1,721,010 research outputs found
Genetics in TNF-TNFR pathway: a complex network causing spondyloarthritis and conditioning response to therapy
Full text linkBackground. The seronegative spondyloarthritis (SpA) are a group of chronic inflammatory diseases resulting from a complex interplay among genetic background (mainly represented by HLA-B27) and environmental factors, that leads to the activation of autoinflammation and the dysregulation of the immune-system.
In many cases, an early diagnosis and an appropriate monitoring of disease activity can be difficult because of the overlap of clinical features. Furthermore, because of the indices of inflammation, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), are in the normal range in at least half of SpA patients with a clear expression of disease activity, a delay in diagnosis and consequently in treatment in these patients has been documented. This imparts a tremendous symptomatic burden and loss of function in these patients during the productive years of life. For all these reasons, much attention is currently devoted to the identification of biochemical and genetic biomarkers to be used in the diagnosis as well as prognostic factors in evaluating the treatment effectiveness.
Among the genetic predisposing factors, a well-known role is that of HLA-B27, which contributes however to only 20–30% of the total heritability, whereas the whole major histocompatibility complex (MHC) accounts for about 40–50% of the genetic risk of developing SpA. This suggested that other genes are involved in pathogenetic mechanism. In fact, in addition to HLA-B27, a number of genetic factors in both, MHC and non-MHC locus, have been claimed to play a role in pathogenesis of SpA.
In this context, because of TNF-α is primarily involved in the propagation and perpetuation of inflammation in SpA, the study of TNF-α genetic is of great interest. Several polymorphisms (SNPs) in genes involved in TNF-α signalling, as TNFA, TNFSF15, TNFR1 and TRADD genes, have been identified as associated with SpA, even if results are controversial. Of great interest are also variants in MEFV gene, involved in the pathogenesis of the autoinflammatory disorder Familial Mediterranean Fever (FMF). Recent studies have shown that the SpA, and in particular the ankylosing spondylitis (AS), are very common among patients affected by FMF and that these patients can present with AS as a sole manifestation.
The present study, conducted in a cohort of 91 SpA patients and 223 controls, coming from a North-East Italian region, was aimed to identify biohumoral (biochemical and haematological) and genetic factors to support the diagnostic and prognostic (response to therapy) work-up of SpA diseases. In particular, in addition to biochemical and haematological indices, we investigated whether SNPs in the promoter region of TNFA, or SNPs in the autoinflammatory TNFRSF1A and MEFV genes, might concur with HLA-B27 in enhancing the risk of developing SpA disease and/or in predicting the response to anti-TNFα drugs.
Methods. The study population comprised 91 patients with a diagnosis of SpA (mean age ± standard deviation: 52.1 ± 12.5 years; 57 males, 34 females) and 223 blood donors (mean age ± standard deviation: 46 ± 11 years; 146 males, 77 females) coming from Veneto Region, a North-East Italian region. Among patients, 36 had a diagnosis of AS and 55 patients of psoriatic arthritis (PsA), which were based on New York and CASPAR criteria respectively. The protocol of this study was approved by the Local Institutional Ethic Committee of University-Hospital of Padua, Italy (Prot.n. 3024P/13), and all participants gave written informed consent before entering the study.
Demographic and physiological data, medical and familial history data were collected for each participant. Blood samples were collected and complete blood count, CRP, ESR, uric acid, prealbumin, alanina aminotransferase (ALT) and glucose were evaluated.
Direct sequencing of MEFV (exons 2,3,5 and 10) and TNFRSF1A (exons 2,3,4 and 6) genes were performed. HLA-B27 and TNFA polymorphisms (-1031T>C;-857C>T;-376G>A;-308G>A;-238G>A) were assayed by Real Time-PCR. HLA-CW6 allele presence was analysed by molecular genetic testing using a commercially available CE-IVD microarray. Statistical analysis was performed using STATA software (version 13.1).
Results. An higher number of circulating polymorphonuclear cells and higher CRP levels could be detected in SpA patients with respect to controls, and in PsA higher levels of ALT could be observed with respect not only to controls but also to AS. Anyway these indices were not highly elevated and often comprised within the reference intervals.
As expected, HLA-B27 was associated with AS (χ2=120.1; p<0.0001). Although a slightly higher frequency of HLA-CW6 carriers was observed among patients with AS (about 6%) or PsA (about 13%) with respect to controls (about 4%), the difference was not statistically significant.
Any single studied TNFA SNP was not associated with SpA diagnosis, nor with AS or PsA considered singly. The haplotypes deriving from the pairwise combinations of the five studied SNPs were also statistically inferred. The most frequent haplotypes in controls were selected as references, and only the haplotype -1031C/-308G was significantly associated with AS (p=0.015) exerting in this disease a protective role (Odds Ratio: 0.43; Confidence Interval 95%: 0.22-0.85).
Three SNPs were identified in TNFRSF1A gene and among them, only the R92Q (Minor Allele Frequency- MAF=0.034) and the c.625+10A>G (MAF=0.479) were selected for their potential functional implications. Both SNPs were not associated with the presence of SpA (χ2=1.073 and p=0.300 for R92Q; χ2=4.721 and p=0.094 for c.625+10A>G), but c.625+10A>G was associated with the response to anti-TNF therapy, assessed by BASDAI score lower /equal or higher than 4 at 10 months (p=0.031).
Twenty-one SNPs were identified in MEFV gene and among them, 10 with a known potential functional significance. Variant alleles were extremely rare in our population (MAF0.05).
Conclusions. In conclusion the results of this study indicate the relevant role of TNF-TNFR pathway genetics in the complex network causing SpA and conditioning response to therapy. TNFA was shown to be a predisposing factor for SpA, but mainly for AS, among Italian patients, while genetics of the autoinflammatory gene MEFV appears of no impact in this setting. The haplotype resulting from TNFA-1031C/-308G, potentially associated with lower TNF-α production, exerts a protective role in AS, while the TNFRSF1A c.625+10A>G polymorphism emerged as a potential predictor of response to anti- TNFα therapy
Quality Indicators for the Total Testing Process
No full textISO 15189:2012 requires the use of quality indicators (Qls) to monitor and evaluate all steps of the total testing process, but several difficulties dissuade laboratories from effective and continuous use of Qls in routine practice. An International Federation of Clinical Chemistry and Laboratory Medicine working group addressed this problem and implemented a project to develop a model of Qls to be used in clinical laboratories worldwide to monitor and evaluate all steps of the total testing process, and decrease error rates and improve patient services in laboratory testing. All laboratories are invited, at no cost, to enroll in the project and contribute to harmonized management at the international level
Plasma lipids paediatric reference intervals: Indirect estimation using a large 14-year database
No full textObjectivesEstablishing direct reference intervals (RIs) for paediatric patients is a very challenging endeavour. Indirect RIs can address this problem, using existing clinical laboratory databases from real-world data research. Compared to the traditional direct method, the indirect approach is highly practical, widely applicable, and low-cost. Considering the relevance of dyslipidemia in the paediatric age, to provide better laboratory services to the local paediatric population, we established population-specific lipid RIs via data mining.MethodsOur laboratory information system was searched for cholesterol (TC), triglycerides (TG), low-density lipoprotein (LDL) and high-density lipoprotein (HDL) of patients aged less than 18 years, performed from January 2009 until December 2022. RIs were estimated using RefineR algorithm.ResultsValues from 215,594 patients were initially collected. After refining data on the basis of specific exclusion criteria that left 17,933 patients, we determined the RIs for each analyte, including corresponding 95% confidence interval (95% CI). Age and sex partitions were required for proper stratification of the heterogenous subpopulations. Age-related variations in TC and TG values were observed mainly in children until 5 years. RIs were defined for children less than 3 years and for those of 3-18 years. In our population, the obtained RIs were comparable with those of the literature, but the upper TG limit in subjects under the age of 3 (2.03 mmol/L with 95% CI: 1.45-2.86) was lower than that previously reported.ConclusionsOur RIs, necessary for paediatric lipid monitoring, are tailored to the serviced patient population as should be done whenever possible.imageWhat is Known Paediatric lipid screening can lead to early dyslipidemia diagnosis. Establishing direct reference intervals (RIs) for paediatric patients is challenging.What is New Indirect estimation can replace expensive direct measurements for paediatric lipid RIs. Accuracy in daily clinical practice could be significantly improved by tailoring RIs to the paediatric population served
Validation model of a laboratory-developed method for the ISO15189 accreditation: The example of salivary cortisol determination
No full textQUALITY INDICATORS IN LABORATORY MEDICINE: THE EXPERIENCE OF A LARGE LABORATORY
No full textBACKGROUND: The use of quality indicators (QIs) is needed to meet the requirements of ISO 15189 or national legi- slation, to provide information and accountability to stakeholders and users, to establish a programme of continual improvement to ensure the quality of care and patient safety. The revision issued in 2007 of ISO 15189 requires the implementation of QIs, but it does not specify what and how QIs have to be used. Only in the revision issued in 2012, the standard reports the definition of QIs and the rationale of their use. In this context, some years ago, our depart- ment designed a QIs system as a part of a coherent and integrated quality improvement strategy. The aim of this work is to report the procedure used to manage QIs and the results obtained.
METHODS: 62 QIs have been identified for the key processes (35 pre-; 13 intra- and 5 post-analitycal phase; 5 POCT), and 4 the support processes. For each QI, an operative procedure and procedural forms describing the rationale, the data collection method to be used, the quality specification to compare data and responsibility, have been defined. A computer application has been create to guarantee an accurate, standardized and traceable data collection. Collected data were processed and results analysed to identify the needed actions.
RESULTS: Some QIs results (percentage) collected in 2009 and 2013, are reported as example. Errors concerning the input of request data: 2.2-0.18 (outpatients) and 0.64-0.078 (inpatients), haemolysed samples: 1.69-1.04; insuffi- cient sample volume: 0.09-0.014; inadequate sample-anticoagulant: 0.75-0.60; inappropriate containers: 0.064-0.043; unacceptable results in IQC: 3.93-1.40; unacceptable performances in EQA/PT: 3.75-1.67. Turn Around Time (minutes) of Potassium: 50.7-44.83 (STAT) and 84.8-77.3 (routine).
CONCLUSIONS: Results demonstrate a general improving for the most of QIs. The improving actions implemented (i.e. training events organized and informative documents issued in order to decrease the error of request data input and of samples unsuitability for administrative and for inside and outside lab staff, respectively) have been effective. The monitoring of performances using QIs is an important tool to assure the improving process and guarantee the patient safety
Verification of examination procedures in clinical laboratory for imprecision, trueness and diagnostic accuracy according to ISO 15189:2012: a pragmatic approach
Full text linkBackground The International Standard ISO 15189 is recognized as a valuable guide in ensuring high quality clinical laboratory services and promoting the harmonization of accreditation programmes in laboratory medicine. Examination procedures must be verified in order to guarantee that their performance characteristics are congruent with the intended scope of the test. The aim of the present study was to propose a practice model for implementing procedures employed for the verification of validated examination procedures already used for at least 2 years in our laboratory, in agreement with the ISO 15189 requirement at the Section 5.5.1.2. Methods In order to identify the operative procedure to be used, approved documents were identified, together with the definition of performance characteristics to be evaluated for the different methods; the examination procedures used in laboratory were analyzed and checked for performance specifications reported by manufacturers. Then, operative flow charts were identified to compare the laboratory performance characteristics with those declared by manufacturers. Results The choice of performance characteristics for verification was based on approved documents used as guidance, and the specific purpose tests undertaken, a consideration being made of: imprecision and trueness for quantitative methods; diagnostic accuracy for qualitative methods; imprecision together with diagnostic accuracy for semi-quantitative methods. Conclusions The described approach, balancing technological possibilities, risks and costs and assuring the compliance of the fundamental component of result accuracy, appears promising as an easily applicable and flexible procedure helping laboratories to comply with the ISO 15189 requirements
Indicatori di Qualità nei Point Of Care Testing (POCT): Sono efficaci?
No full textIl ruolo del professionista di laboratorio risulta cruciale
nella riduzione del rischio d’errore e nella ricerca delle
soluzioni più idonee a migliorare il processo. Il POCT
costituisce un esempio significativo di come la difficoltà
a conciliare le necessità cliniche, quelle del laboratorio
e le aspettative del paziente possa generare problemi
nei flussi operativi se non sono implementate adeguate
procedure e sistemi di assicurazione per la qualità
che garantiscano la qualità dei risultati. L’adozione
di appropriati Indicatori di Qualità (IQs) può risultare
uno strumento efficace per identificare e monitorare gli
eventi indesiderati e valutare l’efficacia delle azioni di
miglioramento intraprese.
Scopo di questo lavoro è riportare i risultati, raccolti
dal 2009 ad aprile 2014, relativi a 3 IQs- risultati non
accettabili nel CQI (PNA); coefficiente di variazione
fuori target (VCV); mancanza/ritardo di manutenzione o
sostituzione degli elettrodi per emogasanalizzatori (RIT)-
identificati per il monitoraggio dei problemi dei POCT (54
glucometri e 37 emogasanalizzatori) sotto il controllo del
nostro Dipartimento.
I risultati ottenuti dimostrano un generale miglioramento
delle prestazioni. In particolare:
Glucometri. La percentuale di PNA è diminuita nel corso
degli anni, da 8,6 (2009) a 1,5 (2013), e pari a 1,1 nei
primi mesi del 2014. La percentuale dei VCV è diminuita
da 1,6 (2010), per entrambi i livelli di CQI, a 0,3 e 0 (2013)
rispettivamente per il livello 1 e 2. Nei primi mesi del 2014
è pari a 0,7 per il livello 1 e a 0 per il livello 2.
Emogasanalizzatori. Il numero medio annuale di RIT
risulta costante nel tempo (3,68), dal 2009 al 2013, ma
ridotto (1,50) nei primi mesi del 2014.
Il miglioramento osservato dimostra l’efficacia delle
azioni correttive intraprese (sostituzione dei glucometri in
uso con glucometri più efficienti; sostituzione anticipata
degli elettrodi degli emogasanalizzatori in caso di
deriva del CQI) e l’utilità degli IQs come strumento di
assicurazione per la qualità. Inoltre l’uso degli IQs si è
dimostrato fondamentale nel migliorare la collaborazione
tra il personale clinico, che deve segnalare i problemi
evidenziati, ed i professionisti di laboratorio suggerendo
le più opportune azioni di miglioramento
POINT OF CARE TESTING (POCTS): THE IMPORTANCE OF CRITICAL PROBLEMS REPORTING
No full textBACKGROUND: POCTs encompass a range of testing and most hospitals use POCTs to deliver results in a timely manner allowing quick clinical decisions and, potentially, a better clinical outcome. Consequently, POCTs demand the need for robust governance and quality assurance procedures are required to guarantee the reliability of POCTs results.
METHODS: The Laboratory records all information about critical problems (ICP) notified by clinical wards and identified from data transmitted in real time by middleware. In this work we counted all ICP collected in March and November, from 2009 to 2013, and we reported the average of two months. The aim of this work is to analyse the collected data and verify if corrective actions undertaken have been effective.
RESULTS: The number of POCT instruments increased from 126 (2009) to 168 (2013). The ICP typology concerns: in- strumentations failures (INS), 25%; non conformities (NC), 25%; failures in Internal Quality Control performances (IQC- F), 39%; calibration problems, 7%; others, 4%. 70% of ICP concerns 168 Blood gas analyzers (BG), 27% from 309 glucose meters (GM) and 3% from 236 coagulometers (CM). The ICP number related to BG decreased from 44 (2010) to 21.5 (2013): IQC-F, 53%; NC, 20%; INS, 17%; others, 10%. The main problem of IQC-F concerns a continuous decreasing of concentrations of lactate at a low level (87%). Nevertheless, the ICP number is decreased: from 15 (2010) to 4.5 (2013). The number of ICP related to GM highlights a variable trend over time: 12 (2009); 17 (2010); 23 (2011); 6 (2012); 11 (2013). The main problems are INS (37%) and NC (34%) that showed an increasing from 2009 to 2011, followed by a decreasing in the last two years (from 11.5 and 15, in 2011, to 0.5 and 6, in 2013 respectively). CM data are not reported for the low percentage.
CONCLUSIONS: The results demonstrate an improvement of POCTs management and the effectiveness of implemented corrective actions. The main implemented actions suggested by laboratory have been the BG electrode replacement, when the performance of IQC starts to decline, and the change of GM with new and more efficient analyzers (after 2011). The continuous monitoring of POCTs problems is an efficient tool for directing the laboratory interventions to the critical issues
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