November 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 3

In this issue
Laboratory Medicine:
Meeting the needs of the Mediterranean nations
Part 1

Foreword from the editor-in-chief
János Kappelmayer

161

Laboratory medicine: meeting the needs of Mediterranean nations
Guest Editors: Sergio Bernardini, Bernard Gouget

162

Communicable diseases in the Mediterranean region
Ghassan Shannan

164

Are medical laboratories ready for the diagnosis of parasitic diseases?
Ahmet Özbilgin

171

Travel, migration and emerging infectious diseases
Nicolas Vignier, Olivier Bouchaud

175

Is the profession of laboratory medicine uniform
across the North Mediterranean countries?
Konstantinos Makris

180

EFLM project “Exchange of practical knowledge and skillsin Laboratory Medicine” – EFLMLabX
Evgenija Homšak

191

Economic evaluation as a tool in emerging technology assessment
Nataša Bogavac-Stanojević

196

Who or what is SHERLOCK?
Ann M. Gronowski

201

In this issue

Advancement in POCT molecular testing:the multiplex PCR POCT devices for infectious diseases
Alpaslan Alp205

New solutions for the sample transport and results delivery: a digital lab
Damien Gruson

210

Next generation sequencing: from research area to clinical practice
Chiara Di Resta, Maurizio Ferrari

215

miRNA and other non-coding RNAs as promising diagnostic markers
Dorota Trzybulska, Eleni Vergadi, Christos Tsatsanis

221

Letter: NGS for metabolic disease diagnosis
Dèlia Yubero, Rafael Artuch

227

Letter: Reflections on the mentor-mentee relationship as a symbiosis
Josep Miquel Bauça

230

Letter: Inter-laboratory exchange of knowledge and technology around our Sea
Guilaine Boursier234

In this issue: Laboratory medicine–meeting the needs of Mediterranean nations

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

The present issue of the eJIFCC is composed ofarticles focused on topics discussed at the conference entitled “Laboratory medicine: meeting the needs of the Mediterranean nations”
The conference was held this year in Rome between July 2-4, with professor Sergio Bernardinias the Conference President.

The current issue is part one of a two-part series,
and contains articles covering three sections of
the conference, namely:• Transmissible diseases in the Mediterraneanarea;• Training and education in laboratory medicine;• Improving health with emerging technologies.
János Kappelmayer
EditorPage 161

eJIFCC2018Vol29No3pp161-161

In this issue: Laboratory medicine–meeting the needs of Mediterranean nations

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: meeting the needsof Mediterranean nations
Guest Editors: Sergio Bernardini1, Bernard Gouget2,3,4,5,6

Department of Experimental Medicine, University of Tor Vergata, Rome, Italy
Chair, IFCC Committee on Mobile Health and Bioengineering in Laboratory Medicine (C-MHBLM)
3
SFBC-International Committee
4
General Secretary of the International Francophone Federation of Clinical Biology and Laboratory Medicine(FIFBCML)
5
Counselor for Public Health-FHF
6President Human Health Care Committee-COFRAC
1
2

ARTICLE INFOEDITORIAL

Corresponding author:
Sergio Bernardini
Department of Experimental Medicine
University of Tor Vergata
Rome
Italy

The Mediterranean Sea connects countries with different traditions, lifestyles and religions, but all havebeen shaped by this extraordinary geographical basin,
which produced the oldest civilizations. Today, unfortunately, the Mediterranean countries also sharewars, terrorism, poverty and large-scale migration.
This conference highlights the value of laboratory
medicine for a greater effectiveness and safety withthe potential to impact numerous health system outcomes at national and regional level and to improvesecurity in the Middle East region with on-site opportunities for diagnosis and care to help victims of war
and sociopolitical instability as well as care of refugees.
It will open a new dialogue for scientific solutions toimprove healthcare delivery under these extraordinary circumstances as well as to demonstrate the capacity of laboratory medicine network of excellence
to combine different expertise in a single joint action
to become of added value. At the healthcare level,
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Sergio Bernardini, Bernard Gouget
Laboratory medicine: meeting the needs of Mediterranean nations

South European Mediterranean countries are
faced with a double burden. They must maintaincommon policies to fight against traditional diseases, which rely mainly on vaccination policy,
while having to face new characteristic diseases
from developed countries (cancer, cardiovascular diseases, HIV, hepatitis, obesity, etc.). In addition to the epidemiological transition, othertransitions are adding up (demographic, organizational and democratic). Financial resources
remain limited and the post-Arab spring context
gave rise to an increasing demand of populations for better access to health care for all andat the lowest cost. Such is the complex healthcontext facing South European Mediterraneancountries. On the other hand, in the Middle Eastand North Africa region, non-communicablediseases such as cardiovascular disease (up by44%), stroke (up 35%), metabolic diseases anddiabetes (up 87%), obesity, maternal mortality
are causing more premature death and disability than they did in the past. Potentially preventable risk factors such as poor diets, high bloodpressure, high body mass index (an indicator ofobesity and overweight), and smoking are contributing to the growing burden of non-communicable diseases in the region. Tuberculosis is
still endemic and some transmissible diseases(HIV) may reoccur. In the last few months, theworld has been vividly reminded by the Ebola
epidemic and by the resurgence of polio andof MERS Coronavirus that health problems do
not stop at borders. In the alarming context
of risk of Zika virus (ZIKV) transmission in theEuro-Mediterranean area, there is a need to examine whether capacities to detect, diagnose
and notify ZIKV infections in the region are inplace and whether ongoing capacity-building
initiatives are filling existing gaps. Moreover collaborating with Mediterranean countries is important, through the networks of pharmacovigilance, to be aware of antimicrobial resistanceby extending the surveillance and laboratory
experience, while reviewing and strengthening shared vaccination strategies. Countries
in Europe and the Mediterranean face several
common health challenges, including, to different extents, the double burden of diet- andphysical inactivity related chronic diseases andof nutritional deficiency disorders. Migrationand health is another common challenge where
EU and non-EU countries in the Mediterranean
are faced with large unexpected flows of migrants, refugees and asylum seekers many ofwhom have particular health needs. This constitutes a third and serious burden that we cannot
underestimate and that should be addressed
jointly by mobilizing needed resources within ashared framework. Deteriorating health and unnecessary deaths and suffering also due to thecurrent turmoil in several areas in the region
are indeed our main common challenges andwe need to devise shared strategies to combat
them and overcome the risk they impose on
our societies. Finally, there is a need for more
stringent relationships between Mediterraneancountries to realize advancements in educationand curriculum of laboratory professionals.

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eJIFCC2018Vol29No3pp162-163

Meeting the needs of Mediterranean nations: transmissible diseases in the Mediterranean area

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.

Communicable diseases
in the Mediterranean region
Ghassan Shannan

Medical Care Centre, Damascus, Syria

ARTICLE INFOABSTRACT

Corresponding author:
Ghassan Shannan
Director of Laboratory
Medical Care Centre
Damascus
Syria
E-mail: ghassanshannan@gmail.com

Communicable diseases still pose a health hazard
and are a major cause of death in many parts of theworld. Tuberculosis is one of the top 10 causes ofdeath worldwide with an annual burden of 1.7 million. Global deaths in 2016 for other communicablediseases included 1.34 million from hepatitis; 1.0 million from HIV-related causes; and almost half a million from malaria. Outbreaks of vaccine-preventablediseases like polio, measles, rubella and other lifethreatening diseases also pose a significant threat tovarious communities around the world. In this paper,
we shed some light on the epidemiology of communicable diseases in the Mediterranean Region andconclude that socioeconomic differences between
the north and the south Mediterranean lead to differences in the epidemiology of communicable diseases.

Key words:
communicable diseases, tuberculosis,
HIV/AIDS, hepatitis

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Ghassan ShannanCommunicable diseases in the Mediterranean region

INTRODUCTION
Socioeconomic, environmental and behaviouralfactors, as well as international travel and migration, foster and increase the spread of communicable diseases.
Vaccine-preventable, foodborne, zoonotic,
health care-related and communicable diseases
pose significant threats to human health andmay sometimes threaten international healthsecurity.
In cooperation with governments, WHO/Europe
develops norms and standards, guidance andTable 1

public health tools to help countries implement
effective disease prevention and control programmes and address their risk factors.
Globally, an estimated 3 out of 10 deaths are
attributed to communicable diseases. Amongthese, the World Health Organization (WHO)global burden of disease baseline projections in2008 revealed that the African Region contributes the highest number of deaths with 41%, followed by the Eastern Mediterranean and SouthEast Asia Regions, each contributing 15% of thedeaths due to infectious and parasitic diseases.

Communicable diseases[* Vaccine-preventable communicable diseases]

HIV/AIDS* Hepatitis

Influenza* Measles

Rotavirus* Rubella

Tuberculosis* Poliomyelitis

Malaria* Diphtheria

Brucellosis* Japanese Encephalitis

Typhoid* Mumps

Cholera* Neonatal Tetanus

Sexually Transmitted Infections* Tetanus

Vector-Born & Parasitic Diseases* Yellow Fever-* Congenital Rubella Syndrome

WHO defines communicable disease as infectious diseases which are caused by pathogenic
microorganisms, such as bacteria, viruses, parasites or fungi, that can be spread, directly or indirectly, from one person to another.

Under this definition, one can include a long listof diseases. However, in this publication we will
focus on the most important communicable diseases, which have significant impact on publichealth (Table 1).

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Ghassan ShannanCommunicable diseases in the Mediterranean region

Table 2

List of the Mediterranean region countries
included in the review
Southern European Coastfrom West to East

Levantine Coastfrom North to South

Gibraltar

Syria

Spain

CyprusFranceLebanonMonacoIsraelItaly

Palestine, Gaza Strip

Malta

Northern African Coastfrom East to West

Slovenia
Croatia

Egypt

Bosnia & Herzegovina

Libya

Montenegro

Tunisia

Albania

Algeria

GreeceMoroccoTurkey-The review includes the countries listed in Table
2 in the Mediterranean Region.

HIV/AIDSRESULTS

The incidence rate in northern Mediterraneancountries is higher than in southern Medi­ter­ranean countries (Table 4).

Table 3 presents the population of each Medi­terranean country, the expenditure on healthper capita and the expenditure on health aspercentage of gross domestic product (GDP).
The table shows clearly the big difference inspending on health between the Northern andSouthern Mediterranean countries.

Of the people living with HIV (PLWHIV), a variable percentage are receiving anti-retroviraltherapy (ART) around the Mediterranean. The
lowest percentage is in Egypt, with 27%; and thehighest in Spain, with 77%. There is no correlation between the expenditure on health and thenumber of PLWHIV (Table 4).

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Ghassan ShannanCommunicable diseases in the Mediterranean region

Table 3

Demographic and health care spending datafor countries in the Mediterranean region

Country

Population

Expenditure on healthper capita Intl. $Expenditure on
health as %of GDP

Albania

2,897,000

615

5.90

Algeria

39,666,000

932

7.20

Bosnia & Herz.

3,810,000

957

9.60

Croatia

4,240,000

1,652

7.80

Cyprus

1,165,000

2,062

7.40

Egypt

91,508,000

594

5.60

France64,365,000

4,508

11.50

Gibraltar

N/A

N/A

N/A

Greece10,955,000

2,098

8.10

Israel

8,064,000

2,599

7.80

Italy

59,798

3,239

9.20

Lebanon5,851,000

987

6.40

Libya

6,278,000

806

5.00

Malta

419,000

3,072

9.80

Monaco38,000

7,302

4.30

Montenegro

26,000888

6.40

Morocco34,378,000

447

5.90

Palestine

N/A

N/A

N/A

Slovenia

2,068,000

2,698

9.20

Spain

46,122,000

2,966

9.00

Page 167eJIFCC2018Vol29No3pp164-170

Ghassan ShannanCommunicable diseases in the Mediterranean region

Syria

18,502,000

376

3.20

Tunisia

11,254,000

785

7.00

Turkey78,666,000

1,036

5.40

Hepatitis

Schistosomiasis in Egypt

The incidence of hepatitis A (HAV) in south Medi­terranean countries is much higher than in northMediterranean countries, especially among
school children. This is also the case for the hepatitis B virus (HBV) and the hepatitis C virus (HCV),with highest incidence rate of HCV (10.70%) being in Egypt (Table 4).

Schistosomiasis is a parasitic disease causedby blood flukes (Trematodes) of the genus
Schistosoma (S.). It is well documented thatschistosomiasis haematobium was endemic inAncient Egypt. Infection was diagnosed in mummies 3000, 4000 and 5000 years old.

Tuberculosis
The incidence rate of tuberculosis (TB) is muchhigher in the southern Mediterranean despite
the increase of TB cases in European countries
among PLWHIV. The same finding applies tomulti-drug resistant (MDR) TB, where the incidence is higher in the southern Mediterranean(Table 4).
Table 4

Schistosomiasis haematobium was highly prevalent (60%) both in the Nile Delta and Nile Valley
South of Cairo. However, by the end of 2010, in
the whole country only 29 villages had a prevalence of >3% and none had more than 10%.
A recent study in 2016 by a group of scientists
from Tanta University report that the prevalenceof S. mansoni infection was found to be 1.8%
among schoolchildren of the studied areas.

Incidence rates of communicable diseases
in Mediterranean countries

CountryHIV
Incidence/105

PLWHIV

Receiving
ART
%

HBV

HCV

TB
Incidence/105

MDR TB
Incidence/105

Albania

0.15

1,700

30%

-

-

16

0.42

Algeria

0.04

13,000

76%

2.30%

8.90%

70

1.10

Bosnia & Herz.

N/A

N/A

N/A

-

-

32

N/A

Croatia

0.04

1,500

70%

2.70/105

-

12

N/A

Cyprus

N/A

N/A

N/A

0.20

0.2/105

5.6

N/A

Egypt

0.03

11,00027%

1.40%

10.70%

14

2.20

France0.21

180,000

78%

-

-

7.7

0.13

Page 168eJIFCC2018Vol29No3pp164-170

Ghassan ShannanCommunicable diseases in the Mediterranean region

Gibraltar

N/A

N/A

N/A

0.20/105

-

N/A

N/A

Greece

N/A

N/A

N/A

-

-

4.4

0.10

Israel

N/A

N/A

N/A

0.20/105

-

3.5

0.30

Italy

0.12

130,00058%

0.60/105

0.3/105

6.1

0.24

Lebanon

0.04

1,200

51%

-

-

12

0.48

Libya

N/A

4,400

73%

3.20%

1.20%

40

1.90

Malta

N/A

N/A

N/A

4.20/105

0.7/105

13

N/A

Monaco

N/A

N/A

N/A

-

-

0

N/A

Montenegro

0.23

<500

60%

-

-

16

N/A

Morocco0.05

22,000

48%

1.80%

1.60%

103

1.80

Palestine

N/A

N/A

N/A

-

-

N/A

N/A

Slovenia

N/A

N/A

N/A

-

-

6.5

N/A

Spain

0.18

14000077%

1.10/105

-

10

0.50

Syria

<0.01

175

70%

3.10%

0.40%

21

2.00

Tunisia

0.05

2900

29%

0.80%

1.90%

38

0.40

Turkey

N/A

N/A

N/A

4.00%

1.00%

18

0.70

Leishmaniosis in Syria
Due to the unrest in Syria over the past sevenyears, the incidence of leishmaniosis cases has
significantly increased: from 35,876 cases in
2014; to 50,972 cases in 2015; and to 48,311
cases in 2016. Scientists attribute the increase
to poor sanitation and the accumulation of rubbish and garbage around towns and villages, asmany municipals authorities are not able toclear the garbage regularly.
Polio in Syria
Outbreaks of polio cases have been reported
by WHO country offices in several parts of Syria(Table 5). These outbreaks are attributed to poor

sanitation and the inability of International organisations to implement the immunization programme in the hard-to-reach areas.
DISCUSSION
The epidemiology of communicable diseases isaffected by the socioeconomic status of the populations of the north and south Mediterranean.
HIV/AIDS prevalence is higher in the northern
than the southern Mediterranean countries;
largely attributed to the conservative societies
and the sexual behaviour of the populations, as
multi-partners sexual relationships and sex outside marriage are not widespread in southern
Mediterranean countries.

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Ghassan ShannanCommunicable diseases in the Mediterranean region

Table 5

2. Annual Epidemiological Report 2015, HIV and AIDS, European Centre for Disease Prevention and Control.

Syria Polio (cVDPV2)
outbreak*Governorate

District

Numberof cVDPV2
cases to date

Deir Ez-Zor

Mayadeen

58

Deir Ez-Zor

01

Boukamal

12

Raqqa

Tell Abyad

ThawraHoms
Total

4. Communicable Disease Threats, European Centre for
Disease Prevention and Control.
5. Elgharably et al, Hepatitis C in Egypt – past, present,
and future, International Journal of General Medicine
2017:10, pp.1-6.
6. Epidemiological update: hepatitis A outbreak in the
EU/EEA mostly affecting men who have sex with men, European Centre for Disease Prevention and Control.

01

7. EWARS, weekly bulletin of WHO Country Office, Syria

01
Tadmour

3. Asmaa Gomaa, et al, Hepatitis C infection in Egypt:prevalence, impact and management strategies, Hepatic
Medicine: Evidence and Research 2017:9, PP. 17-25.

8. Global Tuberculosis Report 2017, World HealthOrganisation.

01

9. Haq Z., Communicable Diseases in the Eastern Mediterranean Region: Prevention and Control, 2010 – 2011,
Eastern Mediterranean Health Journal, Vol. 19, No. 10,
pp. 881 – 891.

74

* Situation Report #34, February 2018

The prevalence of hepatitis, brucellosis, typhoid,schistosomiasis and vaccine-preventable communicable diseases is much higher in the southern Mediterranean countries; mainly due to poor
hygiene and inefficiency of the health systems
to provide viable health services in all areas, especially in remote and hard-to-reach areas. The
outbreak of Hepatitis A among schoolchildren
is an example of the inefficiency of the healthsystem to provide proper hygiene in schools andpublic places.
More effort and funds are needed to combat
many killer diseases in southern parts of theMediterranean to eradicate hepatitis, tuberculosis, typhoid, brucellosis and other communicable diseases.
REFERENCES
1. Annual Epidemiological Report 2015, Hepatitis C, European Centre for Disease Prevention and Control.

10. Measles and Rubella Surveillance 2017, European
Centre for Disease Prevention and Control.
11. Ministry of Health of Syria, CDC annual reports.
12. Mohamed A. Daw, et al, Hepatitis C Virus in North
Africa: An Emerging Threat, The Scientific World Journal, Volume 2016 (2016), Article ID 7370524, 11 pages,
http://dx.doi.org/10.1155/2016/7370524.
13. Rash Raslan et al, Re-Emerging Vaccine-Preventable
Diseases in War-Affected Peoples of the Eastern Mediterranean Region—An Update, Front Public Health.
2017; 5: 2.
14. Rashida M.R. Barakat, Epidemiology of Schistosomiasis in Egypt: Travel Through Time, Journal of Advance Research, (2013) 4, 425 - 432
15. Syria’s health crisis: 5 years on, the Lancet, Vol. 387,
March 12, 2016, PP. 1042-1043.
16. Tozun N. et al, Seroprevalance of hepatitis B and C infections in Turkey, Turk J Gastroenterol 2017; 28: 147-8,
pp.147-148
17. WHO international: http://www.who.int/, WHO Eastern Mediterranean: http://www.emro.who.int/index.
php, WHO Europe: http://www.euro.who.int/en/homePage 170eJIFCC2018Vol29No3pp164-170

Meeting the needs of Mediterranean nations: transmissible diseases in the Mediterranean area

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non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Are medical laboratories readyfor the diagnosis of parasitic diseases?
Ahmet Özbilgin

Department of Parasitology, Faculty of Medicine, University of Manisa Celal Bayar, Manisa, Turkey

ARTICLE INFOABSTRACT

Corresponding author:
Ahmet Ozbilgin
Department of Parasitology
Faculty of Medicine
University of Celal Bayar
Dekanlik Binasi, Uncubozkoy
45030 Manisa
TurkeyPhone: +90 236 233 19 20
Mobile: +90 532 134 35 31
Fax: +90 236 233 14 66
E-mail: a.ozbilgin@yahoo.com

Economic instability, destabilisation with armed conflagration, religious and ethnic conflicts are the mostimportant driving factors for migrations towards
Europe. Mediterranean countries are important routefor refugees who emigrate from the Middle East,
Africa and Asia.

Key words:
parasitic disease, refugee,
mediterranean, migrant, diagnosis

Parasitic diseases, such as intestinal parasites, pediculosis, scabies, lymphatic filariasis, schistosomiasis, malaria and leishmaniasis, which may reach theMediterranean region trough migrations, were briefly
reviewed and the precautions to be taken werementioned.

Disclosures:
The author declares no conflicts of interest.

Viral, bacterial, parasitic and fungal diseases carriedby these refugees constitute a significant health risk
in Mediterranean countries.

It is of utmost importance that laboratories in the
Mediterranean countries pay particular attention toparasitic infections, especially by using experienced
staff and appropriate diagnostic methods in combating such infections.
The diagnosis and screening of all these infections
among the refugees can be done by some basic parasitological laboratory methods such as direct methods
for stool samples (direct wet smear, concentration
methods, permanent stains, special stains), methods
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Ahmet Özbilgin
Are medical laboratories ready for the diagnosis of parasitic diseases?

for blood samples (thick and thin blood films, blood concentration procedures), direct methods
for urogenital specimens, serological methods,
molecular methods and rapid diagnosis kits.
These methods can be easily learned by laboratory employees.
We suggest that migratory related infections
study group should be established in Mediter­
ranean countries, which should inform eachother by sharing their findings and observations
with officials in congresses and symposiums,
and should cooperate on this issue and prepare training and workshop programs and healtheducation programs in these countries should
be updated about the health and risk factors ofrefugees.
trichura, hookworms and Taenia species need to
be kept in mind as well (1).
2. PEDICULOSISEvery year over 100 million cases of pediculosis
are reported in the world. In the United States,
head lice are found in 6-12 million children aged
between 3 to 12 years each year. In studies conducted on at least 1000 students in various countries of the world, it has been found that; 49%of the students in France, 20% in Israel, 25% inEngland and 37% in Nigeria have been subjected
to head lice (2,3).
Pediculosis spread easily and even constituteepidemics in places such as schools, factories,
prisons, refugee camps, temporary tent camps
during the war and nursing homes (4,5).

1. INTESTINAL PARASITES

3. SCABIESParasitic diseases that do not require any intermediate hosts or vectors and are directly transmitted to humans such as Enterobiosis, hymenolepiosis, giardiosis, amoebic dysentery canbe found in almost every area and every society
in the world.

Scabies is a common disease of the world andcan be seen in every age, race, region, climate
and social fraction. In particular, it is noteworthy that the frequency of the disease increases
in autumn and winter seasons when people
have to live together and decreases in summer
seasons. Sporadic or epidemic occurrences may
be seen while every individual shows a different
resistance to scabies.

In order for these diseases to become widespread, people must be in a collective presence or in close contact. These diseases spread
easily and even constitute epidemics in places
like schools, factories, prisons, refugee camps,
temporary tent camps that people live together
during a war and nursing homes.
Amoebiosis, one of the most important intestinal parasitic diseases in the world, is seen in 10%of the world population and 40 million people
die each year from this disease. Giardiosis has
been reported in 200 million people worldwide.
Other than these parasites, Strongyloides species are one of the most important intestinal
parasites that should be considered in the refugee populations. Ascaris lumbricoides, Trichuris

Scabies is responsible for confined epidemics
nowadays but still it is one of the important diseases that may create epidemics for the countries that receive large amounts of refugees in
the recent years. It is known that the numberof people infected with scabies tends to rise
where people have to live together (6,7).
4. VECTOR BORNE DISEASES
There are four important tropical diseases associated with refugees which can cause epidemics in Mediterranean countries.

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Ahmet Özbilgin
Are medical laboratories ready for the diagnosis of parasitic diseases?

4.1. Lymphatic filariasis
In Mediterranean countries, mosquito species
which are vectors of lymphatic filariasis are commonly found in many countries. New foci of lymphatic filariasis may be formed in Mediterraneancountries through people migrating from endemic areas or people staying in these areas
during their migration process (8,17).
4.2. Schistosomiasis
Among migrants, especially those who complain of hematuria should be carefully examinedin terms of schistosoma. It should be noted thatintermediate host snails can be found in some
Mediterranean countries. Special efforts should
be made in order to prevent the spread of thecurrently controlled disease. Schistosomiasis isseen in northern parts of Syria, near the border
to Turkey (9,10,17).
4.3. Malaria
Vector mosquito species are common in allMedi­t erranean countries. Considering thatsome countries have autochtonous cases, special attention should be given to combat malaria in these countries and immigrants should
be screened in terms of Plasmodium species via
laboratory tests (11).
4.4. Leishmaniasis
Visceral and cutaneous leishmaniasis are present in some of the Mediterranean countries
while vector Phebotomus species have a wide
distribution in the region. Syria, which has thebiggest number of refugees nowadays is oneof the top countries in the world for cutaneousleishmaniasis prevalance. For this reason, laboratory tests must be done carefully to screen for
the visceral and cutaneous leishmaniasis among
immigrants. In addition, resistance to meglumine antimonate (Glucantime) which is used in
the treatment of cutaneous leishmaniasis in the
Middle East, has been reported. If resistant cases

can not be detected in time and the number ofcases as well as areas increase, the fight against
this disease will be very difficult and problematic(12-17).
CONCLUSION
It is important that the laboratories in the
Mediterranean countries specifically address
this issue, especially in the case of parasitic infections by utilising experienced personnel and appropriate diagnostic methods to combat these
infections. Gastrointestinal parasitic infections,
Scabies and Pediculosis which can be transmitted directly between humans in places where
people are living with the refugees and where
there is a lack of hygiene, can cause epidemics inthese countries. Unless necessary measures aretaken, Malaria, Leishmaniasis, Lymphatic filariasis and Schistosomiasis, which are among themost important tropical diseases in the world
and are encountered in the geographical paths
where refugees live and migrate, can create
new foci and epidemics in the Mediterraneancountries.
REFERENCES
1. Özcel,M. General Parasitology, Medical Parasitic Diseases (Eds. Özcel MA, Özbel Y, Ak M,), Turkish Society ofParasitology No: 22, 2007;s.3-75
2. Frankowski BL, Weiner LB. Head lice. Pediatrics.
2002;110(3): 638-643
3. Chosidow O. Scabies and pediculosis. Lancet. 2000;355:
819-26, 2000
4. Akısü Ç, Sarı B, Aksoy Ü, Özkoç S, Öztürk S. Investigation of Pediculus capitis prevalence in a primary school
in Narlıdere and comparison with previous results. Turkish Journal of Parasitology, 2003; 27(1):45-48
5. Kokturk A, Bugdayci R, Sasmaz T, Tursen U, Kaya TI,
Ikizoglu G. Pediculosis, Int.J Dermatol, 2003;42(9):694-698
6. Arnold HL, Odom RB, James WD. Andrew’s Disease of
the skin. 8. Edition. s.523-527.(10). WB Saunders Comp.
Philedelphia 1990

Page 173eJIFCC2018Vol29No3pp171-174

Ahmet Özbilgin
Are medical laboratories ready for the diagnosis of parasitic diseases?

7. Budak S, Yolasığmaz A, Scabies. Medical Parasitic Diseases (Eds. Özcel MA, Özbel Y, Ak M,), Turkish Society ofParasitology No: 22, 2007;s.379-397
8. Kuman H.A. Filariasis., Medical Parasitic Diseases (Eds.
Özcel MA, Özbel Y, Ak M,), Turkish Society of Parasitology
No: 22, 2007;s.601-618
9. Berkin T, Berke Z. About Bilharzia disease. Turkish Hygiene
and experimental biology journal, 1950;10(1): 145 – 164
10. Özcel,M. Schistosomiasis, Medical Parasitic Diseases(Eds. Özcel MA, Özbel Y, Ak M,), Turkish Society of Parasitology No: 22, 2007;s.475-497
11. Özcel,M. Malaria, Medical Parasitic Diseases (Eds. Özcel MA, Özbel Y, Ak M,), Turkish Society of Parasitology
No: 22, 2007;s.79-132
12. Magill AJ, Grögl M, Gasser RA Jr, Sun W, Oster CN.
Visceral infection caused by Leishmania tropica inveterans of Operation Desert Storm, N Engl J Med.,
1993;13;328(19):1383-7.
13. AlSamarai, A.M., AlObaidi, H.S. Cutaneous leishmaniasis in Iraq. J Infect Dev Ctries. 2009;Mar 1; 3(2):123-9.
14. Tayeh A, Lama J, Cairncross S, Twenty years of cutaneous leishmaniasis in Aleppo, Syria, Trans R Soc Trop Med
Hyg, 1997;91,657-659.
15. Hadighi, R, Mohebali M, Boucher P. et al, Unresponsiveness to glucantime treatment in Iranian cutaneousleishmaniasis due to drug-resistant Leishmania tropica
parasites. PLoS Med, 2006;3:e162.
16. Report of Syria Ministry of Health, Damascus, Syria(2012)
17. Eckstein B.,Primary care for refugees. Am Fam Physician. 2011 Feb 15;83(4):429-36.

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Meeting the needs of Mediterranean nations: transmissible diseases in the Mediterranean area

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.

Travel, migration and emerging infectious diseases
Nicolas Vignier1,2, Olivier Bouchaud3,4

INSERM, Sorbonne Université, Institut Pierre Louis d’Épidémiologie et de Santé Publique (IPLESP),
Department of Social Epidemiology, Institut Convergences et Migration, Paris, France
2
Groupe hospitalier Sud Ile-de-France, Department of Infectious and Tropical Diseases, Melun, France
3
Paris 13 University, Sorbonne Paris Cité, Groupe hospitalier Paris-Seine-Saint-Denis,
Avicenne Universitary Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Department of Infectious
and Tropical Diseases, Bobigny, France
4
Laboratoire Éducations et Pratiques de Santé (LEPS EA 3412), Bobigny, France
1

ARTICLE INFOABSTRACT

Corresponding author:
Nicolas Vignier
Equipe de Recherche en Epidémiologie Sociale
Institut Pierre Louis d’Épidémiologie
et de Santé Publique (IPLESP)
27 rue de Chaligny
75012 Paris
FrancePhone: 00 33 1 78 94 98 74
Fax: 00 33 1 78 94 98 79
E-mail: vigniernicolas@yahoo.fr

Emerging infectious diseases (EID) threaten publichealth and are sustained by increasing global commerce, travel and disruption of ecological systems.
Travelers could play a role in importing EIDs and could
be a sentinel of major epidemics. In connection withthe extension of poverty, urbanization, extensive livestock rearing and globalization, we could be exposed
to a third epidemiological transition characterized
by zoonotic diseases and infections with multidrugresistant bacteria. The risk appears low for emerging
infectious diseases, or very low for high-risk emerging
infectious diseases, but higher for multidrug-resistantenterobacteriaceae carriage with possibly limited
consequences. The role played by migrants is weaker
than imagined. Immigrants don’t play the role of sentinel epidemic so far. They could play a role in importing multidrug-resistant enterobacteriaceae, but it ispoorly evaluated.

Key words:
migration, travel, emerging infectious diseases,transient and migrants
Competing interests:
The authors declare that they
have no competing interests.
The manuscript is in compliance with the
ethical principles for medical research
involving human subjects and in accordancewith the Declaration of Helsinki.

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Nicolas Vignier, Olivier Bouchaud
Travel, migration and emerging infectious diseases

Emerging infectious diseases (EIDs) have led tocooperation between countries, the first international epidemic response conference in 1851
and the establishment of WHO in 1948.
EIDs are diseases that have appeared recently orthat have recently increased in frequency, geographical distribution or both (1). Since the endof the 20th century, there has been a constantstream of newly identified pathogens and an increasing occurrence of pandemic threats to global health (2).
These infections are due to new agents (HIV-1,
Severe Acute Respiratory Syndrome CoronaVirus-SARS-CoV- (2003), avian influenza virus H5N1
(2005), H1N1 (2009)), geographical area in extension (West Nile, Dengue, Chikungunya, andZika viruses), increased incidence of infectious
disease (HIV, tuberculosis, plague), modificationof virulence (Neisseria meningitidis) or acquisition of resistance (Extended-spectrum betalactamases -ESBL- or carbapenemase producing enterobacteriaceae and multidrug-resistant-MDR- tuberculosis).
We can also compare the re-emerging infections(polio virus (2014), Ebola virus (2014), etc.) (3, 4).
EIDs threaten public health and are sustainedby increasing global commerce, travel and disruption of ecological systems and in particularurbanization. Urbanization is characterized by
rapid intensification of agriculture, socioeconomic change, and ecological fragmentation,
which can have profound impacts on the epidemiology of infectious disease (5). However,their interactions with travel and migrations areless well known.

friends and relatives. Trips can be very short orextended in time.
Infectious diseases are rare health events, withthe exception of common infectious diseases
such as traveler’s diarrhea and are a single causeof death, far behind accidents and cardiovascular disease (6).
The risk of emerging infections such as dengue
in a risk zone was estimated at 1% for one monthof travel (7).
We have seen (re-)emergence of diseases imported by travellers in Europe, such as chikungunya and dengue in France and Itay, and malaria
in Greece (8-10). Apart from these examples,
these are rare situations. However, with global
travel growth, the risk could become more tangible (11).
A particular concern is that of Multidrug ResistantEnterobacteriaceae (MRE) carriage. MRE acquisition is very frequent among travellers to tropical regions (12). The acquisition was higher in
Asia (72%) than in sub-Saharan Africa (48%) or
Latin America (31%). However, the same study
showed that MRE carriage was limited in timeand disappeared after a few months.

Travelers could play a role in importing EIDs andcould be a sentinel of major epidemics.

Migration is a global phenomenon that influences the health of individuals and populations overthe course of their lives (13). Migrants are special travellers who, in most case, do not migrateby choice. Migrants are considered at higher risk
for a range of health problems including infectious diseases as HIV, hepatitis B, tuberculosis,
schistosomiasis and malaria (14, 15). This higher
risk is partly due to poor socioeconomic conditions and, in some countries, is due to the lackof rights to health coverage for undocumented
migrants (16-19).

In France, there are more than 20 million travelers every year, 4.5 million of which are destinedfor areas at high risk for health. There are several modes of travel: tourist, business or visiting

Existing evidence from different European countries highlights the difficulties to access healthservices that migrants are facing (20-23). These
infectious diseases unequally expose the majority

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Nicolas Vignier, Olivier Bouchaud
Travel, migration and emerging infectious diseases

population, from none at all (e.g., malaria) to alittle (e.g., tuberculosis).
One can take the examples of epidemics ofMiddle East Respiratory Syndrome Coronavirus-MersCov- and Ebola, for which no secondarycase has been reported in France.
Among the published studies on migrants and infectious diseases, the majority were non-emergent diseases with the exception of MDR tuberculosis and multidrug-resistant bacteria (24, 25).
In connection with the increased use of antibiotics in low-resource countries, there is a worrying
increase in the prevalence of multidrug-resistant bacteria (26, 27). This increase could leadto an increased risk for migrants and their relatives, but there are few data on this point (28).
The risk seems particularly increased when they
return home to visit friends and relatives (29).
While antimicrobial resistance is of concern, theprospects for pandemic spread of a bacterial or
fungal emerging pathogen by migrants seemless likely (30).
Endemic disease, as tuberculosis, impose a far
higher public health burden than epidemic disease (31). Denmark experienced an increasein the incidence of tuberculosis in the 1990s in
relation to the increase in the number of cases
among migrants (32). The rate of tuberculosis
in France is 10 times higher among immigrants
than in the majority population. Refugees andasylum seekers may have a heightened risk of
MDR-TB infection and worse outcomes but thedata remains poor (33).
Thus, there is little evidence to support the theories by which migrants would expose the hostpopulation to significant infectious risk. However,human diseases acquire a social status based on
their perceived risk that determines their acceptability (31).
In a study that we conducted with a number of347 doctors in France (infectious diseases andgeneral practitioners), they were asked if firsttime migrant people represent a vector of infectious diseases different from the majority population: 8% answered no, 13% yes but weakly,
44% yes but moderately, 27% yes significantly
and 9% did not know.
Thereby, apart from infections such as tuberculosis and multidrug-resistant bacteria, the introduction of EIDs into human populations seems
to be more often a consequence of economic
development that brings zoonotic reservoirs incloser proximity to people.
Indeed, most pandemic threats are caused byviruses from either zoonotic sources or vectorborne sources (30). There is a need for rapid
diagnosis of EIDs. Systems biology approaches
can lead to a greater understanding of EIDs
pathogenesis and facilitate the evaluation of
newly developed vaccine-induced immunity ina timely manner (30, 34).
Close collaboration is therefore needed between specialists in tropical medicine, in public health, immunologists and biologists to anticipate the risk of EIDs in order to achieve theSustainable Development Goals established by
the United Nations in 2015 (35).
The WHO established a Department of Pandemic
and Epidemic Diseases in 2011 to better prepare
for and respond to EIDs.
In conclusion, in connection with the extensionof poverty, urbanization, extensive livestock rearing and globalization, we could be exposed to athird epidemiological transition characterized byzoonotic diseases and infections with multidrugresistant bacteria (36).
The risk appears low for EIDs, or very low for
high-risk EIDs, but higher for MRE carriage withpossibly limited consequences. The role playedby migrants is weaker than imagined (except for
tuberculosis). Immigrants don’t play the role ofPage 177

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Nicolas Vignier, Olivier Bouchaud
Travel, migration and emerging infectious diseases

sentinel epidemic so far. They could play a rolein importing MRE, but it is poorly evaluated.

13. Zimmerman C, Kiss L, Hossain M. Migration andhealth: a framework for 21st century policy-making. PLoS
Med. 2011;8(5):e1001034.

REFERENCES

14. Simon J, Kiss N, Laszewska A, Mayer S. Public HealthAspects of Migrant Health: A Review of the Evidence on
Health Status for Labour Migrants in the European Region. WHO Health Evidence Network Synthesis Reports.
Copenhagen2015.

1. Metcalf CJE, Lessler J. Opportunities and challenges in modeling emerging infectious diseases. Science.
2017;357(6347):149-52.
2. Fauci AS, Morens DM. The perpetual challenge of infectious diseases. N Engl J Med. 2012;366(5):454-61.
3. Drosten C, Gunther S, Preiser W, van der Werf S, Brodt
HR, Becker S, et al. Identification of a novel coronavirus inpatients with severe acute respiratory syndrome. N Engl J
Med. 2003;348(20):1967-76.
4. Ungchusak K, Auewarakul P, Dowell SF, Kitphati R,
Auwanit W, Puthavathana P, et al. Probable person-toperson transmission of avian influenza A (H5N1). N Engl J
Med. 2005;352(4):333-40.
5. Hassell JM, Begon M, Ward MJ, Fevre EM. Urbanization and Disease Emergence: Dynamics at the
Wildlife-Livestock-Human Interface. Trends Ecol Evol.
2017;32(1):55-67.
6. Hargarten SW, Baker TD, Guptill K. Overseas fatalities of United States citizen travelers: an analysis ofdeaths related to international travel. Ann Emerg Med.
1991;20(6):622-6.
7. Steffen R, Amitirigala I, Mutsch M. Health risks among
travelers--need for regular updates. J Travel Med.
2008;15(3):145-6.
8. Delisle E, Rousseau C, Broche B, Leparc-Goffart I,
L’Ambert G, Cochet A, et al. Chikungunya outbreak in
Montpellier, France, September to October 2014. Euro
Surveill. 2015;20(17).
9. Tseroni M, Baka A, Kapizioni C, Snounou G, Tsiodras S,
Charvalakou M, et al. Prevention of Malaria Resurgencein Greece through the Association of Mass Drug Administration (MDA) to Immigrants from Malaria-Endemic
Regions and Standard Control Measures. PLoS Negl Trop
Dis. 2015;9(11):e0004215.

15. De Vito E, de Waure C, Specchia ML, Ricciardi W. Public Health Aspects of Migrant Health: A Review of the
Evidence on Health Status for Undocumented Migrants
in the European Region. WHO Health Evidence Network
Synthesis Reports. Copenhagen2015.
16. Vazquez ML, Vargas I, Jaramillo DL, Porthe V, LopezFernandez LA, Vargas H, et al. Was access to health careeasy for immigrants in Spain? The perspectives of healthpersonnel in Catalonia and Andalusia. Health policy.
2016;120(4):396-405.
17. Derose KP, Bahney BW, Lurie N, Escarce JJ. Review:
immigrants and health care access, quality, and cost. Med
Care Res Rev. 2009;66(4):355-408.
18. Magalhaes L, Carrasco C, Gastaldo D. Undocumented
migrants in Canada: a scope literature review on health,access to services, and working conditions. J Immigr Minor Health. 2010;12(1):132-51.
19. Vignier N, Desgrees du Lou A, Pannetier J, Ravalihasy
A, Gosselin A, Lert F, et al. Access to health insurance
coverage among sub-Saharan African migrants living inFrance: Results of the ANRS-PARCOURS study. PLoS One.
2018;13(2):e0192916.
20. Rechel B, Mladovsky P, Ingleby D, Mackenbach JP,
McKee M. Migration and health in an increasingly diverse
Europe. Lancet. 2013;381(9873):1235-45.
21. Scheppers E, van Dongen E, Dekker J, Geertzen J,
Dekker J. Potential barriers to the use of health services among ethnic minorities: a review. Fam Pract.
2006;23(3):325-48.
22. Gray BH, van Ginneken E. Health care for undocumented migrants: European approaches. Issue Brief(Commonw Fund). 2012;33:1-12.

10. Marchand E, Prat C, Jeannin C, Lafont E, Bergmann T,
Flusin O, et al. Autochthonous case of dengue in France,
October 2013. Euro Surveill. 2013;18(50):20661.

23. Dourgnon P, Jusot F, Silva J, Sermet C. Immigrants’ access to ambulatory care in France. Questions d’économie
de la santé. 2009;146.

11. World Tourism Organization. UNWTO Annual Report2016. Madrid: UNTWO; 2017.

24. Napoli C, Dente MG, Karki T, Riccardo F, Rossi P, Declich S, et al. Screening for Infectious Diseases among
Newly Arrived Migrants: Experiences and Practices in
Non-EU Countries of the Mediterranean Basin and Black
Sea. Int J Environ Res Public Health. 2015;12(12):15550-8.

12. Ruppe E, Armand-Lefevre L, Estellat C, Consigny PH,
El Mniai A, Boussadia Y, et al. High Rate of Acquisition but
Short Duration of Carriage of Multidrug-Resistant Enterobacteriaceae After Travel to the Tropics. Clin Infect Dis.
2015;61(4):593-600.

25. Kentikelenis A, Karanikolos M, Williams G, Mladovsky
P, King L, Pharris A, et al. How do economic crises affect

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Nicolas Vignier, Olivier Bouchaud
Travel, migration and emerging infectious diseases

migrants’ risk of infectious disease? A systematic-narrative review. Eur J Public Health. 2015;25(6):937-44.
26. Laxminarayan R, Matsoso P, Pant S, Brower C, Rottingen JA, Klugman K, et al. Access to effective antimicrobials:
a worldwide challenge. Lancet. 2016;387(10014):168-75.
27. Karanika S, Karantanos T, Arvanitis M, Grigoras C, Mylonakis E. Fecal Colonization With Extended-spectrum
Beta-lactamase-Producing Enterobacteriaceae and Risk
Factors Among Healthy Individuals: A Systematic Review
and Metaanalysis. Clin Infect Dis. 2016;63(3):310-8.
28. Angeletti S, Ceccarelli G, Vita S, Dicuonzo G, Lopalco
M, Dedej E, et al. Unusual microorganisms and antimicrobial resistances in a group of Syrian migrants: Sentinel
surveillance data from an asylum seekers centre in Italy.
Travel Med Infect Dis. 2016;14(2):115-22.
29. Khawaja T, Kirveskari J, Johansson S, Vaisanen J, Djupsjobacka A, Nevalainen A, et al. Patients hospitalizedabroad as importers of multiresistant bacteria-a crosssectional study. Clin Microbiol Infect. 2017;23(9):673
e1- e8.

30. Graham BS, Sullivan NJ. Emerging viral diseases froma vaccinology perspective: preparing for the next pandemic. Nat Immunol. 2018;19(1):20-8.
31. Medley GF, Vassall A. When an emerging disease becomes endemic. Science. 2017;357(6347):156-8.
32. Carballo M, Nerukar A. Migration, refugees, andhealth risks. Emerg Infect Dis. 2001;7(3 Suppl):556-60.
33. Hargreaves S, Lonnroth K, Nellums LB, Olaru ID, Nathavitharana RR, Norredam M, et al. Multidrug-resistanttuberculosis and migration to Europe. Clin Microbiol Infect. 2017;23(3):141-6.
34. Oh SJ, Choi YK, Shin OS. Systems Biology-Based Platforms to Accelerate Research of Emerging Infectious Diseases. Yonsei Med J. 2018;59(2):176-86.
35. United Nations. Resolution adopted by the General Assembly on 25 September 2015. Transforming ourworld: the 2030 Agenda for Sustainable Development.
2015.
36. Zuckerman MK, Harper KN, Barrett R, Armelagos
GJ. The evolution of disease: anthropological perspectives on epidemiologic transitions. Glob Health Action.
2014;7:23303.

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Meeting the needs of Mediterranean nations: training and education 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.

Is the profession of laboratory medicine uniform
across the North Mediterranean countries?
Konstantinos Makris

Clinical Biochemistry Department, KAT General Hospital, Kifissia, Greece

ARTICLE INFOABSTRACT

Corresponding author:
Konstantinos Makris
Clinical Biochemist
Clinical Biochemistry Department
KAT General Hospital
2 Nikis street, Kifissia, 14561
GreeceEmail1: kostas.makris.km@gmail.com
Email2: kostas.makris.km@icloud.com

Harmonization of the postgraduate training of both Cli­
nical Scientists and Physicians, in Laboratory Medicine(LM) has been a goal for many years, for the European
Federation of Clinical Chemistry and Laboratory Med­icine (EFLM) and the Union Européenne de Médecins
Spécialistes (UEMS), Section of Laboratory Medicine/
Medical Biopathology. This was based on the concept of free movement of people within the European
Union.

Key words:
EFLM, UEMS, training, laboratory medicine,
EFLM syllabus

Much has been achieved within the respective Euro­pean organizations in the development of curriculathat will harmonize the postgraduate training at least
within the European Union (EU).
Advances in the area of diagnostics and the needfor particular expertise in distinct areas have led tothe emergence of laboratory scientists and physicians specialized in hematology (including transfusion medicine), clinical biochemistry, immunology,
and microbiology.
However, the training and specialization is varying
and practice is of laboratory medicine is polyvalent
in some countries and single specialties in others
countries.
Moreover, these advances have led to the involvementof non-medical scientists in the clinical laboratories.
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Konstantinos Makris
Is the profession of laboratory medicine uniform across the North Mediterranean countries?

However, the training and the roles of Medical
Doctors and Clinical Scientists in a Clinical laboratory, differ from country to country. These differences still remain today throughout Europe
and even within the EU.


INTRODUCTION
The profession of clinical chemistry and laboratory medicine is practiced in all of the North
Mediterranean countries. However, it differs
among countries in many respects, such as background training, fields of interest, legal status
and professional organization.
In Europe, there are two organizations that
represent national professional organizationsin the field of Laboratory Medicine and Clinical
Chemistry: European Federation of Clinical
Chemistry and Laboratory Medicine (EFLM)
and the Union Européenne de Médecins
Spécialistes (UEMS), Section of Laboratory
Medicine/Medical Biopathology.

objectives of the UEMS are: to promote thehighest level of training of the medical specialists, medical practice and health care within the
EU and to promote free movement of specialist doctors within the EU. The UEMS represents
the medical specialist profession in the member
states of the EU, to EU authorities and any otherauthority dealing with questions concerning the
medical profession. Laboratory Medicine as a
medical specialty is represented in UEMS.
In 1988 the Federation of European Societies forClinical Chemistry (FESCC) was founded, joining
the different national societies for clinical chemistry and laboratory medicine. The harmonization and recognition of laboratory specialists,
particularly of scientific and pharmaceuticalbackground, was the main objective from thestart. The EC4 was subsequently founded, withthe goal to harmonize the training through the
production of a syllabus that will be commonly accepted by all members and establishing a
European register for highly trained specialist,
whatever their background.

Both have as objective to promote mutual recognition of laboratory specialists within theEuropean Union (EU). This is closely related to
the free movement of people, a major goal of
European integration. However, in order this policy to be accomplished in the field of Laboratory
Medicine needs equivalence of standards andharmonization of the training curriculum among
member states, both the central tasks of theEuropean professional organizations.

Until the early 90’s when European Community
started to issue directives to the state members
to adopt a system on a uniform basis of graduation and of post‐graduation/specialization for
all medical graduates, the training of medical doctors in LM was not only variable but insome countries was missing. To be specialized
became, over a few years, a pre‐requisite forpracticing the medical activity in a specific professional field.

Harmonization of the profession has been an important objective, and has a long history. In 1958
– one year after the treaty of Rome was signed –representatives of the professional organizationsof medical specialists of the six-member statesof the very new European Economic Community(EEC), met in Brussels and created the European
Union of Medical Specialists [Union Européenne
des Médecins Spécialistes (UEMS)]. The main

The result was that on the one side we had specialized MDs, on the other side non‐specialized,
non‐MD graduates, creating the potential for serious issues. Each country developed its own solution. Several countries issued by law the training

However, in most European Hospital Laboratories,
are employed not only medical doctors but evenpharmacy, biology and chemistry graduates (theso called scientists).

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Konstantinos Makris
Is the profession of laboratory medicine uniform across the North Mediterranean countries?

of non-MD graduates in order to comply with
the EU directives while other countries did not.
In the latter, professional societies started initiatives of volunteer training programs based on
EC4 syllabus. The result is a tremendous diversity
not only concerning who is qualified to practiceLaboratory Medicine, but also what is the definition of LM and what disciplines should be included in the curriculum. This diversity still exists.
The European Federation of Clinical Chemistry
and Laboratory Medicine developed a syllabus
for the postgraduate education and training for
all Specialists in LM in order to provide a framework for training for all EU countries (now it is inlatest version 5 – 2018).
A common syllabus has many useful applications.
First, it describes in detail the education andtraining associated with high-quality, specialist
practice but also can help in defining the common set of skills, knowledge and competence fornon-medical Specialists in Laboratory Medicine
under EU Directive 2013/55/ EU (The recognitionof Professional Qualifications).
Second, it helps to give a definition to LM throughthe training. What disciplines should be included
under the umbrella of LM? This is not a static definition and should be evolved as clinical researchand technology evolve. and finally, it will provide
the specialists with professional qualifications
able to work without restrictions throughout EU(complying with EU Directive 2013/55/EU in providing safeguards to professional mobility acrossEuropean borders).
THE DEFINITION OF THE PROFESSIONACCORDING TO EFLM AND UEMSIFCC defines clinical chemistry and laboratory
medicine as “the application of chemical, molecular and cellular concepts and techniques tothe understanding and the evaluation of humanhealth and disease”.

At the core of the discipline is the provision of“results of measurements and observations, together with interpretation and informed clinicaladvice relevant to the maintenance of health,
the cause of disease, the diagnosis of disease,predicting and monitoring the response to therapy, and follow-up investigations”. The discipline
is committed to deepening the understanding ofhealth and disease through fundamental andapplied research.
High technical skills and ability to interpret results and provide consultancy to clinicians are
the top requirements for LM scientists
In the latest version of EFLM syllabus the following disciplines are included in the training that
could be common for medical and non-medical
origin scientists: clinical chemistry, immunology,
haematology and blood transfusion (including
blood cells, haemostasis, cellular immunology
and transfusion serology), microbiology (bacteriology, mycology, virology and parasitology),
genetics, genomics and cytogenetics and finallyin vitro fertilisation. Only anatomic pathology isoutside this framework (Figure 1).
While EFLM provides with the present version
a uniform framework for all scientists regardlessof background, UEMS provides training only for
medical doctors and recognizes different specializations for the section of Laboratory medicine.
Under the umbrella of the more recent name ofthe section, Laboratory Medicine/Medical Bio­
pathology, several subspecialty divisions havebeen acknowledged.
At present, the section consists of the following divisions (see also Figure 2): the polyvalent General Laboratory Medicine/Polyvalent
Medical Biopathology, and the monovalent specialities of Laboratory Medicine-Clinical Chemistry,
Clinical and Laboratory Haematology, Clinicaland Laboratory Immunology, and Laboratory
Genetics (Genetic Pathology/Medical Genomics).

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Konstantinos Makris
Is the profession of laboratory medicine uniform across the North Mediterranean countries?

Since 2008 a separate section of Medical Micro­
biology was created within the UEMS with its
own training program. In 1988 Anatomic Pa­
thology was the first specialist section that split
off from laboratory medicine section of UEMS,
and was recognized as separate section withthe main objective to harmonize the practice of
pathology in Europe.
It is important to understand that it is not onlythat the two professional organization have differences when they try to define the professionof laboratory medicine.
There are huge differences between EU (and ofcourse non-EU) countries. State regulations also
allow or not to non-medical scientists to practice the profession of laboratory medicine.
Many specialties are defined differently fromcountry to country within the European Union.
Figure 1

For example, in the Netherlands and Scandinavia,
Clinical Chemistry includes biochemistry, immunology, and hematology (most of the subspecialties included in General Laboratory Medicine/
Polyvalent Medi­cal Biopathology but excluding
Laboratory Microbiology). In other countries(Ireland, UK) LM is named chemical pathology (for the medicine derived scientists) andincludes biochemistry and endocrinology or
Clinical Biochemistry (for the non-medical clinical scientists.
The clinical component of practice varies among
different specialties, with some having a strong
clinical emphasis. For example, in the UK, chemical pathologists and immunologists may have
independent responsibility for patient care andClinical Scientists at the consultant level are allowed to provide clinical advice. This is not acommon practice in other EU countries.

Disciplines of LM according to EFLM syllabus

Laboratory
Medicine

Specialties of Mixedbackground(medical and nonmedical)

Specialties ofMedical only
background

Anatomic
Pathology

Clinical Chemistry/
Immunology

Hematology(incl. Transfusion
medicine)

Microbiology(Inc. bacteriology,
parasitology,
virology)

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Genetics

In vitro fertilization

Konstantinos Makris
Is the profession of laboratory medicine uniform across the North Mediterranean countries?

Figure 2

Polyvalent and monovalent specialties and disciplinesof LM according to UEMS syllabus

Laboratory
Medicine/Medical
Biopathology

Medicalmicrobiology

Monovalent
specialties

Polyvalent specialty

General Laboratory
Medicine/
Polyvalent Medical
Biopathology

Laboratory
Medicine - Clinical
Chemistry

Clinical andLaboratory
Haematology

Clinical andLaboratory
Immunology

The name of the discipline also varies between
countries and clearly reflects the differencesthat exist throughout Europe making particularly challenging the task to harmonize specialist training within the EU and Europe in general.
WHAT IS THE SITUATION NOW
IN NORTH MEDITERRANEAN COUNTRIES?
The countries that comprise the North Mediter­
ranean region are (from west to east):• Spain• France• Italy

Laboratory
Genetics (Genetic
Pathology)•

Slovenia•

Croatia•

Bosnia and Herzegovina•

Serbia•Kosovo•Montenegro•

Albania

•

FYROM

•

Greece•Turkey•CyprusPage 184

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Anatomic
Pathology

Konstantinos Makris
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All of the above are European countries, withseven of them being EU member states.
In the following paragraphs we try to describe
the situation in all north Mediterranean countries. Source of our information was the replies to a questionnaire we sent to all northMediterranean countries (see Appendix A Questionnaire on next page) and the publisheddocuments we found in the internet and scientific journals.
Most of the countries responded to our questionnaire however we did not got responses
from Croatia and Montenegro. And while wewere able to retrieve information for Croatia
from published documents we were unable tohave any information from Montenegro. It is
not easy to group the practices from these countries since there are huge differences. However,
and most interestingly all countries claim that
their training is EFLM syllabus compliant.
In Spain there are two specialties which are closer to what EFLM describes as LM are Bioquímica
Clínica (which is the monovalent specialty),
and Análisis Clínicos (the polyvalent specialty). Medical Genetics, Transfusion MicrobiologyVirology, Immunology, Laboratory Haematology,
Medical Microbiology, and Haemostasis constitute separate autonomous monovalent specialties requiring special training. Medical doctors
and non-medical scientists (of pharmacy, biology, biochemistry and chemistry background)are eligible for training in LM and are accepted
after examination. Training is state regulated
the duration is 4 years for everybody and licensed specialists have equal rights in releasing final results and in providing clinical consultancy to clinicians. From the remaining separate
specialties only Haematology is strictly a medical specialty and genetics is not yet a medical
specialty. The training program is compliant to
EFLM syllabus.

In France we discovered that while MD’s andPharmacy graduates can work as LM specialists
in all labs and the name of the specialty here
is Biologie médicale, non-medical scientists canwork only in University Hospital labs and whenit comes to who has the rights in releasing final
results this is not granted to all clinical scientists
and they cannot provide any clinical consultancy. Training for medical and pharmacy scientists
is state regulated is ELFM syllabus compliant
and the total duration of studies is 10 years (including the undergraduate studies).
In Italy the name is Laboratory Medicine, thesituation is closer to Spain concerning the typeof university degrees that are accepted fortraining. Non-medical trained specialists sharethe same rights in respect of releasing the final
results but are not allowed to provide clinicalconsultancy. Only medical genetics represent
an autonomous specialty. The training programis state regulated and is (at least in part) EFLM
syllabus compliant.
Clinical Chemistry and Laboratory Medicine(CCLM) is a scientific discipline within medicine in
Slovenia, is the largest sub-discipline of laboratory medicine, and is named Medical Biochemistry(Medicinska Biokemija). The practice of Medical
Biochemistry in Slovenia includes clinical biochemistry (including toxicology, therapeutic drug
monitoring, endocrinology, molecular diagnostics, immunology), hematology and coagulation.
The training is 4 years for all, it is state regulated
and open to medicine, pharmacy, chemistry, biochemistry, or other relevant university studies
degrees and finally is ELFM syllabus compliant.
Clinical chemistry and Medical biochemistry is
the terms that used in Bosnia and Herzegovina
to describe the profession. the specialty is open
to scientists from Medical schools, Pharmacy
and non-medical (biologists, biochemists, chemists and other graduates from life-sciences).
State regulated training is provided for bothPage 185

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APPENDIX A - Questionnaire

3. Chemical Pathology

What is the term that describes best the specialty (Clinical Chemistry and Laboratory Medicine)in your country? (please check all appropriate
replies)

4. Pathology

1. Clinical Chemistry

5. Clinical Biology
6. Biological Chemistry
7. Other (please specify)……………

3. Laboratory medicine

Are the following laboratory medicine specialties constitute autonomous medical specialties
requiring special and autonomous training?

4. Medical Biochemistry

1. Medical Genetics

5. Clinical Biology

2. Molecular diagnostics

6. Chemical Pathology

3. Transfusion Microbiology-Virology

7. Other (please describe)……………

4. Immunology

What is the educational background of thescientific staff working in clinical laboratories
in your country (please check all appropriate
replies)

5. Laboratory haematology

2. Clinical Biochemistry

1. Medical (MD)
2. Clinical Scientists (of non-medical, Life
Sciences background)
3. Pharmacist

6. Medical microbiology
7. Other (please specify)……………
Is the training common in content and duration
form medical and non-medical scientists?
1. Yes2. No
What is the total number of years of training
required in order to be eligible to work in theclinical lab.

4. Other
5. Mixed (please describe in detail)……………
If the scientific staff is of mixed-background, canthe non-medical scientist

A. for medical background
1. pre-graduate

1. final release of results

2. post-graduate

a. YES

B. for non-medical backgroundb. NO

3. pre-graduate

2. provide clinical consultancy

4. post-graduate

a. YESIs the training program:b. NO
If the scientific staff is only of medical origin,what is the name of the medical specialty thatis required from an MD in order to be eligible towork?

1. State regulated
2. Scientific Society regulated
3. Other……………
Is your training syllabus EFLM compliant?

1. Medical Biochemistry

1. Yes

2. Medical Biopathology

2. No
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medical and non-medical background candidates. However non-medical scientists are notallowed to do clinical consultancy. Molecular diagnostics, immunology, laboratory hematology
medical microbiology and transfusion medicine
are separate monovalent medical specialties inthis country. Finally, the training program is not
EFLM syllabus compliant.
Medical biochemistry and Medical biochemist(Specijalist Medicinske Biokemije I Laboratorijske
Medicine) are terms commonly used in Croatia,
equivalent to Clinical Chemistry and Clinical
Chemist, respectively, in most European countries. Medical biochemistry is almost exclusively
practiced by medical biochemists. Medical biochemistry in Croatia comprises clinical biochemistry, haematology and coagulation, immunology, toxicology and therapeutic drug monitoringand endocrinology. Blood-banking, microbiology
and cytogenetics are separate entities. Medical
Biochemistry is studied at the Faculty of
Pharmacy and Biochemistry. University degree(Master of Science) is earned after the 5 yearsof the studies and postgraduate training whichis 1 year follows, it is state regulated and is ELFM
syllabus compliant. The Faculty of Pharmacy andBiochemistry provides the postgraduate education within the three years of Doctoral studies
for: (a) Pharmacy sciences; and (b) Biomedical
sciences. PhD degree is requirement for a headof the clinical laboratory at the university hospital. However, PhD degree is not a requirement
for medical biochemistry specialists to practice
the profession in a laboratory.
In Serbia, the terms used are Clinical Biochemistry,
Laboratory Medicine, and Medical Biochemistry
and only Medical Doctors and Pharmacists are allowed to enter the profession. The training is 3-4
years depending on background, it is also state
regulated compliant to EFLM syllabus but medical genetics transfusion medicine immunology
and microbiology are separate medical specialties. And finally all specialists have the right toboth release results and provide clinical consultancy. Kosovo although it is part of Serbia is a
recent full member of IFCC. Regulation of theprofession in kosovo is similar to that in Serbia
only recently only Medical Doctors can enter the
profession.
Small but significant differences we can see in
FYROM where the term Medical Biochemistry
and Clinical Chemistry are used. While Medical
Doctors, Pharmacists and non-medical scientists
are allowed to enter the profession only MD’sand Pharmacists have the right to release results and provide consultancy. Moreover, training is state regulated but only for medical andpharmacists it is 4 years and it is EFLM syllabus
compliant. No post-graduate training is provided
for non-medical scientists.
In Albania, the name is Clinical Biochemistry is
only open to medical doctors and the training isfour years it is state regulated and compliant to
EFLM and UEMS syllabus. Clinical biochemistry
as a specialty here incorporates Haematology
and Immunology but Microbiology is a seperate
medical specialty.
In Greece and Cyprus, Medical Biopathology(Iatriki Biopathologia) is the state regulated
multidisciplinary medical specialty that is given
only to Medical Doctors. It is 5 years in duration and incorporates microbiology, laboratoryhaematology, immunology, biochemistry andtransfusion medicine. However this training program is partly EFLM syllabus compliant. Medical
Genetics is a new state regulated medical specialty which is going to be open to both medical
and non-medical scientists, but the training process has not been decided yet. A medical specialty under the name Clinical Chemistry (open
to both medical and non-medical scientists) isinactive and no regulatory laws are in practice togovern the training of medical and non-medical
scientists. The Greek society for clinical chemistry and clinical biochemistry understanding thePage 187

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gap in non-medical scientists issued a training
program that is compliant to EFLM syllabus andit is available for all non-medical scientists.
In Turkey, the situation is a bit more complicated.
Training is performed either at hospitals or medical faculties in the universities. Although there
is a core curriculum for the training from ministry of health each hospital or medical faculty has
its own training program. The graduates from
the Medical, Pharmaceutical, Chemistry faculties can participate at an examination in order tostart training, but only the medical graduates canbe trained at the Medical faculties. Non-medical
graduates can be trained only at the state hospitals. They all take exams organised by their organisations in order get the diploma. The graduates with the Medical Biochemistry Diplomas
all can work at the Hospital laboratories by law.
But the MoH does not allow them for working
at the hospital laboratories belonged to the
MoH because the MoH and the medical laboratory associations or societies except the Turkish
Biochemistry Society are strongly against to thetraining of non-medical graduates for becoming
Medical Biochemist.
IS THE PROFESSION OF LABORATORYMEDICINE CHANGING?
The definition of Laboratory medicine is not a
static one. Changes in technology and in theeconomic environment drive the changes in
the profession. Techniques that a few years ago
were available only for research now are readyfor everyday clinical use. Moreover, the needfor better and individualised care together withthese emerging technologies has driven manylaboratory tests outside the safe laboratory environment to the clinicians and in certain cases
to the patients themselves. Who has the rightto perform laboratory tests? This also needs tobe re-defined in the next years.

Changes due to technology
During the last 10-20 years, major scientific andtechnological advances were the cause of evolutional changes that happened in the practiceof laboratory medicine:First, the rise of new technologies that produce
biomedical “big data” (next generation sequencing, multiparameter/multiplex flow cytometry,high-throughput proteomics and metabolomics,
systems biology analysis) has caused us to rethink the best approach to diagnostics. Whereas
formerly one could easily spend one’s clinical andinvestigative career developing expertise in justa few analytes, we now have the opportunity to
begin to crack the incredible redundant complexity of living organisms. Moreover, the implementation and growth of clinical testing using mass
spectrometry and molecular diagnostics. Once
only basic research tools, now these technologies provide same-day measurement of proteins,
nucleic acids, and therapeutic drugs, improving
patient care in complex medical cases.
Second, the advent of the electronic medical record (EMR) has added to this potential but, more
importantly, has made it much more possible tocarry out “cost-efficient” clinical consultationin laboratory diagnostics on specific patients
across a wider geographic area. At least theoretically, one pathologist can now consult quickly
on multiple patients from a remote location.
Third, point-of-care laboratory testing is advancing at a furious pace, resulting in both potential
great benefits (imagine each clinical doctor witha handheld device) and potential dangers (theclinician might not be able to tell when the instrument is pout of control or not working at all).
Finally, high-throughput automation, combinedwith electronic identification technologies, provides a platform for reduction of laboratory test–
related medical errors.

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Konstantinos Makris
Is the profession of laboratory medicine uniform across the North Mediterranean countries?

All of these changes work toward progressively
greater centralisation. The risk of our profession to become “big business” in its underlying
structure is evident, and this makes our second
objective (the research) even more difficult.

of the profession and the time to participate inresearch have seemingly suffered.

Changes due to increasing
economic restrictions

I would like to thank the following colleagues
from North Mediterranean countries that responded to my questionnaire and devoted
some time and discussed with me the training
in LM in their respective countries:

Governments and private health-care providers
try to reduce the cost of healthcare in generaland laboratory were easy targets. Laboratory
consolidations, outsourcing of services, andhostile takeovers of hospital laboratories bycommercial companies were common occurrences in the US in the mid-1990s. These measures led to a reduction not only in the number of positions for clinical laboratory staff, butalso to the closing of many medical technology
schools, and downsizing of postdoctoral training programs.
These practices crossed the ocean and are now
common practices in many European countries.
Consolidation and, in some cases, regionalisation of laboratory services with the creationof individual laboratories serving multiple
healthcare facilities is now the driving force inmany countries. Healthcare in Europe used tobe different than in US but is facing the dangers
of an increased privatisation. The private–public
competition also contributed to the increased
perception of health as a commodity (the product of clinical laboratories was no exception).
This is a dangerous path often ignoring the importance and the true impact of diagnostic testing in patient’s health.
Changes due to regulatory requirements
Furthermore, the regulatory requirements, quality assessment programs, compliance issues,and general administrative responsibilities oflaboratory directors have significantly increased
over the past decade. As a result of these clinical service demands, the academic aspects

Acknowledgements

José Queralto – Spain
Philippe Gillery – France
Mario Plebani – Italy
Evgenija Homsak – Slovenia
Jozo Coric – Bosnia-Herzegovina
Danica Labudovic – FYROM
Sanja Stankovitch – Serbia
Anyla Bulo – Albania
Gramos Begolli – Kosovo
Diler Aslan – Turkey
Charis charilaou – Cyprus
Dimitris Rizos – Greece

REFERENCES
1. Jassam N, Lake J, Dabrowska M, Queralto J, Rizos D,
et al. The European Federation of Clinical Chemistry andLaboratory Medicine syllabus for postgraduate educationand training for Specialists in Laboratory Medicine: version 5 – 2018. CCLM in press
2 . h t t p s : / / w w w. u e m s . e u / _ _ d a t a / a s s e t s / p d f _file/0018/44433/UEMS-2013.25-European-Training-Requirements-Medical-Microbiology.pdf (accessed 14/9/2018)
3. https://europathol.wordpress.com/about/ (accessed
14/9/2018)
4 . h t t p s : / / w w w. u e m s . e u / _ _ d a t a / a s s e t s / p d f _file/0019/44452/UEMS-2016.15-European-Training-Requirements-Laboratory-Medicine.pdf (accessed 14/9/2018)
5. http://mahse.co.uk/wp-content/uploads/2016/03/
HSST-v.2.pdf (accessed 14/9/2018)

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6. https://www.healthcareers.nhs.uk/explore-roles/
healthcare-science/roles-healthcare-science/life-sciences/clinical-biochemistry (accessed 14/9/2018)12. Misbah SA, Kokkinou V, Jeffery K, et al The role of thephysician in laboratory medicine: a European perspective
Journal of Clinical Pathology 2013;66:432-437.

7. https://www.healthcareers.nhs.uk/explore-roles/
doctors/roles-doctors/pathology/chemical-pathology/
training-and-development-chemical-pathology (accessed
14/9/2018)

13. Kricka L J, Polsky T G, Jason Y. Park J Y, Fortina P. The
future of laboratory medicine — A 2014 perspective. Clinica Chimica Acta 438 (2015) 284–303

8. https://www.rcpath.org/trainees/training/training-byspecialty/chemical-pathology.html (accessed 14/9/2018)
9. Wieringa G, Zerah S, Jansen R, Simundic AM, Queralto J,
Solnica B, et al. The EC4 European syllabus for post-graduate training in clinical chemistry and laboratory medicine:version 4 – 2012. Clin Chem Lab Med 2012;50:1317–28.
10. McMurray J, Zerah S, Hallworth M, Koeller U, Blaton
V, Tzatchev K, et al. The European Register of Specialists in
Clinical Chemistry and Laboratory Medicine: Code of Conduct, Version 2 – 2008. Clin Chem Lab Med 2009;47:372–5.
11. McMurray J, Zerah S, Hallworth M, Schuff-Werner P,
Haush- ofer A, Szekeres T, et al. The European Registerof Specialists in Clinical Chemistry and Laboratory Medicine: guide to the Register, version 3 – 2010. Clin Chem
Lab Med 2010;48: 999–1008

14. Orth M, Averina M, Chatzipanagiotou S, et al Opinion:
redefining the role of the physician in laboratory medicine
in the context of emerging technologies, personalised
medicine and patient autonomy (‘4P medicine’) Journalof Clinical Pathology Published Online First: 22 December
2017. doi: 10.1136/jclinpath-2017-204734
15. Q&A - Moderators: Mitchell G. Scott and Nader Rifai,
Experts: Brian Smith, Michael Oellerich, Mauro Panteghini, Fred Apple, Ken Sikaris, and Ian Young. The Changing
Face of Laboratory Medicine: A More Service and Less Academically Oriented Profession? Clinical Chemistry 61:2
322–329 (2015)
16. Wytze P. Oosterhuis and Simone Zerah. Laboratory
medicine in the European Union Clin Chem Lab Med
2015; 53(1): 5–14

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Meeting the needs of Mediterranean nations: training and education 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.

EFLM project “Exchange of practical knowledge
and skills in Laboratory Medicine” – EFLMLabX
Evgenija Homšak1,2
1
2

Chair, EFLM WG-CPE
Department for Laboratory Diagnostics, University Clinical Centre Maribor, Slovenia

ARTICLE INFOABSTRACT

Corresponding author:
Evgenija Homšak
Department for Laboratory Diagnostics
University Clinical Centre Maribor
Ljubljanska 5, 2000 Maribor
Slovenia
Email: evgenija.homsak@ukc-mb.si

BackgroundKey words:
EFLM LabX, exchanging practice,
Laboratory Medicine, website, tool

In many laboratories/institutions of the European
Federation for Clinical Chemistry and Laboratory
Medicine (EFLM) there is a need to acquire additional practical knowledge and skills in different fields ofLaboratory Medicine (LM).
Until now, there were no possibilities, in official andopen ways, to find the link to such additional but very
important education, which may be obtained in other laboratories in the country or abroad. The aim of
this EFLM project is to create and operate a networkof medical laboratories willing and able to offer practical training in various fields/aspects of Laboratory
Medicine.
Methods
We conducted the survey among EFLM members,
with the aim to identify the EFLM members’ needs
and possibilities to offer different practical training inlaboratories in the country or abroad. We created the
EFLMLabX website portal within the main EFLM website for offering, searching the practices and establishing direct contacts between applicants and providers
institutions.
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Evgenija Homšak
EFLM project “Exchange of practical knowledge and skills in Laboratory Medicine” – EFLMLabX

Results
According to the very positive survey results (146
responses) about needs (128) and interest to offer different practices (87) on the field of LM, that
we have obtained from EFLM National Societies(28) in 2015, we noted a great interest for training
and exchange of practical knowledge and skills in
LM amongst EFLM countries. In January 2018 wehave launched EFLMLabX portal. Since now wehave already 13 providers/ partners institutions,from 10 different countries, which offer 17 different practice positions. Four practices are alreadyongoing and two were already finished.

on the official and open way to find the link tosuch additional but very important education,
especially for young trainees, but also for all other European Specialists of Laboratory Medicine(EuSpLM), who want to share the knowledge ofLM on a different level. Under the umbrella of
EFLM, as a main and central European professional organization, there is now an option which
could help to address this problem: the project“Exchange of practical knowledge and skills inLaboratory Medicine” which the Working Group
for Congresses & Postgraduate Education (WGCPE) is developing.

Conclusions

THE AIM OF EFLMLABX PROJECTWith this project, according to obtained higher level of knowledge/experience on different
field of laboratory diagnostics of general professional population (of EuSpLM), better networks between professionals, experts, and scientists we will gain higher general quality of our
profession.

The aim of this EFLM project is to create andoperate a network of medical laboratories willing and able to offer practical training in various
fields/aspects of Laboratory Medicine; additionally, to enable the connections and direct communication between providers and potential
users of practices. With this project, we would
be able to establish the big nets-communication
between LM professionals and contribute to
the higher exchange of knowledge and experience and general quality of our profession. This
project is also in a scope of our several year’s attempts to get official recognition of our profession, according to the new EU Council Directive
on recognition of professional qualifications andRegulation with the established free movementof professionals among EU member/European
countries (4).



INTRODUCTION
The Education for the specialists of Laboratory
Medicine (LM) is very complex and according tocommon Syllabus concerns the knowledge on
several different fields of diagnostics, methods,
including practical laboratory training and skills(1,2). LM is undergoing continuing changes, due
to medical information improvement, novel
analytical technologies development and introduction of new tests. In many laboratories/institutions of EFLM Member Societies, to achievecomplete competences of their specialist, there
is a need to acquire additional practical knowledge and skills in different fields of Laboratory
Medicine, due to the lack of opportunity and adequate professional experts (3). These may beobtained in other laboratories in the country or
abroad. Until now, there were no possibilities,

EFLM SURVEY ON THE NEEDAND INTEREST FOR PRACTICALTRAINING IN LM
The first phase of the project was to conduct
the survey among EFLM members with the aim
to identify the EFLM member needs for practical training in laboratories in the country or
abroad and set up possibility and readiness ofPage 192

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EFLM project “Exchange of practical knowledge and skills in Laboratory Medicine” – EFLMLabX

laboratories offering such practical training in
EFLM countries. We have prepared the questionnaire, which included two part of questions
that were related to needs and possibilities tooffer different practical experience and knowledge in EFLM laboratories and institutions. In
March 2015 the related questionnaire was disseminated to all national representatives andsociety presidents and to a number of laboratories in EFLM Countries. According to the very
positive survey results (146 responses) about
needs (128) and interest to offer different practices (87) on the field of LM, that we have obtained
from EFLM National Societies (28) in 2015, weFigure 1

noted a great interest for training and exchangeof practical knowledge and skills in LM amongst
EFLM countries.
Therefore, we were stimulated for the next further step to create the website program to startand running the project.
EFLMLABX WEBSITE-PROGRAM(https://eflmlabx.eflm.eu/en)

A dedicated website for the EFLMLabX program
was developed within the framework of the main
EFLM website (Figure 1), offering the possibility tosearch and apply to the several practical training

EFLMLabX project on EFLM website

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Evgenija Homšak
EFLM project “Exchange of practical knowledge and skills in Laboratory Medicine” – EFLMLabX

positions, and to establish direct links and communication opportunities between both providers and users/applicants of practices (Figure 2).
Training opportunities in the database can range
from visiting, general specialist training to gaining skills necessary for specialized measurement
methods or systems (introduction of new IVD
systems), research methods provided by groups
in laboratories and practical courses in laboratory medicine related topics. According to the added guide, here are the opportunities to sign up/
login as a user or an offerer of practices, with thegeneration of the own user/offerer profile. Eachprovider/offerer of the practice, after application and evaluation/confirmation from the EFLM
WG-CPE and signed contract (Memorandum ofagreement) from both (EFLM and institution)
site, become a trustable partner of the project,with the obligation to manage and update all
information regarding institution and offeredpractice positions. At the end of each concluded
Figure 2practice, each participant will receive Certificate
of attendance. The future task of the WG-CPE
will include also evaluation of these practices,with the possibility to gain CPD points for continuing professional development (5).
GOALS OF THE PROJECTWith such a project we will be able on EFLM level:•to achieve higher level of experience on
different field of laboratory diagnostics•

to share the knowledge and experienceamong practice in different lab-institution•

to learn and get/ exchange the knowledge
and skills of different diagnostic methods(specific-GC –MS, new IVD systems...)•to get the knowledge and skills of specificfield of diagnostics (in terms of development and introduction of new diagnostics
as an interest of participant/applicant’sLaboratory-institution)

EFLMLabX project website

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EFLM project “Exchange of practical knowledge and skills in Laboratory Medicine” – EFLMLabX•

CONCLUSIONS

to offer the opportunity for the young
trainees and specialist to expanding
contacts with (between) the experts(motivation for work and research)•to get the opportunity for research workand as part of that to get additional
knowledge and skills on academic level(eg writing scientific articles)•

to find the new potential co-workers
on diagnostic fields/research science

EFLMLabX project of exchanging practice is/could
be a useful tool for the young and already experienced professionals (EuSpLM) in LM to obtainhigher level of knowledge/experience on different field of laboratory diagnostics and to establish better networks between professionals, experts, and scientists. With this project we could
gain higher general quality of our profession.
REFERENCESFUNDATION FOR BURSARIES
To support this important exchange of knowledge
and skills in LM, especially for young trainees, wewould like to create the fundation for bursaries,that will be supported by IVD partners/sponsors. With bursaries would be possible to cover
expences for traveling, accomodation and possible fee for education of participants. On thatway we would be able to stimulate the exchange
of knowledge between different professionals/
laboratories/institutions and EFLM countries.
PILOT PROJECT AND FIRST EXPERIENCES
The EFLMLabX was launched in January 2018.
The invitation to participate the project and join
as a user or offerer was sent to all national representatives of EFLM. Since now we have already13 providers/ partners institutions, from 10 different countries, which offer 17 different practice positions. Four practices are already ongoing
and two were already finished.

1. Wieringa G, Zerah S, Jansen R, Simundic AM, Queralto J,
Solnica B, et al. The EC4 European syllabus for post-graduate training in clinical chemistry and laboratory medicine:version 4 – 2012. Clin Chem Lab Med 2012;50:1317–28
2. Jassam N, Lake J, Dabrowska M, Queralto J, Rizos
D, Lichtinghagen R, et.al. The European Federation ofClinical Chemistry and Laboratory Medicine syllabus forpostgraduate education and training for Specialists inLaboratory Madicine: version 5-2018. Clin Chem Lab Med
20018;doi: 10.1515/cclm-2018-0344
3. ISO 15189:2012 Medical laboratories – Requirementsfor quality and competence. Available from: https://www.iso.org/standard/56115.html.
4. European Parliament and EU Council. Directive
2013/55/EU of the European Parliament and of the Council of 20 November 2013 amending Directive 2005/36/EC
on the recognition of professional qualifications and Regulation (EU) No 1024/2012 on administrative cooperation
through the Internal Market Information System (‘the IMIRegulation’) 2013: Available from: http://eur-lex.europa.
eu/legal-content/EN/TXT/?uri=OJ:L:2013:354:TOC.
5. Topic E, Beletic A, Zima T. Continuing professional development crediting system for specialists in laboratory
medicine within 28 EFLM national societies. Biochemia
Medica 2013;23(3):332-41. http://dx.doi.org/10.11613/
BM.2013.041

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Meeting the needs of Mediterranean nations: improving health with emerging technologies

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non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Economic evaluation as a toolin emerging technology assessment
Nataša Bogavac-Stanojević

Department of Medical Biochemistry, University of Belgrade-Faculty of Pharmacy, Belgrade, Serbia

ARTICLE INFOABSTRACT

Corresponding author:
Nataša Bogavac-Stanojević
Department of Medical Biochemistry
Faculty of Pharmacy
POB 146, 11000 Belgrade
SerbiaPhone: +381 11 3951279
Fax: + 381 11 3972840
E-mail: naca@pharmacy.bg.ac.rs

Medical technologies are part of health technologies
and they include medical devices (MD) and in vitro
diagnostics (IVD). They have become a vital part ofmodern healthcare. Framework for introduction of
new technology in the healthcare system includes a
few steps: analytical and clinical accuracy assessment,
clinical utility determination and economic evaluation. In addition, payers are interested whether new
technology is adequate for reimbursement. There are
fairly enough specific guidelines for implementationof economic methods at the early stage of IVD development. Searching the available literature in thisfield, this paper discusses the economic evaluationsof emerging medical technologies with focus on pointof care testing (POCT) and genetic testing.

Key words:
in vitro diagnostics, economic evaluations,point of care testing, genetic testing
Acknowledgements:
The work was financially supportedby the Ministry of Education, Scienceand Technological Development,
Republic of Serbia (Project No. 175035).
Conflict of interest
The author reports no conflict of interest,
including any financial, personal or otherrelationships with other people or organisation.

Results of POCT economy studies depend on investigated perspective (payers, policy makers or society),used effectiveness values (utility, effectiveness or consequence estimated as monetary value) and understanding of clinical pathway. There is a need for better
understanding of the care pathway, resource utilisationand how they change with the introduction of POCT.
Introduction of genetic testing before drug therapy
was recommended with the aim to improve treatment
benefit and to reduce costs of adverse drug reaction.
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Clinical utility and cost-effectiveness analyses
should be considered for novel genetic testing– guided treatments. Most of the studies considering genetic testing – guided treatments
showed that those combinations were cost-saving or cost-effective compared to standard care.
For medical tehnology there is no universal
guidance for outcomes measurement, cost calculation, performance requirements, use of acertain type of economic studies and economic
thresholds.


INTRODUCTION
Medical technologies consist of both medical devices (MD) and in vitro diagnostics (IVD)
and represent an important group of healthtechnologies. It was estimated that more than
500,000 medical technologies are available
today (1, 2). They have become a vital part ofmodern healthcare and practically no diagnosis
or treatment is possible without them.
Introduction of medical technologies in thehealthcare system and their reimbursement
is the result of available evidence assessmentwith the scope of ensuring rational resources
allocation (3). Payers are now requiring data
about both clinical and economic value before
they will consider reimbursing and using any
new technology. They initially assess the clinical benefit of the technology with purpose todetermine whether it is adequate for reimbursement. Payers then evaluate the added
clinical benefit of the technology in comparison to existing or alternative technologies (4).
This approach is obstructed by small number ofavailable clinical studies for emerging technologies. European Union regulations consider
premarket evidence, but because of the lackof appropriate data about new MD and IVD effectiveness, expectations of decision makers

included in reimbursement process have rarely
been met (5). Consequently, numerous applications submitted to the payers each year get
rejected or withdrawn due to insufficient data
(6). In addition, there is a lack of information
concerning how, whether or not stakeholder
should perform economic evaluations for MD
and IVD or how cost-effectiveness should beapplied in the health care setting (3). Numberof factors, depending on medical technology,
complicate economic evaluation and limit its informative value. Some of these factors are resultof the fact that technologies have multiple indications or purposes and so they have distinctive
features. All those require different or modified
methods for economic evaluation compared topharmaceuticals (7). Consequently, in 2016 theNational Institute of Health and Care Excellence(NICE) in the United Kingdom published 50
pharmaceutical appraisals, but only 3 MD and
6 diagnostic technologies appraisals (2). The
European parliament decided to reform the EU
legislation for MD and IVD. In 2020, Europe’s
Medical Device Regulation and in 2022 In Vitro
Diagnostic Regulation will come into effect,
which will impact all medical technologies (8).
There are fairly enough specific guidelines for
implementation of economic methods at theearly stage of test development. Drawing on theavailable literature in this field, this paper discusses economic evaluations of emerging medical technologies with focus on point of care testing (POCT) and genetic testing.
ECONOMIC EVALUATION
OF POINT OF CARE TESTING
In 2013, St John and Price published a review paper on economic evaluation of POCT. They analysed five studies which included classical costeffectiveness analysis and two studies whichapplied cost consequence analysis (9). Few economic studies also analysed self-monitoring

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Nataša Bogavac-Stanojević
Economic evaluation as a tool in emerging technology assessment(SM) POCT. Simon et al. applied cost – utility analyse to evaluate SM of blood glucose inpatients with type 2 diabetes (10). The study
showed that SM of blood glucose was more
expensive than usual care. Patients had modest improvements in HbA1c levels and consequently non-significant health benefit. On theother hand in the study of Claes and colleagues,
results of cost effectiveness analyses of various interventions related to INR testing by SM
POCT showed that the intervention after INRlevels measurement in GP surgery combinedwith multifaceted education was dominant overusual care. They showed increased quality (expressed as “more patients with INR values closer
to the target value”) and less cost (11). Contrary
to the previous results, in the Parry et al. study,
effectiveness of SM of INR which was expressed
as “proportion of people with INR values in thetherapeutic range” and costs were higher thanstandard care (12). Connock et al. developed aMarkov model to evaluate cost-effectiveness of
SM of INR in comparison to clinical care. They
estimated costs from the UK NHS perspective
and calculated incremental cost of SM per QALY.
According to the results of Conneck study SM
was cost effective using a threshold of £30,000/QALY (13). Findings of St John and Price review
study were confusing regarding economic analysis of POCT because of limited quality and availability of clinical effectiveness of POCT. Various
studies used different effectiveness or utility
values and compared them to costs of resource
utilisation across different elements of the carepathway (9). In 2014, Ulf Martin Schilling explained main steps in calculation of direct andindirect POCT costs. He pointed out that majoradvantages of POCT are short turnaround times(TATs) and no requirement for dedicated laboratory staff for routine analysis (14). In addition,
long TAT correlates with late diagnosis, less successful treatment and higher associated costs(cost for prolonged therapy, increased morbidity

and mortality). Few studies have showed thatprimary testing costs are increasing while costsof complete patient pathway are decreasing andconsequently adoption of POCT was cost effective (14, 15, 16). An Australian study publishedin 2018 examined cost effectiveness of POCT
as a tool for triage of acutely ill patients in rural communities. Results showed that POCT for
patients with acute chest pain, for patients with
CRF who missed one or more dialysis sessions
and for patients with acute diarrhea, were more
expensive but more effective than Usual Carestrategies. Adopting of POCT in these patientswould lead to cost savings (due to unnecessary
medical evaluations avoided) in rural communities (17).
Results of POCT economy studies depend on
investigated perspective (payers, policy makers or society), used effectiveness values (utility, effectiveness or consequence estimated asmonetary value) and understanding of clinicalpathway. Most often the analysed effectiveness
was from clinical studies with relatively shortduration. Accordingly, main outcomes were notdetected. There is a need for better understanding of the care pathway, resource utilisationand how they change with the introduction of
POCT (9).
ECONOMIC EVALUATIONOF GENETIC TESTING
In the USA, cost of adverse events has been estimated at US$177 billion per year and drug’s efficacy was approximate on 50%. Potential waste ofmoney related to low drug efficacy was approximately $700 billion (18). Introduction of genetic
testing before drug therapy was recommended
with the aim to improve treatment benefit andto reduce costs of adverse drug reaction. For
novel genetic testing – guided treatments clinical utility and cost-effectiveness should be considered. The majority of genetic testing – guided

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treatments were cost-effective or even dominant(cost saving), but with notification that there waslarge heterogeneity in methodology between
studies (19, 20).
According to systematic review conducted by
Verbelen and co-workers, from 68 drugs that met
inclusion criteria for study (FDA-approved drugs
along with the biomarker gene - presented in
The FDA Table of Pharmacogenomic Biomarkers
in Drug Labeling lists), only 10 were economicallyevaluated. 44 economic evaluations were implemented for those 10 drugs. Over half of the 44
economic evaluations took cost utility and costeffectiveness analyses and they favoured genetic
testing-guided therapy (21). Most of the studies
considering genetic testing – guided treatments
showed that those combinations were cost-saving or cost-effective compared to standard care(22). Rest of publications found genetic testing
was not cost-effective or did not reach a definitive conclusion (21). The majority of studies
evaluated genetic testing for azathioprine, clopidogrel, irinotecan and clozapine with positive
economic assessment. Warfarin was evaluatedin most economic studies, but they reached diverging conclusions (21).

patients only. Similarly, Herceptin has been reimbursement since 2007. In Italy, HER2 and KRAS
are publicly funded and available via a networkof public hospital laboratories. HER2, KRAS, EGFR
and BCR-ABL test reimbursement involved pharmaceutical subsidization or sponsorship (18).
CONCLUSION
For medical tehnology there is no universal guidance for outcomes measurement, cost calculation, performance requirements, use of a certain
type of economic studies and economic thresholds. There is no appropriate recommendation
which medical technology should undergo formal national reimmbursement system. It is uncler how existing health technology criteria for
medicines can be translated to medical tehnology reimbursment decision making. Whether itshould be analysed using „real-world” observational evidence rather than experimental data?
Assessment of cost-effectiveness is primarily of
use to the policymaker and the purchaser, while
healthcare provider needs to adopt technology
in order to satisfy a recognised unmet need.
REFERENCES

Verbelen and co-workers concluded that costof genetic testing is an important parameter of
economic evaluations because the price of genetic tests decreased over time. In addition, genetic testing costs may depend on the method
used to determine genetic variants (for example,
PCR or measuring enzyme activity). If alternative
drug for test-positive patients is expensive and if
genetic test has a high proportion of false positive results, genetic test is not cost effective (21).

1. MedTech Europe - European IVD Market Statistics Report 2016: https://www.vdgh.de/media/file/5153.European_IVD_Market_Statistics_Report_2015.pdf. Assesed
20 June 2018.

HER2, EGFR and KRAS testing are reimbursedin the UK and such approval was sponsoredby pharmaceutical industry. In 2008, a Frenchtransparency committee recommended theuse of Amgen’s (CA, USA) Vectibix for metastatic
colorectal cancer treatment for wild-type KRAS

4. Huot L, Decullier E, Maes-Beny K et al. Medical device
assessment: scientific evidence examined by the Frenchnational agency for health – a descriptive study. BMC
Public Health 2012;12:585.

2. Tarricone R, Torbica A, Drummond M. Challenges in theAssessment of Medical Devices: The MedtecHTA Project:
Challenges in the assessment of medical devices. Health
Economics 2017; 26(S1): 5-12.
3. Schnell-Inderst P, Mayer J, Lauterberg J et al. Healthtechnology assessment of medical devices: What is different? An overview of three European projects. Z Evid
Fortbild Qual Gesundhwes 2015; 109: 309-18.

5. Kramer DB, Xu S, Kesselheim AS. Regulation of medical
devices in the United States and European Union. N Engl
J Med 2012; 366: 848–55.

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Nataša Bogavac-Stanojević
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6. Chevreul K, Durand-Zaleski I, Bahrami SB et al. France:
health system review. Health Syst Transit 2010; 12: 1–291,
xxi–xxii

14. Schilling UM: Time is money – the economic impact
of point of care on the emergency department of a tertiary care university hospital. Point Care 2014; 13:21–3.

7. Drummond, M. F. Twenty years of using economic
evaluations for drug reimbursement decisions. What has
been achieved? Journal of Health Politics, Policy and Law,
2013. 38, 1081–1102.

15. Asha SE, Chan AC, Walter E et al. Impact from pointof-care devices on emergency department patient processing times compared with central laboratory testingof blood samples: a randomized controlled trial and costeffectiveness analysis. Emerg Med J 2014; 31:714–29.

8. The new Regulations on medical devices. https://
ec.europa.eu/growth/sectors/medical-devices/regulatory-framework_en. Assesed 20 June 2018.
9. St John A, Price C. Economic Evidence and Point-ofCare Testing. Clin Biochem Rev 2013; 34: 61-74
10. Simon J, Gray A, Clarke P et al. Diabetes Glycaemic
Education and Monitoring Trial Group. Cost effectivenessof self monitoring of blood glucose in patients with noninsulin treated type 2 diabetes: economic evaluation ofdata from the DiGEM trial. BMJ 2008; 336: 1177-80.
11. Claes N, Moeremans K, Frank B et al. Estimating thecost-effectiveness of quality-improving interventions inoral anticoagulation management within general practice. Value Health 2006; 9: 369-76.
12. Parry D, Fitzmaurice D, Raftery J. Anticoagulation
management in primary care: a trial-based economic
evaluation. Br J Haematol 2000; 111: 530-3.
13. Connock M, Stevens C, Fry-Smith A et al. Clinical effectiveness and cost-effectiveness of different models ofmanaging long-term oral anticoagulation therapy: a systematic review and economic modelling. Health Technol
Assess 2007; 11: iii-iv, ix-66.

16. Schilling UM. Chest pain at the emergency department. Hosp Healthcare Eur 2014; 182–6.
17. Spaeth BA, Kaambwa B, Shephard MD et al. Economic
evaluation of point-of-care testing in the remote primary
health care setting of Australia’s Northern Territory. Clinicoecon Outcomes Res. 2018; 10: 269-277.
18. Miller I, Ashton-Chess J, Spolders H et al. Market access challenges in the EU for high medical value diagnostic tests. Per Med. 2011; 8: 137-148.
19. Phillips KA, Ann Sakowski J, Trosman J et al. The economic value of personalized medicine tests: what we know
and what we need to know. Genet Med 2014; 16: 251–7.
20. Beaulieu M, de Denus S, Lachaine J. Systematic review of pharmacoeconomic studies of pharmacogenomic
tests. Pharmacogenomics 2010; 11: 1573–90.
21. Verbelen M, Weale ME, Lewis CM. Cost-effectivenessof pharmacogenetic-guided treatment: are we there yet?
Pharmacogenomics J. 2017;17:395-402.
22. Altar CA, Carhart J, Allen JD et al. Clinical utility of
combinatorial pharmacogenomics-guided antidepressant therapy: evidence from three clinical studies. Mol
Neuropsychiatry 2015; 1: 145–55.

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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.

Who or what is SHERLOCK?
Ann M. Gronowski

Department of Pathology and Immunology, Washington University in St. Louis, MO, USA

ARTICLE INFOABSTRACT

Corresponding author:
Ann M. Gronowski
Washington University School of Medicine
425 S. Euclid Ave., Campus Box 8118
St. Louis, MO 63110
USA
Phone: 314.362-0194
Fax: 314.362-1461
E-mail: gronowski@wustl.edu

BackgroundKey words:
CRISPR, PCR, nucleic acid

Polymerase chain reaction (PCR) is the most commonly used method for detecting nucleic acids. However,
PCR requires specialized and expensive equipment,
as well as specially trained personnel. Recently, newinnovative diagnostic methods have been developed
to detect nucleic acids using the Clustered RegularlyInterspaced Short Palindromic Repeats (CRISPR) gene
editing technology.
Objective
This manuscript reviews the newly emerging diagnostic methods that exploit the CRISPR technology.
Results
The programmable endonuclease properties of CRISPR
have been harnessed for use in diagnostic testing.
Specific High-sensitivity Enzymatic Reporter un-LOCKing (SHERLOCK) and DNA Endonuclease Targeted CRISPR
Trans Reporter (DETECTR) are diagnostic tools that canbe used to detect specific RNA/DNA at low attomolar concentrations. Heating Unextracted Diagnostic
Samples to Obliterate Nuclease (HUDSON), is a process of heat and chemical reduction that allows for
direct detection of nucleotides in body fluids.
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HUDSON and SHERLOCK can be combined to detect RNA/DNA directly from urine, saliva, serum,plasma, and whole blood with limited sample
preparation or equipment with results in 1 to
2 hours. In addition, a lateral flow readout has
been developed to facilitate assay detection.
Conclusions:
Potential uses of this emerging technology are
numerous due to the analytical sensitivity andspecificity, simplicity, speed, and flexibility.


The ability to measure nucleic acids with highly
sensitive methods is important for a number ofapplications such as: environmental monitoring,food safety, and detection of biological threats.
Ultra-sensitive methods also have utility in clinical diagnostics for early detection of infectious
diseases, testing the blood supply, and screening for cancer.
The most commonly used method for detecting
nucleic acids is polymerase chain reaction (PCR).
PCR is capable of routinely detecting <100 copies of nucleic acid per sample, which is in the
low attomolar to zeptomolar range. PCR, however, requires specialized and expensive equipment, as well as specially trained personnel. For
laboratories without this equipment or personnel, sending samples to a specialized laboratory
takes time. In addition, in some cases, such as
certain viral infections, the viral load is so lowthat even PCR is not sensitive enough.

fight against invading viruses. This system has
been harnessed by scientists to modify genes inliving cells.
Bacteria store genetic elements from infectious
agents in genomic loci called CRISPR arrays as
memories for adaptive immunity. In a very simplified explanation, this immune system works
as follows. When bacteria senses the presenceof viral DNA it produces a unique RNA, whichmatches that of the invading virus. This RNA
forms a complex with a protein enzyme called
CAS9 (CRISPR associated protein 9). CAS9 is anendonuclease (an enzyme that cuts DNA). The
endonuclease is guided by the RNA to its DNA
target. When the bacterial guide RNA finds its
match DNA the Cas9 enzyme cuts the DNA in a
specific location. Hence, Cas 9 is referred to asa “programmable endonuclease” because one
can program it to cut a specific DNA by providing a unique RNA.
Over the past few years, researchers have realized that they can harness this system to cut,
not just viral DNA, but any DNA at a specificlocation by changing the guide RNA to matchthe target of interest. In addition, this can bedone, not just in a test tube, but in the nucleus
of a living cell. This technology has enabled scientists to do incredible things such as edit thehuman genome to correct naturally occurring
mutations.

Recently, new innovative diagnostic methods
have been developed to detect nucleic acids using the CRISPR gene editing technology. In orderto understand these new diagnostic methods, it
is important to understand CRISPR.

Recently, this CRISPR technology has been harnessed for use as a diagnostic test. In 2017, agroup of scientists reported the development ofa technology called SHERLOCK which stands for:“Specific High-sensitivity Enzymatic Reporter unLOCKing”. (2) Their goal was to develop a method
to rapidly detect nucleic acids with high sensitivity, single base specificity, on a portable platform.

CRISPR stands for “Clustered Regularly Inter­spaced Short Palindromic Repeats”. (1) This isa naturally occurring genome editing tool thatis part of the bacterial immune system used toInstead of using the Cas9 endonuclease, SHER­LOCK uses a related, but different protein,
Cas13a. Cas13a binds and cleaves RNA rather
than DNA substrates. After Cas13a cleaves its

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Ann M. Gronowski
Who or what is SHERLOCK?

target RNA, it adopts an enzymatically “active”
state rather than reverting to inactive state, likeCas9. Cas13a then binds and cleaves additional
RNAs regardless of homology. This is referred
to as “collateral cleavage”. It is this property of
Cas13a that opens up the possibility of using
Cas13a as a diagnostic tool.
SHERLOCK works by amplifying RNA (or DNA
with a reverse transcriptase) using recombinase
polymerase amplification (RPA) which is an isothermal nucleic acid amplification. Isothermal
amplification does not require specialized instrumentation, as it uses a single temperature.
The amplified nucleotides are combined with
the Cas13a nuclease, a guide RNA that matches the nucleic acid sequence of interest, and ashort nucleotide sequence that is coupled to afluorescent reporter and a quencher. If the target sequence is present in the pool of amplified
nucleotides, the non-specific RNAse activity of
Cas13a becomes activated and the RNA reporter will be cleaved resulting in activation of thefluorophore. Therefore, the fluorescent signal isused as an indicator to determine whether thetarget sequence is present in the original poolof nucleotides. Hence the name “Specific highsensitivity enzymatic reporter unlocking”.
The authors demonstrated that SHERLOCK could
distinguish between Zika virus (ZIKV) and dengue virus (DENV) in clinical isolates (serum or
urine) where concentrations can be as low as2000 copies/mL (3.2aM). They were also able
to distinguish between several pathogenic bacterial strains, genotype human DNA, and identify mutations in cell-free tumor DNA. (2) One
year later, in an issue of science, three papers
were published that further advanced field of
molecular diagnostics using CRISPR technology.
(3-5) A group from Jennifer Doudna‘s group at
the University of California Berkley reported ona detection system similar to SHERLOCK thatthey termed DETECTR for: “DNA EndonucleaseTargeted CRISPR Trans Reporter”. Their systemutilizes Cas12a which cleaves double stranded
DNA and activates non-specific cleavage of single stranded DNA. They use the system to detect
carcinoma associated HPV from clinical specimens also using RPA with attomolar sensitivity.
In another paper in the same issue of Science,
Myyhrvold et al reported on a new method
to release and protect from degradation viralnucleic acid‘s from clinical specimens, thereby
bypassing the need for nucleic acid extraction.
(4) This method, called Hudson for: “Heating
Unextracted Diagnostic Samples to Obliterate
Nuclease”, is a process of heat and chemical reduction that inactivates the high amount of ribonucleases found in body fluids and then lyses
viral particles by disrupting the viral envelope,
thereby releasing nucleic acid’s into solution.
The authors combined HUDSON and SHERLOCK
to detect ZIKV and DENV directly from urine,
saliva, serum, plasma, and whole blood withlimited sample preparation or equipment withresults in 1 to 2 hours.
In the third paper, Gootenberg et al advanced
this technology even further with SHERLOCKv2.
(5) The authors describe the following four advances to SHERLOCK:
1. four-channel multiplexing;
2. quantitative measurement as low as 2 aM;
3. 3.5-fold increase in signal sensitivity;
4. development of a lateral flow readout.
The flexibility of this revolutionary new technology has enormous potential. Proposed uses
have included:•

Rapid detection of pneumonia pathogens(viral and bacterial) in one assay•

Monitoring viral load in HIV patients
receiving therapy in resource limited areas•

Liquid biopsy to detect mutations
in cell free DNA

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•

Rapid TB results before patient is lost
to follow-up

endonuclease in adaptive bacterial immunity. Science
2012;337: 816–821.

•

Rapid detection of pathogen resistance genes•

CRISPR to gene - edit mutations - SHERLOCK
to determine proportion of genes successfully edited

2. Gootenberg JS, Abudayyeh OO, Lee JW, Essletzbichler
P, Dy AJ, Joung J, Verdine V, Donghia N, Daringer NM,
Freije CA, Myhrvold C, Bhattacharyya RP, Livny J, Regev
A, Koonin EV, Hung DT, Sabeti PC, Collins JJ, Zhang F. Nucleic acid detection with CRISPR-Cas13a/C2/c2. Science
2017;356:438-42.

In conclusion, the programmable endonucleaseproperties of CRISPR have been harnessed foruse in diagnostic testing.
SHERLOCK and DETECTR are diagnostic toolsthat can be used to detect specific RNA/DNA.
HUDSON pairs with SHERLOCK for direct detection of nucleotides in body fluids.
Potential uses of this technology are numerous
due to the analytical sensitivity and specificity,
simplicity, speed, and flexibility.
REFERENCES
1. Jinek M, Chilynksi K, Fonfara I, Hauer M, Doudna J,
Charpentier E. A programmable dual-RNA-guided DNA

3. Chen JS, Ma E, Harrington LB, Da Costa M, Tian X,
Palefsky JM, Doudna JA. CRISPR-Cas12a target binding
unleashes indiscriminate single-stranded DNase activity.
Science 2018;360:436-9.
4. Myhrvold C, Freije CA, Gootenberg JS, Abudayyeh
OO, Metsky HC, Durbin AF, Kellner MJ, Tan AL, Paul LM,
Parham LA, Garcia KF, Barnes KG, Chak B, Mondini A,
Nogueira ML, Isern S, Michael SF, Lorenzana I, Yozwiak
NL, MacInnis BL, Bosch I, Gehrke L, Zhang F, Sabeti PC.
Field-deployable viral diagnostics using CRISPR-Cas 13.
Science 2018;360:444-8.
5. Gootenberg JS, Abudayyeh OO, Kellner MJ, Joung J,
Collins JJ, Zhang F. Multiplexed and portable nucleic aciddetection platform with Cas13, Cas12a, and CSM6. Science 2018;360:439-44.

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Meeting the needs of Mediterranean nations: improving health with emerging technologies

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.

Advancement in POCT molecular testing:the multiplex PCR POCT devices
for infectious diseases
Alpaslan Alp

Department of Medical Microbiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey

ARTICLE INFOABSTRACT

Corresponding author:
Alpaslan Alp
Department of Medical Microbiology
Faculty of Medicine
Hacettepe University
AnkaraTurkeyE-mail: alp1086@gmail.com

Rapid and accurate diagnostic tests are very important for the global control of infectious diseases. The
point of care diagnosis has become a promising strategy in recent years. Different kind of point of caretesting devices has been introduced into the market in the last decade. These devices must provide
a low-cost, robust, sensitive, specific, and practicalanalysis in order to replace the conventional clinicallaboratory diagnostic test algorithms when needed.
The successful implementation of point of care diagnostics has a potential to increase the strength of
infectious diseases surveillance programs. Finally, therapid progress in point of care diagnosis can stimulate a shift from a centralized diagnostic model to adecentralized patient-centered approach.

Key words:
point of care test, multiplex point of care device,microfluidics, lab-on-a-chip, infectious disease

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Advancement in POCT molecular testing: the multiplex PCR POCT devices for infectious diseases

INTRODUCTION
It is critically important to reduce the global
burden of infectious diseases and the drug resistant cases. Because of this reason, new diagnostic methods and instruments are continuously being developed through basic research.
Rapid diagnosis of infections is very important
for the initiation of an effective treatment.
After the discovery of polymerase chain reaction (PCR), there are many important milestones
including sequencing, microchip technology,
real-time PCR, and cartridge tests in the historyof diagnostic molecular tests. Actually this amazing history is not more than 40 years that is a tiny
space in the history of human being. The first stepof technological progress is dreaming as stated ina paper published in 2002 by Dunne et al (1).
In that paper the authors introduced a mythicaltake on the future of the clinical microbiology
laboratory based on the technological progressand describe the clinical microbiology in theyear 2025. One of their most important predictions was the reversion of the trend of centralized laboratory services towards a decentralized testing approach that was basically point ofcare testing. Based upon the evolutionary paceof the technology, it will not be surprising to seethat most of their predictions will become true
until that time.

places outside the routine laboratories like clinics, wards or doctor’s offices. The favorable outcome for an ideal MPOCT device is to have a highsensor performance at low system complexity.
The test results can be obtained within 15 minutes to several hours. The development of newmolecular panel diagnostics that can provide
results in 15 minutes would provide both clinical and economic benefits. Analysis of the multiplexed results provides the clinician with an opportunity to administer personalized therapies ina short time.
Potential benefits of MPOCTs for infectious diseases include improved patient health care andmanagement, more appropriate use of antibiotics, improved ability to limit the spread of disease,health care cost savings and increased access totesting in remote or low-resource settings (3).
The set of tests on a multiplex technology is
known as a test panel. Syndromic test panels aredesigned to test for multiple diseases associatedwith a similar set of symptoms, or a syndrome.
These panels help the evaluation of the cause of
the disease at the point of care. Respiratory panels and gastrointestinal panels are two examplesof syndromic panels (4,5).
The main performance characteristics of commercially available MPOCTs (6) include:
1. panel size, or the number of pathogen targets that can be tested in one sample run;

MULTIPLEX POINT OF CARETECHNOLOGIES

2. time to test result;

Multiplex point-of-care diagnostic technologies(MPOCTs) can test the presence of multiple infectious pathogens within a specimen (such as
blood, urine, or sputum) (2). Proteins, cells, DNA,
RNA, exosomes and metabolites can be detectedby using MPOCT devices that contain hybridization papers, array settings, bead technology or
microfluidic systems. This theoretically complex
high technology design actually provides a verypractical application that can be performed in

3. throughput, or the number of patient samples that can be run simultaneously; and4. physical size of the device.
The molecular diagnostic methods were initially expensive due to high investment costs, hadlong turnaround time (hours), and needed experienced user. However, recent developments
in isothermal DNA amplification have madegreat contribution to the workflow of moleculardiagnostics (7,8).

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Advancement in POCT molecular testing: the multiplex PCR POCT devices for infectious diseases

The successful migration of high sensitivity molecular diagnostics from the routine diagnostic
laboratories to the field could dramatically improve the accuracy and sensitivity of MPOCTs,
enhance public health reporting, and facilitate
outbreak containment in difficult settings (9).
The key design features for MPOCTs in resourcelimited settings included: loop-mediated isothermal amplification to eliminate the need fora thermal cycler, lyophilized reagents for longterm stability at high temperature, and relatively
simple procedures for ease-of-use by operators
in a field laboratory (10).
Microfluidic devices can provide a fully integrated MPOCT device for sample processing,fluid handling, and signal generation (11,12). A
major goal is a low-cost diagnostic test for use
in remote settings. Microfluidics-based devices
use channels to transport small amounts of fluidby actuation forces. Solid phase nucleic acid extraction and isothermal enzymatic nucleic acidamplification steps are combined on microfluidic cartridges or chips that contain pre-stored,paraffin-encapsulated lyophilized reagents (13).
The use of microfluidic technologies reduces assay complexity and enables multiplex analysis
and high-throughput screening (14). On-chipnucleic acid analysis is particularly promising because it miniaturizes and integrates the various
assay steps, including the lysis or extraction oftarget cells, the purification of nucleic acids, theamplification of nucleic acids, and on-chip detection of reaction products (15). Current efforts
in the development of lab-on-chip diagnostics
include the identification of new biomarkers, aswell as integrated microfluidic design, construction materials, and detector technologies (16).
A particular concern is the per-test cost and theneed for instrumentation to drive the devices
and product detection. One novel approachto assay construction is the use of layered paper to construct three-dimensional microfluidic

devices that can distribute fluids vertically andhorizontally and enable streams of fluid to cross
one another without mixing (17).
With regard to detector technologies, a universal mobile electrochemical detector wasrecently described that can communicate results to distant sites using a mobile phone (13).
These and similar developments will be criticalfor lab-on-chip diagnostics for resource-limited
settings (18,19).
Effective communication of results for disease
surveillance can be best accomplished if there
is standardization for result recording and reporting. Ideally, multiple detection technologies
might be combined in a single instrument.
The communication of results from MPOCT assays will require the abilities to digitally capture
data and to communicate results to a central
database. But using an electronic reader to scanpoint of care tests and store or transmit patient
data remain as a major concern for data privacy
and security.
The immediate goal of a MPOCT assay is to use
the information gained from the test to impact
the care of the patient. For many diseases, particularly, communicable diseases such as influenza or emerging infectious diseases, the useof MPOCT assays can provide a key element ofdisease surveillance (9). Linking data to specificgeographical locations can provide information
regarding disease emergence, disease spread,or progress toward control.
There are some studies that evaluate the effectiveness of MPOCTs compared to routine, laboratory-based detection methods in order to assess the impact on length of stay and antibiotic
usage. In one of these studies, for the first time,
the ward staff performed the MPOCT (20). The
authors found no association between respiratory PCR MPOC testing and length of stay ormost of the secondary outcomes except the antimicrobial prescribing decision. They concluded

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that this was probably due to a delay in initiating MPOC testing. MPOC testing allowed timecritical antivirals to be given significantly faster,and results were available considerably fasterthan routine laboratory-based testing. It seems
that in order to obtain the most beneficial resultsfrom MPOCTs, the tests must be performed immediately after the collection of the specimens.
This action requires at least one personnel to beallocated for the application of MPOCTS. As highlighted by the authors, new technology itself is
not enough, it should be incorporated into theroutine algorithms in a correct manner.
CONCLUSION
An ideal device for multiplexed point-of-care
testing should offer a high sensor performance,
like high sensitivity and multiplexing capability,
as well as short turnaround times, at low system complexity, including low-cost fabricationand minimized user intervention. The futuretechnology challenges will be the standardization and further miniaturization of the systemcomponents for the most effective use of thistool as a part of infectious diseases surveillance
programs. It seems that the more widely useof MPOCT devices will bring diagnostic testingcloser to patients and will be a driving force fora shift from a centralized model to a decentralized patient-centered approach.
REFERENCES
1. Dunne DW, Pinckard JK, and LV Hooper. Clinical microbiology in the year 2025. J Clin Microbiol. 2002; 40:3889-3893.
2. Dincer C, Bruch R, Kling A, et al. Urban multiplexed
point-of-care testing-xPOCT. Trends in Biotechnol. 2017;35:728-742.
3. Maffert P, Reverchon S, Nasser W, et al. New nucleic
acid testing devices to diagnose infectious diseases inresource-limited settings. Eur J Clin Microbiol Infect Dis.
2017; 36:1717-1731.
4. Brendish NJ, Malachira AK, Armstrong L, et al. Routine
molecular point-of-care testing for respiratory viruses inadults presenting to hospital with acute respiratory illness (ResPOC): a pragmatic, open-label, randomised controlled trial. Lancet Respir Med. 2017; 5: 401-11.
5. Duchesne L, Lacombe K. Innovative technologies forpoint-of-care testing of viral hepatitis in low-resource anddecentralized settings. J Viral Hepat. 2018; 25:108-117.
6. United States Government Accountability Office Center for Science, Technology, and Engineering Health Care.
Medical devices: Capabilities and challenges of technologies to enable rapid diagnoses of infectious diseases. August 2017.
7. Ahmad F, Hashsham SA. Miniaturized nucleic acid amplification systems for rapid and point-of-care diagnostics: A review. Analytica Chimica Acta. 2012; 733: 1-15.
8. Giuffridaa MC, Spoto G. Integration of isothermal amplification methods in microfluidic devices: Recent advances. Biosensors and Bioelectronics. 2017; 90:174-186.
9. Deshpande A, McMahon B, Daughton AR, et al. Surveillance for emerging diseases with multiplexed pointof-care diagnostics. Health Security. 2016; 14: 111-121.
10. Schreckenberger PC, McAdam AJ. Point-counterpoint:large multiplex PCR panels should be first-line tests for
detection of respiratory and intestinal pathogens. J Clin
Microbiol. 2015; 53:3110-3115.
11. Kozel TR, Burnham-Marusich AR. Point-of-care testingfor infectious diseases: past, present, and future. J Clin
Microbiol. 2017; 55:2313-2320.
12. Song Q, Gao Y, Zhu Q, et al. A nanoliter self-priming
compartmentalization chip for point-of-care digital PCR
analysis. Biomed Microdevices. 2015; 17: 64.
13. Mauk MG, Song J, Liu C and Bau HH. Simple approaches
to minimally-instrumented, microfluidic-based point-of-carenucleic acid amplification tests. Biosensors. 2018; 8: 17.
14. Nemiroski A, Christodouleas DC, Hennek JW, et al.
Universal mobile electrochemical detector designed foruse in resource-limited applications. Proc Natl Acad Sci.
2014; 111:11984-11989.
15. Robinson T, Dittrich PS. Microfluidic technology formolecular diagnostics. Adv Biochem Eng Biotechnol. 2013;
133: 89-114.
16. Sackmann EK, Fulton AL, Beebe DJ. The present andfuture role of microfluidics in biomedical research. Nature. 2014; 507: 181-189.
17. Martinez AW, Phillips ST, Whitesides GM. Three-dimensional microfluidic devices fabricated in layered paper and tape. Proc Natl Acad Sci. 2008; 105:19606-19611.
18. Sharma S, Zapatero-Rodriguez J, Estrela P, andO’Kennedy R. Point-of-care diagnostics in low resource

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settings: Present status and future role of microfluidics.
Biosensors. 2015; 5: 577-601.
19. Geng Z, Zhang X, Fan Z, et al. Recent progress in optical biosensors based on smartphone platforms. Sensors.
2017; 17: 2449.

20. Andrews D, Chetty Y, Cooper BS, et al. Multiplex PCR
point of care testing versus routine, laboratory-based
testing in the treatment of adults with respiratory tract
infections: a quasi-randomised study assessing impact
on length of stay and antimicrobial use. BMC Infect Dis.
2017; 17: 671.

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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.

New solutions for the sample transportand results delivery: a digital lab
Damien Gruson1,2

Department of Laboratory Medicine, Cliniques Universitaires St-Luc and Université Catholique de Louvain,
Brussels, Belgium
2
Pôle de recherche en Endocrinologie, Diabète et Nutrition, Institut de Recherche Expérimentale et Clinique,
Cliniques Universitaires St-Luc and Université Catholique de Louvain, Brussels, Belgium
1

ARTICLE INFOABSTRACT

Corresponding author:
Damien Gruson
Service de Biochimie Médicale
Cliniques Universitaires Saint-Luc
Tour Rosalind Franklin
10F Avenue Emmanuel Mounier
B-1200 Brussels
Belgium
Phone: +32-(0)2-7646747
Fax: +32-(0)2-7646930
E-mail: damien.gruson@uclouvain.be

The consolidation of laboratories, the evolution to integrated care network as well as an environment ofconsumerization are disrupting laboratory services
and operations. The switch to SMART (Speed Metrics
Automation Remote Technologies) digital laboratories
based health ecosystems depends on several prerequisites for successes. Intelligent processes, integrationof big data and real-time data management, automation, blockchain, Internet of things and enhancementof user experiences are key element of the smart digital laboratory. Safety, security and cost-effectivenessare pillars for the credibility and transferability of suchsmart digital laboratory environment. This transforming ecosystem will also trigger novel human – machineinterfaces and we will be the gatekeepers for this new“click to brick” ecosystem.

Key words:
big data, automation, machine learning,augmented reality, blockchain,drones, robots, user experience

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INTRODUCTION:
TRANSPORTATION AND DELIVERY
At first sight, we could limit our discussion to“classical” pathways of laboratory transportationof samples and delivery of results to physicians.
Focusing on this perimeter, we can already observe that our laboratory environment is changing and consolidating (1,2). Laboratories andhospitals are operating as networks with someconsolidated hubs for specialty testing. The complexity of these networks are increasing as wellas the need to meet the accreditation requirements, leveraging the need for real-time monitoring, traceability, safety, temperature control
and economy of scale (1-3). These networks andlarge size consolidated core-laboratories havetriggered the evolution of transportation, supply chain management and current progresses
are impacting the intra-laboratory / intra-hospital logistics but also the inter-laboratory / interhospital logistics (1,4). Emerging technologies
offer clear gains for temperature control andmonitoring, holistic supply chain management,
inventory management, sample tracking, standardized connectivity between laboratory information systems, and for a broader control
of whole healthcare facilities through the latest
generations of electronic medical records (1,5).
Innovations make processes more fluids and operations more cost effective, meeting the constraints coming from health care systems understronger economical pressure.
However, broadening the vision led us to consider that our whole ecosystem is transforming.
We are living in smart, inclusive and connected
cities where the paradigms of mobility, motility
and logistics are transforming (12). We are also
citizens of an “accelerated world” where our relation to ordering and transport is influence by“uberization” of goods and services and wishesof “consumerization”. Finally, we are actors of
the ongoing digitalization wave and users ofapplications aimed to facilitate services, empowerment, tracking and monitoring. The efficiency of our transforming SMART (Speed
Metrics Automation Remote Technologies)
based health ecosystems will depend on several
prerequisites for successes.
THE PREREQUISITES OF SUCCESSFOR A SMART DIGITAL LABORATORY
The processes and logistics will be
integrated, intelligent and scalable
The effects of consumerization, competition andthe switch to care pathways trigger real time reporting, integrated workflows, speed and costeffectiveness (1,5). Solutions will need to take agreater control over the supply chain, to ensure
fast and smooth processes, to guarantee quality
and ISO requirements. Intelligent systems will
analyze and sense demands, measure performances, monitor the status of systems and will
respond in real-time to manage capacities, predict needs and avoid disruption and complains.
An example of transformation could be the evolution from temperature maintenance to intelligent cold chain management.
The efficient use of big data
will improve operations
Our new ecosystems are driven by data and our
new healthcare systems are made of opportunities to harness new forms of data to improvepractices (6-9). The use of big data to capture
and analyze, to streamline the operations andoptimize the supply chain will add tremendous
value to laboratory logistics and services. The
application of algorithms and machine learning
to crunch data, unlocking insights and opportunities as never imagine before. The perspectives
include a data based automation to optimize theuse of resources, reduce waste and facilitate lean
operation, an effective real time management, acomprehensive data base inventory and supply

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chain management, the analysis of data to control carbon footprints and contribute to a greener
environment and the use of machine learning tobuild actionable and intelligent network and services (6-9). The benefits of machine learning havealready been demonstrated in electronic healthrecords, omics and mobile data and wearables.
The efficient use of data and data flows is essential to face our transforming biotope and provide
a dynamic response to disruption.
Relying on automation and blockchain
to improve security and safety
The recent reformation of the Global Data
Protection Regulation bring to light for a safe andsecure use and management of data, and this isclearly sensitive when considering healthcare
data. Automation will continue to secure processes and reduce the rate of errors (6-9). The
use of cognitive technologies will prevent mistakes and increase safety (13,14). Inventories,
real-time supply chain management, transfer ofresults to caregivers will be stronger and moresecure. Blockchain represent a way to improve
the security and safety of data monitoring, sample transfer and results communication (16,17).
Blockchain technologies have already demonstrated their benefits in the also sensitive fieldof economics and cryptocurrencies. Blockchain
technologies are offering a decentralized network maintained by users and allowing the development of a stable and secure data set withwhich users can interact through transactionsof various types. The opportunities offered byblockchain technologies to the clinical laboratory and biobanking fields seem therefore evident.
The use of tags and the internetof things to enhance operations
Intelligent, integrated and reactive systems require the capture of data. The applications of
RFID and internet of things (IoT) allow this capture of data. Perspectives include connected

and autonomous transportation solutions, accurate tracking and real time management of the
supply chain and services. The science of cloudcomputing will be the glue to collect, transfer
and agglomerate the data generated by all thesmart sensors and IoT.
Emerging technologies
to unlock new possibilities
Emerging technologies are helping us to transform the way (10,11). Even if the validationand harmonization of pneumatic tube systems
remains a subject of discussion, this solution remains the preferred choice for hospital.
Innovative pneumatic systems are carrier free,faster and could offer more options for megalaboratories. The use of robots and drones arealso tested in hospital and laboratory networks
for human samples transportation and transfer.
Like cars, these new transportation solutions
are becoming more and more autonomous.
Transportation is also a field where sharing vehicles and means is current practices and where
public – private partnerships for a greener andcost-efficient ecosystem could stimulate.
Co-creation and user experience
Meeting the satisfaction and priorities of users
is key and the evolution of the user experienceis fundamental (15). Meeting the user’s expectations means more personalized, faster andtimeless services. The transcription of direct
field observations to user-centered experiencesis also an opportunity to improve patient safety.
Our digital environment and hyper-connectivity
reinforce the quest for more user centric experiences. Therefore the use of agile and users experiences methodologies will offer the possibility
to re-design and co-create with the users themselves more users-centric solutions. The progresses of augmented reality will provide more
option to sense the future experience and discover the benefits of future solutions, products

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Figure 1

The prerequisites for a smart laboratory (IoT, internet of things)

or services. Augmented reality, defined as the
expansion of physical reality by adding layers ofcomputer generated information to the real environment, allow now to have the information at
the right time at the right place and offer mixed
reality simulations for exploring the virtual andthe real.
CONCLUSIONSThe transforming ecosystem, the era of digitalization and the needs to improve efficiency andusers experiences are disrupting laboratory services and operations. Such major ongoing changes allow us to implement emerging technologies
into practices, develop integrated and intelligent
solutions, streamline and standardize structuresand processes, and provide more personalized
and real-time experiences. The transformation
will also offer us the digitalization and integrationof vertical and horizontal value chains throughcloud computing, mobile devices and IoT platforms. Safety, security and cost-effectiveness arepillars for the credibility and transferability ofsuch smart digital laboratory environment. The
future will also trigger novel human – machineinterfaces and we will be the gatekeepers for thisnew “click to brick” ecosystem.
REFERENCES
1. Jonas Vollanda Andreas Fügenerb Jan Schoenfeldera
Jens O.Brunnera. Material logistics in hospitals: A literature review. Omega Volume 69, June 2017, Pages 82-101
https://doi.org/10.1016/j.omega.2016.08.004

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New solutions for the sample transport and results delivery: a digital lab

2. Nybo M, Lund ME, Titlestad K, Maegaard CU. Blood
Sample Transportation by Pneumatic Transportation Systems: A Systematic Literature Review. Clin Chem. 2018
May;64(5):782-790. doi: 10.1373/clinchem.2017.280479.
3. Lippi G, Banfi G, Church S, Cornes M, De Carli G,
Grankvist K, Kristensen GB, Ibarz M, Panteghini M, Plebani M, Nybo M, Smellie S, Zaninotto M, Simundic AM;
European Federation for Clinical Chemistry and Laboratory Medicine Working Group for Preanalytical Phase.
Preanalytical quality improvement. In pursuit of harmony, on behalf of European Federation for Clinical Chemistry and Laboratory Medicine (EFLM) Working group for
Preanalytical Phase (WG-PRE). Clin Chem Lab Med. 2015
Feb;53(3):357-70. doi: 10.1515/cclm-2014-1051.
4. Lippi G, Lima-Oliveira G, Nazer SC, Moreira ML,
Souza RF, Salvagno GL, Montagnana M, Scartezini
M, Picheth G, Guidi GC. Suitability of a transport box
for blood sample shipment over a long period. Clin
Biochem. 2011 Aug;44(12):1028-9. doi: 10.1016/j.
clinbiochem.2011.05.028.
5. Zini A. Robots expand delivery options with seamless integration. A growing number of forward-thinking
hospitals in search of greater efficiencies are embracing
automated delivery robots. Health Manag Technol. 2011
Mar;32(3):10-2..
6. Matías JM, Taboada J, Ordóñez C, Nieto PG. Machinelearning techniques applied to the determination of roadsuitability for the transportation of dangerous substances. J Hazard Mater. 2007 Aug 17;147(1-2):60-6.
7. Pashazadeh A, Jafari Navimipour N. Big data handlingmechanisms in the healthcare applications: A comprehensive and systematic literature review. J Biomed Inform. 2018 Apr 12. pii: S1532-0464(18)30056-X. doi:
10.1016/j.jbi.2018.03.014.
8. Gibbons C, Greaves F. Lending a hand: could machinelearning help hospital staff make better use of patient
feedback? BMJ Qual Saf. 2018 Feb;27(2):93-95. doi:
10.1136/bmjqs-2017-007151.

9. Beam AL, Kohane IS. Big Data and Machine Learning in
Health Care. JAMA. 2018 Apr 3;319(13):1317-1318. doi:
10.1001/jama.2017.18391..
10. Piva E, Tosato F, Plebani M. Pre-analytical phase: The
automated ProTube device supports quality assurance
in the phlebotomy process. Clin Chim Acta. 2015 Dec
7;451(Pt B):287-91. doi: 10.1016/j.cca.2015.10.010.
11. Lippi G, Plebani M. Laboratory applications for
smartphones: risk or opportunity? Clin Biochem. 2011
Mar;44(4):273-4. doi: 10.1016/j.clinbiochem.2010.12.016.
12. Alvear O, Calafate CT, Cano JC, Manzoni P. Crowdsensing in Smart Cities: Overview, Platforms, and Environment
Sensing Issues. Sensors (Basel). 2018 Feb 4;18(2). pii:
E460. doi: 10.3390/s18020460. Review.
13. Cerruela García G, Luque Ruiz I, Gómez-Nieto MÁ.
State of the Art, Trends and Future of Bluetooth Low Energy, Near Field Communication and Visible Light Communication in the Development of Smart Cities. Sensors(Basel). 2016 Nov 23;16(11). pii: E1968.
14. Cresswell KM, Mozaffar H, Lee L, Williams R, Sheikh
A. Safety risks associated with the lack of integration andinterfacing of hospital health information technologies: aqualitative study of hospital electronic prescribing systems in England. BMJ Qual Saf. 2017 Jul;26(7):530-541.
doi: 10.1136/bmjqs-2015-004925.
15. Allyse MA, Robinson DH, Ferber MJ, Sharp RR. Directto-Consumer Testing 2.0: Emerging Models of Directto-Consumer Genetic Testing. Mayo Clin Proc. 2018
Jan;93(1):113-120. doi: 10.1016/j.mayocp.2017.11.001.
16. Yli-Huumo J, Ko D, Choi S, Park S, Smolander K. Where
Is Current Research on Blockchain Technology?-A Systematic Review. PLoS One. 2016 Oct 3;11(10):e0163477. doi:
10.1371/journal.pone.0163477. eCollection 2016.
17. Roman-Belmonte JM, De la Corte-Rodriguez H, Rodriguez-Merchan EC. How blockchain technology canchange medicine. Postgrad Med. 2018 May 10:1-8. doi:
10.1080/00325481.2018.1472996.

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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.

Next generation sequencing:from research area to clinical practice
Chiara Di Resta1,2, Maurizio Ferrari1,2,3

Vita-Salute San Raffaele University, Milan, Italy
Genomic Unit for the Diagnosis of Human Disorders, Division of Genetics and Cell Biology,
IRCCS San Raffaele Hospital, Milan, Italy
3
Laboratory of Clinical Molecular Biology and Cytogenetics, IRCCS San Raffaele Hospital, Milan, Italy
1
2

ARTICLE INFOABSTRACT

Corresponding author:
Maurizio Ferrari
Genomic Unit for the Diagnosis
of Human Pathologies
Division of Genetics and Cellular Biology
IRCCS San Raffaele Hospital
Via Olgettina 60, 20132 Milan
Italy
Phone: 02-26432303
Fax: 02-26434351
E-mail: ferrari.maurizio@hsr.it

Translating the power of high-throughput sequencing
technologies from research area into clinical medicine
is one of the major goal for several researchers andhealth-care providers. One of the important advantages of these technologies is that they can be successfully used in a numerous range of clinical applications. The efficiency of sequencing, that can now
be achieved, is leading impressive progress in the diagnostics of common and rare genetic disorders, inherited forms of cancer, prenatal testing or infectious
diseases, to cite some examples. Despite several challenges and limitations still remain to overcome, thehigh-throughput sequencing technologies are leading
to real and unprecedented benefits for the medicalcare of patients.

Key words:
next generation sequencing,clinical laboratory medicine, medicalcare, high-throughput approach
Disclosures:
The authors declare no conflict of interest.

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Next generation sequencing: from research area to clinical practice

GENERAL OVERVIEWOver the past decade great advances have been
done in sequencing technologies. After Sanger
Sequencing, the current gold standard approach, also known as dideoxy method [1], highthroughput sequencing has been developed andwidespread in biomedical laboratories. The firstone allows to analyse one DNA segment at timein laborious and time-consuming way while thesecond approach has the great advantage ofperforming a simultaneous analysis of several
genomic regions, with a dramatic reduction alsoof the cost of sequencing per base [2].
Today the high-throughput next generation sequencing (NGS) instruments mainly used in biomedical laboratories are the Ion Torrent sequencers (Life Technologies) and the Illumina platforms(Illumina) [3,4].
All NGS technologies are based on the same general process, comprising template preparation,
sequencing and data analysis. The unique combination of specific technical details distinguishes
one technology from another and determines thetype of data produced from each platform [5].
After the extraction of DNA, the first step of thesequencing process is the library preparation,
which consists on the ligation of DNA fragments
to platform specific oligonucleotide adapters [2].
After that each fragment is immobilized andclonally amplified. In Life Technologies approach,clonal amplification is performed by emulsion
PCR, in which DNA fragments are amplified on
the beads surface in oil-aqueous mixture [6–8].
Illumina approach otherwise is based on a unique“isothermal bridge amplification” reaction that
occurs on the surface of the flow cell [9].
For sequencing Life Technologies exploited thenative dNTP chemistry during base incorporation
by DNA polymerase, that relies hydrogen ions,causing the pH modification that is detected by amodified silicon chip [10]. Illumina sequencing isinstead performed on a flow-cell and it is basedon the existing Solexa sequencing by synthesis
chemistry, based on the fluorescent detection
released when the complementary fluorescently
tagged nucleotides are incorporated [11].
In recent years, the advent of these benchtop
NGS platforms on the marketplace has had an
impressive impact in -omics, thanks to the hugeamount of data obtained with a significant reduction of time and costs [12]. Indeed NGS has
been applied in varied contexts, restricted not
only to genomics but also to transcriptomics andepigenomics, such as in non-coding RNA expression profiling, finding transcription factor binding sites, RNA seq, ChIp-Seq or MeDIP, to cite few
examples [13].
In research genetic studies NGS has been successfully exploited to identify new causative
genes or variants associated to inherited diseases, especially in genetically heterogenous disorders, whose genetic basis was partially unknown
and in which gene-by-gene Sanger sequencing
approach would not have been economical or
efficient [2]. For this purpose, NGS has been
applied to whole-genome, exome or targeted
sequencing, leading to the improvement of thecurrent knowledge of genetic basis of several
pathologies, such as retinitis pigmentosa, cardiomyopathies or inherited cancer [14–17].
More recently the widespread use of these rapid high-throughput technologies, the improvement of their performance and the overcomingof initial technical limitations are encouraging
their transition from basic research into clinics with important benefits for routine patientmanagement.
USE OF NGS IN THE CLINICAL PRACTICE
Now NGS is an established test method in many
clinical laboratories, in particular for the detection of germline and somatic genetic mutations.

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The analysis of causative mutations in inherited
diseases is performed using different approaches, exploiting targeted panel, whole exome,
whole genome or mitochondrial DNA sequencing [3,18,19]. More in details, targeted panel
analysis is usually applied to genetic test for different genetically heterogeneous disorders, suchas renal, neurologic, connective tissue disorders,cardiomyopathies, immune deficiencies, blindness, deafness, and several forms of inherited
cancer [15,18,20–23].
Even if the analyzed gene panel may vary between laboratories, target sequencing is thefirst approach of genetic test for inherited disorders, while whole exome sequencing is exploited for negative cases, in which targeted
testing has not been informative. Moreover,whole exome approach is useful in rare diseases
for trio testing, sequencing the child and bothparents [24–26].
In oncology, targeted testing is widely used, exploiting two different approaches. In the first
one the targeted panel may be focused only on
principle genes associated to a particular typeof malignancy, for example BRCA1 and BRCA2
gene for breast and ovarian cancer, while in theother one NGS approach allows to analyze abroader panel including genes associated withother cancers. Given the clinical overlapping
between different forms of cancer, for example
between ovarian cancer and Lynch syndrome,
this latter approach may be useful to enhancethe diagnostic yield [27–29]. In oncology, wholeexome and whole genome sequencing are notcurrently used for clinical purpose, in order toavoid the potential risk of unactionable incidental findings [19,29].
More recently, several new NGS applications
moved to the research area to clinical use, citingfor example the analysis of cell-free DNA in theprenatal genetic-testing [30], circulating tumor
DNA testing [31,32], human leukocyte antigen(HLA) typing [33], microbial analysis [19], RNAsequencing and expression [19], and methylation[19], even if there are yet some challenges
to overcome.
For example in HLA typing, it is difficult to differentiate low-frequency alleles from high-frequency artifacts and newer data analysis approach or
the development of instruments for single-molecule sequencing, called third-generation sequencers, are solving these limitations [33,34].
Today testing of circulating tumor DNA (ctDNA),
often referred to as “liquid biopsy”, is now available in clinics [35,36]. One possible approach
is NGS, that presents a lot of potential applications, including diagnosis of cancer, monitoring for progression or relapse, and targeted
therapy for a patient with a known cancer diagnosis [32,37,38]. Indeed, several studies haveshown that ctDNA sequencing allows at first to
detect somatic mutation in patients with known
cancer diagnosis and then to monitor it in correlation with the relapse and progression of
disease [39]. Without doubt the detection of
ctDNA using NGS presents the great advantage
to be a reasonable alternative to the repeatedinvasive biopsies for patients with metastatic
cancers. However, it still presents some limitations due to a low sensitivity to detect earlystage cancer (false negatives), limiting until now
the practical use of ctDNA for early cancer diagnosis or screening [38].
Other clinical applications of NGS include pharmacogenetics and microbial sequencing but
these topics are beyond the scope of this article.
Although NGS is now widely used in clinics, several challenges still remain to overcome.
The main issues are, for example, the sequencing of genomic portions that are difficult to analyze, due their intrinsic features (pseudogenes,
homologous regions, repetitive regions, GC-richregions) and the limited ability to detect structural gene variation and copy number variation

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Next generation sequencing: from research area to clinical practice(CNV) [40–43]. Sometimes the storage and theinterpretation of huge amounts of sequencedata, mainly of several novel or rare mutations,by trained health care professionals may be still
an open challenge [44,45]. Moreover, a successful NGS testing need a collaborative effort between geneticists and physicians to combine andintegrate clinical data and genetic analyses toguide medical care of patient.
CONCLUSIONSNGS technologies have revolutionized biologicalresearch and have deeply transform the fields ofdiagnostic pathology and clinical medicine. In the
future, the use of NGS in clinical laboratories will
surely increase as technology and bioinformatics, in order to address the current limitations,improve the quality of results, and increase thenumber of possible clinical applications.
However, the challenge for clinical laboratories
will be to perform the most appropriate approach of NGS testing taking into account theclinical relevance, cost-effectiveness and clinicalcare of patient.
REFERENCES
1. Sanger F, Nicklen S, Coulson AR. DNA sequencing withchain-terminating inhibitors. Proc Natl Acad Sci U S A.
1977;74: 5463–7. Available: http://www.pubmedcentral.
nih.gov/articlerender.fcgi?artid=431765&tool=pmcentre
z&rendertype=abstract
2. Jamuar SS, Tan E-C. Clinical application of next-generation sequencing for Mendelian diseases. Hum Genomics.
2015;9: 10. doi:10.1186/s40246-015-0031-5
3. Di Resta C, Galbiati S, Carrera P, Ferrari M. Next-generation sequencing approach for the diagnosis of humandiseases: open challenges and new opportunities. EJIFCC.
2018;29: 4–14. Available: http://www.ncbi.nlm.nih.gov/
pubmed/29765282
4. Mardis ER. Next-generation sequencing platforms.
Annu Rev Anal Chem (Palo Alto Calif). 2013;6: 287–303.
doi:10.1146/annurev-anchem-062012-092628
5. Reuter JA, Spacek D V, Snyder MP. High-throughput
sequencing technologies. Mol Cell. 2015;58: 586–97.
doi:10.1016/j.molcel.2015.05.004

6. McKernan KJ, Peckham HE, Costa GL, McLaughlin SF,
Fu Y, Tsung EF, et al. Sequence and structural variation
in a human genome uncovered by short-read, massively
parallel ligation sequencing using two-base encoding. Genome Res. 2009;19: 1527–41. doi:10.1101/gr.091868.109
7. Wheeler DA, Srinivasan M, Egholm M, Shen Y, Chen L,
McGuire A, et al. The complete genome of an individualby massively parallel DNA sequencing. Nature. 2008;452:
872–6. doi:10.1038/nature06884
8. Margulies M, Egholm M, Altman WE, Attiya S, Bader
JS, Bemben LA, et al. Genome sequencing in microfabricated high-density picolitre reactors. Nature. 2005;437:
376–80. doi:10.1038/nature03959
9. Bentley DR, Balasubramanian S, Swerdlow HP, Smith
GP, Milton J, Brown CG, et al. Accurate whole human genome sequencing using reversible terminator chemistry.
Nature. 2008;456: 53–9. doi:10.1038/nature07517
10. Merriman B, Rothberg JM. Progress in ion torrent
semiconductor chip based sequencing. Electrophoresis.
2012;33: 3397–417. doi:10.1002/elps.201200424
11. Quail M, Smith ME, Coupland P, Otto TD, Harris SR, Connor TR, et al. A tale of three next generation sequencing
platforms: comparison of Ion torrent, pacific biosciences
and illumina MiSeq sequencers. BMC Genomics. BioMed
Central; 2012;13: 341. doi:10.1186/1471-2164-13-341
12. Williams ES, Hegde M. Implementing genomic medicine in pathology. Adv Anat Pathol. 2013;20: 238–44.
doi:10.1097/PAP.0b013e3182977199
13. Choi BY, Kim BJ. Application of next generation sequencing upon the molecular genetic diagnosis of deafness. Korean J Audiol. Korean Audiological Society;2012;16: 1–5. doi:10.7874/kja.2012.16.1.1
14. Carrera P, Di Resta C, Volonteri C, Castiglioni E, Bonfiglio S, Lazarevic D, et al. Exome sequencing and pathway
analysis for identification of genetic variability relevant
for bronchopulmonary dysplasia (BPD) in preterm newborns: A pilot study. Clin Chim Acta. 2015;451: 39–45.
doi:10.1016/j.cca.2015.01.001
15. Di Resta C, Spiga I, Presi S, Merella S, Pipitone GB,
Manitto MP, et al. Integration of multigene panels forthe diagnosis of hereditary retinal disorders using Next
Generation Sequencing and bioinformatics approaches.
EJIFCC. 2018;29: 15–25. Available: http://www.ncbi.nlm.
nih.gov/pubmed/29765283
16. Doyle MA, Li J, Doig K, Fellowes A, Wong SQ.
Studying Cancer Genomics Through Next-Generation DNA Sequencing and Bioinformatics. Methods
in molecular biology (Clifton, NJ). 2014. pp. 83–98.
doi:10.1007/978-1-4939-0847-9_6
17. Di Resta C, Pietrelli A, Sala S, Della Bella P, De Bellis G,
Ferrari M, et al. High-throughput genetic characterization

Page 218

eJIFCC2018Vol29No3pp215-220

Chiara Di Resta, Maurizio Ferrari
Next generation sequencing: from research area to clinical practiceof a cohort of Brugada syndrome patients. Hum Mol Genet. 2015;24: 5828–5835. doi:10.1093/hmg/ddv302
18. Strom SP. Current practices and guidelines for clinicalnext-generation sequencing oncology testing. Cancer Biol
Med. Chinese Anti-Cancer Association; 2016;13: 3–11.
doi:10.28092/j.issn.2095-3941.2016.0004
19. Yohe S, Thyagarajan B. Review of Clinical Next-Generation Sequencing. Arch Pathol Lab Med. 2017;141: 1544–
1557. doi:10.5858/arpa.2016-0501-RA
20. Kamps R, Brandão RD, Bosch BJ van den, Paulussen
ADC, Xanthoulea S, Blok MJ, et al. Next-Generation Sequencing in Oncology: Genetic Diagnosis, Risk Prediction
and Cancer Classification. Int J Mol Sci. Multidisciplinary
Digital Publishing Institute (MDPI); 2017;18. doi:10.3390/
ijms18020308
21. Celestino-Soper PBS, Gao H, Lynnes TC, Lin H, Liu
Y, Spoonamore KG, et al. Validation and Utilization of a
Clinical Next-Generation Sequencing Panel for Selected
Cardiovascular Disorders. Front Cardiovasc Med. 2017;4:
11. doi:10.3389/fcvm.2017.00011
22. Weerakkody RA, Vandrovcova J, Kanonidou C, Mueller
M, Gampawar P, Ibrahim Y, et al. Targeted next-generation
sequencing makes new molecular diagnoses and expands
genotype–phenotype relationship in Ehlers–Danlos syndrome. Genet Med. 2016;18: 1119–1127. doi:10.1038/
gim.2016.14
23. Nijman IJ, van Montfrans JM, Hoogstraat M, Boes ML,van de Corput L, Renner ED, et al. Targeted next-generation sequencing: A novel diagnostic tool for primary
immunodeficiencies. J Allergy Clin Immunol. 2014;133:
529–534.e1. doi:10.1016/j.jaci.2013.08.032
24. Fernandez-Marmiesse A, Gouveia S, Couce ML. NGS
Technologies as a Turning Point in Rare Disease Research ,Diagnosis and Treatment. Curr Med Chem. 2018;25: 404–
432. doi:10.2174/0929867324666170718101946
25. Yang Y, Muzny DM, Reid JG, Bainbridge MN, Willis A, Ward PA, et al. Clinical Whole-Exome Sequencing
for the Diagnosis of Mendelian Disorders. N Engl J Med.
2013;369: 1502–1511. doi:10.1056/NEJMoa1306555
26. Sawyer SL, Hartley T, Dyment DA, Beaulieu CL,
Schwartzentruber J, Smith A, et al. Utility of whole-exome
sequencing for those near the end of the diagnostic odyssey: time to address gaps in care. Clin Genet. 2016;89:
275–284. doi:10.1111/cge.12654
27. Syngal S, Brand RE, Church JM, Giardiello FM, Hampel
HL, Burt RW, et al. ACG clinical guideline: Genetic testing and management of hereditary gastrointestinal cancer syndromes. Am J Gastroenterol. NIH Public Access;2015;110: 223–62; quiz 263. doi:10.1038/ajg.2014.435
28. Park HS, Park S-J, Kim JY, Kim S, Ryu J, Sohn J, et al.
Next-generation sequencing of BRCA1/2 in breast cancer

patients: potential effects on clinical decision-making
using rapid, high-accuracy genetic results. Ann Surg
Treat Res. Korean Surgical Society; 2017;92: 331–339.
doi:10.4174/astr.2017.92.5.331
29. O’Leary E, Iacoboni D, Holle J, Michalski ST, Esplin ED,
Yang S, et al. Expanded Gene Panel Use for Women With
Breast Cancer: Identification and Intervention Beyond
Breast Cancer Risk. Ann Surg Oncol. Springer; 2017;24:
3060–3066. doi:10.1245/s10434-017-5963-7
30. Ordulu Z, Kammin T, Brand H, Pillalamarri V, Redin CE,
Collins RL, et al. Structural Chromosomal Rearrangements
Require Nucleotide-Level Resolution: Lessons from NextGeneration Sequencing in Prenatal Diagnosis. Am J Hum
Genet. Elsevier; 2016;99: 1015–1033. doi:10.1016/j.
ajhg.2016.08.022
31. Thompson JC, Yee SS, Troxel AB, Savitch SL, Fan R,
Balli D, et al. Detection of Therapeutically Targetable
Driver and Resistance Mutations in Lung Cancer Patientsby Next-Generation Sequencing of Cell-Free Circulating Tumor DNA. Clin Cancer Res. 2016;22: 5772–5782.
doi:10.1158/1078-0432.CCR-16-1231
32. Vendrell JA, Mau-Them FT, Béganton B, Godreuil S,
Coopman P, Solassol J. Circulating Cell Free Tumor DNA
Detection as a Routine Tool forLung Cancer Patient Management. Int J Mol Sci. Multidisciplinary Digital Publishing
Institute (MDPI); 2017;18. doi:10.3390/ijms18020264
33. Weimer ET, Montgomery M, Petraroia R, Crawford J,
Schmitz JL. Performance Characteristics and Validationof Next-Generation Sequencing for Human Leucocyte
Antigen Typing. J Mol Diagnostics. 2016;18: 668–675.
doi:10.1016/j.jmoldx.2016.03.009
34. Szolek A, Schubert B, Mohr C, Sturm M, Feldhahn M,
Kohlbacher O. OptiType: precision HLA typing from nextgeneration sequencing data. Bioinformatics. 2014;30:
3310–3316. doi:10.1093/bioinformatics/btu548
35. Brambati C, Galbiati S, Xue E, Toffalori C, Crucitti L,
Greco R, et al. Droplet digital polymerase chain reaction for DNMT3A and IDH1/2 mutations to improveearly detection of acute myeloid leukemia relapse after allogeneic hematopoietic stem cell transplantation.
Haematologica. 2016;101: e157–e161. doi:10.3324/
haematol.2015.135467
36. Whale AS, Devonshire AS, Karlin-Neumann G, Regan J, Javier L, Cowen S, et al. International Interlaboratory Digital PCR Study Demonstrating High Reproducibility for the Measurement of a Rare Sequence
Variant. Anal Chem. 2017;89: 1724–1733. doi:10.1021/
acs.analchem.6b03980
37. Ai B, Liu H, Huang Y, Peng P. Circulating cell-free DNA
as a prognostic and predictive biomarker in non-small
cell lung cancer. Oncotarget. 2016;7: 44583–44595.
doi:10.18632/oncotarget.10069

Page 219

eJIFCC2018Vol29No3pp215-220

Chiara Di Resta, Maurizio Ferrari
Next generation sequencing: from research area to clinical practice

38. Hofman P. Liquid biopsy for early detection of lungcancer. Curr Opin Oncol. 2017;29: 73–78. doi:10.1097/
CCO.0000000000000343
39. Yamada T, Iwai T, Takahashi G, Kan H, Koizumi M, Matsuda A, et al. Utility of KRAS mutation detection using circulating cell-free DNA from patients with colorectal cancer.
Cancer Sci. 2016;107: 936–943. doi:10.1111/cas.12959
40. Wall JD, Tang LF, Zerbe B, Kvale MN, Kwok P-Y, Schaefer C, et al. Estimating genotype error rates from highcoverage next-generation sequence data. Genome Res.
2014;24: 1734–9. doi:10.1101/gr.168393.113
41. Yamamoto T, Shimojima K, Ondo Y, Imai K, Chong PF,
Kira R, et al. Challenges in detecting genomic copy number aberrations using next-generation sequencing data
and the eXome Hidden Markov Model: a clinical exomefirst diagnostic approach. Hum genome Var. 2016;3:
16025. doi:10.1038/hgv.2016.25
42. Li J, Dai H, Feng Y, Tang J, Chen S, Tian X, et al. A Comprehensive Strategy for Accurate Mutation Detectionof the Highly Homologous PMS2. J Mol Diagn. 2015;17:545–53. doi:10.1016/j.jmoldx.2015.04.001
43. Zhang T-H, Wu NC, Sun R. A benchmark study on error-correction by read-pairing and tag-clustering in amplicon-based deep sequencing. BMC Genomics. 2016;17:108. doi:10.1186/s12864-016-2388-9
44. Richards S, Aziz N, Bale S, Bick D, Das S, Gastier-Foster
J, et al. Standards and guidelines for the interpretation ofsequence variants: a joint consensus recommendation of
the American College of Medical Genetics and Genomics
and the Association for Molecular Pathology. Genet Med.
2015;17: 405–24. doi:10.1038/gim.2015.30
45. Amendola LM, Jarvik GP, Leo MC, McLaughlin HM,
Akkari Y, Amaral MD, et al. Performance of ACMG-AMP
Variant-Interpretation Guidelines among Nine Laboratories in the Clinical Sequencing Exploratory ResearchConsortium. Am J Hum Genet. 2016;98: 1067–1076.
doi:10.1016/j.ajhg.2016.03.024

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Meeting the needs of Mediterranean nations: improving health with emerging technologies

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.

miRNA and other non-coding RNAs
as promising diagnostic markers

Dorota Trzybulska1, Eleni Vergadi2 and Christos Tsatsanis1,2

1
2

Molecular Reproductive Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden
Department of Clinical Chemistry, School of Medicine, University of Crete, Heraklion, Greece

ARTICLE INFOABSTRACT

Corresponding author:
Christos Tsatsanis
Medical School
University of Crete
Voutes, 70013 Heraklion, Crete
GreecePhone: +30 2810394833
E-mail: tsatsani@uoc.gr

Since the discovery of non-coding RNAs (ncRNAs)a new area has emerged in the field of biomarkers.
NcRNAs are RNA molecules of different sizes that aretranscribed as independent genes or as part of protein
coding genes and are not translated, therefore they do
not produce proteins. They have been classified according to their size and function and include micro­RNAs(miRNAs), piwiRNAs (piRNAs), snoRNAs and long nonco­ding RNAs (lncRNAs). These non-coding RNAs arepresent in different cell compartments participatingin multiple cell functions, but they have also been
identified in biological fluids, also known as cell-freeor circulating ncRNAs, where they can be detected in
exosomes, bound on lipoproteins as well as free circulating molecules. The role of circulating ncRNAs is still
under investigation but are believed to be paracrine
or endocrine messengers to systematically deliver
signals between cells and tissues. Detecting ncRNAs
in biological fluids has opened a new field in Clinical
Chemistry utilizing them as biomarkers of diseases or
prognostic markers for different pathological conditions. Herein, the different types of ncRNAs and theirpotential in the field of diagnostics are outlined.

Key words:
miRNA, lncRNA, piRNA, serum,
biomarkers, cancer, inflammation
Ackgnowledgements:
This article is part of the ReproUnion
collaborative study, co-financed by theEuropean Union, Interreg V ÖKS.

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Dorota Trzybulska, Eleni Vergadi, Christos Tsatsanis
miRNA and other non-coding RNAs as promising diagnostic markers

INTRODUCTION
Protein-coding genes have been studied thoroughly during the last decades, even though
they represent only 1.5% of the genome, which
can increase to 2% if untranslated regions(UTRs) are included. The remaining genome, thenon-protein coding region has remained a ‘blackbox’ until recently when characterization of
non-coding RNAs (ncRNAs) has emerged, due tothe development of novel nucleotide sequencing technologies. The importance of the ncRNAs
has become increasingly apparent and ourknowledge on the significance and contributionof ncRNAs in development and disease pathogenesis is expanding rapidly (1). NcRNAs canalso explain phenotypic diversity between species given the fact that i.e. protein-coding genes
are very similar among mammals while theirncRNAs do not exhibit the same level of similarity. The functional role of a class of ncRNAs,
this of microRNAs (miRNAs), in cell physiology
and human disease has been widely studied andacknowledged. In nearly all diseases miRNA expression pattern has been shown to differ bothin tissues and extracellularly, contributing to disease pathogenesis. However, miRNAs are only
the tip of the iceberg since additional ncRNAs are
emerging as contributors of tissue homeostasis
and regulators of cell function and fate. Hence,
PIWI-interacting RNAs (piRNAs), transcribed
small nucleolar RNAs (snoRNAs), ultraconserved
regions (T-UCRs), large intergenic non-coding
RNAs (lincRNAs) and the heterogeneous groupof long non-coding RNAs (lncRNAs), are also key
contributors to tissue homeostasis and disease
pathogenesis. Among those, a significant number has been detected in biological fluids, allowing their use as circulating biomarkers.
Emergence of novel technologies has allowed tocharacterize sequences of ncRNAs in different
healthy and diseased tissues as well as biological fluids from healthy and diseased individuals.

The most prominent and widely studied ncRNAs
are miRNAs which are already utilized as diseasebiomarkers.
miRNAs AS BIOMARKERSOF HUMAN DISEASE
After the discovery of miRNAs and their first
association with human disease sixteen years
ago (2), their contribution in human disease has
been established. miRNAs are ncRNAs 19-24
nucleotides(nt) long, and control gene expression by targeting the 3’UTR of mRNAs leadingthem to degradation or inhibiting translation.
Alternatively, miRNAs stabilize mRNA molecules
and lead to more efficient translation, thus positively affecting gene expression (3). Changes inintracellular miRNA expression have been causally associated with multiple diseases including cancer (4), neurodegenerative diseases (5),cardiovascular diseases (6) and more. Similar
as well as distinct changes in miRNA expression
pattern has been observed in the serum of patients, introducing detection of serum miRNAs
as biomarkers of human diseases (7). MiRNAs
are present in the serum in different configurations; they are transported inside exosomes,
bound on lipoproteins such as LDL and HDL,
and also bound on proteins such as Argonaut 2(Ago2) (8).
All configurations allow miRNAs to be uptaken
by distant tissues and cells, altering gene expression in the target cells. Initial studies werefocusing in functionally relevant miRNAs but
utilization of serum-specific miRNA arrays has
led to the identification of additional diagnostic and prognostic miRNAs. Recent work fromour group has shown that miRNA levels in theserum are potential markers linking different
diseases. For example, changes in miR-155-5p,
miR-200a-3p, miR122-5p and miR-200c-3p
are common determinants of male subfertility and metabolic disease, suggesting potential

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miRNA and other non-coding RNAs as promising diagnostic markers

common causal events and mechanisms (9, 10).
MiRNAs in the circulation can transmit information similar to that of cytokines, chemokines
and hormones but with more specificity in targeting gene expression in the recipient cell. In
the context of inflammation, expression of miRNAs such as miR-155-5p and let-7 family in theserum may modulate expression of their target
genes such as SOCS1 or TLR4, thus limiting detrimental effects of inflammation or augmenting
anti-pathogen responses from distant cells andorgans (11-14).
piRNAs AS BIOMARKERSPiRNAs are ncRNAs slightly larger than miRNAs
having size of 24–30 nt and are characterized
by their ability to bind to the PIWI subfamily of
Argonaut family proteins which are involved inmaintaining genome integrity in germline cells,
primarily in those of the male (15, 16). PiRNAs
are transcribed from genomic regions that contain transposable elements and other repetitiveelements and is believed that their function is tosuppress those. PiRNA/PIWI complexes bind on
transposable elements and inhibit their mobilization either by cleavage of transposable elementtranscripts by PIWI proteins using a mechanism
based on recognition of homology between
piRNAs and transposable elements or throughheterochromatin-mediated silencing of transposable element transcription. PiRNAs, eventhough they are not abundant, they utilize the‘ping-pong’ amplification cycle based on PIWI
proteins (such as PIWILI1, PIWIL1 and PIWIL4)
resulting in generation of antisense moleculesthat repress transcripts. PIWI proteins are also
involved in DNA methylation and piRNAs mediate epigenetic changes (17). PiRNAs are also
expressed in additional cell types to germ cells
including endothelial cells but their function
remains to be elucidated (18). Recent reports
have shown that piRNAs are present in biological fluids, primarily in the seminal fluid and theirexpression has been associated to fertility (19).
Whether soluble piRNAs are signals to mediate information imprinting between cells is notknown. Profiling of soluble piRNAs can provide
functionally significant and, more importantly,
cell-source specific biomarkers for diseases.
snoRNAs AS POTENTIAL BIOMARKERSSnoRNAs is another family of ncRNAs of intermediate size ranging from 60 to 300 nucleotides.
They are components of small nucleolar ribonucleoproteins (snoRNPs), which are complexes
controlling sequence-specific 2′ O-methyla­tionand pseudouridylation of ribosomal RNA (rRNA).
RRNAs are post-transcriptionally modified in the
nucleolus facilitating rRNA folding and stability.
SnoRNA sequences are responsible for targetingthe assembled snoRNPs to a specific target (20).
Recently snoRNAs have been detected in biological fluids and have been suggested to be usefulas biomarkers (21, 22). Whether they possess
functional significance in biofluids remains to be
determined.
lncRNAs AS POTENTIAL BIOMARKERS
LncRNAs include a broad and heterogeneousfamily of non-coding RNAs defined by their size
being over 200 nt long. LncRNAs are involved ina diverse array of biological processes. This family is the largest family of ncRNAs including thelargest portion of the mammalian non-coding
transcriptome. The main function of lncRNAs
is regulation of gene expression. Thus, lncRNAs
mediate epigenetic modifications of DNA by
recruiting chromatin remodeling complexes
to target genes and therefore controlling theirtemporal and spatial expression (23). Amongthe known functions of lncRNAs, one involves
regulating chromatin accessibility through histone modification enzymes and RNA polymerases. Physiological processes such as X chromosome inactivation occurs by the X-inactivation

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Dorota Trzybulska, Eleni Vergadi, Christos Tsatsanis
miRNA and other non-coding RNAs as promising diagnostic markers

specific transcript (XIST) lncRNA which recruits
the polycomb complex to silence the X chromosome from which it is transcribed. TSIX, another lncRNA, is transcribed from the opposite
strand to XIST and regulates XIST levels during
X-chromosome inactivation (24). In addition,
multiple lncRNAs are expressed by imprinted
loci, where they contribute in genetic imprinting(25). A distinct family of lncRNAs are lincRNAs,
which are transcribed from intergenic regions.
LincRNAs control transcription, such as the p53
regulated lincRNA, lincRNA p21, which is located near the p21 gene and suppresses transcription when p53 is activated upon DNA damage(26). LincRNAs do not only regulate expression
Table 1of neighboring genes but also act on distantones. Another family of lncRNAs is this including lncRNAs transcribed from ultraconserved
regions (UCRs). UCRs are conserved between
vertebrates and are thought to date from a very
early period in evolution. Some UCRs overlap
with coding exons, although it is believed that
more than half of the UCRs do not encode proteins. The UCRs that are transcribed are termed
T-UTRs (27). The length of UCRs ranges from
200 to 80 nucleotides while T-UCRs have an unspliced length of up to 2kb. Their function remains unknown and the expression pattern has
not been determined in disease conditions to allow them to serve as biomarkers.

ncRNAs, their function and use as biomarkers

Family of ncRNAs

Size (nucleotides)

Potential function

Used as biomarker

miRNAs

19–24

Regulation of mRNA
expression

Yes, widely

piRNAs

26–31

Repression of transposons
and DNA methylation in
germ cells

Yes, limited

tiRNAs

17–18

Regulation of transcription

nosnoRNAs

60–300Regulation of rRNAs

Yes, limited

PASRs

22–200Unknownno

TSSa-RNAs

20–90

Transcriptional regulationno

PROMPTs<200

Transcriptional regulation

nolincRNAs>200

Chromatin regulation

Yes, limited

T-UCRs200-780

Regulation of miRNAs

no

Other lncRNAs>200

Transcriptional andepigenetic regulation ofgene expression

Yes, limited

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miRNA and other non-coding RNAs as promising diagnostic markers

OTHER ncRNAs AND THEIRPOTENTIAL AS BIOMARKERS

genes miR15 and miR16 at 13q14 in chronic lymphocytic
leukemia. Proc Natl Acad Sci U S A 99: 15524-15529.

Different ncRNAs have been shown to associate with transcriptional initiation sites such as
the promoter-associated small RNAs (PASRs),
promoter upstream transcripts (PROMPTs), theTranscription Start Site-associated RNAs (TSSRNAs) and transcription initiation RNAs (tiRNAs) (28,29). The biological role of these ncRNAs
is not well characterized but it is believed thatthey also regulate transcription. Another familyof ncRNAs is this of telomeric repeat-containing RNAs (TERRAs), which are transcribed fromtelomeres (30). TERRAs regulate telomerase
function and secure maintenance of heterochromatin integrity (31).
CONCLUSIONS
Since the initial characterization of non-coding
RNAs and their identification as determinants
on human disease pathogenesis, a new area in
the field of biomarkers has emerged. Thus, ourknowledge on the differential expression of different families of ncRNAs as well as their contribution in tissue homeostasis will open a new
field of biomarkers that could be measured bothin tissues and in biological fluids, and support
disease diagnosis and prediction. A bottleneckat the moment in the field is the availability of
automated rapid detection methods of ncRNAs
and the identification of the most importantones that will serve as biomarkers. A list of different types of ncRNAs, their size, function andwhether are currently used as biomarkers is presented in Table 1.

3. He, L., and G. J. Hannon. 2004. MicroRNAs: small RNAs
with a big role in gene regulation. Nat Rev Genet 5: 522-531.
4. Esquela-Kerscher, A., and F. J. Slack. 2006. Oncomirs - microRNAs with a role in cancer. Nat Rev Cancer 6: 259-269.
5. Gupta, P., S. Bhattacharjee, A. R. Sharma, G. Sharma,
S. S. Lee, and C. Chakraborty. 2017. miRNAs in Alzheimer
Disease - A Therapeutic Perspective. Curr Alzheimer Res
14: 1198-1206.
6. Navickas, R., D. Gal, A. Laucevicius, A. Taparauskaite,
M. Zdanyte, and P. Holvoet. 2016. Identifying circulating
microRNAs as biomarkers of cardiovascular disease: asystematic review. Cardiovasc Res 111: 322-337.
7. Backes, C., E. Meese, and A. Keller. 2016. SpecificmiRNA Disease Biomarkers in Blood, Serum and Plasma:
Challenges and Prospects. Mol Diagn Ther 20: 509-518.
8. Robbins, P. D., and A. E. Morelli. 2014. Regulation of
immune responses by extracellular vesicles. Nat Rev Immunol 14: 195-208.
9. Trzybulska, D., J. Bobjer, A. Giwercman, and C. Tsatsanis. 2017. Serum microRNAs in male subfertility-biomarkers and a potential pathogenetic link to metabolic
syndrome. J Assist Reprod Genet 34: 1277-1282.
10. Tsatsanis, C., J. Bobjer, H. Rastkhani, E. Dermitzaki, M.
Katrinaki, A. N. Margioris, Y. L. Giwercman, and A. Giwercman. 2015. Serum miR-155 as a potential biomarker ofmale fertility. Hum Reprod 30: 853-860.
11. Androulidaki, A., D. Iliopoulos, A. Arranz, C. Doxaki, S.
Schworer, V. Zacharioudaki, A. N. Margioris, P. N. Tsichlis,
and C. Tsatsanis. 2009. The kinase Akt1 controls macrophage response to lipopolysaccharide by regulating microRNAs. Immunity 31: 220-231.
12. Vergadi, E., K. Vaporidi, E. E. Theodorakis, C. Doxaki,
E. Lagoudaki, E. Ieronymaki, V. I. Alexaki, M. Helms, E.
Kondili, B. Soennichsen, E. N. Stathopoulos, A. N. Margioris, D. Georgopoulos, and C. Tsatsanis. 2014. Akt2 deficiency protects from acute lung injury via alternative
macrophage activation and miR-146a induction in mice.
J Immunol 192: 394-406.

1. Esteller, M. 2011. Non-coding RNAs in human disease.
Nat Rev Genet 12: 861-874.

13. Doxaki, C., S. C. Kampranis, A. G. Eliopoulos, C. Spilianakis, and C. Tsatsanis. 2015. Coordinated Regulationof miR-155 and miR-146a Genes during Induction ofEndotoxin Tolerance in Macrophages. J Immunol 195:
5750-5761.

2. Calin, G. A., C. D. Dumitru, M. Shimizu, R. Bichi, S. Zupo,
E. Noch, H. Aldler, S. Rattan, M. Keating, K. Rai, L. Rassenti, T. Kipps, M. Negrini, F. Bullrich, and C. M. Croce. 2002.
Frequent deletions and down-regulation of micro- RNA

14. Trzybulska, D., D. Eckersten, A. Giwercman, A. Christensson, and C. Tsatsanis. 2018. Alterations in Serum MicroRNA Profile During Hemodialysis - Potential Biological
Implications. Cell Physiol Biochem 46: 793-801.

REFERENCES

Page 225

eJIFCC2018Vol29No3pp221-226

Dorota Trzybulska, Eleni Vergadi, Christos Tsatsanis
miRNA and other non-coding RNAs as promising diagnostic markers

15. Aravin, A. A., R. Sachidanandam, A. Girard, K. FejesToth, and G. J. Hannon. 2007. Developmentally regulated
piRNA clusters implicate MILI in transposon control. Science 316: 744-747.
16. Carmell, M. A., A. Girard, H. J. van de Kant, D.
Bourc’his, T. H. Bestor, D. G. de Rooij, and G. J. Hannon.
2007. MIWI2 is essential for spermatogenesis and repression of transposons in the mouse male germline. Dev Cell
12: 503-514.
17. Camprubi, C., R. A. Cigliano, A. Salas-Huetos, N. Garrido, and J. Blanco. 2017. What the human sperm methylome tells us. Epigenomics 9: 1299-1315.
18. Yin, K. J., M. Hamblin, and Y. E. Chen. 2014. Non-coding RNAs in cerebral endothelial pathophysiology: emerging roles in stroke. Neurochem Int 77: 9-16.
19. Hale, B. J., A. F. Keating, C. X. Yang, and J. W. Ross.
2015. Small RNAs: Their Possible Roles in Reproductive
Failure. Adv Exp Med Biol 868: 49-79.
20. Kiss-Laszlo, Z., Y. Henry, J. P. Bachellerie, M. Caizergues-Ferrer, and T. Kiss. 1996. Site-specific ribose methylation of preribosomal RNA: a novel function for small
nucleolar RNAs. Cell 85: 1077-1088.
21. Steinbusch, M. M., Y. Fang, P. I. Milner, P. D. Clegg,
D. A. Young, T. J. Welting, and M. J. Peffers. 2017. SerumsnoRNAs as biomarkers for joint ageing and post traumatic osteoarthritis. Sci Rep 7: 43558.
22. Umu, S. U., H. Langseth, C. Bucher-Johannessen, B.
Fromm, A. Keller, E. Meese, M. Lauritzen, M. Leithaug, R.
Lyle, and T. B. Rounge. 2018. A comprehensive profile ofcirculating RNAs in human serum. RNA Biol 15: 242-250.
23. Gupta, R. A., N. Shah, K. C. Wang, J. Kim, H. M. Horlings, D. J. Wong, M. C. Tsai, T. Hung, P. Argani, J. L. Rinn,
Y. Wang, P. Brzoska, B. Kong, R. Li, R. B. West, M. J. van deVijver, S. Sukumar, and H. Y. Chang. 2010. Long non-coding RNA HOTAIR reprograms chromatin state to promote
cancer metastasis. Nature 464: 1071-1076.
24. Navarro, P., D. R. Page, P. Avner, and C. Rougeulle.
2006. Tsix-mediated epigenetic switch of a CTCF-flanked

region of the Xist promoter determines the Xist transcription program. Genes Dev 20: 2787-2792.
25. Guttman, M., I. Amit, M. Garber, C. French, M. F. Lin,D. Feldser, M. Huarte, O. Zuk, B. W. Carey, J. P. Cassady, M.
N. Cabili, R. Jaenisch, T. S. Mikkelsen, T. Jacks, N. Hacohen,
B. E. Bernstein, M. Kellis, A. Regev, J. L. Rinn, and E. S.
Lander. 2009. Chromatin signature reveals over a thousand highly conserved large non-coding RNAs in mammals. Nature 458: 223-227.
26. Huarte, M., M. Guttman, D. Feldser, M. Garber, M. J.
Koziol, D. Kenzelmann-Broz, A. M. Khalil, O. Zuk, I. Amit,
M. Rabani, L. D. Attardi, A. Regev, E. S. Lander, T. Jacks,
and J. L. Rinn. 2010. A large intergenic noncoding RNA induced by p53 mediates global gene repression in the p53
response. Cell 142: 409-419.
27. Lujambio, A., A. Portela, J. Liz, S. A. Melo, S. Rossi,
R. Spizzo, C. M. Croce, G. A. Calin, and M. Esteller. 2010.
CpG island hypermethylation-associated silencing of noncoding RNAs transcribed from ultraconserved regions inhuman cancer. Oncogene 29: 6390-6401.
28. Kapranov, P., J. Cheng, S. Dike, D. A. Nix, R. Duttagupta, A. T. Willingham, P. F. Stadler, J. Hertel, J. Hackermuller,
I. L. Hofacker, I. Bell, E. Cheung, J. Drenkow, E. Dumais, S.
Patel, G. Helt, M. Ganesh, S. Ghosh, A. Piccolboni, V. Sementchenko, H. Tammana, and T. R. Gingeras. 2007. RNA
maps reveal new RNA classes and a possible function forpervasive transcription. Science 316: 1484-1488.
29. Preker, P., J. Nielsen, S. Kammler, S. Lykke-Andersen,
M. S. Christensen, C. K. Mapendano, M. H. Schierup, andT. H. Jensen. 2008. RNA exosome depletion reveals transcription upstream of active human promoters. Science
322: 1851-1854.
30. Montero, J. J., I. Lopez-Silanes, D. Megias, F. F. M, A.
Castells-Garcia, and M. A. Blasco. 2018. TERRA recruitment of polycomb to telomeres is essential for histone
trymethylation marks at telomeric heterochromatin. Nat
Commun 9: 1548.
31. Koch, L. 2017. Non-coding RNA: A protective role for
TERRA at telomeres. Nat Rev Genet 18: 453.

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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.

NGS for metabolic disease diagnosis
Dèlia Yubero1, Rafael Artuch2
1

Department of Genetics and Molecular Medicine, Institut de Recerca Sant Joan de Déu, Barcelona, Spain

2

Department of Clinical Biochemistry, Institut de Recerca Sant Joan de Déu, and
CIBER de Enfermedades Raras (CIBERER), Barcelona, SpainINFO

LET TER TO THE EDITOR

Corresponding author:
Dèlia Yubero
Department of Genetics
and Molecular Medicine
Institut de Recerca Sant Joan de Déu
Barcelona, Spain.
Phone: + 34936009451
E-mail: dyubero@sjdhospitalbarcelona.org

Inborn errors of metabolism (IEM) comprise heterogeneous and rare genetic diseases with a variety of overlapping or unspecific clinical phenotypes.
Multiple proteins with enzymatic, transporter, regulatory and other functions participate in the complexity of metabolic pathways.

Key words:
inborn errors of metabolism,
next generation sequencing

The breakdown of the normal function of some ofthese proteins may impair the metabolic state ofan organism. These disruptions can generally be assessed biochemically through the detection of metabolites in different biological fluids.
However, the specificity and sensitivity of some ofthese biomarkers are not always high. IEM are, generally, severe diseases, and the accurate identification of the molecular basis of these diseases is important for appropriate patient treatment and genetic
counselling.
Thus, even though the establishment of an IEM diagnosis is supported by clinical suspicion and biochemical investigations, genetic investigations also play asignificant role. Genetic diagnosis in clinical practicehas substantially changed in the past decade. The
incorporation of next generation sequencing (NGS)
technologies allows researchers, depending on the
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Dèlia Yubero, Rafael Artuch
Letter: NGS for metabolic disease diagnosis

selected strategy, to obtain the molecular sequence of the desired genes simultaneously,
offering high-quality data. The utility of NGS in
the clinical field has been widely demonstrated
in different groups of diseases (1,2,3), but theactual debate encompasses two main points:
the reinterpretation of the classical diagnostic
algorithms and the chosen NGS strategy.
Today, regarding NGS strategies, targeted genepanels have been progressively replaced withlarger panels, including all known disease-associated genes, or directly by whole exome sequencing (WES) (4).
In terms of rare genetic diseases, the identification of the genetic basis of disease is reachedin 20 to 40% of patients using WES (5). Some of
the reasons why up to 70% of patients might remain unsolved are explained by methodologicalissues like incomplete coverage of the exome
and genetic mutations elusive to the technology itself. However, in most of the cases, thedisease-causing variant is within the WES data,
but there is insufficient evidence to support adefinitive diagnosis (5).
Whole genome sequencing (WGS) is the ideal
framework, in which a unique approach provides the most complete knowledge of an individual genetics, offering the possibility to analyze and interpret the genomic data along withthe advances of scientific learning (6).
In a recent work, we demonstrate the importanceof biomarkers as a key clue for genetic diagnosis
achievement (7). In spite of this, the most common picture in IEM is represented by a patientwith unspecific clinical features and also unspecific biomarkers. Although accurate characterization of clinical, biochemical and pathologicalpatterns of patients are immensely valuable tounderstand genetic findings, NGS technology canbe a step forward in terms of diagnostic issues.
Some IEM are straight ahead to the causative
gene, but others are not so easy to solve.

One of the most evident examples are CoQ deficiency syndromes, which are defects of the energy metabolism system. Several proteins with
unclear molecular functions facilitate CoQ biosynthesis through unknown mechanisms, andmultiple steps in this pathway are catalyzed bycurrently unidentified proteins (8).
This intricate metabolic process implies unidentified enzymes and, there are several genes thatremain to be identified as essential for CoQ biosynthesis regulation. Furthermore, negative findings in COQ genes do not completely discard thepossibility of a CoQ primary deficiency.
Thereby, biochemical measurements maintain asignificant role in the diagnostic strategy. The heterogeneity of clinical and biochemical patterns
in this specific mitochondrial disease reinforces
the idea of using widespread NGS strategies likehuge genic panels or whole exome sequencing toreach molecular diagnosis.
In conclusion, analysis and comprehension of genomic data must be closely connected to all thehints that classical biomarkers can offer, which is
crucial information to guide the interpretation of
an individual’s exome or genome.
REFERENCES
1. Wong LJ. Challenges of bringing next generation sequencing technologies to clinical molecular diagnostic
laboratories. Neurotherapeutics 2013;10:262-272
2. DaRe JT, Vasta V, Penn J, et al. Targeted exome sequencing for mitochondrial disorders reveals high genetic
heterogeneity. BMC Med Genet 2013;14:118
3. Ghosh A, Schlecht H, Heptinstall LE, et al. Diagnosing childhood-onset inborn errors of metabolism by next-generation sequencing. Arch Dis Child
2017;102(11):1019-1029
4. LaDuca H, Farwell KD, Vuong H, et al. Exome sequencing covers >98% of mutations identified on targeted next generation sequencing panels. PLoS One
2017;12(2):e0170843
5. Sawyer SL, Hartley T, Dyment DA, et al. Utility ofwhole-exome sequencing for those near the end of the

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Dèlia Yubero, Rafael Artuch
Letter: NGS for metabolic disease diagnosis

diagnostic odyssey: time to address gaps in care. Clin Genet 2016;89(3):275-284
6. Petersen BS, Fredrich B, Hoeppner MP, et al. Opportunities
and challenges of whole-genome and -exome sequencing.
BMC Genet 2017;18(1):14

7. Yubero D, Brandi N, Ormazabal A, et al. Targeted Next
Generation Sequencing in Patients with Inborn Errors ofMetabolism. PLoS One. 2016;11(5):e0156359
8. Stefely JA, Pagliarini DJ. Biochemistry of Mitochondrial Coenzyme Q Biosynthesis. Trends Biochem Sci
2017;42(10):824-843

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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.

Reflections on the mentor-mentee
relationship: a symbiosis
Josep Miquel Bauça1,2
1

Department of Laboratory Medicine, Hospital Universitari Son Espases, Palma, Balearic Islands, Spain

2

Institut d’Investigació Sanitària de les Illes Balears (IdISBa), Spain

INFO

LETTER

Corresponding author:
Josep Miquel Bauça
Ctra. de Valldemossa, 79
07010 Palma, Mallorca
Spain
Phone: +34 871205876
E-mail: pepmiquel@gmail.com

Residents in laboratory medicine need to develop theproper skills to become true clinical scientists for the
mid-21st century. A key figure towards expertise is thementor, who is responsible for the motivation andguidance of the young scientist from the moment of
their landing in the laboratory.

Key words:
clinical biochemistry,teaching, research
Disclosure:
The author declares no conflict of interest.

It is essential for the mentor to assure the expertiseof the mentee in the different areas of wisdom inlaboratory medicine, which encompass laboratoryorganization and management, analytical techniques(instrumentation and methodology) and clinical outcomes (pathophysiology, test usefulness and appropriateness and result interpretation) (1). Towards thispurpose, not only should the mentor guide the young
scientist along the residency path, but also check andproof that the required concepts, aptitudes and abilities were properly acquired and integrated.
Every year, new analytical tools and devices are developed, and more sensitive and accurate biomarkers arebrought from the bench to the clinic, so it is of utmost
importance not only for the young clinical scientists
but also for their senior mentors to keep up to date.
Sail or sink.
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Josep Miquel Bauça
Letter: Reflections on the mentor-mentee relationship as a symbiosis

The otherwise called ‘advisors’, ‘coaches’ or‘counsellors’ also need to motivate and encourage their mentees to be involved and masterthe three basic pillars of laboratory medicine:
healthcare, research and teaching. Each of themis absolutely essential, and to outstand in our
medical field, none of them should be forgotten(Figure 1). With no doubt, we all agree that patient care and safety are our ultimate goal andthe reason we (laboratory professionals) wakeup every day -earlier and more accurate diagnostic strategies, better prognostic tools andimproved means to check the effectiveness oftreatments and prediction of relapse. However,no excellence may be reached if not involvedin scientific research and the transmission ofknowledge to others.

discussions makes a resident more independentand gives them a powerful and critical thinking.

Besides the need of technological developmentin our field, the active participation of a young
scientist in research projects and scientific

As we prepare those explanations and anticipate
possible questions, further concepts appear, and
it is easier to secure them in our minds.

Figure 1

Those who do not participate in research themselves are forced to believe what others say ortell them. Investigation may also help in-housemethod development and translate into interesting economic benefits for the whole institution itself. Nevertheless, the taking-off and specialization of a young scientist in research areusually of extreme toughness, so the aid of thementor is highly appreciated.
And teaching. By preparing lectures to a big audience, giving a presentation to our closest colleagues or simply by explaining basic concepts
to students, a laboratory professional strengthens their knowledge on a specific topic.

Pillars in Laboratory Medicine

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Josep Miquel Bauça
Letter: Reflections on the mentor-mentee relationship as a symbiosis

Knowledge, advice and benefits do not flow
only one-way from the (senior) mentor to the(young) mentee, but the profits do also travel the other way around. Teamwork. Mutual
growth. A proper mentorship represents a fullcommitment and creates an environment oftrust and enrichment; a climate of collaboration
between two professionals with common interests; a long-term biological interaction between
two living organisms. An explicit and respectfulalliance.

of research findings, the introduction of newlydescribed analytical procedures and biomarkers
in the laboratory and the participation in clinically-focused meetings or committees, among
other, helps to create this climate of well-being
and enthusiasm for both. A great example ofsuch win-win situation may be found in a previous manuscript on this journal (3). The mentor
shapes the mentee, who in turn does shape thementor.

Thanks to an altruistic, generous and patient personality, the mentor learns from the mentee’squestions and novel ideas, and is intellectuallystimulated as a result of the exposure to new information or to the relearning of past material;
rejuvenation (2).

This two-way street demands attentive listening, defying the mentee with increasingly complex challenges, giving them autonomy, letthem take risks and face both wins and failures(4,5). This atmosphere requires a fluid communication with emotional support and psychologic encouragement.

The engagement and participation of both senior and junior professionals in academic projects is also of substantial interest for the institution. The preparation of courses, the publication

In addition to personal fulfillment, a publication
for the mentee (whether article, book chapter,
poster or oral communication in a congress) isa publication for the mentor; an award for the

Figure 2

Requirements for good residency training

funhumilityeffortEnglishPage 232

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Josep Miquel Bauça
Letter: Reflections on the mentor-mentee relationship as a symbiosis

mentee turns into a recognition for the people
who made that possible and a grant or internshipfor them turns into a considerable opportunity
for all the working group.

error-prone, so residents are too. It is humility
itself what enables the learning process. If own
failures are not recognized, progress and growth
are inconceivable.

Besides the guidance by a mentor, additional key
contributions need to be made by the mentee
him- or herself. According to Dr. A. Buño (Hospital
La Paz, Spain), a successful residency and careerin laboratory medicine requires fun, effort andhumility.

Embarking in a mentorship program will (surely) provide greater confidence and career satisfaction for the mentor, along with stronger
connections within the clinical biochemistrycommunity. And for the mentee, success may
be reached in any part of the world by integrating all the above-mentioned abilities, effort,
enthusiasm, and with the irreplaceable feedback and advice from a trusted mentor. It justrequires having fun.

We could also add that proficiency in the English
language for non-English speakers means a great
leap for them (Figure 2).
Fun is, by far, the most important. Happy, proactive and passionate residents (not surprisingly)
get luckier. Inspiration comes with fun. After all,a laboratory professional spends large amountsof time at work, so it is great advice to have as
much fun as possible there. Effort: although it
does not guarantee success, it has proven to bea great source of confidence. A smooth sea never made a skilled sailor, so no effort translates
into no gain.
And in regard to humility, scientists need to identify their limitations, value group work as wellas individual collaborations, help others andnot be afraid of making mistakes. Humans are

REFERENCES:
1. Greaves R and Smith JM. The IFCC Curriculum. Rev 0– 2017.
2. Henry-Noel N, Bishop M, Gwede CK, Petkova E, Szumacher E. Mentorship in Medicine and Other Health Professions. J Cancer Educ 2018 Apr 24.
3. IFCC Task Force for Young Scientists presents: a mentorship interview. IFCC eNews June 2018.
4. Craig PA. Lessons from my undergraduate research students. J Biol Chem 2018 [Epub ahead of print].
5. Toklu HZ, Fuller JC. Mentor-mentee Relationship: a
Win-Win Contract in Graduate Medical Education. Cureus
9(12):e1908

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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 exchange of knowledge andtechnology around our Sea – a lab surfing project
Guilaine Boursier1,2
1

IFCC Task Force for Young Scientists

2

CHU Montpellier, Univ Montpellier, Department of Genetics, Montpellier, France

INFO

LETTER

Corresponding author:
Guilaine Boursier
Department of Genetics
CHU Montpellier, University of Montpellier
Montpellier
FranceE-mail: guilaineboursier@yahoo.fr

There is a need for stringent relationships between
young scientists in laboratory medicine from all over
the world and networking is the key to ensure a goodcommunication and to encourage participation ofyoung scientists.

Key words:
networking, lab-surfing

In this aim, the task force for young scientists developed
some ways of communication to extend the young scientists network and uniting young scientists globally.
Our community includes the five core members ensuring geographical representation, one corporate member, corresponding members nominated by thirty-six
different National Societies and also more than thousand members through our different media. Thanks to
our regular workshops for young scientists organizedworldwide within the framework of IFCC&LM international or regional meetings, the community grows
every year.
Different kinds of social networking media are easily
accessible on the web. More than six hundred people
follow us on our Facebook page, Twitter account andour LinkedIn group, where we share our activities (@ifccYOUNG). We communicate through our webpage(http://www.ifcc.org/task-force-young-scientists-webpages/) and mailing list which is a Google group
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Guilaine Boursier
Letter: Inter-laboratory exchange of knowledge and technology around our Sea

including more than 280 members (ifcc-taskforce-ys@googlegroups.com).
All this ways of communication are devoted toestablish formal and informal networks to facilitate the communication between young scientists who are involved in laboratory medicine.
Our social medias facilitate regular exchange of
information dealing with activities of the task
force, moreover young scientists can submit interrogations to the community when they are
faced to a problem in their clinical practice.

interested in connecting young scientists and facilitating opportunities for them to share theirexperiences.
The Lab-surfing website (https://www.lab-surfing.com/) was created the next year with thesupport of IFCC&LM through the task force foryoung scientists. Today, more than six hundredusers are registered at the website.

Our best way of inter-laboratory exchange is theLab-surfing project initiated in 2016. A successful evening event dedicated to young scientists
was conducted at EuroMedLab Paris congress in2015. Strong relationships between young delegates have emerged.

For those interested in networking with young
scientists from foreign countries, once registered, Lab-surfing is a tool where you can finda contact from the country of interest with only
two clicks.You will find some information about
the contact and can reach him directly by email.
Last year, a discussion forum was created for
improving fast and easy communication about
the fields of laboratory medicine.

That’s how the two founders of the Lab-surfing
project, Marie Lenski (France) and Santiago
Fares Taie (Argentina) have met. They both liketravelling and discovering foreign countries bythemselves, meeting new people. They wereLab-surfing project encourage young scientists
to exchange knowledge and to contribute to advances in our field of work. Our community aims
at helping you to face the ongoing challenges inlaboratory medicine. Join us!

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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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