Volume 50, Issue 11

Early diagnosis of cancer and early detection of relapse following surgery are critical for the effective treatment of the disease and for a positive clinical outcome. Identification of novel diagnostic, prognostic and predictive biomarkers will contribute utmost to clinical decision-making. The human tissue kallikrein and kallikrein-related peptidases (KLKs), encoded by the largest contiguous cluster of protease genes in the human genome, are secreted serine proteases with diverse expression patterns and physiological roles. The aberrant expression of KLK s in various malignancies as well as their involvement in many cancer-related processes, such as cell growth regulation, angiogenesis, invasion, and metastasis, has prompted scientists to investigate their potential as cancer biomarkers. Expression of distinct KLKs is associated with clinicopathological parameters of cancer patients. Moreover, several KLKs possess significant favorable or unfavorable prognostic value in various malignancies, with prostate-specific antigen (PSA) being the most widely used biomarker in clinical practice, today. KLKs are also considered as very promising biomarkers for cancer personalized medicine, especially for prediction and monitoring of patients’ response to chemotherapy, therefore opening up new horizons towards effective patient monitoring post-treatment. This review describes the current status of KLKs as tumor biomarkers.

Volatile biomarker analysis in exhaled breath is becoming one of the desirable strategies for cancer detection because it may offer a relatively inexpensive, rapid, and non-invasive screening method for early diagnosis. Breath analysis has attracted a considerable amount of scientific and clinical interest over the past decade. However, breath is not yet used for routine medical diagnostic purposes. Challenges faced in the development of breath analysis for cancer diagnosis include developing techniques that can measure biomarkers in exhaled breath at ultratrace levels, providing definitive evidence for their presence and for the relationship between the proposed biomarker and the underlying condition. Various analytical methods are used for the detection of breath biomarkers. Gas chromatography-based methods which involve sample collection, analyte preconcentration, desorption, and separation steps are the most popular. However, direct-sampling mass spectrometry techniques have been proven more reliable for air analysis without prior sample pretreatment or chromatographic separation. This review focuses on the most commonly used direct mass spectrometry methods for the direct online analysis of endogenous cancer biomarkers in exhaled breath, with particular attention to principle of detection, method performance, advantages, shortcomings, recent advances, and applications within health-related studies for cancer biomarkers research. The principle behind the science of breath analysis for cancer diagnosis is also discussed.

γ′ Fibrinogen is an isoform of fibrinogen that normally constitutes about 7% of total plasma fibrinogen, and arises from an alternative processing event in the γ chain mRNA. γ′ Fibrinogen is a newly-emerging cardiovascular disease (CVD) risk factor that appears to have an independent association with CVD from that of total fibrinogen, which is itself a well-established CVD risk factor. γ′ Fibrinogen shows a significant association with coronary artery disease and myocardial infarction in at least four case-control studies, including the Stockholm Coronary Artery Risk Factor study and the Framingham Heart Study. γ′ Fibrinogen is also significantly associated with stroke, as shown in the Erasmus Stroke Study and others. The role of genetic polymorphisms in the association between γ′ fibrinogen and CVD is under active investigation. γ′ Fibrinogen increases during inflammation, and is differentially regulated from total fibrinogen under pathologic conditions, as demonstrated in the Periodontitis and Vascular Events study. The association between γ′ fibrinogen and venous thromboembolism remains unclear, however, with some studies showing an inverse association with γ′ fibrinogen levels and other studies showing the opposite.

Serum ferritin is used for diagnosing iron-related disorders. However, most studies validating this application were performed before the introduction of the 2nd and 3rd WHO International Standards (ISs) to harmonize assay results. We revised the available literature to evaluate if consolidated clinical applications of ferritin and recommended cut-offs have been validated using ISs calibrated assays. All Medline retrieved reviews and individual studies performed since ISs availability were selected and analyzed according to predefined criteria. Concerning ferritin and iron deficiency (ID), only one review, including studies published before 1988, met established criteria. Results showed that ferritin can effectively rule out ID anemia in patients with or without inflammatory disease at cut-offs of 70 and 40 μg/L, respectively. From two studies using ISs calibrated assays that met inclusion criteria, no information emerged on which cut-off should be employed to obtain similar sensitivity. Regarding iron overload, even when the framework was restricted to hereditary hemochromatosis, no synthesis of scientific evidence, if any, about diagnostic accuracy of ferritin was available both before and after ISs introduction. Available evidence of the ferritin diagnostic effectiveness is limited to ID conditions. Recommended cut-offs for this application are, however, based on studies published from 1970 to the 1980s using non-harmonized assays.

Background: Several studies have suggested that pre-B-cell colony-enhancing factor (PBEF) gene polymorphisms are associated with susceptibility to and prognosis of acute lung injury (ALI) in several populations of Caucasians. The aim of this study was to detect the distribution of PBEF alleles and to evaluate any potential relationship between PBEF polymorphisms and ALI, sepsis, and pneumonia in the Han population of Northeast China. Methods: Genotyping of two PBEF promoter single-nucleotide polymorphisms (SNPs), rs61330082 (C–1535T) and rs9770242 (T–1001G) , were performed in patients with ALI (n=130), sepsis alone (n=107), bacterial pneumonia (n=195) and 150 healthy volunteers using a polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method. Results: We found no variation in the T-1001G allele of PBEF . The homozygous TT genotype was the only genotype. This result is different from that observed in Caucasians. The frequency of the -1543T allele was lower in patients with ALI and sepsis than that in healthy subjects ALI vs. healthy controls: OR=0.60, 95% CI 0.43–0.84, p=0.003; and sepsis vs. healthy controls: OR=0.69, 95% CI 0.49–0.99, p=0.04, respectively). The frequency of TT genotype of - 1543T was significantly lower in patients with ALI and sepsis than in healthy subjects (ALI vs. healthy controls: OR=0.23, 95% CI 0.10–0.54, p=0.001; and sepsis vs. healthy controls: OR=0.36, 95% CI 0.15–0.83, p=0.02, respectively). Conclusions: This study suggested that -1543T allele might be a protective factor for ALI and sepsis, but it apparently had no connection with pneumonia in northeastern Chinese Han patients.

Background: This paper describes the evolution, structure, operation and some outcomes of the Brazilian Laboratory Indicators Program created by the Brazilian Society of Clinical Pathology/Laboratory Medicine (Sociedade Brasileira de Patologia Clínica/Medicina Laboratorial, or SBPC/ML), in partnership with ControlLab, a Brazilian Company that provides services for proficiency testing, internal control, calibration, and training indicators for clinical laboratories. Methods: This web-based program is confidential for all participants. It contains 61 indicators categorized into three groups. Program operation and data analysis methods are described and indicators are reported in box plot format, with grouping varying in accordance with the profiles of the participating laboratories. Three indicators were selected as examples of program effectiveness in 2011: hemolysis, blood re-collection and productivity. Results: Participants profile, examples of three indicators for the year 2011 (hemolysis, blood re-collection and productivity) and exploratory research conducted in 2012 on the implementation of the program are presented. Data related to laboratories participating in the program from 2006 to 2011 were collected and graphically represented. Conclusions: The Brazilian Laboratory Indicators Program brings important benefits for participants, contributing to the improvement of existing health systems in Brazil.

Background: Errors in the transfusion process can compromise patient safety. A study was undertaken at our center to identify the errors in the transfusion process and their causes in order to reduce their occurrence by corrective and preventive actions. Methods: All near miss, no harm events and adverse events reported in the ‘transfusion process’ during 1 year study period were recorded, classified and analyzed at a tertiary care teaching hospital in North India. Results: In total, 285 transfusion related events were reported during the study period. Of these, there were four adverse (1.5%), 10 no harm (3.5%) and 271 (95%) near miss events. Incorrect blood component transfusion rate was 1 in 6031 component units. ABO incompatible transfusion rate was one in 15,077 component units issued or one in 26,200 PRBC units issued and acute hemolytic transfusion reaction due to ABO incompatible transfusion was 1 in 60,309 component units issued. Fifty-three percent of the antecedent near miss events were bedside events. Patient sample handling errors were the single largest category of errors (n=94, 33%) followed by errors in labeling and blood component handling and storage in user areas. Conclusions: The actual and near miss event data obtained through this initiative provided us with clear evidence about latent defects and critical points in the transfusion process so that corrective and preventive actions could be taken to reduce errors and improve transfusion safety.

Background: Laboratory protocols used to calibrate commercial clinical chemistry systems affect test result quality. Mathematical models of system uncertainty can be developed using performance parameters provided by the manufacturer for various subsystems. These models can be used to evaluate protocols for specific laboratory operations. Methods: A mathematical model was developed to estimate the uncertainty inherent in the Roche Diagnostics P-Modular system, and included uncertainties associated with the sample and reagent pipettes, spectrometer and the calibration process. The model was then used to evaluate various alternate calibration protocols: calibration based on mean of replicate measurements (n=1–6) and calibration based on conditional acceptance when the following quality control specimen was within one standard deviation of target. The effect of calibrator concentrations on assay measurement uncertainty was also studied, and calibrator concentrations that minimize uncertainty at a specific concentration were identified. Results: The simulation model produced uncertainty estimates of 3.5% for the serum cholesterol assay and identified sample pipette (40%) and spectrometer (21%) as the largest contributors to measurement uncertainty. Each additional replicate calibrator measurements result in diminishing reductions in measurement uncertainty, with maximum reductions (19%) achieved with five replicate measurements. The conditional acceptance of calibration only when the control was within 1 s resulted in an 18% reduction. Conclusions: The model can be used to evaluate the utility of laboratory protocols and establish realistic assay performance targets. The model also can help instrument manufacturers and laboratorians identify major contributors to assay measurement uncertainty, which helps improve performance in future assay systems.

Background: Clinical laboratories require accurate and precise 25-hydroxyvitamin D (25-OHD) immunoassays to allow comparison of patient results with published decision limits. However, some variation in performance has been found with the previous generation of automated 25-OHD immunoassays. This study assessed the performance of four recently released automated 25-OHD immunoassays against a liquid chromatography-tandem mass spectrometry (LC-MS/MS) assay. Methods: A total of 983 samples from apparently healthy adults, plus 253 samples chosen to challenge the performance of the assays, were analyzed by the latest generation of immunoassays from Abbott, DiaSorin, Roche and Siemens. LC-MS/MS analysis was performed on a random subset of 264 samples. The precision of the immunoassays was assessed over 5 days with samples ranging between 3.0 and 370 nmol/L in concentration. Results: Immunoassays showed significant differences in precision at 25-OHD concentrations of 3.0–86.5 nmol/L but all showed acceptable precision at higher concentrations. The DiaSorin assay agreed with LC-MS/MS across the measuring range of samples tested (7.7–425 nmol/L). The other assays showed generally good performance, but had some limitations when their performance was challenged with samples with low and high 25-OHD concentrations, heterophilic antibodies or high 25-OHD 2 concentrations. The C3-epimer of 25-OHD was identified in 40.4% of healthy adults tested and was a source of analytical variance in immunoassays. Conclusions: The latest generation of 25-OHD immunoassays has improved performance compared to previous assays. However, some immunoassays can still give discrepant results and this is most apparent when immunoassays are evaluated with a range of samples that challenge their analytical performance.

Background: Vitamin D deficiency is considered a major health issue and therefore there is a need for reliable routine tests for measurement of the vitamin in blood samples. Here we present a validation of the recently released Roche 25-OH Vitamin D Total assay (Vitamin D Total). Methods: We analyzed control materials (2 levels) and patient serum pools (3 levels) ranging from 34 to 123 nmol/L 84 times over a period of 21 days, and we analyzed five serum pools in 10 separate runs to verify the limit of quantification. We also analyzed 53 paired samples of serum and Li-heparin plasma. We evaluated the 25-OH Vitamin D Total assay in comparison to our in-house liquid chromatography tandem mass spectrometry (LC-MS/MS) method [194 patient samples without 25-hydroxy vitamin D 2 (25OHD 2 ) and 23 patient samples containing 25OHD 2 ]. Results: At concentrations of 34 and 56 nmol/L within-run CVs were 4.8% and 1.9% and total CVs were 8.3% and 6.1%. We verified that the limit of quantification was 22.5 nmol/L, as stated by the manufacturer. No significant difference was observed between serum and plasma samples (Li-heparin). Comparison with LC-MS/MS using 194 samples containing 25OHD 3 only (no 25OHD 2 ) showed Vitamin D Total nmol/L=1.07×(LC-MS/MS) nmol/L+4.7 nmol/L, whereas comparison of 25OHD 2 using 23 patient samples showed Vitamin D Total nmol/L=0.55×(LC-MS/MS) nmol/L–2.38 nmol/L (Demings regression). Conclusions: The Roche Vitamin D Total assay is judged suitable for measurement of 25OHD in serum and Li-heparin plasma. Results for 25OHD 3 are comparable to those obtained by LC-MS/MS, while results for 25OHD 2 are around half of those obtained by LC-MS/MS.

Background: Measurement of serum 25-hydroxyvitamin D [25(OH)D] is used to assess vitamin D status. We evaluated the analytical performance of a new automated assay, Elecsys Vitamin D Total (Roche Diagnostics, Mannheim, Germany), based on competitive protein binding. Methods: The Elecsys assay was tested for imprecision, linearity and functional sensitivity at three test-sites and compared to a liquid chromatography-tandem mass spectrometry (LC-MS/MS) method, a high-performance liquid chromatography (HPLC) method and the Liaison 25(OH) Vitamin D Total immunoassay (Diasorin). Results: Imprecision testing with human serum specimens showed within-run CVs of ≤6% and between-run CVs of ≤8%. The assay was linear from 33 up to at least 111 nmol/L and showed equivalent 25(OH)D levels for matched serum and heparinized plasma samples. The assay correlated reasonable to well with LC-MS/MS (r=0.93; y=1.07x–5.04 nmol/L), HPLC (r=0.91, y=0.90x+3.03 nmol/L) and the Liaison assay (r=0.86, y=1.19x+2.80 nmol/L). Some of the samples showed large between-method differences. Conclusions: The new Elecsys assay fulfilled present analytical performance requirements and showed close agreement to other well-established methods for 25(OH)D analysis, making it fit for routine assessment of vitamin D status.

Background: The aim of this study was to evaluate population parameters (medians, standard deviations and coefficients of correlation) different from those used by the commercial software Elipse ® v3.0 (Perkin Elmer) in the calculation of prenatal risk of trisomy 18. Moreover, the truncation limits used for extreme values of free β-human chorionic gonadotropin (fβ-hCG), pregnancy associated plasma protein-A (PAPP-A) and nuchal translucency (NT) were revised. Methods: A calculation engine for the prenatal risk of trisomy 18 was developed [called FMF (Fetal Medicine Foundation) calculator]. Recently, published population parameters for fβ-hCG and PAPP-A as well as new truncation limits were included in this calculator. The patient-specific risks obtained by Elipse ® v3.0 and FMF calculators, were compared in 18,801 pregnant women, including 13 cases of trisomy 18, four cases of trisomy 13 and one case of triploidy. Results: Using a cut-off point of 1:250, FMF calculator increased the detection rate of trisomy 18 from 62% to 100% with a 0.31% increase in the false-positive rate (FPR). When the detection rate was fixed at 100%, the FPR generated by Elipse v3.0 (1.52%) was significantly higher (p<0.0001) than that generated by the FMF calculator (0.36%). Moreover, an improved detection in cases of trisomy 13 and triploidy was observed. Conclusions: It is recommended that each laboratory reviews the population parameters and truncation limits used in the risk calculation of trisomy 18, in order to obtain an adequate performance in the screening.

Background: Osteopontin is a glycoprotein widely expressed in many tissues and in different physiological conditions. Osteopontin concentrations are usually measured through immunological methods; however, little is known about the pre-analytical management of the sample. We evaluated the effects of different times and temperatures storage conditions on serum and plasma concentrations of osteopontin. Methods: Serum and plasma aliquots were frozen at –80°C, following storage at 4°C or room temperature for 0, 2, 4, 8, 12, 24 and 48 h. Osteopontin concentrations were determined by enzymoimmunometric assay. Serum samples obtained from tubes with or without gel separator were compared to verify the effect of gel. Western blotting analysis was performed to characterize the antibody. Results: Osteopontin concentrations were stable over time in all conditions in both serum and plasma. Plasma showed 3.8–4.8-fold higher concentrations than serum. Comparable levels were found between serum tubes with or without gel separator and always lower than those in plasma, demonstrating no effect of gel in serum tubes. Western blotting analysis showed various osteopontin bands, indicating that the antibody recognizes the entire panel of different osteopontin forms. Conclusions: We demonstrated the stability across 48 h of osteopontin in serum and plasma at either room temperature or 4°C, when the evaluation is carried out by an immune-based method. The minimal variations observed over time were always lower than the calculated intra- and inter-assay coefficients of variation. Plasma specimens should be preferred when osteopontin concentration are assayed by immunological methods.

Background: Implementation of tight glycemic control (TGC) and avoidance of hypoglycemia in intensive care unit (ICU) patients require frequent analysis of blood glucose. This can be achieved by accurate point-of-care (POC) hospital-use glucose meters. In this study one home-use and four different hospital-use POC glucose meters were evaluated in critically ill ICU patients. Methods: All patients (n=80) requiring TGC were included in this study. For each patient three to six glucose measurements (n=390) were performed. Blood glucose was determined by four hospital-use POC glucose meters, Roche Accu-Check Inform II System, HemoCue Glu201DM, Nova StatStrip, Abbott Precision Xceed Pro, and one home-use POC glucose meter, Menarini GlucoCard Memory PC. The criteria described in ISO 15197, Dutch TNO quality guideline and in NACB/ADA-2011 were applied in the comparisons. Results: According to the ISO 15197, the percentages of the measured values that fulfilled the criterion were 99.5% by Roche, 95.1% by HemoCue, 91.0% by Nova, 96.6% by Abbott, and 63.3% by Menarini. According to the TNO quality guideline these percentages were 96.1%, 91.0%, 81.8%, 94.2%, and 47.7%, respectively. Application of the NACB/ADA guideline resulted in percentages of 95.6%, 89.2%, 77.9%, 93.4%, and 45.4%, respectively. Conclusions: When ISO 15197 was applied, Roche, HemoCue and Abbott fulfilled the criterion in this patient population, whereas Nova and Menarini did not. However, when TNO quality guideline and NACB/ADA 2011 guideline were applied only Roche fulfilled the criteria.

Background: The utility of conventional prostate-specific antigen (PSA) measurements in blood for monitoring rapid responses to treatment for prostate cancer is limited because of its slow elimination rate. Prior studies have shown that free PSA (fPSA), intact PSA (iPSA) and human kallikrein-related peptidase 2 (hK2) are eliminated more rapidly after radical prostatectomy. In contrast, all three markers have similarly slow elimination rates after castration induced by gonadotropin-releasing hormone (GnRH) agonists, possibly due to the slow onset of castration. Therefore, we assessed elimination rates of tPSA, fPSA, iPSA and hK2 after rapid induction of castration with degarelix (Firmagon ® ), a novel GnRH antagonist. Methods: This study included 24 patients treated with degarelix. Blood was taken at 1, 3, 7, 14, 21 and 28 days after injection of degarelix. Free and total PSA were measured with a commercial dual-label assay, and with inhouse research assays of intact PSA and hK2. Results: Median (interquartile range, IQR) tPSA at baseline was 23.4 (15.8, 59.8). Twenty-two patients (92%) reached castrate levels of testosterone within 24 h of degarelix initiation, and all patients did so within 72 h. All kallikrein forms declined in an exponential fashion after degarelix administration. The median time to 50% reduction in biomarker level was 8–9 days for tPSA or complexed PSA vs. 2–4 days for hK2, iPSA and fPSA. The percentage eliminated at day 3 and day 7 was significantly higher for hK2, iPSA and fPSA than for tPSA (all p<0.02), while tPSA and complexed PSA were similar. Conclusions: The rapid decline of fPSA, iPSA and hK2 after fast induction of castration with degarelix is similar to that reported after prostatectomy and offers a novel, informative method to monitor rapid onset of therapeutic action targeting signaling of the androgen receptor.

Background: The ABCB1 gene encodes P-glycoprotein implicated in the development of cellular drug resistance. The aim of this study was to develop high-resolution melting (HRM) analysis for determination of ABCB1 polymorphisms and evaluate their associations with clinical data of breast carcinoma patients. Methods: HRM analysis was designed to assess five single nucleotide polymorphisms (SNPs) in ABCB1 (rs2214102, rs1128503, rs2032582, rs2032583 and rs1045642) in genomic DNA from 103 breast carcinoma patients. Results were confirmed by direct DNA sequencing. Results: HRM analysis revealed distinct patterns of melting curves for the respective genotypes of all followed SNPs. Sensitivity of HRM analysis compared with direct DNA sequencing was superior (97.1% vs. 93.9%). The overall accuracy of HRM was 97.6%. The coefficients of variation in replicate experiments encompassed the range 0.002%–0.038%. On the basis of the examined SNPs, one strong haplotype block containing rs2032582 and rs1128503 SNPs was identified. Significant associations of rs2032582 SNP with tumor size, negative HER-2/neu status, and family history of breast carcinoma were found. Patients carrying the ancestral homozygous genotype (GG) in rs2214102 had significantly worse progression-free survival in comparison with carriers of the non-ancestral allele (A) in the adjuvant set (p=0.005). Conclusions: A rapid, accurate, low-cost and time-effective method for screening ABCB1 SNPs was developed. Significant associations of ABCB1 rs2032582 and rs2214102 SNPs with prognostic factors and survival of patients were found.

Background: The aim of this study is to test the hypothesis whether the combined use of a cardio-specific biomarker, the brain natriuretic peptide (BNP) and a marker of early renal damage, the assay of urinary neutrophil gelatinase-associated lipocalin (uNGAL), may improve risk stratification in pediatric cardiac surgery. Methods: We prospectively enrolled 135 children [median age 7 (interquartile range 1–49) months] undergoing to cardiac surgery for congenital heart disease. All biomarkers were evaluated pre- and post-operatively at different times after cardiopulmonary-bypass (CPB): uNGAL at 2, 6 and 12 h; BNP at 12 and 36 h; serum creatinine at 2, 6, 12, and 36 h. Primary endpoints were development of acute kidney injury (AKI) (defined as 1.5 serum creatinine increase) and intubation time. Results: AKI occurred in 39% of patients (65% neonates and 32% older children, p=0.004). The peak of uNGAL values occurred more frequently at 2 h. uNGAL values at 2 h [median 28.2 (interquartile range 7.0–124.6) ng/L] had a good diagnostic accuracy for early diagnosis of AKI with an AUC (area under the curve) ROC (receiver operating characteristic) curve of 0.85 (SE 0.034). Using multivariable logistic regression analysis, development of AKI was significantly associated with uNGAL values at 2 h after CPB [OR=1.88 (1.30–2.72, p=0.001)], together with the CPB time and Aristotle score, as an index of complexity of the surgical procedure, while pre-operative BNP values were not. Furthermore, uNGAL and pre-operative BNP values (together with Aristotle score) were significantly associated with adverse outcome (longer intubation time and mortality). Conclusions: Pre-operative BNP and uNGAL values after surgery (together with the Aristotle score) were independently associated with a more severe course and worse outcome in children undergoing cardiac surgery for congenital heart disease.

Background: Pregnancy is a stressful condition linked with altered lipid profile, increased oxidative stress and increased inflammation processes. The purpose of the present study was to determine the associations between those alterations with increased weight gain during pregnancy. Methods: The atherogenic index of plasma (AIP) and oxidative stress status parameters were determinated in 50 healthy and 172 pregnant women with non-complicated pregnancy. Pregnant women were divided in four groups according to body mass index (BMI) values (BMI quartiles). Results: Oxidative stress parameters were significantly lower in the control group compared with all the pregnant women quartiles. Unexpectedly, differences in oxidative stress parameters between BMI quartiles groups were not significant. The antioxidant defence parameters remained quite similar in the different BMI quartiles. Weight gain and paraoxonase-1 (PON1) activities were independently associated with increased AIP while weight gain and triglyceride concentration were found to be significant predictors of PON1 activities. Conclusions: The results of our current study indicate the association of maternal weight gain during pregnancy and altered lipid profile, elevated oxidative stress and changed antioxidative capacity of PON1. Taken together all these facts indicate possible increased risk of cardiovascular disease (CVD) development in later life if the weight gain during pregnancy is excessive.

Background: Cardiac troponin T (cTnT) has been reported to be a predictor of stroke outcome. We hypothesized that the high-sensitivity cTnT (hs-cTnT) assay is superior to its previous assay generation for stroke outcome prediction. Methods: cTnT was measured on emergency department admission in 60 consecutive patients (35 males, age 69.4±13.9 years) with ischemic stroke. Adverse 90-day clinical outcome was defined as death or dependence (modified Rankin scale ≥3 or Barthel index <75). Results: Stroke aetiology was microangiopathy in three, macroangiopathy in 17, cardiac embolism in 26, dissection in one and unknown in 13 patients. At 90-day follow-up 16 (27%) patients had an adverse outcome. Receiver operating characteristics (ROC) curve analysis yielded a significantly better performance of hs-cTnT vs. cTnT (area under ROC curve: 0.80 [95% CI 0.68–0.89] vs. 0.70 [95% CI 0.57–0.82], p=0.017). The optimal discriminator values according to ROC analysis were 5.1 ng/L (hs-cTnT assay) and 11 ng/L (4th generation cTnT assay) with: sensitivities 94% vs. 56%, specificities 57% vs. 84%, positive predictive values 44% vs. 56%, and negative predictive values 96% vs. 84%. Conclusions: Improvements in cTnT assay sensitivity and precision at the low measuring range resulted in a more accurate prediction of ischemic stroke outcome, particularly for ruling out worse outcome.