novel statistical approach is described to test the clinical relevance of differences between two analytical procedures. The new procedure requires a population-based probability which describes the distribution of values within the population under study and an analytical probability quantifying the risk of errors due to replacing one method by the other. The population probability was derived from 171 subjects from two outpatient departments (internal medicine and dermatology) who were subjected to an oral glucose tolerance test because type 2 diabetes mellitus was suspected. The analytical probability was determined from duplicate glucose measurements in venous and capillary blood, and venous plasma in the fasting and 2 h post-challenge state by the routine method used in a central laboratory (Ebio analyzer) and a (POCT) glucometer (Elite). The two probabilities were combined into one “error rate” (discordance rate). The new concept was applied to three examples. In the first example, a comparison between two analytical systems led to discordance rates above 15%. After transforming the Elite analyzer results by a regression function, the discordance rate decreased below 5%, which was considered to be acceptable for the diagnostic purpose studied. In the second example, discordance rates were estimated by comparing different sample systems with each other. The use of whole blood in comparison with venous plasma led to discordance rates of 5–7% for venous blood and 7–10% for capillary blood. The same data set was also used in a third example to derive decision limits for capillary and venous blood from the established plasma values. The proposed procedure estimates the diagnostic error rate based on analytic performance characteristics and population probabilities. It extends the concept of (un)efficiency by including the effect of variability about a decision limit and the distribution of the measurement values in the patient population.

To detect and follow-up the metabolic status of patients with alkaptonuria (AKU), urinary homogentisic acid (HGA) was measured by gas chromatography. These results were close to values we obtained by colorimetric method (linearity: up to 700 mg/l, detection limit: 1 mg/l, within-run imprecision (CV): 1.2% at 100 mg/l HGA, 4.9% at 10 mg/l, between-run CV: 6.8% at 100 mg/l). To determine urinary reference ranges of HGA, 84 healthy children (age: 2months–18 years) were divided into five age groups. HGA and creatinine were measured in their morning urine. Statistical analysis proved that urinary HGA/creatinine ratio is age-dependent. The ratio is relatively high between 1 and 6 years of age, with large scatter (upper limit of reference ranges given as mean + 2 SD: 5.5–7.2 mg/mmol = 0.03–0.04 mmol/mmol creatinine), and it decreases with age. Approximately at the age of 7 years, HGA/creatinine ratio becomes constant, and later it is similar to the adult value (upper limit: 2.8 mg/mmol = 0.017 mmol/mmol creatinine). We monitored a patient during her 1–5th year of life, and her urinary HGA was 80–200 times higher than the upper limit of the age-matched reference ranges. The measurement of HGA supports the decision for starting restricted protein diet and is useful for the evaluation of the effectiveness of therapy.

To decide on the acceptability of a specimen for the measurement of serum CK-MB, troponin I and myoglobin, we investigated the influence of hemolysis, turbidity, and icterus on those tests by adding arbitrarily made interferents. A total of 16 cases each for CK-MB and troponin I, and 18 cases for myoglobin tests were studied to verify the effects of hemolysis, turbidity, and unconjugated hyperbilirubinemia. A total of 16 cases were studied to clarify the effects of the conjugated hyperbilirubinemia. We graded the severity of hemolysis, turbidity, and icterus as mild, moderate, and severe after adding hemolysate, Intralipos (20% soybean oil), and unconjugated or conjugated bilirubin to sera. ACS180SE automated chemiluminescence system was used to measure CK-MB, troponin I, and myoglobin. CK-MB and troponin I were affected by any degree of hemolysis, turbidity, unconjugated hyperbilirubinemia, and conjugated hyperbilirubinemia, while myoglobin was affected only by severe unconjugated hyperbilirubinemia and conjugated hyperbilirubinemia in the samples with concentration higher than reference range, resulting in concentration level lower than baseline. In conclusion, the results of cardiac markers should be carefully interpreted when the specimens are hemolyzed, turbid or icteric.

The new selective access analyser Cobas Integra ® 800 from Roche Diagnostics was evaluated in an international multicentre study at six sites. Routine simulation experiments showed good performance and full functionality of the instrument and provocation of anomalous situations generated no problems. The new features on Cobas Integra ® 800, namely clot detection and dispensing control, worked according to specifications. The imprecision of Cobas Integra ® 800 fulfilled the proposed quality specifications regarding imprecision of analytical systems for clinical chemistry with few exceptions. Claims for linearity, drift, and carry-over were all within the defined specifications, except urea linearity. Interference exists in some cases, as could be expected due to the chemistries applied. Accuracy met the proposed quality specifications, except in some special cases. Method comparisons with Cobas Integra 700 showed good agreement; comparisons with other analysis systems yielded in several cases explicable deviations. Practicability of Cobas Integra ® 800 met or exceeded the requirements for more than 95% of all attributes rated. The strong points of the new analysis system were reagent handling, long stability of calibration curves, high number of tests on board, compatibility of the sample carrier to other Roche systems, and the sample integrity check for more reliable analytical results. The improvement of the workflow offered by the 5-position rack and STAT handling like on Cobas Integra ® 800 makes the instrument attractive for further consolidation in the medium-sized laboratory, for dedicated use of special analytes, and/or as back-up in the large routine laboratory.

Recent advances in the laboratory diagnostic approach to inherited thrombophilia call for an update on laboratory strategies and organization. The present paper therefore deals in particular with: the panel test choice, timing and test appropriateness, and analytical methods in several clinical conditions. Specific recommendations are supported by the state-of-the-art in this branch.