December 2018ISSN 1650-3414

Communications and Publications Division (CPD) of the IFCC
Editor-in-chief: Prof. János Kappelmayer, MD, PhD
Faculty of Medicine, University of Debrecen, Hungary
e-mail: ejifcc@ifcc.org

The
Journal of theInternational
Federation ofClinicalChemistry andLaboratory
Medicine

Volume 29 Number 4

In this issue
Laboratory Medicine:
Meeting the needs of the Mediterranean nations
Part 2

Foreword from the editor-in-chief
János Kappelmayer

241

Traceability in laboratory medicine: what is it and why is it important for patients?
Graham H. Beastall

242

Laboratory medicine in Palestine
Rania Abu Seir, Osama Najjar

248Inter-laboratory comparisons and EQA in the Mediterranean area
Alexander Haliassos

253

An evidence-based laboratory medicine approach to evaluate new laboratory tests
Tommaso Trenti

259

Which skills are needed and how they should be gainedby laboratory medicine professionals for successful ISO 15189 accreditation
Diler Aslan

264

Prenatal screening for chromosomal abnormalities:
where do we stand today in Mediterranean countries?
Demetrios Rizos

274

The role of laboratory medicine for health during pregnancy
Adnan Alkhatib

280

Alcohol abuse
Tomáš Zima

285

In this issue

Urinary proteomics in biomarker discovery of kidney-related disorders:
diabetic nephropathy and drug-induced nephrotoxicity in chronic headache
Elisa Bellei, Emanuela Monari, Stefania Bergamini, Luigi Alberto Pini,
Aldo Tomasi, Tomris Ozben

290Standardization of the HbA2 assay
Renata Paleari, Andrea Mosca

298

Surrogate biomarkers for monitoring healthcare quality
for chronic diseases such as diabetes care
Diler Aslan

303

The role of laboratory medicine in addressing migrant health problems
Adekunle Bashiru Okesina, Ademola Adelekan

309

In this issue: Laboratory medicine–meeting the needs of Mediterranean nations (Part 2)

This is a Platinum Open Access Journal distributed under the terms of the Creative Commons Attribution Non-Commercial License which permits unrestricted
non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Foreword from the editor-in-chief
János Kappelmayer, MD, PhD

This issue of the eJIFCC incorporates the second
part of a series of manuscripts that were presented at the conference entitled “Laboratory medicine: meeting the needs of the Mediterraneannations”.
The conference was held in Rome, between
July 2-4, 2018, with professor Sergio Bernardinias the Conference President.

This issue is part 2 of a two-part series, and contains articles covering the following sections:•Improving efficiency in laboratory medicine;•

Perinatal and pregnancy laboratory
medicine; and•Mediterranean diet and the area’s specificdiseases.
János Kappelmayer
EditorPage 241

eJIFCC2018Vol29No4pp241-241

Meeting the needs of Mediterranean nations: improving efficiency in laboratory medicine

This is a Platinum Open Access Journal distributed under the terms of the Creative Commons Attribution Non-Commercial License which permits unrestricted
non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Traceability in laboratory medicine: what is it
and why is it important for patients?
Graham H. Beastall1,2
1

University of Glasgow, Mayfield, Birdston, Glasgow, United Kingdom

2

The Joint Committee for Traceability in Laboratory Medicine (JCTLM)

ARTICLE INFOABSTRACT

Corresponding author:
Graham H. Beastall
University of Glasgow
Mayfield, Birdston
Glasgow G66 1RW
United Kingdom
E-mail: gbeastall@googlemail.com

The between method variability of patient results isa source of uncertainty that can have adverse consequences for patient safety and clinical outcomes.
Globalisation requires that laboratory medicine results
should be transferable between methods. Traceability
in laboratory medicine aims to reduce between method variability so that results are independent of timeor location. Application of the metrological traceability
chain facilitates a universal approach based around the
preparation, adoption and use of higher order international commutable reference materials and reference
measurement procedures, supported by expert reference laboratories. Global collaboration is required,involving several different stakeholder groups ranging
from international experts to laboratory medicine specialists in routine clinical laboratories.

Key words:
metrological traceability,commutability, stakeholder action plan
Acknowledgements:
Published on behalf of the Joint Committee
for Traceability in Laboratory Medicine (JCTLM)

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Graham H. Beastall
Traceability in laboratory medicine: what is it and why is it important for patients?

INTRODUCTION
Laboratory medicine results influence a high percentage of all clinical decisions. Patients expectthat different laboratories, using different methods, will give the same result for an analyte measured in a clinical sample. Often this is not thecase and an inappropriate clinical decision fora patient may be the consequence. Laboratory
medicine specialists have a professional responsibility to provide a high-quality service that is
optimised to the needs of the patient [1].
Traceability in laboratory medicine aims to reduce between method variability so that results
are independent of time or location [2]. Achieving
traceability is a global multi-stakeholder cooperative activity involving metrologists; international standards organisations; scientific andclinical experts from international professional
bodies; healthcare regulators; and the in-vitro
diagnostics (IVD) industry that is responsible forthe manufacture and sale of diagnostic testing
systems [3]. The Joint Committee for Traceabilityin Laboratory Medicine (JCTLM) was established
to co-ordinate the activity of these stakeholders,
to provide educational support for traceability,
and to establish and maintain a database of reference materials, reference methods and reference laboratories [4].
THE IMPORTANCE
OF REDUCING BETWEEN-METHOD
AND BETWEEN-LABORATORY VARIABILITY
There are several reasons why efforts should
be made to reduce between-method and between-laboratory variability [5]. These include:•

Improving patient safety•

Facilitating patient empowerment•

Ensuring public confidence•

Enabling consolidation and networking•

Supporting laboratory accreditation•

Implementing evidence-based clinicalguidelines•

Guaranteeing clinical governance•

Adopting common informatics•

Introducing the electronic patient record

TRACEABILITY IN LABORATORYMEDICINE AND THE METROLOGICALTRACEABILITY CHAIN
Metrology is the science of measurement. The
basics of measurement involve:•

A measurable property, known as a quantity(e.g. concentration)•

Definition of the measurand – the quantitythat is intended to be measured. The description of the measurand should include
the matrix (e.g. plasma); the component(analyte) of interest, and the amount of
substance concentration•

The units in which the measurement will bemade. Metrological traceability requires theinternational system of units (SI) or units
with well-established conversions•

The uncertainty with which the measurement can be madeMetrological traceability is the property of ameasurement result, which can be related toa reference through a documented unbroken
chain of calibrations. The principles of a reference measurement system for establishing
metrological traceability are described in the
ISO17511:2003 document [6]. The components
of a reference measurement system comprisereference materials (calibrators) and measurement procedures (methods), both of which exist at different hierarchical levels.
The inter-relationship between the components
of a reference measurement system describes
the metrological traceability chain [6]. Figure 1
depicts this traceability chain with higher order

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Graham H. Beastall
Traceability in laboratory medicine: what is it and why is it important for patients?

Figure 1

Metrological traceability chain for laboratory medicine

Primary reference material

Primary reference
measurement procedure

Metrological traceability

Primary calibrator
Secondary reference
measurement procedure

Metrology
institute /Reference lab

Secondary calibrator
Manufacturer selected
measurement procedure

Manufacturer master
calibrator

IVD method
manufacturer

Manufacturer standing
measurement procedure

Product calibrator

Routine laboratory method
Patient result

Measurement uncertainty

Definition of measurand: concentration in SI units

Routinelab

Adapted from EN ISO 17511 2003 [6]reference materials and measurement procedures at the top and lower order towards thebottom. This hierarchy is depicted by the rising ‘metrological traceability’ arrow. Descentthrough the traceability chain is accompanied
by increasing measurement uncertainty as depicted by the downward arrow.
The traceability status of an individual measurement result depends on the existence of an unbroken chain to higher order materials and/or
measurement procedures. To be effective theunbroken chain requires commutable materials[7] and sufficiently low imprecision at each step.
In the case of structurally simple molecules,
like many of those measured routinely in clinical chemistry, it is possible to have a complete
unbroken chain to primary reference measurement procedures and primary reference materials. Even for some protein molecules it is possible

to achieve full metrological traceability by usinga unique, signature peptide as the primary reference material. The measurement of serum cholesterol and blood haemoglobin A1c are examplesof full metrological traceability where the agreement between methods is excellent [3]. Serumparathyroid hormone and blood haemoglobin A2
are examples where the between-method variability is unacceptably high, causing clinical risk.
In both these cases method standardisation/harmonisation initiatives have commenced [3].
For many biological materials, including complex proteins and viruses it is not possible toprepare secondary calibrators. In these circumstances international conventional calibrators
are adopted as being the highest order materials available. The global acceptance of such international conventional calibrators can facilitate reduced between method variability.

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Graham H. Beastall
Traceability in laboratory medicine: what is it and why is it important for patients?

SOURCES OF REFERENCE MATERIALSAND REFERENCE MEASUREMENTPROCEDURESCHALLENGES IN IMPLEMENTINGTRACEABILITY IN LABORATORY MEDICINEAT A GLOBAL LEVELThe JCTLM maintains a database of reference materials, reference measurement procedures and reference laboratories [8]. Strict
criteria are required for inclusion in the JCTLM
database, including evidence of commutability of reference materials and measurement
uncertainty.

There are several challenges to implementing
global traceability [3]. These include:

The World Health Organization Expert Committee
for Biological Standardization (WHO-ECBS) maintains a catalogue of international conventional
calibrators for blood products and biologicalstan­dards [9].
Figure 2••••

Geographical differences
Lack of uniformity of units
Complex analytes
Global coordination

STAKEHOLDERS IN IMPLEMENTINGTRACEABILITY IN LABORATORY MEDICINEThe stakeholders involved in delivering traceability in laboratory medicine into routine practice are summarised in Figure 2.

Global stakeholders involved in delivering traceability
in laboratory medicine into routine practice

Select methods based on
quality performance

Routinelab

Use commutable materials tomonitor method performance

EQA
providers

Produce higher-order methods
with commutable calibrators
Raise analytical and clinicalquality targets
List available materials andmethods. Promote traceability
Provide reference materials
and reference methods
Define clinical decision values
and analytical requirements

IVD method
manufacturers
Standards / accreditation /professional bodies
Global database of referencematerials & methods
National metrology institutes
Professional bodies / societies
Internationally recognised expert
clinical / laboratory committees
Adapted from Beastall et al. [3]Page 245

eJIFCC2018Vol29No4pp242-247

Graham H. Beastall
Traceability in laboratory medicine: what is it and why is it important for patients?

The initiative begins at the bottom of the triangle with international recognition of the needfor traceability for a specific analyte. Thereafter,international and national standards organisations and metrology institutes are responsible
for producing and listing the available referencematerials and measurement procedures. These
are used by the IVD method manufacturers to
produce the methods made available for routine
use with their performance evaluated throughexternal quality assessment (EQA) schemes
based on commutable control materials.

3. Global database of reference materials andmethods:

Develop international consortium forcommunication and sharing information on the need for traceability•

Prioritise and agree methods that require harmonisation and issue invitations to expert groups to undertake
method harmonisation projects [10]•Provide educational support materials
to promote the importance of traceability in laboratory medicine•

Include traceability in laboratory medicine in the training of laboratory medicine specialists and in the standards
required for laboratory accreditation•

Provide educational support materials
to promote the importance of traceability in laboratory medicine•

Produce IVD methods that conformwith the highest available order of metrological traceability•

Provide details of the traceability statusof methods in the information for use
documentation

6. EQA providers:

2. National metrology institutes/international
professional bodies/societies:••

5. IVD method manufacturers:

1. Internationally recognised expert clinical/
laboratory committees:•

Using freely available lists and catalogues publicise available referencematerials and methods that meetagreed standards, including informationon commutability and measurement
uncertainty

4. Standards/accreditation/professional bodies:

ACTION PLAN TO IMPLEMENTTRACEABILITY IN LABORATORY MEDICINEAT A GLOBAL LEVEL
The implementation of traceability in laboratory
medicine at a global level requires a coordinatedaction plan. This can be derived from Figure 2
by assigning actions to each of the seven stakeholder groups [3].

•Develop commutable reference materials and measurement procedures forindividual analytes to the highest available order of metrological traceability•

Promote the use of commutable EQA
materials•

Provide educational support about
traceability for EQA scheme participants

7. Routine laboratory medicine specialists:

Publish the outcome of harmonisation
projects in peer-reviewed scientific
literature
Page 246•

Know the traceability status of themethods used and understand themeasurement uncertainty involved•

Educate staff about traceability in laboratory medicine and its importance tohealthcare

eJIFCC2018Vol29No4pp242-247

Graham H. Beastall
Traceability in laboratory medicine: what is it and why is it important for patients?

Resources for educational support are available
from JCTLM [4]. Readers of this article are invited
to discuss with their peers how they can contribute to the coordinated action plan.
REFERENCES
1. Beastall GH. Adding value to laboratory medicine: aprofessional responsibility. Clin Chem Lab Med 2013; 51:
221-228
2. White GH. Metrological traceability in clinical biochemistry. Ann Clin Biochem 2011; 48: 393-409
3. Beastall GH, Brouwer N, Quiroga S, Myers GL. Traceability in laboratory medicine: a global driver for accurate
results for patient care. Clin Chem Lab Med 2017; 55:
1100-1108
4. JCTLM: Traceability, education and promotion. www.
jctlm.org (accessed 25 July 2018)

5. Plebani M. Harmonization in laboratory medicine: thecomplete picture. Clin Chem Lab Med 2013; 51: 741-751
6. ISO 17511: 2003 In vitro diagnostic medical devices measurement of quantities in biological samples – metrological traceability of values assigned to calibrators andcontrol materials ISO, Geneva, Switzerland; 2003
7. Young IS. The enduring importance and challenge ofcommutability. Clin Chem 2018; 64: 421-423
8. JCTLM database of reference materials and measurement procedures www.bipm.org/jctlm/ (accessed 25 July
2018)
9. WHO catalogue of blood products and related biologicals http://www.who.int/bloodproducts/catalogue/en(accessed 25 July 2018)
10. The International Consortium for Harmonization ofClinical Laboratory Results. www.harmonization.net (accessed 25 July 2018)

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Meeting the needs of Mediterranean nations: improving efficiency in laboratory medicine

This is a Platinum Open Access Journal distributed under the terms of the Creative Commons Attribution Non-Commercial License which permits unrestricted
non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Laboratory medicine in Palestine
Rania Abu Seir1, Osama Najjar2
1
2

Department of Medical Laboratory Sciences, Al-Quds University, Abu Dis, Palestine
Ministry of Health, Palestine

ARTICLE INFOABSTRACT

Corresponding author:
Rania Abu Seir
Department of Medical Laboratory Sciences
Al-Quds University
Abu Dis
Palestine
Phone: +972 54 359 4382
E-mail: rabusear@staff.alquds.edu

BackgroundKey words:
Palestine, accreditation,
molecular testing, quality assurance

Laboratory Medicine (LM) is one of the cornerstonesof healthcare. In Palestine, 3.5% of health expenditureis allocated to clinical laboratories.
Methodology
The Palestinian Ministry of Health (MOH) started toinvest in the development and expansion of laboratory services including the introduction of full automation in blood banks and histopathology, molecular
testing in microbiology, and testing for autoimmune
diseases and metabolic disorders. Improvements
have not been limited to new tests but also included
external quality assurance (EQA) and accreditation
programs.
Results
Latest investments have cut the costs of purchasing
tests from outside MOH by more than 3.6 million
dollars during the last five years. Al-Quds University
established a Center for External Quality Control in
LM which was supported by the Palestinian MOH
and the National Metrology Institute of Germany.
This has led to a significant improvement in the performance of the affiliated laboratories. An accreditation unit was established within the MOH, yet the
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Rania Abu Seir, Osama Najjar
Laboratory medicine in Palestine

number of laboratories that have been accredited with ISO-15189 are still limited but significantly increasing.
The academic institutions have been working in parallel to the MOH in improving LM in
Palestine. A new academic curriculum for LM
has been developed according to the quality
standards of curricula-based competencies determined by the needs of the labor market andthe emerging technologies.
Conclusions
Despite the invested efforts, still, the PalestinianLM suffers from shortage of human resources
which are qualified in the new emerging diagnostic approaches.


BACKGROUND
The Palestinian population is approximately 4.8
million living in two geographically separate regions; the West Bank and Gaza Strip, ruled by
the Palestinian Authority since 1994 [1]. The
Palestinian Ministry of Health (MOH) is the primary provider of healthcare services for thePalestinian population. Other healthcare providers include non-governmental organizations(NGOs), United Nations Relief and Works Agency(UNRWA) for Palestine Refugees and Military
Medical Services.
The Palestinian population is a young population, although it has been aging over the lasttwo decades. Further, decrease in infant andmaternal mortality rates indicate improvementsin the healthcare system. Nevertheless, changes
in morbidity and mortality patterns which havebeen shifting from infectious diseases to noncommunicable diseases raise new challenges
to the healthcare system, especially with theincreasing demand for personalized and quality
patient care [2].

MEDICAL LABORATORIESIN PALESTINIAN HEALTHCARE SYSTEM
Issues and challenges
The Palestinian MOH has been working on
building a comprehensive strategy to address
the needs of the healthcare system and LM in
particular. The total health expenditure was approximately 430 million dollars in 2016, an increase of 40% since 2010. Of the total healthexpenditure, 3.5% is allocated for medical laboratories [2, 3]. The role of medical laboratories in medical practices has been highlighted
over the last few years, and since then several
investments to improve the capacity and quality of LM have taken place. The MOH increased
the number of laboratories in their facilities.
The statistics of 2016 showed that the numberof laboratories increased to 14 medium laboratories (hospital laboratories), 188 peripheral
laboratories, three histopathology laboratories
and one public health central laboratory. Sixhundred and thirteen laboratory technicians
have been employed in the MOH laboratories,
representing 12% of the Palestinian laboratory technicians [2]. The improvements havenot been limited to only the number of laboratories, but also included investments in new
equipment to increase the range of tests performed within the MOH laboratories. The total
number of laboratory tests performed within
the laboratories of the MOH increased from 4.5
million tests in 2011 to 6.9 million in 2016 [2].
Consequently, the Palestinian MOH significantly
reduced the purchased services from the neighboring countries’ healthcare institutions.
Education and training
Education in medical laboratory sciences (MLS)
was introduced in the West Bank and Gaza Strip
in 1979. Currently, ten MLS programs exist; one
diploma, three master programs, and the remainder offer bachelor degrees. These programs are

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Rania Abu Seir, Osama Najjar
Laboratory medicine in Palestinecertified by the Palestinian Ministry of Educationand Higher Education and by the National
Accreditation and Quality Assurance Commission
which is the only body responsible for accreditation and quality assurance of Palestinian educational programs.
Palestinian MLS academic curricula lack international accreditation. Moreover, the shortageof specialized faculty members in many fields
of MLS in educational institutions is one of thelimitations of education in Palestine, especiallyin the newly emerging fields. This problem is
expected to grow even further as older faculty members retire in addition to the increased
need for new technical skills in MLS.
The number of training facilities and supervisors is limited, and annually around 300
students require training in medical laboratories
as part of their graduation requirements. This issue created a surplus in laboratory technicians
whose skills are not the most optimal. Amongthe graduates, and according to the records of
the Palestinian Medical Technology Association(PMTA), there currently is around a forty percent unemployment rate, primarily among females. Further, the majority of the graduatesare bachelor degree holders.
Recently, Al-Quds University launched a joint
project with prominent health institutions aiming at improving the education quality of the
MLS graduates by developing a new academic
curriculum according to national and international standards. The new curriculum will be developed according to the new quality standardsof the curricula-based competencies determinedby the labor market needs and the provision of
the partner institutions. In addition, the emerging technologies in LM will be included within
the curriculum which will contribute to enhancing the hands on practice of Palestinian laboratory professionals.

Molecular diagnostics in disease control
Molecular testing is becoming a crucial diagnostic tool in the setting of inherited genetic diseases, neoplastic diseases, and infectious diseases.
For the last decade, morbidity and mortality
patterns of the Palestinians shifted from communicable to non-communicable diseases. The
leading causes of mortality during 2016 werecardiovascular diseases, cancer, cerebrovascular diseases, and diabetes which are responsiblefor 65.4% of all deaths among Palestinians [2].
Molecular testing has only been introduced into
the Palestinian MOH medical laboratories since2010. Molecular testing requires specialized
training and skill set. Currently, ninety-four molecular tests are available at the MOH Central Public
Health Laboratory which are used to diagnose viral and bacterial infectious agents. Infectious diseases and respiratory diseases are responsible
for less than 10% of all deaths in the West Bankand Gaza Strip [2]. During the period between
2010 and February 2017, a total of 19403 molecular tests had been performed to diagnose sevenprimary causes of respiratory tract infections including influenza A and B, Bordetella pertussis,
Adenovirus, enteroviruses, Streptococcus pneumoniae and Respiratory Syncytial Virus (RSV).
Among these, only 39.3% of the test results werepositive and had a confirmed differential diagnosis. Molecular testing of infectious diseases is an
essential tool not only for accurate and timely
diagnosis and treatment monitoring but also,
for disease control and surveillance. Therefore,
more molecular tests should be introduced tocover a wider range of infections to enhance thedifferential diagnosis of communicable diseases. In addition, molecular testing is crucial in the
diagnosis of genetic diseases that are common
among Palestinians such as thalassemia, hemophilia, inborn errors of metabolism, and cystic
fibrosis, but as yet they are not introduced into
the Palestinian laboratories.

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Rania Abu Seir, Osama Najjar
Laboratory medicine in Palestine

Moreover, the importance of molecular testingin personalized medicine and in oncology, in particular, has been confirmed, shedding light on its
value for accurate diagnosis, targeted therapy,
and oncology genomic-based effective treatment. Furthermore, the use of biomarkers isthe essence of individualized oncology and has
already proven to result in more effective treatment protocols [4]. The use of personalized medicine assays requires a highly qualified team ofmolecular biologists who are almost absent in
the West Bank and Gaza Strip, creating a challenge in introducing the new emerging tests into
the Palestinian laboratories.
Accreditation and quality assurance
Efficiency, cost-effectiveness, and quality ofhealthcare are the top priorities in today’s world.
Accurate laboratory tests are required for the
diagnosis of diseases and monitoring of treatment. Testing errors can be reduced throughquality management and accreditation to ensure reliability and quality results. Over the last
few years, quality improvement in medical laboratory testing received increased attention from
the MOH. In 2014, the Palestinian MOH and
the National Metrology Institute of Germany:
Physikalisch – Technische Bundesanstalt (PTB),
supported the external quality assurance program (EQAS) that was established by Al-Quds
University in 1996. The center’s activities include
preparation of quality control (QC) samples, distribution of samples to the participating laboratories, collection of the QC samples’ results,
and finally analyzing the results to evaluate theperformance of the affiliated laboratories [5].
Subsequently, participation in the EQAS program became mandatory in 2016, resulting in asignificant increase in the number of affiliatedlaboratories from 148 to 435. The program testing panel currently includes the basic laboratory
tests in chemistry, hematology and hemostasis.
Each laboratory’s performance is determined by

calculating the mean-variance index score (VIS).
Findings from the EQAS program showed a significant improvement in the performance of thelaboratories upon joining the program comparedto their performance before joining. As regards
to laboratory accreditation, up until 2016 theonly laboratory that had already received theISO 15189 accreditation was the Central Public
Health Laboratory (CPHL), which is under the supervision of MOH. It is noteworthy that, recently,
a few more laboratories have started working on
implementing quality management systems.
Recommendations
The role of medical laboratories in healthcare
has been highlighted over the past few years
within the Palestinian MOH. Several improvements that facilitated accessibility and added awide range of new tests were achieved. In addition, the importance of quality assurance andaccreditation in providing quality care became
well recognized. Regardless, continuous efforts
are still required. In this context, there is an urgent need to work on broadening the use ofmolecular testing in LM for non-communicablediseases especially cancer. Moreover, personalized medicine assays should be implemented
to provide the best possible cancer care interms of treatment and prediction of prognosis of the patient. On the top of that, academic
institutions should play an integral part in thecontinuous improvement of laboratory technicians’ qualifications by updating the academic
curricula to include the most recent approaches
and technologies in LM. In addition, partnership and collaborations with international bodies specialized in laboratory medicine should beinitiated to offer opportunities for training andcapacity building of human resources which willconsequently enforce the transformation process. Finally, a coherent national policy for accreditation and quality assurance should be emphasized and implemented by the PalestinianPage 251

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Rania Abu Seir, Osama Najjar
Laboratory medicine in Palestine

MOH to all laboratories and for all types of tests
to ensure a high quality of the provided laboratory services.
REFERENCES
1. Palestinian Central Bureau of Statistics (PCBS). Estimated Population in the Palestinian Territory Mid-Yearby Governorate,1997-2016.[cited 12.07.2018] Available
from http://www.pcbs.gov.ps/Portals/_Rainbow/Documents/gover_e.htm.
2. Ministry of Health MOH. Health annual report,
Palestine, 2016. 2017.[cited 10.07.2018] Available
from: https://www.site.moh.ps/Content/Books/ZxRcynmiUofNqt66u4CrHRgmJR6Uv7z77srjjIEAho6xnz-

5V3rgLTu_RhO7xf2j2VusNiIvWkjwp84yXHLdGleB97gKrHHI5iZ9oPJ25owGEN.pdf.
3. Ministry of Health (MOH). Health annual report, Palestine, 2010. 2011.[cited 10.07.2018] Available from:https://www.site.moh.ps/Content/Books/NNdajiUdOAIiBzEWQjlGRNukeRac6zrXCdZLWfkiwVvCEoEzDkqZaJ_
yNPgmf1T95wPO8Oox7wyDb6ejWuh1Gr9jhQEFdaon474oRwPc2XlEH.pdf.
4. M. Kalia, Personalized oncology: recent advancesand future challenges. Metabolism, 2013. 62 Suppl 1:
p. S11-4.
5. Center for Quality Control in Laboratory Medicine(EQC).[cited 12.07.2018] Available from: http://eqas.
alquds.edu/en/

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Meeting the needs of Mediterranean nations: improving efficiency in laboratory medicine

This is a Platinum Open Access Journal distributed under the terms of the Creative Commons Attribution Non-Commercial License which permits unrestricted
non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Inter-laboratory comparisons and EQA
in the Mediterranean area
Alexander Haliassos1,2
1
2

IFCC Committee on Proficiency Testing (C-PT)
ESEAP – Proficiency Testing Scheme for Clinical Laboratories

ARTICLE INFOABSTRACT

Corresponding author:
Alexander Haliassos
47 Alopekis Street
GR-106 76 Athens
GreecePhone: +30 694 4373473
E-mail: haliassos@moleculardiagnostics.gr

The role of Proficiency Testing schemes (PT) or
External Quality Control programs (EQA), involves theuse of inter-laboratory comparisons for the determination of laboratory performance. EQA-PT schemes
are of primordial importance to the analytical quality, standardization of methods and harmonizationof the results. Laboratories are familiar with EQA-PT
schemes as they are a prerequisite for their accreditation according to the ISO/IEC 15189 standard.

Key words:
Proficiency Testing scheme (PT),
External Quality Control programs (EQA),
Mediterranean countries, laboratory
medicine, clinical chemistry, IFCC
Acknowledgements:
Published on behalf of the IFCC Committee
on Proficiency Testing (C-PT)
and of the ESEAP – Proficiency Testing
Scheme for Clinical Laboratories.

The IFCC Committee on Proficiency Testing (C-PT)
conducted a survey among the colleagues of theMediterranean countries in order to evaluate thestatus of the EQA-PT providers in the region, their acceptance among laboratories, and possible issues intheir implementation. The survey was organized electronically and we received 59 replies from colleagues(IFCC National Representatives and affiliated EQA-PT
providers), from 17 of the 23 countries (74%) of theMediterranean area.
We concluded that there is a broad difference in theapplication of the rules of External Quality Control
programs or Proficiency Testing schemes, among
the Laboratories in the Mediterranean countries.
Moreover, as the Accreditation of the Laboratories isPage 253

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Alexander Haliassos
Inter-laboratory comparisons and EQA in the Mediterranean area

not mandatory in the majority of these countries, there is no valid reason for participation in
EQA-PT schemes.


The role of Proficiency Testing schemes (PT) or
External Quality Control programs (EQA), involves the use of Inter-Laboratory comparisons
for the determination of Laboratory Performance (1). The application of comparative analysis adds value to the competency of the laboratories and provides room for improvement (2).
Laboratories are familiar with EQA-PT schemes
as they are a prerequisite for the accreditationaccording to the ISO/IEC 15189 standard (3).
EQAs-PT schemes are of primordial importanceto the analytical quality, standardization of
methods and harmonization of results (4-6).
IFCC has been recognized for its leading role andefforts towards the standardization of ClinicalLaboratory methods. Many commercially available IVD tests acknowledge, in their inserts, theuse of IFCC methods. The work of the federation
also led to novel analytical approaches, which,although recognized by the different regulating bodies are not, yet, unanimously accepted
worldwide as in the case of HbA1c.
Meanwhile, the IFCC possesses the resources
and knowledge via the involvement of member
societies running Proficiency Testing schemes
as non-profit organizations, and also the expertise provided by distinguished scientists who
have the know-how to design and produce thenecessary novel control materials for specialized External Quality Control programs.
The IFCC Committee on Proficiency Testing (CPT), ex Task Force on Proficiency Testing (TF-PT),
helps publicize the existence of specialized andof general-purpose EQA-PT schemes in the fieldof clinical Chemistry - Laboratory Medicine. The
main project of the committee is the creation of

an online database - web application (PTDB) accessible via web browsers and via specific client
applications, for the major mobile platforms,
offering broader functionality and ease of use.
The foundation of this database are the analytes (tests, measurands) and the corresponding analytical methods (assays, instruments,
reagents, etc.).
The second part of the database is the PT providers section containing all their contact information, and their programs, their accreditationor certification status, etc. The providers part ofthe database was completed in mid-February
2017 and June 2018, the PTDB includes 68 providers from all around the globe. The PTDB canbe consulted directly at http://ptdb.ifcc.org/
providers.
On the occasion of the First IFCC, EFLM, AFCB
Conference, “Laboratory Medicine: Meetingthe needs of Mediterranean Nations”, held
between 2-4 July 2018 in Rome, Italy, the C-PT
conducted a survey among the colleagues from
the Mediterranean countries in order to accessthe status of the EQA-PT schemes in the region,
their acceptance, as well as possible issues intheir implementation.
The survey was organized electronically, and59 colleagues replied, mostly IFCC National
Representatives and affiliated EQA-PT providers,from 17 of the 23 countries of the Mediterraneanarea (74% of the Mediterranean countries).
For the first question“Is the participation of medical laboratories
in External Quality Control Proficiency Testing schemes inyour country mandatory, by:”
53% of the countries replied by law, 29% of thecountries replied by Scientific Society guidelines, 6% of the countries replied by Social
Security organization in order to reimburse thetests and finally 47% of the countries replied

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Alexander Haliassos
Inter-laboratory comparisons and EQA in the Mediterranean area

Figure 1

Reasons for participation of medical laboratories in EQA-PT schemesin Mediterranean countries

Figure 2

Frequency of participation by discipline of medical laboratories
equency o Partic patoin EQA-PT schemes inF Mediterraneancountries

70

60

50

40

30

20

10

Eg
yp
t
Lib
ya
Tu
nis
ia
Al
ge
r
M ia
or
oc
co
Jo
rd
an

Ita
ly
M
al
Slo ta
ve
nia
Cr
oa
tia
M Bos
n
on
te ia
ne
gr
o
Al
ba
F.Y nia
.R.
O.
M
.
Gr
ee
ce
Tu
rke
y
Cy
pr
us
Sy
r
Le ia
ba
no
n
Isr
a
Pa el
les
tin
e

Fra
nc
e

0

Clinical Chemistry
Immunology
Genetics - Molecular Testing

Coagulation
Microbiology
P.O.C.T.

Haematology
Transfusion Medicine

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Alexander Haliassos
Inter-laboratory comparisons and EQA in the Mediterranean areathat the participation of Medical Laboratories
in EQA-PT schemes is non mandatory at all(Figure 1).
For the second question“If it is mandatory in which sectors
and which is the minimum frequencyof participation per year”
71% of the countries replied in Clinical Chemistrywith minimum frequency of participation peryear 1 and maximum 12, (median 3), 59% of
the countries replied in Coagulation with minimum frequency of participation per year 1 andmaximum 12, (median 3), 59% of the countries
replied in Hematology with minimum frequency of participation per year 1 and maximum
12, (median 3), 47% of the countries replied in
Immunology with minimum frequency of participation per year 1 and maximum 12, (median3), 41% of the countries replied in Microbiology
with minimum frequency of participation peryear 1 and maximum 12, (median 2,5), 41% of
the countries replied in Transfusion Medicine
with minimum frequency of participation peryear 1 and maximum 7, (median 2,5), 18% of
the countries replied in Genetics - Molecular
Figure 3

Testing with minimum frequency of participation per year 1 and maximum 3, (median 1), and
29% of the countries replied in Point Of Care
Testing (POCT) with minimum frequency of participation per year 1 and maximum 7, (median2), (Figure 2).
For the third question“The External Quality Control - Proficiency
Testing schemes are organized by the:”18% of the countries replied by the State, 41%of the countries replied by a Scientific Society,
47% of the countries replied by a non-profit organization and 76% of the countries replied bycommercial companies (Figure 3).
For the fourth and last question“Is the accreditation of the laboratories
mandatory by:”
30% of the countries replied by law, 12% of
the countries replied by Social Security organization in order to reimburse the tests andfinally 58% of the countries replied that the accreditation of Medical Laboratories is non mandatory at all (Figure 4).

Organizers of EQA-PT schemes for medical laboratories
in Mediterranean countries

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Inter-laboratory comparisons and EQA in the Mediterranean area

Moreover, we received as remarks that:•

In Italy•

The accreditation is mandatory based on
Regional requirements.

•

Some laboratories are accredited, on voluntary basis, according to ISO 15189:2012.

•

The frequency of EQA Schemes participation is not specified in the requirements anddepends on test typology. Generally fluctuates, from two surveys (4 control materials)
to six surveys (12 control materials) per year.

The External Quality Control in Jordan•

Is not mandatory.

•

Ministry of Health Law and guidelines encourage the participation in External Quality
Assurance programs.

•

In fact, the Laboratory Directorate of the
Ministry of Health had established an external quality control scheme for HBsAg, HCV,and HIV tests, where they provide two samples twice a year for each of these tests freeof charge, and it will be mandatory soon for
all laboratories performing these tests toparticipate in this program.

In Spain•

The establishment of the conditions andtechnical requirements for clinical laboratories corresponds to the respective Spanish
Autonomous Region where the laboratory
is located.

•

In the Autonomous Regions in which thismatter is regulated, the respective regulations require the participation of laboratories
in external quality assurance programs, organized by official bodies or by scientific societies of recognized prestige and authority.

Figure 4

The frequency of participation depends on regional regulation also and, in some of them,
it is stated that the frequency should be atleast once per month for common tests.

In Croatia•

The accreditation is not mandatory now, but
it will be in the near future.

•

The CROQALM is a non-profit organization,
one of the CSMBLM activities, where, according to the Croatian Chamber for Medical

Accreditation status of medical laboratories in Mediterranean countries

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Inter-laboratory comparisons and EQA in the Mediterranean area

Biochemistry, each laboratory in Croatia must
participate. Laboratories also participate inother type of external quality control according to their practice, accreditation etc.

2. Panagiotakis O., Chaliasou A.L., Haliassos A. (2016).
Contribution of ESEAP ‑ The Greek Proficiency Testing
Scheme for Clinical Laboratories in the improvement ofanalytical performance of participating laboratories. Clin
Chem, Vol. 62, No. 10, Supplement, 2016, S165-165.

In conclusion, we can remark that there is abroad difference in the application of the rules ofExternal Quality Control programs - Proficiency
Testing schemes among the Laboratories in
the Mediterranean countries. Moreover, as
the Accreditation of the Laboratories is notmandatory in the majority of Mediterraneancountries, there is not any trend for increased
participation in the EQA-PT schemes that helps
the harmonization of the quality specificationsin Laboratory Medicine.

3. Ntzifa A., Kroupis C., Haliassos A., Lianidou E. (2018) A
pilot plasma-ctDNA ring trial for the cobas® EGFR mutation
test in clinical diagnostic laboratories. ClinChemLabMed2018 aop https://doi.org/10.1515/cclm-2018-0676
4. Rizos D., Panagiotakis O., Makris K., Haliassos A. (2014).
Evaluating the Reproducibility of Analysis in the Clinical Laboratories. Results from a proficiency testing (PT)
scheme and comparison with biological variability. Clin
Chem, Vol. 60, No. 10, Supplement, 2016, S174.

REFERENCES

5. Panagiotakis O., Rizos D., Makris K., Haliassos A. (2014).
Measuring Reproducibility of analysis in a proficiency
testing (PT) scheme using modified control materials. A
novel approach using big data analysis. Clin Chem, Vol.
60, No. 10, Supplement, 2016, S133.

1. Panagiotakis O, Anagnostou-Cacaras E, Jullien G, Evangelopoulos A, Haliassos A, Rizos D. (2006). ESEAP: thenational External Quality Assessment Scheme for clinical chemistry in Greece and Cyprus. Clin Chem Lab Med.
2006;44(9):1156-7.

6. Panagiotakis O., Makris K., Rizos D., Haliassos A. (2015).
Serum Iron assays during inflammation - What do theymeasure? An investigation triggered from the results ofa proficiency testing scheme. Clin Chem, Vol. 61, No. 10,
Supplement, 2015, S46-47.

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Meeting the needs of Mediterranean nations: improving efficiency in laboratory medicine

This is a Platinum Open Access Journal distributed under the terms of the Creative Commons Attribution Non-Commercial License which permits unrestricted
non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

An evidence-based laboratory medicine approachto evaluate new laboratory tests
Tommaso Trenti

Department of Laboratory Medicine & Pathology, University Hospital and Local Healthcare Unitof Modena, Italy

ARTICLE INFOABSTRACT

Corresponding author:
Department of Laboratory Medicine
and Pathology
University Hospitaland Local Healthcare Unit of Modena
via Giardini 1355
Modena I-41126
Italy
Email: t.trenti@ausl.mo.it

The evidence-based recommendations for the evaluation of new tests to be used in practice are a key
issue to improve diagnostic clinical pathway inducing effective care. Emerging precision or personalized medicine requires innovative and pioneeringbiomarker tests for molecularly targeted therapies,
possibly fitted for the individual patient’s condition.
Beyond the traditional analytical specifications thatshould guarantee the proper clinical diagnostic performances in response to a specific clinical question,
the outcomes of a new test should be clearly definedand evaluated. Analytical and diagnostic performances such as sensitivity, specificity, imprecision, positive and negative predictive values are traditionallyestablished measures but the clinical impact and thehealthcare outcomes, to which these accuracy measures are related, are complex to measure. The extent
of the improvement of the patients’ health due to adiagnostic test remains a “holy grail” notwithstanding it should be the ultimate goal.

Key words:
evidence-based laboratory medicine,test evaluation, guidelines, clinicaldiagnostic outcomes, GRADE

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An evidence-based laboratory medicine approach to evaluate new laboratory tests

HARMONIZATION
AND RISK MANAGEMENT POLICIESIN LABORATORY MEDICINE
Harmonization and risk management policies
represent the key-issues in laboratory medicine as they directly rely on a patient-centreddelivery of laboratory information based on therecognition of the importance of the total testing process for assuring healthcare quality andpatient safety.
The term “harmonization” is intended to assurethat the results of a test are equivalent, being
either traceable to a reference material andbased on a consensus approach in agreementwith the mean values obtained with different
methods (1-3).
Nevertheless, the concepts of commutability,
uncertainty and reference intervals to harmonize laboratory results are well known issues,a growing body of evidence demonstrates thatclinical benefits can be achieved only by focusing on the total testing process, where the appropriateness of test request and interpretation
are the main steps. If the scope of harmonization goes beyond method and analytical results
to consider all the other aspects of laboratory
testing, including strategies for test demandand criteria for result interpretation (1,2), robust and methodologically high-quality recommendations to evaluate new tests are pivotal
tools to promote the cooperation at the clinical-laboratory interface to guarantee a valuable
medical decision-making process.
In risk management, the new approaches toquality and patient safety in the healthcare system emphasize that diagnostic improvements
are based on the assurance of the desired outcomes rather than on the sole identification of
the errors. The outcome-based approach proposed by Epner et al. (4) on testing-related diagnostic errors appeals for a more effective selection and interpretation of useful biomarkers inorder to prevent adverse events, failure to diagnose and to provide the appropriate treatment.
Patient safety is compromised by inappropriately requested tests or by misinterpretation of theresults so harmonization and risk management
policies in the laboratory increasingly recognizes the need to consider patient outcomes in
the assessment of tests and test strategies (4,5).
The development of high-quality recommendations may be the common framework to promote harmonisation and risk management indiagnostic pathway by evaluation of proposed
innovative diagnostic tests translated in clinicalpractice from research (6).
THE TEST EVALUATION WORKINGGROUP (WG-TE) OF THE EUROPEAN
FEDERATION OF CLINICAL CHEMISTRYAND LABORATORY MEDICINE (EFLM):IDENTIFYING UNMET CLINICAL NEEDSFOR NEW BIOMARKERS
The Test Evaluation Working Group (WG-TE) of
the European Federation of Clinical Chemistry
and Laboratory Medicine (EFLM), a working
group composed of laboratorians, epidemiologists, evidence-based medicine (EBM) methodologists, health technology assessment andpolicy experts and the IVD industry, deliveredpractical tools to improve the clinical and costeffectiveness evaluation of new biomarkers
to facilitate their implementation as medical
tests within the clinical pathway (7-8). It proposed an outcome-focused approach that canbe used by stakeholders for any medical test,
irrespective of the purpose and role of testing
to identify clinical management decisions, linking biomarker testing to health outcomes. Thismethod including worked examples are suggested to assist researchers, clinical scientists,
and the IVD industry working with clinicians,
to identify unmet clinical needs to improve thedevelopment of IVD medical tests to improved
health outcomes.

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The 14-item checklist is organized into 4 domains: 1/ identifying the clinical management
problem and desired outcome and 2/ verifying
the unmet need and an existing solution; 3/validating the intended use, how the biomarker
contributes to the solution; and 4/ assessing thefeasibility of the new biomarker to influence
clinical practice and health outcome. A more efficient biomarker development and translation
into practice are the purpose of the proposed
checklist as it was field tested to promote therole of the clinical laboratory specialist to forward interdisciplinary and multi-professional
collaboration. A complete picture of the guideto identify unmet clinical needs for new biomarkers is described in a recent paper (9), thischecklist proposed by EFLM TE-WG is aimed toassist all stakeholders engaged in the discovery
or implementation of new biomarkers or new
diagnostic pathway.
THE GRADE APPROACH:
THE GRADING OF RECOMMENDATIONSASSESSMENT, DEVELOPMENTAND EVALUATIONThe Grading of Recommendations Assessment,
Development and Evaluation (GRADE) approachto assess the certainty in evidence and to develop recommendations is a widely, patientcentred method (10). This approach is presently
used by over 100 organizations worldwide andhas become one of the reference standard forproviding health care recommendations (11).
The GRADE methodology is increasingly used in
the area of medical testing where the GRADE
framework is turning away from simple test accuracy to incorporate main health outcomesin light of the resulting downstream clinicalactions. Since direct studies assessing the impact of diagnostic tests or strategies on patient
important outcomes are rarely available, the
GRADE process requires two main steps. The

first is the judgments about directness in assessing the link between test accuracy and the evaluated health outcomes and the second aims to
the criteria used in moving from evidence to a
recommendation (12).
THE GRADE EVIDENCE TO DECISION (ETD)
FRAMEWORKS
EtD frameworks may be utilized to assess thecertainty of the evidence and to model theconsequences of a decision about a test. The
frameworks include not only the traditional
criteria to assess test analytical and diagnostic
performances but also the assessment of thecertainty of evidence to estimate if the test effects match patient outcomes. At first a clear
clinical question and related outcomes (important to the patient) are defined and then astructured systematic review of the available
evidence is performed. Diagnostic test performances are then judged by taking eight criteria
into consideration, of which five are to downgrade the quality of evidence, such as risk ofbias, indirectness, inconsistency, imprecision,and publication bias. The last three criteria are
to upgrade evidence quality, such as the magnitude of the effect, dose response in relation to
the effect, and opposing plausible residual bias
or confounders.
The GRADE evidence to decision (EtD) frameworks (6) for tests offer a structured approachas described as follow.
Formulating the question
Formulating a question needs a clear problem
draw and the definition of purpose, type androle of a test and alternative intervention(s),the main outcomes focused and the expected
setting. PICO, the population intervention comparison outcome format is a suitable method
for formulation of the question (13).

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Making an assessment
The problem
A definition of the magnitude and the priorityof the problem should be established depending on the setting in which the test will be used
and the influence on current or future practices.
Test accuracy
A summary of findings from systematic reviewsis the means to interpret the accuracy of a test.
An acceptable overall accuracy is the starting
point for entering a laboratory test into an EtD
framework evaluation.
Benefits & harms
The judgment about the benefits and harms tointroduce a new test is based on findings about
desirable and undesirable effects. Evidence
should be derived from up-to-date systematic reviews and summarized in a table of findings (14).
Certainty of the evidence
The GRADE overall rating the certainty of theevidence about the effects of a new test and thesubsequent management decisions on patientimportant outcomes is now extensively used by
guideline developers (15) and a complete reportof this approach can be found elsewhere (16).
EtD tests framework includes five criteria forreaching judgments and making assessment of
the evidence certainty: 1) test accuracy, 2) any
critical or important direct benefits, adverse effects or burden of the test, 3) effects of natural
history or the management that is guided by
the test results, 4) the link between the test results and the management decisions and 5) theevidence about the effects of the test.
ValuesThe perceived value of the main outcomes includes test downstream outcomes. For example, a blood test may replace more dangerous

interventions, such as bowel biopsy in coeliac
disease diagnosis, tumor prostate biopsy, or fetal
cell genotyping through maternal blood sampling
instead of amniocentesis.
Balance between the desirable
and undesirable effects
Desirable and undesirable effects following the
introduction of a new test need to be judged incomparison to the old or traditional test througheither formal or informal modeling evaluating
the actions due to a new test.
Resource use
In the case of the selection of the proposed diagnostic test, judgments about the magnitude
of costs, certainty of evidence of resource requirements and the cost-effectiveness of interventions should include the evaluation of
the impact both within the laboratory and thedownstream consequence. The great challenge
is to identify the overall health care cost and not
only the plan cost of the test itself (17).
Equity, acceptability and feasibility
Assessments of equity, acceptability and feasibility comprise both the test and the consequentinterventions. The use or misuse of tests for a
specific clinical presentation in different professional settings affects equity of access to clinical care. For example, in the same healthcare
setting, the introduction of a new test may varyfrom one hospital to another.
CONCLUSIONHigh quality and evidence-based recommendations may support a transparent clinical governance policy where the introduction of newlaboratory test based on assessed outcome forpatients is a value allowing the laboratory people
to contract with the management the allocationof resources in terms of health priorities (18).

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REFERENCES
1. Plebani M, Panteghini M. Promoting clinical and laboratory interaction by harmonization Clin Chim Acta. 2014;
432: 15-21.
2. Tate JR, Johnson R, Barth J, Panteghini M. Harmonization of laboratory testing - Current achievements and future strategies. Clin Chim Acta. 2014; 432:4-7.
3. Panteghini M. Implementation of standardization inclinical practice: not always an easy task. Clin Chem Lab
Med. 2012; 50:1237–41.
4. Epner PL, Janet EG and Graber ML. When diagnostic
testing leads to harm: a new outcomes-based approach
for laboratory medicine BMJ Qual Saf. 2013; 0:1-5.
5. McLawhon RW. Patient safety and clinical effectiveness as imperatives for achieving harmonization insideand outside the clinical laboratory. Clin Chem. 2011;57:936–83.
6. Trenti T, Schünemann HJ, Plebani M. Developing
GRADE outcome-based recommendations about diagnostic tests: a key role in laboratory medicine policies.
Clin Chem Lab Med. 2016; 54:535-43.
7. Monaghan PJ, Lord SJ, St John A, Sandberg S, Cobbaerth CM, Lennartz L, Verhagen-Kamerbeek WD, Ebert C,
Bossuyt PM; Horvath AR. Test Evaluation Working Groupof the European Federation of Clinical Chemistry andLaboratory Medicine Biomarker development targeting
unmet clinical needs Clin Chim Acta. 2016; 420: 211–219

10. Schünemann HJ, Oxman AD, Brozek J, Glasziou P, Jaeschke R, Vist GE, Kunz R, Williams J, Craig J, Montori V,
Bossuyt P, Guyatt GH, and the GRADE Working Group.
Grading the quality of evidence and strength of recommendations for diagnostic tests and strategies. BMJ 2008;
336:106–110.
11. GRADE Working Group: Organizations that have endorsed or that are using GRADE available from http://
www.gradeworkinggroup.org last accessed July 12th2018
12. Gopalakrishn G, Mustaf RA, Davenport C, Scholten
RJPM, Hyde C, Brozek J, Schunemann HJ, Bossuyt PMM,
Mariska M.G. Leeflang MMG. Langendam MW. Applying
Grading of Recommendations Assessment, Development
and Evaluation (GRADE) to diagnostic tests was challenging but doable. J Clin Epidemiol. 2014; 67:760-768
13. Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow CD,
Teutsch SM, Atkins D; Methods Work Group, Third US
Preventive Services Task Force Current methods of the US
Preventive Services Task Force: a review of the process.
Am J Prev Med. 2001; 20: 21-35.
14. Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek
J, Norris S, Falck-Ytter Y, Glasziou P, DeBeer H, Jaeschke
R, Rind D, Meerpohl J, Dahm P, Schünemann HJ GRADE
guidelines: 1. Introduction-GRADE evidence profiles andsummary of findings tables. J Clin Epidemiol. 2011; 64:
383-394.
15. Guyatt GH, Oxman AD, Kunz R, Vist GE, Falck-Ytter
Y, Schünemann HJ and GRADE Working Group. What is“quality of evidence” and why is it important to clinicians? BMJ 2008; 336: 995-998.

8. Horvath AR, Lord SJ, St John A, Sandberg S, Cobbaert
CM, Lorenz S, Monaghan PJ, Verhagen-Kamerbeek WD,
Ebert C, Bossuyt PM. From biomarkers to medical tests:
the changing landscape of test evaluation. Clin Chim Acta.
2014; 427:49–57.

16. Spencer FA, Iorio A, You J, Murad MH, Schünemann
HJ, Vandvik PO, Crowther MA, Pottie K, Lang ES, Meerpohl JJ, Falck-Ytter Y, Alonso-Coello P, Guyatt GH. Uncertainties in baseline risk estimates and confidence in treatment effects. BMJ 2012; 345:e7401.

9. Monaghan PJ, Robinson S, Rajdl D, Bossuyt PMM,
Sandberg S, St John A, O’Kane M, Lennartz L, Röddiger,
Lord SJ, Cobbaert CM, Horvath AR. Practical guide for
identifying unmet clinical needs for biomarkers. eJIFCC
2018; 29:129-137 http://www.ifcc.org/media/477379/
ejifcc2018vol29no2pp129-137.pdf last accessed July
12th 201817. Brunetti M, Pregno S, Schünemann H, Plebani M,
Trenti T. Economic evidence in decision-making process in laboratory medicine Clin Chem Lab Med. 2011
Apr;49:617-21.
18. Trenti T, Canali C, Scognamiglio AM Clinical Governance and evidence-based laboratory medicine. Clin
Chem Lab Med. 2006; 44:724-32

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Meeting the needs of Mediterranean nations: improving efficiency in laboratory medicine

This is a Platinum Open Access Journal distributed under the terms of the Creative Commons Attribution Non-Commercial License which permits unrestricted
non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Which skills are needed and how they should
be gained by laboratory medicine professionals
for successful ISO 15189 accreditation
Diler Aslan

Department of Medical Biochemistry, Medical Faculty, Pamukkale University, Denizli, Turkey

ARTICLE INFOABSTRACT

Corresponding author:
Diler Aslan
Department of Medical Biochemistry
Medical Faculty
Pamukkale University
Denizli
TurkeyE-mail: daslan@pau.edu.tr

Clinical laboratories worldwide are accredited according to the “ISO standard, 15189:2012: Medical
Laboratories—Requirements for Quality and Competence.”

Key words:
ISO 15189, accreditation,
training

Seeking accreditation has many challenges. Successrequires the right competencies and knowledge andthe right technical expert and trainer to lead the laboratory through the process. The right competencies
and knowledge typcially are beyond the core knowledge, skills and attitudes gained during education oflaboratory professionals. The main objective of thispaper is to discuss what competencies, knowledge
and expertise are essential for laboratories to meetaccreditation challenges and gain ISO 15189:2012
accreditation.

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Skills needed by laboratory medicine professionals for successful ISO 15189 accreditation

INTRODUCTION
The “ISO 15189 Standard: Medical Laboratories–
Requirements for Quality and Competence” isan internationally accepted accreditation standard based on a series of requirements (1). Likeother ISO Standards, ISO 15189 identifies what
laboratories need to do, but not how to do. Eachlaboratory specifies the “how” for its situation
using knowledge thought to be acquired during
the training of medical laboratory specialists andincluded in the core curricula/syllabi publishedby scientific, professional and government authorities (2,3). However, ISO 15189 accreditation typically requires knowledge and competencies beyond the educational scope. A key to
ISO 15189 accreditation is the quality management system. In this context, it is useful to understand and apply concepts from “ISO 9001:2015
Quality Management Systems-Requirements,”
Figure 1

and the CLSI Guideline, “GP26-A3: Applicationof a Quality Management System Model for
Laboratory Services (4,5). This paper presents
the main areas and basic tools for gaining thecompetencies required by ISO 15189:2012 andto share my experiences of the ISO 15189 technical expert and trainer.
MAIN AREAS AND BASIC TOOLSFOR SUCCESSFUL ACCREDITATIONWITH ISO 15189:2012
The medical laboratory environment is rapidlychanging. In order for effective management,
the laboratory directors must be technically andclinically competent in their defined specialty areas, and also have relevant and common managerial, statistical and computer knowledge andskills. These attributes can be collected underthe main topics such as “Quality Management”,

Areas and topics for competencies required for the ISO 15189:2012

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Skills needed by laboratory medicine professionals for successful ISO 15189 accreditation

Figure 2

The medical laboratory total testing process

Adapted from:https://ftp.cdc.gov/pub/cliac_meeting_presentations/pdf/addenda/cliac0314/16a_west_cdclabtoolkit2013_handout.pdf.

“Process Management”, “Risk– Based Thinking”,“Laboratory Mathematics and Statistics”,“Evidence-Based Laboratory Medicine” and“Project Management” (Figure 1) (6–10).
The clauses’ numbers of the ISO 15189: 2012
Standard that are related to the competencies
that should be gained by laboratory professionals are listed under the competency topics inFigure 1.
To establish a quality management system requires a systematic, process-oriented approachso that quality objectives/requirements areachieved. The sub-processes of the total testingprocess of a medical laboratory seen in Figure 2

can be managed according to the simple work
flow shown in Figure 3 in regard to the processcore components (e.g., inputs, outputs, resources, activities and controls), and its elements (e.g.,
personnel, methods, materials, equipment, environment and measures).
Since continuous improvement is one of the
key requirements of the ISO 15189, the methodologies and standards such as the “Plan, Do,
Check, Act (PDCA)” Cycle, Six Sigma, Lean, Lean
Six Sigma, total quality management, statisticalprocess control and cause-effect analysis are
the improvement tools used widely as listed in
Figure 1 (6,8,11,12).

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Figure 3

A process approach

Adapted from the ISO 9001:2015.

In addition to the topics mentioned in the previous paragraph, knowledge of quality management sub-processes is important to provide asystematic initiation. Such that establishment
the QMS is composed of three processes; quality planning (QP), quality assurance (QA), andquality control (QC) (Figure 4) (6).
In the QP process, the managerial, operationaland functional (supportive) processes of total
testing process of a medical laboratory as required by ISO 15189 are defined, the resources
according to each test system are allocated, andquality objectives and quality indicators of each
subprocess are defined considering each test
(Figure 5).
QC process covers the operational process control techniques to fulfill quality requirements

defined for each test in order to achieve each
subprocess (analytical and non-analytical processes) performance.
QA process is composed of planned and systematic activities to provide evidence-based information that a medical laboratory fulfills quality requirements defined as quality objectives
and quality indicators for each sub-processes in
the QP stage, and provides the report for continuous improvement activities (Clause 4.12).
Learning resources, required knowledge, skills
and competencies for each activities in the subprocesses are summarized in Figure 5.
The important common issue in preparation
for accreditation is confusion about the differences between quality system certification andaccreditation.

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Figure 4

Quality levels that define the quality management processes
required to establish a quality management system

DIFFERENCE BETWEEN ACCREDITATION
AND QUALITY SYSTEM CERTIFICATION
It is important to realize the difference between
the ISO 9001 quality system certification andthe ISO 15189 accreditation. The ISO 9001 certifies the consisted business processes are being applied, but it is not guarantee the quality ofthe end products and services such as the ISO
15189 that focuses on the technical and clinical competencies for reliable and cost-effective test results (1,4). The first part of the ISO
15189 (Clause 4 Management Requirements)
is based on the ISO 9001. However, there arecorrelations of the second section of the ISO
15189 (Clause 5 Technical Requirements) with
the ISO 9001:2015 that uses process approachand risk-based thinking (1,4). In this context,
the ISO 9001:2015, especially risk-based process approach, should be well understood
before accreditation process. Although there
are correlations between two standards, it is
crucial to keep in mind the differences because
accreditation is deserved for specific activities
such as to provide effective and efficient test results whereas certification relates to the wholeorganization.

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Figure 5

The decision, design and implementation processes for a new analyte,
and required knowledge, skills and competencies

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Table 1

Correlations between “NCCLS (CLSI) GP26-A3 Application of a Quality
Management System Model for Laboratory Services;
Approved Guideline — Third Edition (2004)” with the ISO 15189:2012

GP26-A3

Documents and Records

ISO 15189:2012

4.3 Document control
4.13 Control of records (quality and technical records)
4.1 Organization and management responsibility

Organization

4.1.1.3 Ethical conduct
4.2 Quality management system
4.15 Management review

Personnel
Equipment

5.1 Personnel
5.3.1 Laboratory equipment
5.10 Laboratory information management
4.4 Service agreements

Purchasing and Inventory

4.5 Examination by referral laboratories
4.6 External services and supplies
5.4 Pre-examination processes

Process Control

5.5 Examination processes
5.6 Ensuring quality of examination results
5.7 Post-examination processes
5.8 Reporting of results

Information Management

5.10 Laboratory information management
4.11 Preventive action

Occurrence Management

4.10 Corrective action
4.14.6 Risk management
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5.6.2 Quality control (IQC)
5.6.3 Interlaboratory comparisons

Assessment: External and Internal

5.6.3.2 Alternative approaches
5.6.4 Comparability of examination results
4.12 Continual improvement
4.14 Evaluation and audits

Process Improvement

4.14.7 Quality indicators
4.15 Management review
4.1.2.2 Needs of users
4.7 Advisory services
4.8 Resolution of complaints

Customer Service

4.14.3 Assessment of user feedback
4.14.4 Staff suggestions
4.14.8 Reviews by external organizations

Facilities and Safety

5.2 Accommodation and environmental conditions

PREPARATION FOR ISO 15189
ACCREDITATIONThe quality system essentials in the GP26-A3 canbe used as framework with the process approach(5). Table 1 depicts the correlations between the
QSEs and the ISO 15189. The QSEs are matching
to the process core components and elements in
Figure 3 of total testing process in Figure 1. As
seen in Figure 5, all activities that are performedfor decision of a new analyte and its application
are also in between the requirements of the ISO
15189.
Preparation for the ISO 15189 accreditation ischallenging, and requires comprehensive knowledge and competency (13). Learning the topics

listed under the main areas related to the competencies required by the ISO 15189 accreditation summarized in Figure 1 may be helpful for
successful accreditation.
The steps may be organized as:1) Defining activities according to the quality
levels (Figure 4);2) Defining the process core components andprocess elements of the total testing process and its sub-processes for each test according to the process approach (Figure 3);3) Defining all key process controls (key performance specifications and quality indicators)
for each test process that is in the accreditation scope.

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TRAINING PROGRAMS, PROFESSIONAL
DEVELOPMENT AND CAREER PLANS
The main duty of a laboratory professional is toprovide the reliable and accurate laboratory test
results cost-effectively and timely. Besides this,
there are responsibilities of laboratory in respect
to the value-based health care (14,15).
Accreditation against the ISO 15189, if it is performed ideally, adds value to health care quality
in respect to both human health, and the tracking and evaluation of in vitro diagnostic medical
devices at the national level if the government
establishes infrastructure for collecting the data.
However, acquiring diverse knowledge and competencies that are growing exponentially is achallenging issue for a laboratory director.
The other challenging issue is that it is not possible to find a university or teaching hospitalthat has sufficient trainers who have all required
knowledge and skills. One of the solutions may be
the training courses organized by experts both inclassroom and in distance-learning formats. The
training programs should be competency-basedin the concepts of “case-based”, “entrustableprofessional activities” and task-based (16,17).
Distance-learning courses (DLCs) can provide
the rapidly increasing knowledge that should belearned and replace live on-site courses, whichhave high participation costs. However, the DLCs
on the “Medical Laboratory Mathematics andStatistics” organized for the last 2 years encountered some challenges (18). These courses are
1.5 - 2 months long and require 3-hours of study
per week. They contain texts, presentations,virtual classrooms and videos that enable theparticipants to practice with Microsoft Excel and
SPSS calculations of problems and the assessment quizzes. However, it was observed thatthe laboratory specialists usually do not haveenough time to work on the material.

Standardization of core knowledge of laboratory professionals required for the ISO 15189
accreditation can be established and online
central examinations which would assess theserequirements can be organized by the IFCC or
the Regional Federations. Such initiatives will
be helpful for laboratory professionals to decide
what they need to learn and self-evaluate theirknowledge.
REFERENCES
1. ISO. ISO 15189:2012 Medical laboratories — Requirements for quality and competence. 2012;
2. Greaves AUR, Smith JM, Greaves SEAUR, Florkowski C,
Langman L, Sheldon J, et al. The IFCC Curriculum. 2017.
http://www.ifcc.org/media/477173/2017-ifcc-curriculum.pdf
3. Wieringa G, Zerah S, Jansen R, Simundic A, Queralto
J, Solnica B, et al. The EC4 European Syllabus for PostGraduate Training in Clinical Chemistry and Laboratory Medicine : version 4 – 2012. Clin Chem Lab Med.
2012;50(8):1317–1328.
4. ISO 9001:2015 Quality management systems -- Requirements. International Organization for Standardization; 2015.
5. NCCLS. GP26-A3 Application of a Quality Management
System Model for Laboratory Services ; Approved Guideline — Third Edition. NCCLS, 940 West Valley Road, Suite
1400, Wayne, Pennsylvania 19087-1898 USA; 2004.
6. Harmening DM. Laboratory Management, Principles and Processes. Third. St. Petersburg, Florida: D.H.
Publish,ng and Consulting Inc.; 2013. 1-544 p.
7. Westgard JO, Sten A. Westgard. Basic Quality Management Systems Eessentials for Implementing Quality Management in the Medical Laboratory. Madison USA: Westgard QC, Inc.; 2014. 1-285 p.
8. Westgard JO. Six Sigma Risk Analysis: Designing Analytic QC Plans for the Medical Laboratory. Madison US:
Westgard QC, Inc.; 2011. 1-296 p.
9. Christopher P. Price; Robert H. Christenson, editor.
Evidence-Based Laboratory Medicine: From Principles to
Outcomes. 2nd ed. AACC Press; 2003. 1-279 p.
10. P. Price C, Christenson RH, editors. Evidence-BasedLaboratory Medicine: Principles, Practice, and Outcomes.
2nd ed. Washington, DC. US: AACC Press; 2007. 1-545 p.

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11. The Proceess Approach in ISO 9001:2015. International Organization for Standardization. 2015. www.iso.
org/tc176/sc02/public
12. Boutros T, Cardella J. The Basics of Process Improvement. CRC Press. 2016. p. 69–99.
13. David Burnett. A practical guide to ISO 15189 in laboratory medicine. ACB Venture Publications; 2013. 1-372 p.

16. Ned-Sykes R, Johnson C. Competency Guidelines
for Public Health Laboratory Professionals: CDC andthe Association of Public Health Laboratories. Centers for Disease Control and Prevention MMWR.
2015;64(1):1-81. http://www.ncbi.nlm.nih.gov/pubmed/
25974716

14. Porter ME. What Is Value in Health Care? N Engl J
Med. 2010;363(26):2477–81.

17. McCloskey CB, Domen RE, Conran RM, Hoffman RD,
Post MD, Brissette MD, et al. Entrustable Professional
Activities for Pathology. Acad Pathol. 2017;4:1-9. http://
journals.sagepub.com/doi/10.1177­/2374289517714283

15. Schmidt RL, Ashwood ER. Laboratory Medicine andValue-Based Health Care. 2015;(September):357–358.

18. https://www.d-tek.com.tr/en/training/distancelearning-programs/ (Accessed on 12 October 2018)

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Meeting the needs of Mediterranean nations: perinatal and pregnancy laboratory medicine

This is a Platinum Open Access Journal distributed under the terms of the Creative Commons Attribution Non-Commercial License which permits unrestricted
non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Prenatal screening for chromosomal
abnormalities: where do we stand today
in Mediterranean countries?
Demetrios Rizos

Hormone Laboratory, “Aretaieion” University Hospital, Medical School, National and Kapodistrian
University of Athens, Greece

ARTICLE INFOABSTRACT

Corresponding author:
Demetrios Rizos
Hormone Laboratory“Aretaieion” University Hospital
Medical School
National and Kapodistrian
University of Athens
76, Vas. Sofias ave.
15 28, Athens
GreecePhone: +30 210 7286229
E-mail: drizos@aretaieio.uoa.gr

Over the last 4 decades the practice of prenatal screening has evolved from the second-trimester triple test
to complex combinations of biophysical and biochemical testing for aneuploidy, testing of fetal DNA in thematernal circulation and development of screening
tests for adverse pregnancy outcomes. Presently,
combined test in the 1st trimester is the preferred multimarker screening protocol in most countries. Since
2010, cell-free fetal DNA (cffDNA) in maternal plasma,in combination with the next generation sequencing
techniques, made a big breakthrough step in screening for Down Syndrome (DS) and other aneuploidies.
It seems that the position of cffDNA in the current
screening strategies is a secondary contingent use
to combined test, at least as long as its price is stillhigh and its use as a primary test is not cost effective.
Concerning the situation in Mediterranean countries,
at least with those who answered the questionnaire,
screening in the 1st trimester is an established practice,reimbursed from social security organizations, and notcompulsory. cffDNA is used in all countries and its average cost is about 500 €.

Key words:
biochemical screening for aneuploidy,
cell free fetal DNA, cffDNA

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Prenatal screening for chromosomal abnormalities: where do we stand today in Mediterranean countries?

INTRODUCTION
Screening is the process of surveying a population with specific markers in order to identify
those individuals with a higher risk for a particular disorder. For high risk individuals, a diagnostic test is applied to definitely diagnose thedisorder. A successful screening program should
be complemented with an accurate diagnostic
test to identify those who are truly affected andalso with a clear strategy of how to treat the affected individuals.
Over the last four decades, the practice of prenatal screening has evolved from the simple
second-trimester maternal serum α-fetoprotein(AFP) test for open neural tube defects (NTDs)
to complex combinations of biophysical andbiochemical testing for aneuploidy. It continues to evolve with the testing of fetal DNA in
the maternal circulation and the developmentof screening tests for adverse pregnancy outcomes such as pre-eclampsia. Diagnosis of major fetal chromosomal aneuploidies is done bykaryotype of fetal cells, obtained through amniocentesis after the 15th week of pregnancy,or chorionic villus sampling (CVS) between the
12th and 14th weeks. There are several financial
and ethical implications of how pregnancies
with affected fetuses are treated in different
countries and these differences are even bigger
between Mediterranean countries with different economical, social and cultural status.
BRIEF HISTORICAL OVERVIEW
Screening for fetal aneuploidy in pregnancy began in the 1960-1970s with maternal age as the
only available marker. As maternal age increases,
the chance of delivering a child with Down syndrome (DS) or other major autosomal trisomies
like trisomy 18 (T18; Edwards syndrome) or
13 (T13; Patau syndrome) increases. However,screening with maternal age alone (cut-off>35years), could detect about 30% of trisomies.

The majority of babies with DS are born by women less than 35 years of age.
The first breakthrough in screening for fetal
chromosomal abnormalities was done in 1988
with the introduction of a multiple marker
screening test, based on a “risk” calculation foreach pregnant woman using her age and theconcentrations of 3 biochemical markers: human Chorionic Gonadotropin (hCG), AFP, andunconjugated Estriol (uE3) (Triple test) fromblood samples in the 2nd trimester of pregnancy [1]. Such screening has led also to the diagnosis of a large proportion of the other common
trisomies, like T18 and T13. In 1992, ultrasoundfetal nuchal translucency (NT), by far the single
best individual marker, was introduced [2] and in
1997, a new multiple marker screening test the
Combined test, using NT, Fb-hCG and Pregnancy
Associated Plasma Protein –A (PAPP-A) wasstarted [3]. The following years, several complex screening protocols were introduced using
both first- and second-trimester markers. Table
1 [4] shows the model predicted detection rate(DR) and positive predictive value (PPV) for a 1%or 5% false positive rate (FPR) for the traditional
screening strategies described above.
Comparing the first and second trimester
screening protocols, 1st trimester’s Combined
test has better DR than the Triple or Quadruple(Triple+inhibin) test in the 2nd trimester, for 5%
FPR. Presently, the Combined test is the preferredmultimarker screening protocol in most countries.
Protocols combining 1st and 2nd trimester markers, in one step or contingently or using morebiochemical or ultrasound markers gave better
performance but made the screening more cumbersome, expensive and time consuming.
DNA SCREENING FOR ANEUPLOIDIESThe discovery that there is sufficient cffDNA inmaternal plasma, in combination with the next
generation sequencing techniques, made thePage 275

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Prenatal screening for chromosomal abnormalities: where do we stand today in Mediterranean countries?

next breakthrough step in screening for DS andother aneuploidies [5]. In principle, the screening
is based on counting a large number of DNA fragments (both maternal and fetal) using massive
sequencing, assigning them to a chromosome
and quantifying the proportion assigned e.g. tochromosome 21. The results are expressed as az score computed by comparison to an expected
proportion for a sample from a euploid fetus.
Table 1

In a recent review and metanalysis [6], the DRof cffDNA for DS was found 99.4% for 0.1% FPR(results from 148344 tests); for T18, 97.7% for
0,1% (results from 146940 tests); and for T13,
90,6% for 0,1% (results from 134691 tests). The
authors concluded that “cffDNA based non-invasive prenatal testing (NIPT) can be diagnostic forfetal sex and rhesus D, but only screening test in
aneuploidy”.

Model predicted DR and PPV for different policies
for Down syndrome screening according to FPR
FPR = 1%

PolicyDR (%)FPR = 5%

PPV a

DR (%)

PPV a

1 in 1671

1 in 54

1 in 1285

1 in 46

Second trimester
Quad

50
First trimester

Combined

72
Both trimesters

Serum integrated

58

1 in 1476

1 in 51

Integrated

83

1 in 1092

1 in 42

Contingent b

83

1 in 1091

1 in 42

Improvedab

Combined plus NB

88

1 in 1094

1 in 41First trimester contingent b

86

1 in 1090

1 in 43

Quad plus facial profile

83

1 in 1093

1 in 42

Combined plus PlGF and AFP

77

1 in 1189

1 in 44

At termFirst stage cutoff risks 1 in 50 and 1 in 2000 at term

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Prenatal screening for chromosomal abnormalities: where do we stand today in Mediterranean countries?

Concerning the position of cffDNA based NIPTin the established screening strategies, two main
approaches have been suggested:a) as “primary” testing replacing the conventional screening; andb) as “secondary” testing offered after the 1sttrimester’ s Combined test.
In both approaches, a confirmatory invasive
prenatal diagnosis by CVS or amniocentesis
is necessary for positive results. As a primarytest, cffDNA has a much higher screening performance, at least for Down syndrome, thanany of the conventional policies summarizedin Table 1. However, the major concern of
this approach is the cost. With the cost for a
Down syndrome birth avoided to be almost 10
Figure 1times higher for cffDNA than the conventional
screening [7], this screening approach could be
an unaffordable burden for every health caresystem. Another consideration is the test failure rate of cffDNA testing. The reported rates
for “no-call” results from the commercial companies vary between 2-6%. The main reason
for the test failures is the low fraction of fetal DNA in the total amount of free DNA in thematernal circulation. The fetal fraction has tobe higher than 10% optimally, and today all themain commercial companies include the fetal
fraction in their results’ report. As a secondary
test, a contingent use of cffDNA test is morecost effective than the use as a primary test.
With this approach, conventional 1st trimester

Example model for contingent screening for Down syndrome

NIPT: non-invasive prenatal tets, “no call”: test could not be reported
Non-invasive prenatal testing may be best used in a contingent approach. In the example, combined firsttrimester screening is offered to all women as an initial screening tool. From this, women are stratified byrisk to determine further management. Women with a high risk are offered an invasive test (chorionic villus
sampling or amniocentesis). Women with a low risk are reassured and advised that no further testing is needed.
Women with an intermediate level of risk are offered a non-invasive prenatal test. Contingent screening allows
highest detection rate (in the example 97%) while reducing the false positive rate (in the example 1.4%).

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Prenatal screening for chromosomal abnormalities: where do we stand today in Mediterranean countries?

Table 2

Brief summary of the responses received
from some Mediterranean countries
QuestionSlovenia

FranceGreeceTurkeyIsraelAlbania

Is screening regulated by low?

Yes

Yes

No

Yes

Yes

No

Is screening compulsory?

No

No

No

No

No

No

Is screening reimbursed?

Yes

Yes

Yes

Yes

Yes

No

Screening strategies

1st trimester only

No

Yes

No

No

No

No

1st or 2nd trimester

Yes

-

Yes

Yes

Yes

Yes

cfDNA testing

Yes

Yes

Yes

Yes

Yes

Yes

cfDNA testing reimbursed?

No

No

No

No

No

No

Primary or secondary

Sec

Sec

Sec

Cost of cfDNA testing (€)~ 450

350-650

400-600-

600-800

Invasive cytogenetic diagnosis

Woman’s age only

Yes

No

Yes

Yes

Yes

Yes

Screening results

Yes

Yes

Yes

Yes

Yes

Yes

Other indications (US, family)

Yes

Yes

Yes

Yes

Yes

Yes

US monitoringYes

Yes (3)

Yes (3)Yes

Yes (3)

Yes

combined screening is offered to all women. To
those women with a very high risk for all type of
aneuploidy (e.g. >1:50), invasive prenatal diagnosis is offered.
To all other women, the result of the combined
test could be used for counseling, giving themthe choice of selecting either:a) no further action with a result lower thane.g. 1:1000;b) proceed with cffDNA testing orc) having invasive diagnosis.
An option for this approach is depicted in Figure 1.
(https://www.nps.org.au/australian-prescriber/
articles/non-invasive-prenatal-testing-for-downsyndrome)

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Prenatal screening for chromosomal abnormalities: where do we stand today in Mediterranean countries?

RECENT GUIDELINES FOR SCREENING•

In recently published recommendations of theAmerican College of Obstetrician and Gyne­
cologists (ACOG) and the Society for MaternalFetal Medicine for screening for fetal aneuploidy(https://www.acog.org/Clinical-Guidance-andPublications/Committee-Opinions/Committeeon-Genetics/Cell-free-DNA-Screening-for-FetalAneuploidy), among others it is mentioned that:•

A discussion of the risks, benefits, and alternatives of various methods of prenatal
screening and diagnostic testing, including
the option of no testing, should occur withall patients.

•

Given the performance of conventional
screening methods, the limitations of cell-free
DNA screening performance, and the limited
data on cost-effectiveness in the low-risk obstetric population, conventional screening
methods remain the most appropriate choicefor first-line screening for most women in thegeneral obstetric population.

•

•

•
•

The cell-free DNA test will screen for only thecommon trisomies and, if requested, sex
chromosome composition.
Given the potential for inaccurate results
and to understand the type of trisomy forrecurrence-risk counseling, a diagnostic test
should be recommended for a patient who
has a positive cell-free DNA test result.
Cell-free DNA screening is not recommended for women with multiple gestations.
If a fetal structural anomaly is identified on
ultrasound examination, diagnostic testingshould be offered rather than cell-free DNA
screening.

Patients should be counseled that a negative cell-free DNA test result does not ensure an unaffected pregnancy.

THE SITUATIONIN MEDITERRANEAN COUNTRIES
Trying to imprint the situation of prenatal screening for chromosomal abnormalities in the different Mediterranean countries, a questionnaire
in cooperation with MZ Congressi, was send tothe members of Scientific Committee and was
uploaded as a survey (https://docs.google.com/
forms/d/e/1FAIpQLSdu6i2dvWbeCbObkGToJV
51V8C0A6vA7LYTu0JBPtr4UrL_TQ/viewform).
Unfortunately, a limited number of responses
was received (Slovenia, France, Greece, Turkey,
Israel and Albania) (Table 2).
REFERENCES
1. Wald, N.J., et al., Maternal serum unconjugated oestriol as an antenatal screening test for Down’s syndrome.
Br J Obstet Gynaecol, 1988. 95(4): p. 334-41.
2. Nicolaides, K.H., et al., Fetal nuchal translucency: ultrasound screening for chromosomal defects in first trimester of pregnancy. BMJ, 1992. 304(6831): p. 867-9.
3. Wald, N.J. and A.K. Hackshaw, Combining ultrasoundand biochemistry in first-trimester screening for Down’s
syndrome. Prenat Diagn, 1997. 17(9): p. 821-9.
4. Cuckle, H. and R. Maymon, Development of prenatal
screening--A historical overview. Semin Perinatol, 2016.
40(1): p. 12-22.
5. Chiu, R.W., et al., Maternal plasma DNA analysis withmassively parallel sequencing by ligation for noninvasive
prenatal diagnosis of trisomy 21. Clin Chem, 2010. 56(3):p. 459-63.
6. Mackie, F.L., et al., The accuracy of cell-free fetal DNAbased non-invasive prenatal testing in singleton pregnancies: a systematic review and bivariate meta-analysis.
BJOG, 2017. 124(1): p. 32-46.
7. Cuckle, H., Strategies for Implementing Cell-Free DNA
Testing. Clin Lab Med, 2016. 36(2): p. 213-26.

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Meeting the needs of Mediterranean nations: perinatal and pregnancy laboratory medicine

This is a Platinum Open Access Journal distributed under the terms of the Creative Commons Attribution Non-Commercial License which permits unrestricted
non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

The role of laboratory medicine
for health during pregnancy
Adnan Alkhatib

Syrian Clinical Laboratories Association, Damascus, Syria

ARTICLE INFOABSTRACT

Corresponding author:
Adnan Alkhatib
Syrian Clinical Laboratories Association
Damascus
Syria
E-mail: khatiblab@gmail.com

Pregnancy produces profound physiological changes
that increase in significance as it progresses. Thesechanges include hormonal changes, metabolic changes, increases of plasma volume up to 50%, alterations
to the balance of the coagulation system in favour ofclotting, and GFR increases to a peak 50% above prepregnancy levels. Since healthy physiological changes
occur during pregnancy, different reference intervals
may be needed. First antenatal screens usually include Complete blood count, Blood group and antibody screen, rubella antibody status, syphilis serology,
Hepatitis B serology and HIV abs testing. Additional
testing in early pregnancy may be added to the firstantenatal screen such as varicella, Chlamydia andvitamin D tests. The most important test in the second antenatal testing screen is gestational diabetes
screening and protein detection in urine to rule out
preeclampsia. Screening for Down syndrome, otherchromosomal abnormalities and neural tube defects
is recommended for all pregnant women above theage of 35 years. Additionally, 37 weeks into pregnancy, a swab to detect Group B streptococcal (GBS) infection is recommended.

Key words:
pregnancy, GFR , reference intervals,
Rubella, Syphilis, hepatitis B,
preeclampsia, Down Syndrome,chromosomal abnormalities, neuraltube defects, group B streptococcal

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Adnan Alkhatib
The role of laboratory medicine for health during pregnancy

INTRODUCTION
Human Pregnancy is not a disease, it is a physiological condition; pregnancy produces profoundphysiological changes that become more significant as pregnancy progresses.
The hormonal changes starts from the ovaries,
and then later the placenta. The first hormone
to make its appearance after conception is human chorionic gonadotropin (hCG) then followed by hormones include estrogen, progesterone, prolactin, renin and human placental
lactogen. It is also worth mentioning that adequate levels of circulating thyroid hormones areof primary importance for normal reproductivefunction, all these changes are accompanied by
growing uterus with gradual mechanical effect.
Metabolic changes are also due to an increased
insulin production, and pregnancy is associatedwith insulin resistance caused predominantly
by human placental lactogen. This facilitates
placental glucose transfer and any carbohydrateload will cause a greater than normal increasein plasma glucose.
Plasma volume increases progressively throughout normal pregnancy; most of this 50% increase
occurs by 34 weeks’ gestation and is proportional to the birth weight of the baby. Because
the expansion in plasma volume is greater than
the increase in red blood cell mass, there is a fallin haemoglobin concentration.
Changes in the coagulation system during pregnancy produce a physiological hypercoagulable
state. The concentrations of certain clotting factors, particularly VIII, IX and X are increased.
Fibrinogen levels rise significantly by up to 50% andfibrinolytic activity is decreased. Concentrationsof endogenous anticoagulants such as antithrombin and protein S decrease. Thus, pregnancy alters the balance within the coagulation system infavour of clotting.

During pregnancy renal vasodilatation increases
renal blood flow early during pregnancy, this increase cardiac output (CO), GFR and renal plasma flow (RPF) by 50%, also an increase in Renin& Aldosterone level promotes Na+ retention
leading to volume overload.
The kidneys face remarkable demands during
pregnancy, GFR rises early to a peak of 40% to
50% that of pre-pregnancy levels, resulting inlower levels of serum creatinine, urea, and uricacid. There is a net gain of sodium and potassium, but a greater retention of water, with gains
of up to 1.6 L.
Clinicians should be aware of the role of pregnancy specific reference ranges and how thesecan assist correct diagnosis and managementin pregnancy. Appropriate pregnancy reference
intervals help clinicians to avoid interpreting
normal results as pathological and help them toidentify when results are truly abnormal.
REVIEW
Tests includedin the first antenatal screen•Complete blood count•Blood group and antibody screen•

Rubella antibody status•

Syphilis serology•

Hepatitis B serology•

HIV

Although the first antenatal screen usually occurs early in pregnancy, it may be requested atany stage of pregnancy, i.e., if a woman presents for the first time late in pregnancy, sheshould still receive a first antenatal screen.
Complete blood countAnaemia is most common medical disorderespecially in underdeveloped countries which

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Adnan Alkhatib
The role of laboratory medicine for health during pregnancy

increases maternal morbidity and mortality; it iswell accepted that there are three main causes:•

Decreased erythrocyte production as iniron, vitamin B12 and folate deficiency.

•

RBCs destruction as in hemoglobinopathies.

•

RBCs loss as in any haemorrhage.

Gestational age should be considered when assessing haemoglobin, as levels decrease during
pregnancy due to haemodilution caused by increased plasma volume. The lower limit for haemoglobin is usually 12 g/dL, but for pregnant
women the lower limit is usually reported as 10
g/dL.
Pregnancy causes a two- to three-fold increasein the requirement for iron, not only for haemoglobin synthesis but also for the foetus and the
production of certain enzymes. There is a 10- to
20-fold increase in folate requirements and a twofold increase in the requirement for vitamin B12.
The platelet count tends to fall progressively
during normal pregnancy, although it usuallyremains within normal limits. In a proportion of
women (5–10%), the count will reach levels of
100–150 × 109 cells/L by term and this occurs in
the absence of any pathological process
Blood group and antibody screen
Identifying ABO blood group, rhesus D status
and red cell antibodies in pregnant women isimportant to prevent “haemolytic disease of
the new-born” in subsequent pregnancies. If
the foetus is rhesus D-positive (and the motheris negative), the mother may form anti-D antibodies, which may affect a subsequent rhesus
D-positive foetus. Haemolytic disease of the
new-born in subsequent pregnancies.
Recently Non-invasive prenatal genetic testing (NIPT) is used to determine foetal rhesus
D status and prevent rhesus D negative mothers from undergoing unnecessary prophylactic
treatment, this allows to prevent the risk of

foetal anaemia and haemolysis when the mother is serologically RhD negative and the foetus
is RHD positive.
Rubella antibody status
All pregnant women should be screened for rubella antibodies. Congenital Rubella Syndrome
occurs when the rubella virus infects the developing foetus, especially during the first trimester when up to 90% of affected infants will
be born with a birth defect, e.g. deafness, eyedefects, heart defects, mental retardation. The
risk of birth defects is decreased when infection
occurs after 20 weeks’ gestation.
The aim of screening is to identify women who
have not been immunized or have diminishedimmunity and are susceptible to contracting
rubella, so they can be immunized in the postnatal period to protect future pregnancies.
Rubella antibody titers should be measured ineach pregnancy as levels may decline and fall
below protection levels.
Syphilis serology
All pregnant women should be screened forsyphilis, mothers infected with syphilis can experience long-term morbidity and the complications for pregnancy are significant; 70 to 100%of infants will be infected and one-third will be
stillborn.
Treponema Elisa Screen assay is used to screen
for syphilis as this can detect primary or secondary infection.
Hepatitis B serology
Up to 85% of infants born to mothers infectedwith hepatitis B (particularly mothers who are
HBeAg positive, i.e. with active infection), will
become carriers and will be more likely to develop chronic liver disease, including cirrhosis,
liver failure or liver cancer. Transmission of thehepatitis B virus from mother to infant can be

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The role of laboratory medicine for health during pregnancy

prevented by administration of the hepatitis B
vaccine and immunoglobulin to the infant atbirth, therefore screening is important.
HIV screening
All pregnant women should be screened forHIV. Women who are HIV positive can be given
treatment to reduce the risk of HIV being transmitted to their infant (risk reduced from 32% toless than 1%). Interventions to reduce motherto-child transmission of HIV infection include antiretroviral therapy, elective caesarean sectiondelivery and the avoidance of breastfeeding.
If a patient is considered at risk for HIV, hepatitis
C screening should also be considered.
Additional testing in early pregnancy
Consider checking varicella antibody status in
pregnant women with no (or uncertain) historyof illness (i.e. chicken pox or shingles) or vaccination. Contracting varicella during pregnancy
is associated with a significant risk of harm toboth mother and infant.
Testing for chlamydia and gonorrhoea should beconsidered for those who may be at increased
risk based on age (e.g. less than 25 years) andsexual history.
Vitamin D is required for normal bone growthdevelopment in the foetus. Mothers with known
vitamin D deficiency or at risk for deficiency (e.g.
dark-skinned women, women who wear a veil)should receive vitamin D supplementation.

Screening for gestational diabetes
Gestational diabetes affects 5–8% of pregnant,
it is recommended that testing for gestational
diabetes occurs for all women between 26 and
28 weeks of gestation.
A 50 g glucose tolerance test (the polycose test)
is used to screen for gestational diabetes. A 50 g
glucose load is given to the non-fasting patient,and a glucose level is determined after one
hour. Women with an elevated result should be
followed up with a 100 g oral glucose tolerance
test (OGTT).
Repeat CBC and antibody screening
The CBC should be repeated at 28 weeks’ gestation, to check haemoglobin and platelet levels(see commentary in previous section on how tointerpret and manage these levels in pregnancy). Antibody screening should also be repeatedat 28 weeks’ gestation.
Proteinuria in pregnancy can also be a sign ofpreeclampsia if it’s accompanied by high bloodpressure. Preeclampsia is a condition that only
occurs in pregnancy and causes high blood pressure. It usually occurs after week 20 of pregnancy and can happen in women who didn’t havehigh blood pressure before pregnancy. It canlead to serious complications with mother andbaby that can sometimes be fatal.
Additional tests during pregnancy
Sub-Clinical urine infection

At 26–28 weeks’ gestation, a second round ofblood tests, commonly referred to as the second antenatal screen includes:

It is recommended that all women have a midstream urine culture at the time of the first antenatal screen, again at the second antenatal
screen and then at 36 weeks’ gestation, to exclude a sub-clinical urine infection (asymptomatic bacteriuria).

•

50 g glucose tolerance test (the” polycose” test)•

CBC

Screening for Group B streptococcus•

Blood group antibodies

Blood tests includedin the second antenatal screenGroup B streptococcal (GBS) infection is a significant cause of serious neonatal infection.
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The role of laboratory medicine for health during pregnancy

Approximately 15–25% of women will be carriers, and one in 200 of these women will have infants who develop neonatal sepsis.
Women may have a vaginorectal culture collected at 35 to 37 weeks’ gestation.
Testing for Down syndrome
and other genetic conditions
Screening for Down syndrome, other chromosomal abnormalities and neural tube defects is
recommended to all pregnant women above theage of 35 years.
First trimester screening is based on the combination of results of the following:
The PAPP-A and βhCG tests must be taken between nine and 13 weeks’ gestation (ideally between 10 and 12 weeks), and the NT scan carried out after 11 and before 14 weeks’ gestation.
Second trimester screening can be offered to all
women who present after 14 weeks’ gestation
but before 20 weeks, who have not completed
first trimester screening (bloods are ideally taken between 14 to 18 weeks gestation). This serum screen measures βhCG, alpha-fetoprotein(AFP), unconjugated estriol (µE3), and inhibin A.

6. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Diagnosis ofgestational diabetes mellitus. College Statement, RANZCOG 2008.
7. Sejeny SA, RD Eastham, SR Baker. Platelet counts during normal pregnancy. J Clin Pathol 1975;28:812-3.
8. Op de Coul EL, Hahne S, van Weert YW, Oomen P, SmitC, van der Ploeg KP, et al. Antenatal screening for HIV,hepatitis B and syphilis in the Netherlands is effective.
BMC Infect Dis. 2011;11:185.
9. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Hepatitis B.
College Statement. RANZCOG, 2009.
10. Committee on Obstetric Practice. ACOG. 2011;504:1-3.
11. National Screening Unit. Guidelines for maternity
providers offering HIV screening in New Zealand. Wellington: National Screening Unit, 2008.
12. National Collaborating Centre for Women’s and Children’s Health (Editor). Antenatal care: routine care for thehealthy pregnant woman. Royal College of Obstetricians
and Gynaecologists, 2008.
13. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Pre-pregnancy counselling and routine antenatal assessment in theabsence of pregnancy complications. College Statement.
RANZCOG, 2009.
14. Verlohren.S.,et.al (2012)Am J Obstet Gynecol 202(161):e1-11

REFERENCES

15. Anderson, U.D. Conssen.J.S. et.al (2012). Placenta
33(A-26), S42-S47

1. Priya Soma-Pillay, MB ChB, MMed (O et G) Pret, FCOG,
Cert (Maternal and Foetal Med) SA,Nelson-Piercy Catherine, MA, FRCP, FRCOG, Heli Tolppanen, MD, Alexandre
Mebazaa, MD, Heli Tolppanen, MD, andAlexandre Mebazaa, MD

16. Morley R, Carlin JB, Pasco JA, Wark JD. Maternal
25-hydroxyvitamin D and parathyroid hormone concentrations and offspring birth size. J Clin Endocrinol Metab
2006;91:906–12.

2. Kyle C, ed. A handbook for the interpretation of Laboratory Tests. 4th Edition. Wellington, 2008.
3. William’s Obstetrics Twenty-Second Ed. Cunningham,
F. Gary, et al, Ch. 8.
4. LoY.M.etal. Am J Hum Genet, 1998,62:768-775
5. Hoffman L, Nolan C, Wilson JD, et al. Gestational diabetes mellitus - management guidelines. The Australasian
Diabetes in Pregnancy Society. Med J Aust 1998;169(2):93.

17. Chitayat D, Langlois S, Douglas Wilson R SOGC Genetics Committee, CCMG Prenatal Diagnosis Committee. Prenatal screening for fetal aneuploidy in singleton
pregnancies. J Obstet Gynaecol Can. 2011;33:736–50.
[PubMed]18. The Royal Australian and New Zealand College ofObstetricians and Gynaecologists (RANZCOG). Screening
and treatment for Group B Streptococcus in pregnancy.
College Statement. RANZCOG, 2009.

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Meeting the needs of Mediterranean nations: Mediterranean diet and the area’s specific diseases

This is a Platinum Open Access Journal distributed under the terms of the Creative Commons Attribution Non-Commercial License which permits unrestricted
non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Alcohol abuse
Tomáš Zima

Institute of Medical Biochemistry and Laboratory Diagnostics, First Faculty of Medicine,Charles University and General University Hospital, Prague, Czech Republic

ARTICLE INFOABSTRACT

Corresponding author:
Institute of Medical Biochemistry
and Laboratory Diagnostics
First Faculty of Medicine
Charles University andGeneral University Hospital
U Nemocnice 2
CZ-128 08 Prague 2
Czech Republic
E-mail: zimatom@cesnet.cz

Chronic alcohol consumption is a world-wide socioeconomic problem. Three metabolic pathways of ethanol were describe in human - alcohol dehydrogenase(ADH), microsomal ethanol oxidizing system (MEOS,CYP2E1) and catalase. Ethanol directly bounds to different molecules (e.g. etylglucuronid) and ethanol per
se and its metabolites have toxic effect on biologicalstuctures.

Key words:
alcohol, cancer, epidemiology,
alcohol dehydrogenase, liver diseases
Acknowledgments:
The study was supported by research projects
Progres Q25 and MH CZ DRO VFN 64165..

Alcohol abuse is well known for its liver diseases e.g.
cirrhosis (the most frequent cause in Europe and US)
and hepatocellular carcinoma.
Chronic alcohol consumption leads to cardiovasculardiseases (e.g. hypertension, cardiomyopathy), pancreas damage, myopathies, osteoporosis, neurological and psychiatry diseases including fetal alcohol syndrome and addiction.
Alcohol comsumption may lead to cancer via several
mechanisms, per se (solvent for carcinogens) and its
metabolites. Acetaldehyde, a cancerogen, has mutagenic effect on DNA, oxidation of ethanol produces
the reactive oxygen and nitrogen species with different effects e.g. cell transformation, DNA, protein andlipid damage. The changes of folate metabolism, altered methylation of DNA, reduction of retionic acidinfluences on cancer development.
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Alcohol abuse

The high rate of alcohol consumption has becomea great social-health problem. Consumption of
alcohol is still increasing in many countries, but
in some countries is stable or decreasing (e.g.
Mediterranean region). The data across Europe
shows that 10% of all cancers in men and 3% of
all cancers in women can be attributed to alcohol consumption. Australian data suggests that
alcohol intake accounts for 5% of the total cancer burden of disease. Alcohol consumption is
one of the leading causes of mortality and morbidity in many developed countries.


Alcohol has been consumed by people since
the dawn of mankind. Beer was commonly produced already in ancient Egypt and wine has
been known for millennia. However, excessive
alcohol consumption has been mainly attributed to the second half of the twentieth century.
Alcohol is a very dangerous cytotoxic substancedamaging the organism both acutely and chronically; what is even more dangerous is that it
causes addiction. Any alcoholic beverage in any
quantity is potentially harmful to human health.
Alcohol-induced damage to the organism derives from its direct effect, in particular its metabolism and the substances produced thereof. The direct effect manifests itself mainly inchanges to biological membranes and influencing their fluidity, potentially also by intercellularinteractions with the possible alcohol-induced
malnutrition caused by its effect on the epithelium of the small intestine.
There are four metabolic pathways of ethanol in
the human organism:
1) alcohol dehydrogenase (ADH);
2) microsomal ethanol oxidizing system(MEOS, CYP2E1);3) catalase, and
4) non-oxidative metabolism.

These enzyme systems can remove 90–98 percentage of alcohol from the human body; theunchanged residual amount is excreted from thebody through breath, sweat and urine.
The main enzyme in ethanol metabolism belongs
to the cytosolic dimeric alcohol dehydrogenase(ADH, E.C. 1.1.1.1) which catalyses the conversion of ethanol to acetaldehyde, which is carcinogenic. In addition to oxidation of alcohols, italso contributes to the metabolism of steroids
and omega-oxidation of fatty acids. Oxidation of
ethanol in the digestive tract can reduce the systemic ethanol concentration by up to 20%. ADH
is developmentally and gender conditioned, resulting in lower ADH activity in females. In addition, this enzyme is not inducible and its rate islimited not only by NAD+ and oxidises in 92–96%
of the alcohol ingested.
The emerging acetaldehyde is further metabolised by aldehyde dehydrogenase (AlDH,
E.C.1.2.1.3.) into the end product acetate, which
can be involved in a number of metabolic processes within the organism. AlDH can be identified in almost all organs, with high activity inthe liver and in tissues that are in direct contact
with the ambient environment. In a large portion of the Asian population, the genetic polymorphism ALDH2*2 is described, which results
in an increase in acetaldehyde due to the lower
activity of AlDH; there is also a higher incidenceof tumour growth in this population.
Oxidation of alcohol to acetaldehyde and subsequently to acetate requires reduced nicotine
cofactors, which alter the ratio of reduced andoxidized NAD, thereby altering the redox cell
environment. These changes result in increased
lactate and ketone body formation and reduced
gluconeogenesis and Krebs cycle activity, followed by increasing of acetate for lipid synthesis. Acetaldehyde is a very reactive compoundbinding itself to nucleic acids, phospholipids
and, above all, to proteins, including albumin,

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Tomáš Zima
Alcohol abusecollagen and haemoglobin, thus altering theirstructure and function. Nucleic acid modifications, the formation of etheno-DNA adducts, are
one of the possible mechanisms of carcinogenicity of alcohol, including inhibition of DNA repair.
Microsomal ethanol oxidizing system (MEOS,
cytochrome P450IIE1 or CYP2E1), is an inducible ethanol oxidizing system that metabolizes
xenobiotics and many other substances including vitamin D. Induced CYP2E1 can activate carcinogens and hepatotoxins by converting theminto even more toxic metabolites. Among theby-products of ethanol oxidation, there is theincreased formation of reactive oxygen species,changes in human antioxidant protection systems, and the development of oxidative stress,
which has many pathobiochemical effects on
the organism (1,2,3,4).
Alcohol consumption is associated with morethan 200 diseases (5), including a number oftumours, hypertension (6), liver cirrhosis (7),brain damage and diabetes (8). Ethanol abuse
also damages the pancreas (causes up to 50% ofchronic pancreatitis), the nervous system (psychiatric diseases, addiction treatment) and themuscles; it affects the immune system, the nourishment of the organism; and contributes to theformation of osteoporosis. Drinking alcohol during pregnancy may cause fetal alcohol syndrome
with an incidence of 3.7 per 1000 live births inEurope (9). Children and pre-adolescents (people under 18 years of age) who consume alcohol are at an increased risk of alcohol-induced
damage to the organism (10), including the riskof alcohol dependence.
Alcohol is most commonly associated with liver
damage. Alcohol-induced liver damage includes
a variety of nosological units, such as steatosis,
alcoholic hepatitis, cirrhosis, and hepatocellular
carcinoma. In Europe and the US, alcohol is themost common cause of liver cirrhosis. According
to the GDB (Global Burden of Disease) study,

roughly half of the cirrhosis deaths were causedby alcoholic liver cirrhosis. The basic mechanismsof hepatic tissue damage include centrilobular
hypoxia, neutrophil infiltration and immune response activation (IL-8 activation, leukotriene
B4, inflammatory cell infiltration), cytokine andendotoxin exposure, antigen adduct formation,and oxidative stress damage (7).
The influence of ethanol on the cardiovascularsystem is very much debated in terms of its cardioprotective effects at very small doses (20 g/day). The protective mechanism is enabled byan increase in HDL-cholesterol, ApoA I, paraoxonase activity and adiponectin through lowering LDL-cholesterol; by an antithrombotic
effect; and by an increase in insulin receptor
sensitivity (11). In a recent study (12), the authors have processed data from 83 studies on
59,912 participants, deriving interesting conclusions. When evaluating a total of 40,310
deaths, it was found that the risk rose from 100
g of ethanol per week. In the study of deaths for
cardiovascular disease (39,018), there was a decrease in the risk of death in people consuming
100–200g of ethanol per week. When analysingthese overall data, the decrease was observed
only in myocardial infarction. The above-mentioned paper states that a person aged forty
who consumes more than 350 g of ethanol per
week will shorten his life by four to five years.
Consuming higher doses of alcohol means ahigher risk of heart attack, atrial fibrillation andalso hypertension (approx. 10% of hypertension
is estimated to be caused by alcohol consumption) and cardiomyopathy (11).
Chronic alcohol consumption is associated with
10 % of tumours in males and 3% in females. It isconsidered a risk factor in upper gastrointestinal
tract tumours (UADT – oral cavity, pharynx, larynx, and oesophagus), hepatocellular carcinoma, colorectal carcinoma and breast cancer (13,14). The impact of alcohol abuse on the risk oflung and pancreatic carcinoma is also discussed.

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Alcohol abuse

As for the UADT tumours, 25–68% of them areassociated with alcohol consumption with therisk increasing significantly in smokers. The riskof developing the tumour is significantly higher– twice to six times – when consuming 50–100
g/day (13). The threshold risk value for colorectal cancer is 20 g of ethanol a day (15). The incidence of hepatocellular carcinoma increases
and alcohol is the major risk factor in Europe
and the US. There are a number of mechanisms
leading to tumour growth – high dose of alcohol,increased oxidative stress, formation of modified DNA bases, DNA repair disorder, increased
acetaldehyde, folic acid deficiency (methylation
disorder), inflammatory reactions, changes iniron metabolism, increased estrogen, decreased
levels of retinoic acid (hyperregeneration andhyperproliferation), risk allelic variants of alcohol metabolising genes (ALDH2*2, ADH1B*2,
ADH1C*1) leading to increased acetaldehyde
concentration (16,17), coincidence with precancerous condition (gastroesophageal reflux
disease, colon polyps, colitis) or other diseases(e.g. hepatitis, NASH, hemochromatosis).
According to WHO data, alcohol consumption
declined in Europe between 1990 and 2014,
contrary to East Asia, South America and Africa,
where there was an increase in consumption. A
significant drop in consumption occurred in the
Mediterranean countries – Italy, Spain, France,
Greece (18, 19). The European Union estimates
the damages caused by consumption of alcoholic beverages at 125 billion EUR per year. In the
EU countries, 195 000 people on average die ofalcohol-related injuries, liver disease, tumours,
etc. every year. It is worth pointing out that in
the European Union, every seventh death (14 %)in males and every thirteenth (7 %) in females
aged 15–64 are related to alcohol consumption,
which means about 95 000 males and 25 000 females per year (12 % of all deaths). It is the third
most common cause of early deaths and illnesses in the EU, following smoking and high bloodpressure related diseases. Alcohol is linked tothe deaths of young people (15–29 years) at 5%
globally, 25% in Europe and, unfortunately, 33% in Eastern Europe. Around 55 million adults in
Europe are at risk of alcohol addiction (consuming more than 40 g/day) (20).
Alcohol as a chemical molecule has been accompanying mankind for several millennia. Current
data and meta-analysis of studies suggest that
consumption of 100–200 g of ethanol per week
can be tolerated (not recommended) on condition
that there is a two-day gap between consumption. Alcohol-induced damages are importantfrom both the health and the social point of view
(psycho-social and economic consequences).
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1. Sun AY, Ingelman-Sundberg M, Neve E, Matsunomo H,
Nishitani Y, Minowa Y, Fukui Y, Bailey M, Patel VB, Cunningham CC, Zima T, Fialová L, Mikulíková L, Popov P,
Malbohan I, Janebová M, Nešpor K, Suri GY Ethanol andOxidative Stress. Alcoholism: Clinical and Experimental
Research 2001; 25,Suppl: 237-243.
2. Zima T, Fialová L, Mestek O, Janebová M, Crkovská J,
Malbohan I, Štípek S, Mikulíková L Oxidative Stress, Metabolism of Ethanol and Alcohol-Related Diseases. Journal of Biomedical Science 2001; 8: 59-70.
3. Zima T, Albano E, Ingelman-Sundberg M, Arteel GE,
Thiele GM, Klassen LW, Sun AY Modulation of Oxidative
Stress by Alcohol. Alcohol Clinical and Experimental Research 2005;29: 1060 – 1065.
4. Zima T, Kalousová M Oxidative Stress and signal transduction pathways in alcoholic liver disease. Alcoholism: Clinical and Experimental Research 2005;29 Suppl.:
110S-115S.
5. Rehm J et al. Statistical modeling of volume of alcohol exposure for epidemiological studies of population
health: the US example. Population Health Metrics,
2010;8:3 doi:  10.1186/1478-7954-8-3.
6. Marmot MG et al. Alcohol and blood pressure: the INTERSALT study. British Medical Journal 1994; 308: 1263–1267.
7. Rehm J et al. Alcohol as a risk factor for liver cirrhosis:
a systematic review and meta-analysis. Drug and Alcohol
Review 2010; 29: 437–445.
8. Baliunas DO et al. (2009): Alcohol as a risk factor for
type 2 diabetes: A systematic review and meta-analysis.
Diabetes Care 2009; 32: 2123–2132.

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Alcohol abuse

9. Popova S, Lange S, Probst C, Gmel G, Rehm J Estimationof national, regional, and global prevalence of alcohol use
during pregnancy and fetal alcohol syndrome: a systematic review and meta-analysis. Lancet Glob Health 2017;
5: e290–299.
10. Laucht M, Blomeyer D, Buchmann, A Alkohol und
Tabak in der Adoleszenz. In: Singer MV, Batra A, Mann
K (Hrsg): Alkohol und Tabak. Grundlagen und Folgeerkrankungen. Stuttgart; New York: Thieme 2011: 433–444.
11. Fernández-Solà J Cardiovascular risks and benefits ofmoderate and heavy alcohol consumption. Nat Rev Cardiol 2015; doi:10.1038/nrcardio.2015.91.
12. Wood AM et al. Risk thresholds for alcohol consumption: combined analysis of individual-participant data for599 912 current drinkers in 83 prospective studies. Lancet
2018;391: 1513-1523.
13. Bagnardi V, Blangiardo M, La Vecchia C, Corrao G. A
meta-analysis of alcohol drinking and cancer risk. Br J
Cancer 2001; 85: 1700–1705.
14. Seitz HK et al. Epidemiology and pathophysiology ofalcohol and breast cancer: Update 2012. Alcohol and Alcoholism 2012; 47: 204–212.
15. Fedirko V, Tramacere I, Bagnardi V, Rota M, Scotti
L, Islami F, Negri E, Straif K, Romieu I, La Vecchia C,
Boffetta P, Jenab M Alcohol drinking and colorectal

cancer risk: an overal and dose–response meta-analysis of published studies. Annals of Oncology 2011; 22:
1958–1972.
16. Yokoyama A, Muramatsu T, Ohmori T, Yokoyama
T, Okuyama K, Takahashi H, Hasegawa Y, Higuchi S,
Maruyama K, Shirakura K, Ishii H Alcohol-related cancers
and aldehyde dehydrogenase-2 in Japanese alcoholics.
Carcinogenesis 1998; 19: 1383–1387.
17. Seitz HK, Stickel F. Molecular mechanisms of alcohol­
mediated carcinogenesis. Nature Reviews Cancer 2007;
7: 599–612.
18 Shield KD, Rylett M, Rehm J Public health successes
and missed opportunities. Trends in alcohol consumption
and attributable mortality in the WHO European Region
1990–2014, WHO Regional Office for Europe, WHO 2016,
75 pp.
19. Ezzati M, Riboli E Behavioral and Dietary Risk Factors for Noncommunicable Diseases. N Engl J Med
2013;369:954-64.
20. Status Report on Alcohol and Health in 35 European
Countries 2013. WHO Regional Office for Europe. WHO
2013, 170 pp.

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proteomics
n nephopath sMeeting the needsof Mediterraneannations: Mediterranean diet and the area’s specific diseases

This is a Platinum Open Access Journal distributed under the terms of the Creative Commons Attribution Non-Commercial License which permits unrestricted
non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Urinary proteomics in biomarker discovery ofkidney-related disorders: diabetic nephropathy anddrug-induced nephrotoxicity in chronic headache
Elisa Bellei1, Emanuela Monari1, Stefania Bergamini1, Luigi Alberto Pini1,2,Aldo Tomasi1, Tomris Ozben3

Department of Diagnostic Medicine, Clinic and Public Health, University of Modena and Reggio Emilia,
Modena, Italy
2
Headache and Drug Abuse Study Center, University-Hospital of Modena and Reggio Emilia, Modena, Italy
3
Department of Clinical Biochemistry, Medical Faculty, Akdeniz University, Antalya, Turkey
1

ARTICLE INFOABSTRACT

Corresponding author:
Tomris Ozben
Department of Clinical Biochemistry
Akdeniz University
Dumlupinar Boulevard 07058
Konyaalti, Antalya
TurkeyE-mail: ozben@akdeniz.edu.tr

Objective

Key words:
urinary proteomics, biomarkers, diabetic
nephropathy, drug-induced nephrotoxicity

Urinary proteomics is primarily applied to the studyof renal and urogenital tract disorders. Here are reported two distinct successful examples of this approach for the discovery of early urinary biomarkers
of kidney-related dysfunctions: diabetic nephropathy(DN), a well-known complication of diabetes frequently leading to dialysis, and drug-induced nephrotoxicity, a possible condition caused by medicationoveruse headache (MOH). Early detection of kidney
disorders based on selective biomarkers could permit
to diagnose patients at the initial stage of the disease,
where the therapy may be suspended or prevent disease advancement.
Methods
Urine samples were first concentrated and desalted.
Subsequently, they were subjected to two-dimensional gel electrophoresis (2-DE) coupled to mass spectrometry (MS) for protein identification. Furthermore,
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Elisa Bellei, Emanuela Monari, Stefania Bergamini, Luigi Alberto Pini, Aldo Tomasi, Tomris Ozben
Urinary proteomics in nephropathies

some proteins were verified by Western blot and
ELISA test.
Results
In diabetes-related study, 11 differentially expressed proteins were detected (8 up-regulated
and 3 down-regulated) in type 2 diabetic (T2D)
and T2DN patients compared to the healthy
control subjects. In the MOH study, a total of 21
over-excreted proteins were revealed in urine ofnon-steroidal anti-inflammatory drugs (NSAIDs)
and mixtures abusers vs controls. Particularly, 4proteins were positively validated by immunoblotting and ELISA.
Conclusion
Urinary proteomics allows non-invasive assessment of renal diseases at an early stage by theidentification of characteristic protein pattern.


INTRODUCTION
Proteomics is the study of protein expression ina definite tissue, cell type or biological body fluid. The comparison of protein patterns between
healthy subjects and patients with a given pathological condition can be useful to identify specific diagnostics or prognostics biomarkers of
diseases. Particularly, urinary proteomics has
rapidly developed and has been extensively applied in the field of early diagnostics and differentiation of renal damage (1).
Urine is a valuable source of proteins and peptides; it has the advantage of being obtained
non-invasively, easily and frequently, and in alarge quantity. It has been defined as a fluid biopsy of the kidney and urogenital tract, thus providing considerable information about these organs. Consequently, many changes in kidney andurogenital tract function may be detected in theurinary proteome (2).

Urine proteomics studies were conducted in the
search for early biomarkers of renal changes in:
1. type 2 diabetic nephropathy (T2DN), a complication linked to diabetes, which leads to
end-stage renal disease (3);2. drug-induced nephrotoxicity in medicationoveruse headache (MOH), a chronic disorderassociated with overuse of analgesic drugs
or compounds for acute headache (4-6).
MATERIALS AND METHODS
Subjects
1) Diabetic nephropathy
Diabetic patients were enrolled from the“Division of Nephrology, Dialysis and Renal
Transplantation” of the University-Hospital of
Modena and Reggio Emilia, Italy: 10 normoalbuminuric patients with type 2 diabetes (T2D),
12 T2DN patients with microalbuminuria (range
130-280 mg/mL) and/or proteinuria (>10 mg/dL), and a control group of 12 healthy volunteer
subjects with a history of regular renal function.
The duration of diabetes was similar in the twopatients groups. Moreover, all groups werematched for age and gender (3).
2) Drug-induced nephrotoxicity
A total of 87 MOH patients were recruited from the“Headache and Drug Abuse Center”, UniversityHospital of Modena and Reggio Emilia, Italy. They
were divided into three groups, according to thetype of the primary abused drug, as follows: 31
patients who consumed exclusively triptans, 27
non-steroidal anti-inflammatory drugs (NSAIDs)
and 29 taking mixtures. Healthy volunteers(n=30) were enrolled as controls. Each group wasmatched for age and gender; moreover, patients
showed similar MOH duration, days with headache/month and about daily drug intake. Kidneydiseases and urogenital tract dysfunctions,Page 291

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Elisa Bellei, Emanuela Monari, Stefania Bergamini, Luigi Alberto Pini, Aldo Tomasi, Tomris Ozben
Urinary proteomics in nephropathies

together with other important illness, were considered as exclusion criteria (5).

min at +4C°, to remove cell debris and contaminants. Commonly, human urine has a very diluted protein concentration and, at the same time,a high-salt content, which hampers the proteomic analysis. Sample preparation is therefore
a pivotal step in urinary proteomics, especiallyduring two-dimensional polyacrylamide gel electrophoresis (2-DE) (2). In order to concentrate
proteins, eliminating the interfering salts, urine
samples were treated with filter devices, 3 kDa
MW-cut off (Merck Millipore). Subsequently,
total protein content was estimated by the

Both studies were in compliance with the ethicalprinciples for medical research involving humansubjects, in accordance with the Declarationof Helsinki. Written informed consent were received from both, patients and healthy subjects.
Urine proteomics analysis
Morning midstream urine samples were collected and immediately centrifuged at 800 g for 10
Table 1

Differentially expressed proteinsdetected in T2D and T2DN patients by MS
Acc.
number(a)Protein name

MW
(kDa)

Function

Up-regulated proteins
Transthyretin precursor

P02766

16.0

Hormone-binding

Ig Kappa chain C-region

P01834

11.8

Immune response

Ig Kappa chain V-II region Cum

P01614

12.8

Antigen-binding

Ig Kappa chain V-II region SIE

P01620

11.9

Immune response

Carbonic anhydrase 1

P0091528.8

Miscellaneous

Plasma retinol-binding protein

P02753

23.3

Transport

Beta-2-microglobulin precursor

P61769

13.8

Immune response

Beta-2-glycoprotein 1

P0274939.6

Binding protein

Down-regulated proteins
Prostatic acid phosphatase precursor

P1530944.9

Dephosphorylation

Ribonuclease 2

P1015318.9

Miscellaneous

Kallikrein-3

P0728829.3

Hydrolysis(a) Primary accession number from the SwissProt database.

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spectrophotometric Bradford method, and 100
mg of protein was premixed with a specific lysis
buffer. The first-dimension separation (isoelectrofocalization) was performed using IPG strips
17 cm long, wide pH range 3-10 (Bio-Rad), whilein the second-dimension separation, 8-16%
polyacrylamide gradient gels were used, that finally were staining with a silver-nitrate staining
protocol. Afterwards, gels images were acquiredwith a calibrated densitometer (GS800 model,
Bio-Rad) and analyzed by a specific image analysis software (PDQuest, Bio-Rad), to reveal differentially expressed protein spots among thepatients and control groups (3, 5). The spots ofinterest were cut from the gels and subjected
to trypsin digestion. Peptides were finally extracted and analyzed by the mass spectrometry
using a quadrupole-time of flight-liquid chromatography mass spectrometer (Q-ToF-LC/MS,
Agilent-Technologies).

were further confirmed and validated by Western
blot and ELISA test (6).

In the second study (drug-induced nephrotoxicity), the results obtained by proteomic analysis

Proteomic analysis allowed to detect alterations of urinary proteins in both T2DN and T2D

Table 2

RESULTS AND DISCUSSION
1) Diabetic nephropathy
Comparing the urinary proteomic profiles obtained by 2-DE analysis, 11 differential proteins
were identified that progressively changed between controls and T2D and T2DN patients.
Precisely, 8 proteins were significantly up-regulated: transthyretin precursor, Ig k chain C region, Ig k chain V-II region Cum, Ig k-chain V-III
region SIE, carbonic anhydrase 1, retinol binding protein, beta-2-microglobulin precursor andbeta-2-glycoprotein 1.
Except for the last one, all the other proteins
were in the low MW range (<30 kDa). Three proteins were found down-regulated: prostatic acidphosphatase precursor, ribonuclease 2 and kallikrein-3 (Table 1).

Differentially expressed proteins identified by Q-ToF-LC/MS

Protein nameAcc.
number(a)

MW
(kDa)

Over-expression vscontrols(b)Mixtures

NSAIDsTriptans

Low - MW proteins
Prostaglandin-H2-D-isomerase

P41222

18.7

x

x

x

Ig kappa chain C region

P01834

11.8

x

x

NS

Perlecan (fragment)

P98160

479.2

x

x

x

Transthyretin

P02766

15.9

NS

x

NS

Proactivator polypeptide

P07602

9.11

x

x

x

Nuclear transport factor 2

P61970

14.6

x

x

x

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Urinary proteomics in nephropathies

Fatty acid-binding protein

Q01469

15.5

NS

x

x

Beta-2-microglobulin

P61769

11.7

NS

x

x

Protein S100-A11

P31949

11.8

NS

x

x

Non-secretory ribonuclease

P10153

18.9

x

x

NS

Cystatin-C

P01034

13.3

x

x

NS

Protein S100-A8

P05109

10.8

x

x

x

Medium - MW proteins
Alpha-1-antitrypsin

P01009

46.9

x

x

NS

Actin, cytoplasmic1

P60709

42.1

x

x

x

Alpha-1-microglobulin

P02760

39.9

x

x

NS

Apolipoprotein H

P02749

38.3

NS

x

NS

Serpin B3

P29508

44.6

x

x

x

Annexin A1

P04083

38.6

x

x

x

High - MW proteins
Serum albumin

P02768

66.5

x

x

NS

Uromodulin

P07911

69.7

x

x

x

Inter-α-trypsin inhibitor heavy chain H4

Q14624

70.6

x

x

NS

(a) Primary accession number from the SwissProt database(b) Expression difference calculated by the PDQuest software: x: significant, NS: not-significant

normo­albuminuric patients. Thus, this protein
pattern might be of potential interest to identify
diabetic patients prone to develop nephropathy,
contributing to a better understanding of diabetic-related renal damage. The strength of proteomics in this research area has been confirmed
also by recently published review articles (7, 8).

2) Drug-induced nephrotoxicity
In this study, both qualitative and quantitative
differences in urine of MOH patients were studied and revealed. Interestingly, by 2-DE combinedwith MS analysis, 21 over-excreted proteins and asignificantly higher number of total protein spots
were identified in the urine of NSAIDs, mixtures

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Urinary proteomics in nephropathies

and triptans abusers compared to the controls(Table 2).
Some differentially expressed proteins detectedby proteomic analysis were found to be strongly
related to renal injury (9), as assessed by an extensive literature review. Particularly, 4 proteins
were validated by Western blot: prostaglandinH2 D-synthase (PTGDS), uromodulin (UROM),alpha-1-microglobulin (AMBP) and cystatin-C(CYSC), as shown in Figure 1.
Figure 1

Immunoblotting allowed to confirm previous
data of over-expression of these proteins inurine of MOH patients (especially NSAIDs andmixtures abusers) vs normal controls (6).
Finally, PTGDS was further quantified by the
ELISA test (Figure 2), which proved its significant increase in all MOH groups: mixtures (681
± 218 ng/mL), NSAIDs (572 ± 135 ng/mL,) andtriptans (450 ± 116 ng/mL), compared to thecontrols (303 ± 130 ng/mL). These data points,

Western blot analysis

PTGDS

UROM

AMBP

CYSC

Ctrl

Trip

NSAIDsMix

The protein expression was evaluated on urine samples in controls (Ctrl), triptans (Trip), NSAIDs and mixturesgroup (Mix). For each protein tested the signal is higher in NSAIDs and mixtures abusers compared to controls.

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Urinary proteomics in nephropathies

Figure 2

ELISA test of PTGDS protein

***

700

**

600

*

500
400
300
200
100
0

Mixtures

NSAIDsTriptans

Controls

Significant difference was estimated by the Student’s t-test (*p<0.01, **p<0.0001, ***p<1.00-06 vs controls).

expressed as mean ± standard deviation, werein strict accordance with MS and Western blot
results (6).
The results of this study allowed to define theurinary protein profile of MOH, in relation to thetype of drug abused. The use of powerful proteomic methodologies could permit to identify
promising candidate biomarkers of kidney dysfunctions, and consequently those chronic headache patients at risk to develop drug-induced
nephrotoxicity.
CONCLUSIONSIn conclusion, urinary proteomics proved to bea suitable tool in nephro-toxicological research.
Actually, its application may be useful in the
search of early biomarkers, providing importantdiagnostics and prognostics indications.

Additionally, the study of the urinary proteome
can offer significant data for a better understanding of renal pathophysiology.
REFERENCES
1. Pejcic M, Stojnev S, Stefanovic V. Urinary proteomics – atool for biomarker discovery. Renal Failure 2010; 32:259-268.
2. Kalantari S, Jafari A, Moradpoor R, Ghasemi E, Khalkhal
E. Human urine proteomics: analytical techniques and clinical applications in renal diseases. Int J Proteomics 2015;
ID 782798
3. Bellei E, Rossi E, Lucchi L, Uggeri S, Albertazzi A, Tomasi A, Iannone A. Proteomic analysis of early urinary
biomarkers of renal changes in type 2 diabetic patients.
Proteomics Clin Appl 2008; 2:478-491.
4. Bellei E, Cuoghi A, Monari E, Bergamini S, Fantoni LI,
Zappaterra M, Guerzoni S, Bazzocchi A, Tomasi A, Pini LA.
Proteomic analysis of urine in medication-overuse headache patients: possible relation with renal damages. J
Headache Pain 2012; 13:45-52.

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Elisa Bellei, Emanuela Monari, Stefania Bergamini, Luigi Alberto Pini, Aldo Tomasi, Tomris Ozben
Urinary proteomics in nephropathies

5. Bellei E, Monari E, Cuoghi A, Bergamini S, Guerzoni S,
Ciccarese M, Ozben T, Tomasi A, Pini LA. Discovery by aproteomic approach of possible early biomarkers of druginduced nephrotoxicity in medication-overuse headache.
J Headache Pain 2013; 14:6.
6. Bellei E, Monari E, Bergamini S, Cuoghi A, Tomasi A,
Guerzoni S, Ciccarese M, Pini LA. Validation of potential
candidate biomarkers of drug-induced nephrotoxicity
and allodynia in medication-overuse headache. J Headache Pain 2015; 16:77.
7. Pena MJ, Nischak H, Heerspink HJI. Proteomics forprediction of disease progression and response totherapy in diabetic kidney disease. Diabetologia 2016;
59:1819-1831.
8. Moresco RN, Mainardi de Carvalho JA. Applying proteomics to diagnosis of diabetic kidney disease. Exp Rev
Proteomics 2017; 14:841-843.
9. Dieterle F, Perentes E, Cordier A, Roth DR, Verdes P,
Grenet O, Pantano S, Moulin P, Wahl D, Mahl A, End P,
Staedtler F, Legay F, Carl K, Laurie D, Chibout SD, Vonderscher J, Maurer G. Urinary clusterin, cystatin C, β2microglobulin and total protein as markers to detect druginduced kidney injury. Nat Biotechnol 2010; 25:463-469.

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Meeting the needs of Mediterranean nations: Mediterranean diet and the area’s specific diseases

This is a Platinum Open Access Journal distributed under the terms of the Creative Commons Attribution Non-Commercial License which permits unrestricted
non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Standardization of the HbA2 assay
Renata Paleari, Andrea Mosca

Department of Physiopathology and Transplantation, Center for Metrological Traceabilityin Laboratory Medicine (CIRME), University of Milano, Italy

ARTICLE INFOABSTRACT

Corresponding author:
Prof. Andrea Mosca
Dip. Fisiopatologia mct, L.I.T.A.
Via Fratelli Cervi 93
20090 Segrate, (MI)Italy
Phone: +39 02 5033 0422
Email: andrea.mosca@unimi.it

BackgroundKey words:
HbA2, β-thalassemia,
standardization, traceability

A project for the standardization of HbA2 was launchedby the IFCC back in 2004.
Materials and methods
In this work we report on the state-of-the-art of the
project on standardization of HbA2. Data obtained
from various EQAS studies, and from previous experimental evaluations, are presented.
Results
We have proven that biases between various commercial methods are still currently significant. We
have also shown that calibration by commutable control materials may halve the inter-method variability.
Conclusions
The foundation of the reference system for HbA2, together with a brief preliminary presentation of the
proposed primary reference measurement procedure based on ID-MS are outlined.

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Standardization of the HbA2 assay

WHY TO STANDARDIZE
The promotion of the standardization of routine
laboratory methods is one of the mission statement of the International Federation of Clinical
Chemistry (IFCC) general policy.
In the specific case of the methods used for thedetermination of hemoglobin A2 (HbA2), theirstandardization is a real need, not only an academic specific exercise. Indeed, there are several important motivations to meet this:a) most of the routine laboratory methods arepoorly aligned;b) important decision limits have been proposed as markers for the diagnosis of thalassemia syndromes;c) the correct diagnosis of carriers in couples
at risk is the basic instrument to reduce theburden of thalassemia syndromes;
Table 1d) β-thalassemia is one of the few examples
among genetic disorders in which identification of carriers is performed, mostly, bysimple hematological and biochemical tests.
The evidence that the laboratory methods are
not aligned may come from the information
provided by the external quality assessment
schemes (EQAS) or by specific investigations. We
have previously reported that the overall interlaboratory CVs evaluated from a pilot exercise
in Italy with 48 Italian laboratories were in theorder of 6 to 8% and that the fraction of laboratories reporting unacceptable results ranged
from 17 to 32% [1]. We have also shown thatdata collected in Italy from a mandatory exercise
performed in Tuscany and surrounding regions
reported CV values between methods similar to
those found in another EQAS exercise provided
by a manufacturer [2].

Performance characteristics
of different methods for HbA2 testing
MethodBetween-run
reproducibility

Bio-Rad D10

Bias versus consensus mean

r

Slope

Intercept

1.7

0.978 to 1.018

0.07 to 0.24

0.9981

Bio-Rad Variant II β-thalassemia

0.9

0.866 to 0.905

0.20 to 0.38

0.9977

Bio-Rad Variant II dual kit

1.7

1.026 to 1.047-0.23 to -0.14

0.9995

Menarini HA8160

2.3

0.790 to 0.826

0.56 to 0.72

0.9976

Trinity Premier High Resolution

6.6

1.012 to 1.087-0.08 to 0.24

0.9941

Trinity Premier Quick Scan

1.4

1.115 to 1.156-0.42 to -0.24

0.9985

Sebia Capillarys 2 FP

1.9

0.898 to 0.946-0.19 to 0.02

0.9969Tosoh G8

1.9

1.150 to 1.180-0.63 to -0.50

0.9992

Data were derived from reference 3. Reproducibility is expressed as CV %.
For slope and intercept, the 95% confidence intervals are reported.

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Standardization of the HbA2 assay

Besides that, we have recently evaluated theperformance of current high-performance methods for HbA2 by measuring 40 blood samples indouble over two separate days by the HPLC andone capillary electrophoresis system [3]. We
have found a mean imprecision ranging from
0.9 to 6.6 %, and a significant bias between themethods which were however quite well correlated (r between 0.9941 and 0.9995). In Table 1
the main data concerning the performance of theevaluated methods are summarized. In the same
work we have tested the commutability of various control materials and we have shown that
it is possible to reduce the variability between
the methods by using a couple of commutablehome-made control materials as calibrators.
With regard to the overall variability, we have
Figure 1

seen that after calibration the CVs were reduced
from 6.8 to 3.4 %, from 6.6 to 4.6 %, and from 6.7
to 3.0 % for HbA2 to concentrations lower than
3.0 %, between 3.1 and 4.5 % and above 4.6 %,respectively.
HOW TO BUILD A ROBUSTSTANDARDIZATION SYSTEM
In 2004, the IFCC approved a project for the development of a complete reference system for
HbA2, as shown in Fig. 1. At the top of the traceability chain, pure recombinant hemoglobins(HbA and HbA2) are used to calibrate the reference measurement procedure. This reference
measurement procedure is based on peptide
mapping and isotopic dilution mass spectrometry

IFCC reference system and traceability chain
for HbA2 measurement

HbA2 traceability chain
Reference materials(recombinant HbA0 and HbA2)
Certified Reference Material(lyophilized hemolysate)

Manufacturer’s
working calibrator
Manufacturer’s
product calibrator

Reference Measurement
Procedure(ID-LC-MS/MS)IFCC
WG-HbA2

Manufacturer’s internalreference measurement
procedure
Manufacturer’s standing
measurement procedure

Routine measurement procedure
Patient Sample

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Manufacturer

Individuallaboratory

Renata Paleari, Andrea Mosca
Standardization of the HbA2 assay(ID-MS), as described previously [2]. Specifictryptic fragments of the δ and α chains (i.e. δT2and αT5) are selected as signature peptides representing either HbA2 or total hemoglobin, andquantified. The principle of the method together
with the main performance characteristics areunder publication. According to the traceability
chain reported in Fig. 1, the reference measurement procedure will then be used to assign the
HbA2 value to certified reference materials which
will be produced in collaboration with the Joint
Research Centre (JRC).
We have already prepared and characterized
one pilot batch of this material consisting of astabilized hemolysate in the lyophilized form [4].
The material was found to be quite stable withrespect to HbA2 content for at least seven years
when stored at -20°C, commutable with the
majority of routine methods and to have a totalhemoglobin concentration and methemoglobin(MetHb) content similar to that of fresh blood.
Manufacturers will then use these certified reference materials to calibrate their methods andto assign values traceable to the primary reference measurement procedure to their calibrators. Finally, the laboratorians using a routine
method traceable to a reference measurement
procedure will hopefully provide a more robust
and accurate result.
TIME-SCALE FOR IMPLEMENTING
THE REFERENCE SYSTEM
The first major step is to publish and validate
the reference measurement procedure. The
principle of this novel method is under publication at the moment of writing this report. The
validation of the method according to the various ISO standards will require more work andthe involvement of another laboratory because
the minimum number of three laboratories isrequired in order to assign the values to any certified reference material. We estimate at least

one more year to accomplish this second step.
Almost in parallel we hope to be able to prepare
the certified material to be used as calibrator incollaboration with the JRC. So, it is not unlikelythat a couple of years will be necessary in orderto have the manufacturers align their methods.
CONCLUSION
Some are of the opinion that the novel moleculartechniques such as next generation sequencing(NGS) may substitute the use of HbA2 in the fieldof thalassemia screening and diagnosis. We
have performed a survey among various opinion leaders and apparently this will not be thecase, at least in the next coming years. Indeed,
the following points were drawn:
1. Measuring a protein is not the same as sequencing the DNA. Measuring HbA2 is a functional analysis at protein level, and it will never be replaced by DNA technology.
2. NGS requires a lot of work for the interpretation and, in many cases, the significance ofnovel SNPs or variants of unknown significance is not known. In addition, it is reallycritical to know who is going to perform thisinterpretation.
3. There are still unresolved ethical problems
in handling “incidental findings” with DNAtechnologies.
4. NGS is very expensive and it is unlikely thatit could be implemented in poor countries
where the burden of thalassemia syndromes
is greater than in some richer countries.
5. On the contrary, measuring HbA2 is simple
and fast and it has to be considered that inprenatal screening, as for couples at risk, it
is desired to have the result in 1 or 2 days.
As such it can be concluded that HbA2 assay still
remains a gold standard for thalassemia screening and consequently its standardization is a major and topical issue.

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Standardization of the HbA2 assay

Acknowledgements
We would like to acknowledge the following persons who gave their opinion, as experts in the field,with regards to the need for a standardizationof HbA2 measurements: Prof. Suthat Fucharoen(Mahidol University, Nakornpathom, Thailand),Dr. Cornelis L. Harteveld (Leiden University Medical
Center, Leiden, the Netherlands), Dr. Serge Pissard(INSERM, Paris, France), Prof. Vip Viprakasit(Mahidol University, Bangkok, Thailand), Prof.
Henri Wajcman (INSERM, Creteil, France).


REFERENCES
1. Paleari R, Giambona A, Cannata M, Leto F, Maggio A,
Mosca A. External quality assessment of hemoglobin A2

measurement: data from an Italian pilot study with fresh
whole blood samples and commercial HPLC systems. Clin
Chem Lab Med 2007;45:88-92.
2. Paleari R, Caruso D, Kaiser P, Arsene CG, Schaeffer-Reiss
C, Van Dorsselaer A, Bissé E, Ospina M, De Jesús VR, Wild
B, Mosca A, on behalf of the IFCC Working Group on Standardisation of Hemoglobin A2 (WG-HbA2). Developing areference system for the IFCC standardization of HbA2.
Clin Chim Acta. 2017;467:21-6.
3. Paleari R, Ceriotti F, Harteveld CL, Strollo M, BakkerVerweij G, ter Huurne J, Bisoen S, Mosca A. Calibrationby commutable control materials is able to reduce intermethod differences of current high-performance methods for HbA2. Clin Chim Acta 2018;477:60-5.
4. Paleari R, Muñoz A, Mosca A, on behalf of the IFCC
Working Group on Standardization of HbA2 (WGHbA2). Towards the development of a certified reference material for hemoglobin A2. Clin Chem Lab Med
2010;48:1611-8.

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Meeting the needs of Mediterranean nations: Mediterranean diet and the area’s specific diseases

This is a Platinum Open Access Journal distributed under the terms of the Creative Commons Attribution Non-Commercial License which permits unrestricted
non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Surrogate biomarkers for monitoring healthcare
quality for chronic diseases such as diabetes care
Diler Aslan

Department of Medical Biochemistry, Medical Faculty, Pamukkale University, Denizli, Turkey

ARTICLE INFOABSTRACT

Corresponding author:
Diler Aslan
Department of Medical Biochemistry
Medical Faculty
Pamukkale University
Denizli
TurkeyE-mail: daslan@pau.edu.tr

Some laboratory tests or biomarkers are used as surrogate outcomes for health care effectiveness. HbA1c
is defined as a surrogate biomarker since HbA1c values have been approved to be used in predictions ofclinically important complications of diabetes mellitus. With the advance of information technology (IT)the real life data are aggregating as electronic healthrecords (EHRs). About 70-85% of individuals admitted to hospitals have laboratory test results. As such,
medical laboratories are the data centers in the hospitals. The test results can be used for assessment ofhealth care delivered, especially for chronic diseases.
This information provides insights of healthcare services, and can be used to enhance for individual andpopulation well-being, research, and education. This
article focuses on the importance of using laboratory
tests results as outcome measures for specific population health status that are important in assessing
the quality of health care services. The findings fromour studies on the diabetic care quality is presented.

Key words:
diabetes care, surrogate outcomes,
HbA1c, healthcare quality

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Diler Aslan
Surrogate biomarkers for monitoring healthcare quality for chronic diseases such as diabetes care

INTRODUCTION

monitoring. Although the information obtained
from the real life data is not enough for determination of the actual status, it can provide insights
into further structured outcome studies. The
data can be used by policy makers, especially incountries where no outcome assessments havebeen performed at the patient and/or population level. Laboratory professionals working in
hospitals should have sufficient knowledge andskills in data management for extracting meaningful information from patients’ test results
besides their core professional knowledge. The
objectives of this paper are to emphasize rolesof medical laboratory professionals in the valuebased health care model, present the examples
on diabetes care quality, and to point out whatcompetencies should be gained by laboratory
professionals.

Medical laboratories are one of the key players
in the provision of healthcare, and responsible
for healthcare quality. In order to create valuebased health care, population-level outcomes
and cost-effectiveness should be measured aswell at the patient-level (1). The test results fromthe electronic health records can be used for getting information about population-level healthcare quality, especially for chronic diseases. In
this context, laboratory professionals can present some valuable information about the qualityof care to the health policy makers, since 70-85%
of individuals admitted to a hospital have laboratory tests (2).
It is suggested that quality of care can be assessed according to the conceptualized frameworks suggested by Donabedian and the World
Health Organization, and randomized controlled
trials (RCTs) are suggested as the best model forassessment. However, RCTs of diagnostic procedures are not common because of the challenges
in design and implementation (3-9). Electronic
health records are providing new oppurtunities with high data collection capacity and canbe used for assessment of the population status
with specific disease according to the surrogate
outcome measures such as HbA1c for diabetes
Table 1HEALTH CARE QUALITY MEASURES,
OUTCOMES AND VALUE-BASEDHEALTH CARE
Quality measures have been used in order to assess and compare the healthcare quality of anorganization, quality of health care delivery services, and population health quality (3). The performance of health care is assessed by outcome
measures. The “value-based health care-VBHC”

Percentages of patients who have test values outside the HbA1c targets
at the beginning and after six months
Poor controlled diabetics (%)
Hospital
0. month

6. month

Hospital A

19

14

Hospital B

53

39

Hospital C

52

22

Data from our 6-month cohort study of 3 hospitals in different regions in Turkey (11).
Targets: HbA1c <53 mmol/mol (7%) (American Diabetes Association. Standards of medical care in diabetes, 2004).

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Diler Aslan
Surrogate biomarkers for monitoring healthcare quality for chronic diseases such as diabetes care

Six month-cohort study on diabetic populations of three hospitals
from three different regions of Turkey (2003-2004)

HbA1c (mmol/mol)Figure 1

Hospital A is in the Western Part of Turkey (n=48), Hospital B in the South Eastern Part (n=145), and Hospital C is in the
Shouthern (n=23). A an B are university hospitals, C is aprivate hospital.
All patient results were collected together with the evidence of quality assurance results of the laboratories.

,

model that is implemented in the US aims to ing
crease the value that is provided from healthcare
labora available
o ies. for a population (1). A reportservices
prepared according to the laboratory test results
for specific disease population extracted from
EHRs can provide an overall look about all the
key supporting elements of the VBHC model.
ELECTRONIC HEALTH RECORDS, BIG DATA,POPULATION HEALTHCARE QUALITY
The EHRs are being recognized as an important
tool for research as well as clinical care. The main
objective should be to learn data mining techniques for extracting meaningful informationfrom database obtained from the EHRs. Somecountries have been establishing systems for enhancing the data mining capacities of relevantorganizations (4,5). The laboratory professionf
als with their data mining knowledge complemented with their core professional knowledge
should be part of the data management teams
at the hospitals along with epidemiologists anddata scientists. They provide meaningful information from test results as a basis for tracking
chronic diseases and insights into public healthtrends, and can aid the management of publichealthcare policies (6,7).
DIABETES CARE QUALITY,
HbA1c AND BIG DATA
Quality indicators for several diseases, for example, diabetes care quality, are being definedby government organizations and by scientificsocieties (8,9). Most of quality measurement inPage 305

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Diler Aslan
Surrogate biomarkers for monitoring healthcare quality for chronic diseases such as diabetes care

Figure 2Monthly HbA1c distributions of diabetics in 2017from data collected in two hospitals in Denizli, Turkey

N= 4 691 (M: 1 921, F: 2 770)
Good controlled DM: 44.6%

N= 4 286 (M: 1 254, F: 3 032)
Good controlled DM: 63.7%

A is a university hospital, B is a private hospital.
Target for HbA1c: 53 mmol/L (7.0%).
All patient results were collected together with the evidence of quality assurance results of the laboratories.

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Diler Aslan
Surrogate biomarkers for monitoring healthcare quality for chronic diseases such as diabetes carediabetes mainly includes measures of process
and intermediate outcomes, such as HbA1c assurrogate biomarker (10). Laboratory test results can be treated as part of indicative data
and the findings from data mining can provide
meaningful knowledge to the policy makers atnational and individual levels.
DIABETIC CARE QUALITY TRACKING
FOCUSING ON THE HbA1c LEVELSOF PATIENTS WITH DIABETES MELLITUS
The HbA1c values of diabetics admitted to thehospitals were collected for 40 years together
with the evidence for the analytical quality assurance. In the first 12 years, there were noelectronic health records. The test results ofdiabetics were recorded on their “diabetes test
follow-up cards”. Our laboratory collected theresults of glucose, HbA1c, and lipids tests andestimated the percentages of poorly controlled
diabetics (1982-1994) and 93% of diabetics had
HbA1c values higher 7.0% (53 mmol/mol).
Furthermore, HbA1c results of diabetics admitted to the Center of the Turkish Diabetes
Society in Denizli between 1999-2003 were alsocollected and 53% of the patients had HbA1cvalues higher than 7.0% (53 mmol/mol).
The HbA1c distributions established from ourresearch studies (2003-2005) and the distributions obtained from data extracted from the
LISs (2017) are seen in the Figures 1 and 2, respectively (11,12). The percentages of patientsthat have values outside the targets at the beginning and the 6th month can be seen in the
Table 1 extracted from our cohort study (11). All
patient results were collected together with theevidence of analytical quality assurance resultsof the laboratories.
CONCLUSION
Observations and findings from our studies haveshown that laboratory professionals should bepart of the data management team in healthcare organizations along with epidemiologists,
statisticians, data scientists, and professionals
from relevant disciplines. Laboratory professionals are one of the key players in health careservices. They should be aware of the laboratory’s value in improving the health of the population, not only the health of a single patient. The
key issue is to realize what future challenges
will be and what skills should be gained in order
to cope with these challenges. Additional skills
may be acquired to use relevant information
technology and data mining methods in order
to be part of the multidisciplinary teams.
REFERENCES
1. Putera I. Redefining Health : Implication for ValueBased Healthcare Reform Health and outcomes are set
for specific medical conditions. Cureus. 2017;9(3):1–11.
2. Goswami B, Singh B, Chawla R, Mallika V. Evaluation oferrors in a clinical laboratory: a one-year experience. Clin
Chem Lab Med. 2010 Jan;48(1):63–6. http://www.ncbi.
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3. NQMC Measure Domain Framework. Content last reviewed July 2018. Agency for Healthcare Research andQuality, Rockville, MD. http://www.ahrq.gov/gam/summaries/domain-framework/index.html
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Knowledge (BD2K) initiative : capitalizing on biomedical
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5. Hemingway H, Feder GS, Fitzpatrick NK, Denaxas S,
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6. Baudhuin ELM, Cervinski MA, Chan AS, Holmes DT,
Horowitz G, Klee EW, et al. “Big Data” in Laboratory Medicine. Clin Chem. 2015;61(12):1433–40.
7. Kaufman HW. Big Data Analytics in Healthcare – How
Laboratories Can Play a Leading Role. Quest Diagnostics,
Madison, NJ. 2016. https://education.questdiagnostics.
com/insights/95

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Surrogate biomarkers for monitoring healthcare quality for chronic diseases such as diabetes care

8. Coffey RM, Trudi L. Matthews, McDermott K. Diabetes
Care Quality Improvement : A Resource Guide for State
Action. Rockville, MD: Agency for Healthcare Research andQuality, Department of Health and Human Services; 2004.
9. Deeks J. Assessing outcomes following tests. In: P.Price
C, Christenson RH, editors. Evidence-Based Laboratory
Med-icine: Principles, Practice, and Outcomes. 2nd ed.
Washington, DC: AACC Press; 2007. p. 95–140.
10. Aron DC. Quality Indicators and Performance Measures in Diabetes Care. Curr Diab Rep. 2014;14:472.

11. Aslan D, Sermez Y. Diyabet bakım kalitesinindeğerlendirilmesinde laboratuvar test sonuçları nasıl
kullanılabilir ? How to laboratory test results can be usedin assessing the quality of diabetes care ? Pamukkale Tıp
Derg. 2013;68–81.
12. Aslan D, Fenkçi S. Use of data obtained from
hospital and laboratory information systems forgeneration knowledge for diabetes care quality.
Clin Chem Lab Med. 2017;55 (Special Supplement):
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Meeting the needs of Mediterranean nations: Mediterranean diet and the area’s specific diseases

This is a Platinum Open Access Journal distributed under the terms of the Creative Commons Attribution Non-Commercial License which permits unrestricted
non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

The role of laboratory medicine
in addressing migrant health problems
Adekunle Bashiru Okesina, Ademola Adelekan

Department of Chemical Pathology and Immunology, University of Ilorin Teaching Hospital, Ilorin, Nigeria

ARTICLE INFOABSTRACT

Corresponding author:
Adekunle Bashiru Okesina
Department of Chemical
Pathology and Immunology
College of Health Sciences
University of Ilorin
PMB 1515, Ilorin
NigeriaE-mail: drokesina@yahoo.com

Introduction

Key words:
laboratory medicine, migrant,
health issues

Health challenges of migrants

A migrant is a person who has relocated to anothercountry for varying reasons. Laboratory medicine is a
medical speciality in which body specimens are examined and results interpreted for the appropriate management of patients in healthy and diseased states.
Migrants have health problems like the general population but may be affected by factors such as theirgeographic origin, living conditions, and their physical and psychological conditions.
The role of laboratory medicine
Laboratory medicine will play a vital role in the provision of quality healthcare services to migrants. It will
be actively involved in the screening, diagnosis, andmonitoring of response to treatment. Effective public health surveillance among migrants will require
laboratory services. The data gathered from researchusing laboratory resources will help in the improvement of the quality of migrant health.

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Adekunle Bashiru Okesina, Ademola Adelekan
The role of laboratory medicine in addressing migrant health problems

INTRODUCTION
Laboratory medicine is a medical speciality involved in the selection, provision, analytical
testing and interpretation of tests’ results using
specimens from patients (1). A medical laboratory is where tests are carried out on specimens
in order to obtain information about the healthof a patient with regards to the diagnosis, treatment, and prevention of disease.
A migrant can be defined as a person who moves
from a place to another in order to find workor better living conditions. Migration may bevoluntary (economically motivated) or forced.
Each of these forms of migration presents withdifferent health challenges. Some of these challenges are related to where people come from,
where they go and how they move. Others are afunction of national policies and social attitudes
to migrants and their living conditions.
Over 200 million people migrate every year for
economic reasons (2). The number of people
who are forced to move for reasons of conflictis also growing (3). People flee across borders
and become refugees, while at the same time
millions of others are forced to flee from theirhomes but remain within their own borders;the internally displaced.
HEALTH CHALLENGES OF MIGRANTS
The health of displaced populations is mainly
affected by infectious diseases, mental healthissues and chronic diseases (3). It also depends
on the migrant’s geographic origin, conditionsof migrant camps or urban settings where they
live, and the physical and psychological stateof the migrant, either pre-existing or acquired(4). Their health problems may be similar to
those of the rest of the population, albeit witha higher prevalence. Each migrant should havefull, uninterrupted access to high-quality healthcare, without discrimination on the basis of gender, age, religion, nationality or race. The World

Health Organization (WHO) supports policies
to provide health care services irrespective of
migrants’ legal status. As rapid access to healthcare can result in cure and reduce the spread of
diseases; it is in the interests of both migrants
and the receiving country to ensure that the local population is not unnecessarily exposed tothe importation of infectious agents (5).
THE ROLE OF LABORATORY MEDICINE
While the roles of clinical laboratories in the
management of diseases in a stable population
are clearly defined, the same cannot be said fora migrant population. Laboratory testing helps
determine the presence, extent or absence ofdisease and monitor the effectiveness of treatment. An estimated 60 to 70% of all decisions regarding a patient’s diagnosis, treatment, hospital
admission and discharge are based on laboratory
test results (6). A well trained and competentlaboratory staff working harmoniously is needed
to perform the following roles in addressing migrant health issues.
Screening for specific diseases
Screening is the systematic application of a test
to identify subjects at sufficient risk of a specificdisorder to benefit from further investigation or
direct preventive action, among persons who
have not sought medical attention on accountof symptoms of that disorder (7). It can detect
indicators of active or latent disease that may
lead to a cure or diminish the impact medical
conditions may have. Some infectious diseases screened for include tuberculosis (TB), hepatitis. Non-communicable diseases can also be
screened for e.g., diabetes mellitus (DM), sickle cell disease, malnutrition, etc. Screening forpremalignant lesions e.g. cervical cancer (Papsmear), colorectal cancer (faecal occult blood
testing) has the potential to reduce mortality
from cancer. The WHO does not recommend
obligatory screening of migrant populations

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Adekunle Bashiru Okesina, Ademola Adelekan
The role of laboratory medicine in addressing migrant health problems

because there is no clear evidence of benefits
and it may cause anxiety among migrants andthe local community (5).

least invasive source of the objective information used in clinical decision-making.

Diagnosis

Laboratory investigations play a major role inmonitoring and evaluating the efficacy of medical treatments. Microbiological tests play anessential part in effective infection control program, and management of antimicrobial resistance. Chemical Pathology and Haematogicaltests help in monitoring various non-communicable diseases.

Laboratory medicine plays an important rolein the identification and management of public health threats. Accurate laboratory-based
information is critical for disease surveillanceand control programmes. Before an outbreak,laboratory-supported surveillance allows early
detection of cases. During an outbreak a sample of cases should be laboratory confirmed toassess changes in the aetiological agent andto guide decisions about the allocation of resources. Support of varying nature is provided
by laboratories of differing capabilities. Field
laboratories are useful in providing laboratory
services to a migrant population. More complete testing is usually done in nearby regional laboratories. Reference laboratories may
identify rare or dangerous pathogens, identify
newly described organisms, and provide uncommon diagnostic reagents.

Prognostication

Economic value

Potential adverse outcomes due to disease or
drug treatments can be evaluated by laboratory
tests. These can minimize the severity of disease
and its effect on mortality, morbidity and qualityof life.

When the role laboratory medicine plays in theprevention and useful guidance of treatment is
considered, its economic utility as determinedby cost-effectiveness analysis is not in doubt.
Clinical laboratory tests save time, costs, andlives by enabling early detection and preventionof disease.

Laboratory medicine is crucial to the accurate determination of the cause of diseases. Infectious
diseases can often be diagnosed using microbiological tests. The Chemical Pathology laboratory is useful in the diagnosis of diseases suchas DM, kidney disease, etc. The Haematology
and Histopathology laboratories also play crucial roles in the diagnosis of cancers.
Monitoring effectiveness of treatment

Quality of patient care
Healthcare delivery systems aim to provide quality care with the patient at the centrepiece via
safety, effectiveness, timeliness, efficiency, equity and patient centeredness. Laboratories play
crucial role in caring for the patient; over 50% ofelectronic medical records come from laboratory data (8). Laboratory information enables physicians and other healthcare professionals to
make appropriate evidence-based diagnostic ortherapeutic decisions for their patients. Clinicallaboratory services are the most cost effective,

Public health surveillance

Research
Laboratories also play a pivotal role in performing research, especially operational researchthat supports evidence-based decisions for
guiding laboratory practice. Whenever possible,
such research should be performed in migrantcamps, where the conditions represent the realsituation. This is because research performed inacademic centres may differ from those in thefield and may not always provide reproducible

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Adekunle Bashiru Okesina, Ademola Adelekan
The role of laboratory medicine in addressing migrant health problems

results under different conditions. Research canalso be carried out to improve diagnostic methods and techniques.
REFERENCES
1. Bruns DE, Ashwood ER, Burtis CA. Clinical chemistry,
molecular diagnostics and laboratory medicine. In: Burtis CA, Ashwood ER, Bruns DE, editors. Tietz textbook ofclinical chemistry and molecular diagnostics. 5th ed. Philadelphia, Pa: Elsevier Saunders; 2012. p. 3–6.
2. Carballo M, Mboup M. International migration andhealth. A paper prepared for the Policy Analysis andResearch Programme of the Global Commission on International Migration, Geneva. 2005. Website: http://
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3. Owoaje E, Uchendu O, Ajayi T, Cadmus E. A review ofthe health problems of the internally displaced persons in
Africa. Niger Postgrad Med J. 2016;23(4):161.

4. Palinkas LA, Pickwell SM, Brandstein K, Clark TJ, Hill LL,
Moser RJ, et al. The Journey to Wellness: Stages of Refugee Health Promotion and Disease Prevention. J Immigr
Health. 2003 Jan 1;5(1):19–28.
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migration-and-health-key-issues
6. Mayo Clinic. Medical Laboratory Sciences – Academics[Internet]. Mayo Clinic School of Health Sciences; 2018[cited 2018 Feb 19]. Available from: http://www.mayo.
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7. Wald NJ. The definition of screening. J Med Screen.
2001 Mar 1;8(1):1–1.
8. Beasley DM. The laboratory’s role in the transformation to patient-centered care. MLO: Medical Laboratory
Observer. 2016 Apr;48(4):46.

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Editor-in-chief
János Kappelmayer
Department of Laboratory Medicine, University of Debrecen, Hungary

Assistant Editor 				Case Editor			Harjit Pal Bhattoa				Department of Laboratory Medicine		
University of Debrecen, Hungary		Reinhard B. Raggam
Department of Internal Medicine
Division of Angiology, University of Graz, Austria

Editorial Board

Khosrow Adeli, The Hospital for Sick Children, University of Toronto, Canada
Borut Božič, University Medical Center, Lubljana, Slovenia
Edgard Delvin, CHU Sainte-Justine Research Center, Montréal, Québec, Canada
Nilda E. Fink, Universidad Nacional de La Plata, Argentina
Ronda Greaves, School of Health and Biomedical Sciences, RMIT University, Victoria, Australia
Mike Hallworth, Shrewsbury, United Kingdom
Andrea R. Horvath, Prince of Wales Hospital and School of Medical Sciences, University of New
South Wales, Sydney, Australia
Ellis Jacobs, Abbott, Orlando, FL, USA
Allan S. Jaffe, Mayo Clinic, Rochester, USA
Bruce Jordan, Roche Diagnostics, Rotkreuz, Switzerland
Gábor L. Kovács, University of Pécs, Hungary
Evelyn Koay, National University, Singapore
Tamas Kőszegi, University of Pécs, Hungary
Janja Marc, University of Ljubljana, Slovenia
Gary Myers, Joint Committee for Traceability in Laboratory Medicine, USA
Tomris Ozben, Akdeniz University, Antalya, Turkey
Maria D. Pasic, Laboratory Medicine and Pathobiology, University of Toronto, Canada
Maria del C. Pasquel Carrera, College of Chemists, Biochemists and Pharmacists, Pichincha, Ecuador
Oliver Racz, University of Kosice, Slovakia
Rosa Sierra Amor, Laboratorio Laquims, Veracruz, Mexico
Sanja Stankovic, Institute of Medical Biochemistry, Clinical Center of Serbia, Belgrade, Serbia
Danyal Syed, Ryancenter, New York, USA
Grazyna Sypniewska, Collegium Medicum, NC University, Bydgoszcz, Poland
Jillian R. Tate, Queensland Royal Brisbane and Women’s Hospital, Herston, Australia
Peter Vervaart, LabMed Consulting, Australia
Stacy E. Walz, Arkansas State University, USA

				

			

				
		
		

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