Band 49, Heft 3

Neurodegenerative diseases are major world wide causes of morbidity and mortality. They form a heterogeneous group of diseases, ranging from rare monogenic inherited errors of metabolism to common multi-factorial dementias. Major research efforts focus on the development of disease modifying drugs for neurodegenerative diseases. As a result, there follows a need for reliable tools for diagnosis, prognosis and monitoring of therapy. Processes in the brain can be monitored by analysis of cerebrospinal fluid (CSF). Several CSF biomarkers of pathological processes in the brain are now available. Such biomarkers may be used for both research and in the clinical setting. However, several difficult problems remain to be solved. More intensive collaboration between academia, industry and government is likely needed to develop treatments and biomarkers for neurodegenerative diseases. This article reviews the definitions, usage and current limitations of CSF biomarkers in this field.

Background: To evaluate the value of total tau (tau) and phosphorylated tau (p-tau) in cerebrospinal fluid (CSF) in the differential diagnosis of dementia, more specifically: dementia with Lewy Bodies (DLB), frontotemporal lobar degeneration (FTLD), vascular dementia (VaD), and Creutzfeldt-Jacob disease (CJD). Methods: A systematic literature search was performed to identify studies on tau and p-tau in DLB, FTLD, VaD and CJD. Tau concentrations were compared to healthy controls and to subjects with Alzheimer's disease (AD) using random effect meta-analysis. Outcome measures were Cohen's delta, sensitivity and specificity. Results: Compared to controls, tau concentrations are moderately elevated in DLB, FTLD and VaD, while p-tau concentrations are only slightly elevated in DLB and not elevated in FTLD and VaD. Compared to AD, lower tau concentrations differentiated DLB with a sensitivity of 73% and a specificity of 90%, FTLD with sensitivity and specificity of 74%, and VaD with a sensitivity of 73% and a specificity of 86%. Relative to AD, lower p-tau values differentiated FTLD with a sensitivity of 79% and specificity of 83%, and VaD with a sensitivity of 88% and a specificity of 78%. CJD is characterized by extremely elevated tau concentrations with a sensitivity of 91% and a specificity of 98% vs. AD. Conclusions: CSF tau concentrations in DLB, FTLD and VaD are intermediate between controls and AD patients. Overlap with both controls and AD patients results in insufficient diagnostic accuracy, and the development of more specific biomarkers for these disorders is needed. CJD is characterized by extremely increased tau values, resulting in a sensitivity and specificity that exceeds 90%.

A growing body of evidence suggests that Alzheimer's disease (AD) is a multifactorial disease resulting in the well-known, common neuropathological pathway characterized by extracellular fibrillar β amyloid (Aβ) deposits in the brain, intracellular neurofibrillary tangles (NFT) and neuronal as well as axonal degeneration. While fairly accurate, the clinical diagnosis of probable AD based on standard diagnostic criteria does not take into account the long preclinical and prodromal course of AD. AD-related pathophysiological changes can occur many years and even decades before the appearance of clinical dementia syndrome. Biomarkers that are related to the pathophysiology of AD may thus help detect the preclinical stages of disease, and improve early and differential diagnosis. Here, we provide an overview of current literature on the core AD biomarkers, Aβ and phosphor-tau (p-tau), on different methods and modalities of assessing them [e.g., cerebrospinal fluid (CSF) analysis and PET imaging], and on their diagnostic and predictive value in preclinical and clinical stages of AD.

The presence of the ɛ4 allele in apolipoprotein E (ApoE) represents the most important genetic risk factor for late onset sporadic Alzheimer's disease (AD), together with age and mid-life hypercholesterolemia. ApoE4 is the most important lipid transporter between cells in the CNS and it was found that ApoE4 is involved in Amyloid β (Aβ) formation, fibrilisation, accumulation, in the aggregation and hyperphosphorylation of tau and in the metabolism of brain cholesterol and in neurodegeneration. Low cerebrospinal fluid (CSF) Aβ1-42 is a marker of Aβ plaque load in the brain. High CSF t-tau and p-tau concentrations reflect axonal and neuronal damage and injury, which correlates with a neurofibrillary tangle stage and load, also reflecting the intensity of the disease process. Magnetic resonance imaging (MRI) brain atrophy is a biomarker of neurodegeneration and is the result of loss of neurons, synapses and dendritic arborization. ApoE genotype interacts with the AD biomarkers: ɛ4 carriers were found to present with lower concentrations of Aβ1-42, higher tau and p-tau, higher tau/Aβ ratio and a higher degree of brain atrophy at any disease stage, changing the test performances and the ability to distinguish between the different cognitive condition. The presence of the ɛ4 allele was also found to increase the power to predict further cognitive decline. Even if the presence of ApoE4 is not a deterministic factor for AD, it seems to shift the progression of the disease towards a younger age and faster progression. It is also likely that the ɛ4 allele increases the intensity of the pathological process in several ways. In the study of cognitive impaired patients and in their follow-up, biomarkers should be interpreted in consideration of the ApoE genotype in order to better predict the progression of the disease.

Alzheimer's disease (AD) is the most common dementia disorder of later life. Although there might be various different triggering events in the early stages of the disease, they appear to converge on a few characteristic final pathways in the late stages, characterized by inflammation and neurodegeneration. Here, we review the hypothesis that advanced glycation end products (AGEs), which reflect carbonyl stress, an imbalance between the production of reactive carbonyl compounds and their detoxification, can serve as biomarkers for the progression of disorder. AGE modification may explain many of the neuropathological and biochemical features of AD, such as extensive protein cross-linking shown as amyloid plaques and neurofibrillary tangles, inflammation, oxidative stress and neuronal cell death. Although accumulation of AGEs is a normal feature of aging, it appears to be significantly accelerated in AD. We suggest that higher AGE concentrations in brain tissue and in cerebrospinal fluid might be able to distinguish between normal aging and AD.

There is currently no well-established biomarker for Parkinson's disease. The need to better diagnose the condition, define the subtypes of disease, and follow its course independent of any symptomatic drug effects is well-established. In this review, we will begin by reviewing the evidence for biological fluid biomarkers in Parkinson's disease. We will then touch upon the role of brain imaging in diagnosis and defining prognosis, as well as the value of studying motor phenotype and its potential applications for characterising Parkinson's disease subtypes with differing natural histories.

With the aging population in the Western hemisphere, neurodegenerative parkinsonism and dementia will become two of the great public health challenges of this century. A major pillar in the effort to treat these conditions will be the shift from symptomatic treatment to disease modifying therapy. This step will absolutely require cheap and reliable biomarkers; patients will need to be diagnosed before irreversible change has occurred. α-Synuclein (αS) is a recent candidate biomarker for Lewy body neurodegeneration. It is a 140 amino acid protein that forms the pathological substrate in idiopathic Parkinson's disease (IPD), dementia with Lewy bodies (DLB), as well as multiple system atrophy (MSA), a group of disorders collectively known as the synucleopathies. Biomarker research has investigated αS in blood, skin and cerebrospinal fluid (CSF). Plasma assays have demonstrated inconsistent results but CSF assays show a higher degree of uniformity, mostly demonstrating lower levels of αS in patients with Lewy body disease compared to controls. These results are not yet accurate or reliable enough to use as screening tools or isolated diagnostic tests in established disease. It has become clear that factors other than neurodegeneration affect αS concentrations in these tissue samples, such as genetic and environmental influences. Future studies using standardized techniques and larger patient numbers are awaited to realise the full potential of αS as a more definitive diagnostic biomarker.

“Classic” neurodegenerative disorders, such as Alzheimer's disease and amyotrophic lateral sclerosis share common pathophysiological features and involve progressive loss of specific neuronal populations, axonal or synaptic loss and dysfunction, reactive astrogliosis, and reduction in myelin. Furthermore, despite the absence of astrogliosis, impaired expression of astrocyte- and oligodendrocyte-related genes has been observed in patients with major psychiatric disorders, including schizophrenia and mood disorders. Because S100B is expressed in astrocytes and oligodendrocytes, its concentration in cerebrospinal fluid (CSF) or serum has been considered a suitable surrogate marker for the diagnostic or prognostic assessment of neurodegeneration. This review summarizes previous postmortem, CSF and serum studies regarding the role of S100B in this context. A general drawback is that only small single-center studies have been performed. Many potential confounding factors exist because of the wide extra-astrocytic and extracerebral expression of S100B. Due to lack of disease specificity, reliance on S100B concentrations for differential diagnostic purposes in cases of suspected neurodegenerative disorders is not recommended. Moreover, there is no consistent evidence for a correlation between disease severity and concentrations of S100B in CSF or serum. Therefore, S100B has limited usefulness for monitoring disease progression.

The paralysis of an acute spinal cord injury (SCI) remains a catastrophic condition for which there are currently no effective treatments. While the diagnosis of acute traumatic SCI is typically quite easy to make, distinguishing the exact degree of severity and prognosticating the extent of neurologic recovery are challenging. Functional neurologic measures are currently used to stratify injury severity and predict neurologic outcome. However, these measures are often impossible to determine in acutely injured patients. Additionally, for patients deemed to be of a specific injury severity, the variability in spontaneous neurologic recovery is high. Both of these issues severely impair the ability to perform clinical trials in novel therapies for SCI. Biomarkers that could more precisely define the severity of injury and better predict neurologic outcome would be extremely valu-able. Furthermore, biological surrogate outcomes measures would be very useful in small preliminary clinical trials of novel therapies if they could inform decisions around the therapeutic regimen for subsequent larger clinical trials. This review highlights our ongoing work in establishing biomark-ers for SCI using cerebrospinal fluid samples from acutely injured patients.

Diseases of the central nervous system are found in patients with severe hyperhomocysteinemia (HHcy). Epidemiological studies show a positive, dose-dependent relationship between mild-to-moderate increases in plasma total homocysteine concentrations (Hcy) and the risk of neurodegenerative diseases, such as Alzheimer's disease, vascular dementia, cognitive impairment or stroke. HHcy is a surrogate marker for B vitamin deficiency (folate, B12, B6) and a neurotoxic agent. The concept of improving the patient's clinical outcome by lowering of Hcy with B vitamins seems to be attractive. Recent B vitamin supplementation trials demonstrated a slowing of brain atrophy and improvement in some domains of cognitive function. Meta-analysis of secondary prevention trials showed that B vitamins supplementation caused a decrease in plasma Hcy and a trend for lowering the risk of stroke. HHcy is common in elderly people. Therefore, it seems prudent to identify B vitamin deficient subjects and to ensure sufficient vitamin intake. Therefore, recent evidence supports the role of Hcy as a potential biomarker in age-related neurodegenerative diseases.

The antiphospholipid syndrome (APS) is an autoimmune condition characterised by a wide range of clinical features (primarily thrombosis and/or obstetric related), associated with the presence of antiphospholipid antibodies (aPL) as detected by a diverse range of laboratory tests. APS remains a significant diagnostic challenge for clinicians across a wide range of specialities, largely due to issues related to laboratory testing as well as the expanding range of reported clinical manifestations of APS. The laboratory issues include limitations in detailed knowledge by both clinical and laboratory personnel regarding the ‘complete’ range of available aPL tests, as well as ongoing problems with assay reproducibility and standardisation. aPL are identified using diverse laboratory procedures based on one of two distinct test processes, namely solid phase and liquid phase assays. The former includes anticardiolipin antibodies (aCL) and anti-β 2 -glycoprotein I antibodies (aβ 2 GPI). The latter are centred on clot-based tests that are used to identify the so-called lupus anticoagulant (LA). This article will discuss: (i) issues related to laboratory testing for APS in terms of the currently available solid-phase and liquid-phase assays, and identifiable biases resulting from these tests usually being performed in different laboratories; (ii) current problems with calibration, standardisation and reproducibility of these assays; (iii) pre-analytical, analytical and post-analytical considerations and ongoing initiatives for improvement; (iv) issues related to potential combinations/panels of available aPL tests; and (v) the entities of seropositive APS, seronegative APS and non-APS aPL-positivity. In doing so, this review will hopefully help bridge the two disciplines of haematology and immunology (‘representing’ liquid-phase and solid-phase aPL testing, respectively), by improving the understanding of those working in each of these disciplines of the merits and limitations of the assays performed in the other discipline, and encouraging inter-discipline cooperation in the reporting of aPL test results.

Background: The results of 5 years of experience (2004–2008) with process-based quality management using quality indicators for key laboratory processes (analytic and extra-analytic) in a group of clinical laboratories affiliated with the Catalan Health Institute are presented. Our purpose was to analyze the evolution of the indicators, identify processes that require corrective measures, and obtain specifica tions that are more robust than the preliminary ones proposed in a previous study by the same group. Methods: The yearly average was recorded for each indicator in each laboratory, the yearly interlaboratory median was calculated, and the changes occurring were studied to determine their continuity in the 5-year period. For each indicator, the average of the yearly medians was calculated and the results transformed to the Six Sigma scale to estimate the degree of control over the related process. It was suggested to establish the yearly interlaboratory median as the desirable specification for each indicator. Results: The medians for most indicators were stable during the period studied. Thus, the specifications proposed in the first study were considered robust in these cases. The Six Sigma statistic provided added value in this study because it enabled detection of processes that should be improved, in which case the specifications proposed were considered provisional despite their stability. After identifying processes that have the greatest impact on patient safety, the group set a specification of 0%, regardless of the actual specification obtained, although the members are conscious of the difficulty in attaining this level of quality. Certain processes that are in a period of change obtained specifications that are considered in a phase of consolidation. Conclusions: The results for indicators related with sample collection indicate that the process is stable and well controlled. However, based on the results for Hemolyzed serum sample, the group saw the need for installing centrifuges in all phlebotomy centers and established a recommendation to unify the system for measuring hemolysis. The indicator External control exceeds acceptance limit clearly highlighted the need to rigorously monitor the analytic phase of the clinical laboratory. The values obtained for the indicator Reports from referred tests exceed delivery time show that there is considerable deviation regarding the expected report delivery time, whereas for in-house laboratory reports, delivery time is satisfactory.

Background : In previous work, we demonstrated that some occupational workers in stressful conditions can have increases in several markers of oxidative stress when compared to other workers. We investigated two antioxidant enzymes, superoxide dismutase (SOD) and catalase (CAT) activities, and malondialdehyde (MDA) concentrations, according to demographics, lifestyle and occupational parameters in palliative care unit workers, and analyzed the relationship with occupational burnout. Methods : Fifty-two palliative care unit workers and 50 gender- and aged matched healthy individuals as controls were surveyed. Spectrophotometric and high-pressure liquid chromatography methods were used for biochemical determinations. Results : No significant variation with respect to gender were detected with respect to SOD and CAT activities, MDA concentrations or occupational burnout. MDA concentrations increased with age in controls and palliative care unit workers, and we observed significant differences in MDA between controls and palliative care unit workers for all age groups. Significant variation in MDA concentrations were detected between unmarried (287.22±8.31 nmol/mg hemoglobin) and married individuals (317.18±6.24 nmol/mg hemoglobin), but not with respect to divorced individuals (288.41±5.64 nmol/mg hemoglobin). Significant differences were detected between smokers and non-smokers for SOD, CAT and MDA, but not for alcohol, coffee, tea or cola consumption. Significant differences were seen in MDA concentrations between those who frequently practice some kind of sport (280.59±7.62 nmol/mg hemoglobin) and those who never practice any kind of sport (299.12±8.09 nmol/mg hemoglobin), and between those who frequently ate fruit and greens (291.05±8.11 nmol/mg hemoglobin) and those who never eat fruit and greens (316.31±7.42 nmol/mg hemoglobin). SOD activity and MDA concentrations are higher in palliative care workers who work the evening and night shifts (p<0.01), and these workers also show significantly higher levels of stress. Conclusions : Our findings suggest that oxidative stress, occupational stress and occupational burnout levels are similar in men and women. Occupational stress increases oxidative stress levels probably as a response to increased generation of reactive oxygen species. Working during the evening and night shifts increases oxidative levels and burnout levels.

Background: Cigarette smoking has been recognized as a major risk factor for cardiovascular disease, while the role of homocysteine is still not clear. This study investigated the effects of smoking on plasma homocysteine concentration and determined the correlation between this parameter and biological markers of tobacco use, such as plasma thiocyanate and urine cotinine. Methods: Folate, vitamin B12 and homocysteine were measured in 300 subjects: 138 non-smokers and 162 smokers using immunoassay methods. Cotinine was measured using an enzymatic colorimetric method and thiocyanate by a selective electrode. Results: In smokers, we found a significant increase in homocysteine and a decrease in folate and vitamin B12 levels compared to non-smokers. Homocysteine was strongly correlated with the duration of use and the number of cigarettes consumed. Folate and vitamin B12 were significantly reduced in subjects smoking for more than 20 years compared to those who smoked less than 5 years. Among smokers, we noted a positive correlation between homocysteine and both plasma thiocyanates and cotininuria, and a negative-correlation between cotininuria and plasma folate. Conclusions: Cigarette smoking increases homocysteine, which is strongly correlated with cotininuria and plasma thiocyanates. Moreover, smokers had tendency to develop hypofolatemia and hypovitamin B12, particularly when the duration of consumption exceeded 20 years.

Background: Sodium dodecyl sulphate polyacrylamide gel electrophoresis (SDS-PAGE) is currently the reference method for detecting protein deficiencies related to hereditary spherocytosis. The aim of the study was to evaluate an automated capillary gel electrophoresis system, the Experion instrument from BioRad, for its ability to separate and quantify the erythrocyte membrane proteins. Methods: The major erythrocyte membrane proteins (actin, protein 4.2, protein 4.1, band 3, ankyrin, α- and β-spectrin) were extracted and purified from membrane ghosts by centrifugation, immunoprecipitation and electroelution. Analyses were performed using SDS-PAGE and sodium dodecyl sulphate capillary gel electrophoresis (SDS-CGE) to establish a separation profile of the total ghosts. Then, the samples from patients received for investigations of erythrocyte membrane defects were analysed. Results: Five of the seven expected erythrocyte membrane proteins were finally separated and identified. In the 20 studied cases, taking into account the screening test results and the clinical and family histories, the SDS-CGE method allowed us to achieve the same conclusion as with SDS-PAGE, except for the patient with elliptocytosis. Conclusions: The new SDS-CGE method presents interesting features that could make this instrument a powerful diagnostic tool for detection of erythrocyte membrane protein abnormalities, and can be proposed as an automated alternative method to the labour intensive SDS-PAGE analysis.

Background: We evaluated the complete blood count (CBC) for the prediction of 7-day in-hospital mortality in a large adult trauma cohort. Methods: We conducted an analysis of two prospectively collected databases on 1673 patients aged ≥18 years admitted to a level I trauma center (2005–2007). Comparisons between survivors and non-survivors within 7 days after admission and between single and multiple trauma patients were made. Discriminative performance for 7-day in-hospital mortality was assessed using the area under the receiver operating characteristic curve (ROC). Logistic regression was used to identify independent prognostic factors for 7-day in-hospital mortality. Results: Comparison between survivors and non-survivors showed significant differences in white blood cell (WBC) count, absolute neutrophil count, segmented neutrophil count and most red blood cell (RBC) and platelet indices. Comparison between single and multiple trauma patients showed significant differences for WBC count and differential count and most RBC and platelet indices. Among the CBC parameters, RBC count (ROC=0.748), hemoglobin concentration (Hb) (ROC=0.734), hematocrit (Ht) (ROC=0.726), platelet count (PLT) (ROC=0.684) and plateletcrit (PCT) (ROC=0.696) showed the highest ROC. Using logistic regression we showed that RBC count, Hb, Ht, PLT and PCT were predictors of 7-day in-hospital mortality independently of patient's age, injury severity and initial physiological state. Conclusions: Significant differences in CBC parameters were found between survivors and non-survivors and between patients with single and multiple trauma, but most of the CBC parameters demonstrated poor to moderate pre dictive ability for 7-day in-hospital mortality in adult trauma patients. Routine laboratory workup of trauma patients should be performed as treatment guidance. However, prognostic value of initial hematological parameters remains limited.

Background: Sodium citrate is the most commonly used anticoagulant for platelet function testing. However, the use of citrated blood for platelet function analysis has been criticized due to creation of a non-physiological milieu. Moreover, platelet function measurements performed with citrated blood need to be completed within 4 h after blood collection. Alternatively, hirudin and recently, a dual thrombin/factor Xa inhibitor benzylsulfonyl- d -Arg-Pro-4-amidinobenzylamide (BAPA), can be used to improve the reactivity after prolonged storage of platelets. The present study investigated platelet function tests using hirudin and BAPA anticoagulated blood. Methods: Blood was obtained from 30 healthy individuals and 20 patients on aspirin or clopidogrel therapy, and stored for 2, 12, 24 or 48 h. Light transmission aggregometry and impedance platelet aggregometry were performed using adenosine 5-diphosphate (ADP) and arachidonic acid as agonists. The vasodilator stimulated phosphoprotein (VASP) phosphorylation assay was evaluated. Results: Platelet aggregation measurements of healthy individuals and patients showed stable platelet aggregation values induced by arachidonic acid, after 24 h, when hirudin or BAPA anticoagulated blood was used. However, citrated blood resulted in significantly reduced platelet response after 12 h. ADP-induced light transmission aggregation of healthy individuals and patients exhibited unchanged platelet aggregation after 12 h using hirudin or BAPA anticoagulated blood, while significantly reduced platelet response was observed after 12 h when using citrated blood. In contrast, measurement of ADP-induced aggregation by use of impedance aggregometry resulted in reduced stability over 12 h using hirudin or BAPA anticoagulated blood. The VASP assay exhibited no significant changes in results over a storage period of 48 h, independent of the anticoagulants used. Conclusions: Use of hirudin or BAPA anticoagulated blood resulted in improvement of stability of platelet function measurements.

Background: The novel urine chemistry analyzer iChem Velocity (IRIS Diagnostics) offers improved urinalysis automation options through integration with the well-established iQ200 urine microscopy analyzer. In the course of optimizing the workflow in our hospital routine laboratory, we evaluated the performance of the iChem Velocity. Methods: A total of 257 random urine samples were analyzed with the iChem Velocity, iQ200, Clinitek Atlas (Siemens Healthcare Diagnostics) and by manual microscopy. Results: Depending on the parameter, 93% (hemoglobin) to 100% (urobilinogen), the iChem Velocity and Clinitek Atlas results agreed within the same rank or within one level of difference. The Clinitek Atlas featured a higher sensitivity for hemoglobin (area under the curve 0.86) and leukocyte esterase (area under the curve 0.85) compared with the iChem Velocity (area under the curve for hemoglobin 0.73, leukocytes 0.78). Imprecision was highest for hemoglobin and leukocytes in a pathological sample pool. While the precision of the Clinitek Atlas for hemoglobin measurements was superior, the iChem Velocity was more precise in analyzing protein and pH. Conclusions: Through urinalysis automation with the iChem Velocity and iQ200, we achieved a reduction of hands-on time by 89%. The sensitivity of this new system should be further improved through ongoing development.

Background: Studies on the frequency of the different types of urinary crystals and the role of Fourier transform infrared microspectroscopy (FTIRM) for identification are few. We describe the results of a retrospective study on the prevalence and typology of crystalluria and on the role of FTIRM. Methods: Urinary crystals were identified using the combined knowledge of crystal morphology, birefringence features and urine pH (combined approach). When this was inconclusive, FTIRM was performed. Results: Crystalluria was found in 807 out of 9834 samples (8.2%). In 793, the combined approach identified “typical” crystals, while in 14 FTIRM was needed to identify “atypical” crystals. Among “typical crystals”, calcium oxalate (75.9%), uric acid (25.9%) and amorphous urates (7.9%), alone or in combination, were the most frequent. Brushite, ammonium biurate and cystine were the most rare (0.1%–0.7%). FTIRM identified 12 of 14 atypical crystals: three crystals were due to a drug (amoxicillin, indinavir, doubtful phenytoloxamine); four were due to calcium oxalate mono- or bihydrate, uric acid bihydrate or struvite; five were due to calcium carbonate, Tamm-Horsfall glycoprotein, or rare salt combinations. Conclusions: Crystalluria is not rare and most crystals can be identified by the combined approach. Occasionally, identification of crystals will require FTIRM.

Background: The study is aimed at evaluating the performance of the predictive model ROMA (Risk of Ovarian Malignancy Algorithm), which utilizes the combination of human epididymis protein 4 (HE4) and CA125 values to assess the risk of epithelial ovarian cancer (EOC) in women with a pelvic mass. Methods: One hundred and four women diagnosed with a pelvic mass (55 EOC and 49 benign cases) and scheduled to have surgery were enrolled, along with 49 healthy females. Preoperative serum concentrations of HE4 and CA125 were measured. Separate logistic regression algorithms ROMA for pre-menopausal and post-menopausal women were used to categorize patients into low- and high-risk groups for EOC. The area under the curve (AUC), sensitivity and specificity were calculated for HE4, CA125 and ROMA for the diagnosis of ovarian cancer using receiver operating characteristic (ROC) analysis. Results: The median CA125 and HE4 serum concentrations were significantly higher among EOC patients than in healthy females (both p<0.05) and those with a benign mass (both p<0.05). The pre-menopausal group included 36 benign cases (29 of which were classified by ROMA as low-risk with a specificity of 80.6%; 95% CI: 64.0%–91.8%), and 15 EOC (eight of which were classified by ROMA as high-risk, with a sensitivity of 53.3%; 95% CI: 26.6%–78.7%). The post-menopausal group enclosed 13 benign cases (11 of which were classified by ROMA as low-risk with a specificity of 84.6%; 95% CI: 54.6%–98.0%), and 40 EOC (33 of which were classified by ROMA as high-risk with a sensitivity of 82.5%; 95% CI: 67.2%–92.7%). In the pre-menopausal group, the AUC was 0.64 (p=0.12, 95% CI: 0.44–0.83) for CA125, 0.77 (p=0.003, 95% CI: 0.62–0.92) for HE4 and 0.77 (p=0.002, 95% CI: 0.63–0.92) for ROMA. In the post-menopausal group, the AUC was 0.84 (p=0.0003, 95% CI: 0.73–0.94) for CA125, 0.94 (p<0.0001, 95% CI: 0.88–0.99) for HE4 and 0.92 (p<0.0001, 95% CI: 0.85–0.99) for ROMA. Conclusions: The ROMA is a simple scoring system which shows excellent diagnostic performance for the detection of EOC in post-menopausal women, but not in pre-menopausal women. Moreover, the dual marker combination of HE4 and CA125 (ROMA) does not show better performance than HE4 alone.

Background: This study aimed to determine the serum concentrations of CA125 and human epididymis protein 4 (HE4) in patients with ovarian cancer, and to evaluate the sensitivity and specificity of these biomarkers for differentiating between patients with benign gynecological disease and those with ovarian cancer, when used alone and in combination in a Korean population. Methods: We consecutively recruited 159 women with an adnexal mass, including 78 women with ovarian cancer. A total of 224 healthy women served as controls. The serum concentrations of HE4 and CA125 were analyzed using immunochemiluminescence assays. The concentrations of the markers were compared among the different subgroups, and the diagnostic accuracy of each marker and the combination of the two markers was assessed by plotting receiver operating characteristic (ROC) curves. In addition, the Risk of Ovarian Malignancy Algorithm (ROMA) was utilized to categorize patients into low- and high-risk groups for epithelial ovarian cancer. Results: Serum HE4 and CA125 concentrations were significantly higher in the ovarian cancer patients compared with those seen in patients with benign disease or in the healthy controls (p<0.0001 in both). In patients with an adnexal mass, the area under the ROC curve was higher when the combination of the markers was used compared with use of CA125 only. Using ROMA, patients could be successfully classified into high- and low-risk group, with 87.5% sensitivity at a specificity of 93.8%. Conclusions: These findings suggest that measuring serum HE4 concentrations along with CA125 concentrations may provide higher accuracy for detecting ovarian cancer.

Background: Functional studies suggest that the APOA5 −1131 T/C polymorphism plays an important role in triglyceride (TG) metabolism, which is an event contributing to the pathogenesis of coronary artery disease (CAD). However, genetic evidence of its effect on CAD is inconsistent. To assess this correlation, we performed a meta-analysis of published data. Methods: A comprehensive meta-analysis was performed on nine published studies, with a total sample of 2049 subjects and 2373 controls using a fixed effect model. Results: Under the fixed effect model, the risk of the disease was significantly higher in subjects with CC genotype in comparison with both TT (OR: 1.99; 95% CI: 1.64–2.41) and TC (OR: 1.48; 95% CI: 1.22–1.80) subjects. Compared with TT homozygotes, there was 43% increase in the incidence of CAD (OR: 1.43; 95% CI: 1.26–1.61) of C carriers ( CC + TC ). There was no heterogeneity for these effect estimates. Conclusions: Our findings support the view that −1131 T/C polymorphism of the APOA5 gene is associated with CAD and the C allele might be a genetic risk factor that increases susceptibility to CAD.

Background: Myocardial ischemia may alter the metal binding capacity of circulating serum albumin. Thus, the aim of this study was to describe an automated method to measure ischemia-induced alterations in the binding capacity of serum albumin for exogenous nickel, and to evaluate the diagnostic characteristics of this assay for the assessment of acute coronary syndrome (ACS) in patients presenting to the emergency room (ER) with acute chest pain. Methods: We assessed the concentrations of cardiac troponin I (cTnI), serum albumin, ischemia-modified albumin (IMA) measured by the cobalt-albumin binding assay (CABA), and by an automated nickel-albumin binding assay (NABA) in the following groups: ACS (n=63) and non-ischemic chest pain (NICP, n=26). Biochemical markers were determined in blood samples obtained from patients within 3 h of ER admission. Results: cTnI, CABA and NABA concentrations were higher in ACS group in comparison to the NICP group. A significant correlation between NABA and CABA was observed (r=0.5387, p<0.001). Areas under the curve for CABA and NABA were 0.7289 and 0.7582, respectively. Both CABA and NABA have the ability to discriminate patients with ACS. However, NABA has a slightly higher ability to discriminate ACS compared with CABA. Conclusions: Patients with ACS have reduced nickel binding to human serum albumin, and NABA may have an important role as an early marker of myocardial ischemia, particularly in patients presenting to the ER with acute chest pain.