The financialization of medical laboratories in France: what are the risks for the profession and public health? / La financiarisation des laboratoires de biologie médicale en France : quels sont les risques pour la profession et la santé publique ?

Medical laboratories in France have always adapted to technical and medical progress, as well as to the regulations imposed by the supervisory authorities. However, over the last ten years, this evolution has been so important that biologists are witnessing a revolution in their mode of practice. The supervisory authorities wanted to increase and harmonize the quality of laboratory results. But the new legislation, sometimes misused, as well as the fear and the cost of accreditation, are at the origin of the excessive acceleration of the financialization of medical biology laboratories. We will see how the hegemony of financial groups can be detrimental to the quality of service provided to patients and to the independence of the medical biologist.

Les laboratoires de biologie médicale en France se sont toujours adaptés aux progrès techniques et médicaux, ainsi qu'à la réglementation imposée par des autorités de tutelle. Mais, depuis une dizaine d'années, cette évolution est si importante que les biologistes assistent à une révolution de leur mode d'exercice. Les autorités de tutelle ont souhaité accroître et harmoniser la qualité des résultats des laboratoires. Mais la nouvelle législation, parfois détournée, ainsi que la peur et le coût de l'accréditation, sont à l'origine de l'accélération démesurée de la financiarisation des laboratoires de biologie médicale. Nous verrons comment l'hégémonie des groupements financiers peut nuire à la qualité du service rendu aux patients et à l'indépendance du biologiste médical.

[Medical biology in the face of the evolution of health care needs]. / Rapport des Académies nationales de médecine et de pharmacie sur la biologie médicale La biologie médicale face aux défis de l'évolution des besoins de santé.

Since the publication of the ordinance of January 13th 2010, ratified by the law of May 30th 2013, medical biology in France has undergone a massive restructuration with the emergence of groups of several hundred laboratories. This evolution, which leads to a considerable reduction in the number of structures, causes numerous problems related to increased industrialization and financialization, difficulties of accreditation and disappearance of the proximity link between the biologist and the prescriber or the patient. It also leads to a clear disaffection of students, especially medical students, for this specialty whose medical character has been clearly affirmed by the law. This report takes stock of the current situation of medical biology and makes recommendations to strengthen the role of the medical biologist in the health system and patients' care.

Measurement of free and total sialic acid by isotopic dilution liquid chromatography tandem mass spectrometry method.

The measurement of urine sialic acid (N Acetylneuraminic Acid: Neu5Ac) is useful for screening sialic acid storage disorders. We developed a new LC MS/MS method for the determination of a sialic acid. Urine samples were analyzed, after an HCl n-Butanol derivatization step, by a reverse phase based high-performance liquid chromatography method using 1,2,3-(13)C(3) N-Acetyl-D-neuraminic Acid ((13)C-Neu5Ac) as an internal standard. Selective detection was performed by tandem mass spectrometry using an electrospray source operating in positive ionization mode employing multiple reactions monitoring to monitor N-Acetylneuraminic Acid and the internal standard. The transitions m/z 366→330 and 369→333 for Neu5Ac and (13)C-Neu5Ac were respectively monitored. The limit of the method quantification was 1.40 µM of N-Acetylneuraminic Acid and the calibration curve showed a good linearity up to 1000 µM. The within assay precision and accuracy of the method ranged from 3.22 to 5.95% and 98.69 to 109.18%, respectively and the between assay precision and accuracy ranged, respectively, from 5.15 to 7.65% and 96.14 to 102.30%. The method can be applied for the determination of N-Acetylneuraminic Acid concentrations in urine and other biological fluids (e.g., amniotic and peritoneal fluids).

A new homolog of FocA transporters identified in cadmium-resistant Euglena gracilis.

To better understand the cellular mechanism of stress resistance to various pollutants (cadmium, pentachlorophenol), we undertook a survey of the Euglena gracilis transcriptome by mRNA differential display and cDNA cloning. We performed a real-time RT-PCR analysis upon four selected genes. One of them significantly changed its expression level in response to stress treatments: B25 gene was overexpressed in Cd-resistant cells whereas it was down-regulated in PCP-adapted cells. By Race assays we obtained for B25 a 1093bp cDNA. The deduced protein was identified as a bacterial formate/nitrite transporter (FocA) homolog and the gene was named EgFth. From all the data, we concluded that EgFth overexpression was related to chronic exposure to cadmium.

Reference intervals for follicle-stimulating hormone, luteinizing hormone and prolactin in children and young adults on the bioMérieux Mini-Vidas system.

We measured serum follicle-stimulating hormone (FSH), luteinizing hormone (LH) and prolactin concentrations on a bioMérieux Mini Vidas system in a pediatric population ranging in age from 1 to 19 years. Reference intervals were established separately for females and males, with stratification by age group and by Tanner's pubertal stage. FSH values were higher in females than in males, and were lowest in both sexes of age class 2 (4-8 years), increasing thereafter to the upper limit for stage PIV (females) and stage PV (males). LH values showed a similar pattern of change: concentrations were lowest for class 1 (1-3 years) and class 2 (4-8 years), and highest for stage PII (females) and stage PV (males). No significant difference was observed according to gender. Prolactin values did not differ markedly according to gender or pubertal status.

Peroxisome proliferator-activated receptor alpha physically interacts with CCAAT/enhancer binding protein (C/EBPbeta) to inhibit C/EBPbeta-responsive alpha1-acid glycoprotein gene expression.

Recently, the role of the peroxisome proliferator-activated receptor alpha (PPARalpha) in the hepatic inflammatory response has been associated to the decrease of acute phase protein transcription, although the molecular mechanisms are still to be elucidated. Here, we were interested in the regulation by Wy-14643 (PPARalpha agonist) of alpha1-acid glycoprotein (AGP), a positive acute phase protein, after stimulation by Dexamethasone (Dex), a major modulator of the inflammatory response. In cultured rat hepatocytes, we demonstrate that PPARalpha inhibits at the transcriptional level the Dex-induced AGP gene expression. PPARalpha exerts this inhibitory effect by antagonizing the CCAAT/enhancer binding protein (C/EBPbeta) transcription factor that is involved in Dex-dependent up-regulation of AGP gene expression. Overexpression of C/EBPbeta alleviates the repressive effect of PPARalpha, thus restoring the Dex-stimulated AGP promoter activity. Furthermore, glutathione-S-transferase GST pull-down and coimmunoprecipitation experiments evidenced, for the first time, a physical interaction between PPARalpha and the C-terminal DNA binding region of C/EBPbeta, thus preventing it from binding to specific sequence elements of the AGP promoter. Altogether, these results provide an additional molecular mechanism of negative regulation of acute phase protein gene expression by sequestration of the C/EBPbeta transcription factor by PPARalpha and reveal the high potency of the latter in controlling inflammation.

Molecular basis of methylmalonyl-CoA mutase apoenzyme defect in 40 European patients affected by mut(o) and mut- forms of methylmalonic acidemia: identification of 29 novel mutations in the MUT gene.

Methylmalonyl-CoA mutase (MCM) apoenzyme deficiency is a rare metabolic disease that may result in distinct biochemical phenotypes of methylmalonic acidemia (MMA), namely mut(o) and mut-. We analyzed a cohort of 40 MCM-deficient patients with MMA affected by either the mut(o) or the mut- form of the disease. By direct sequencing of cDNA and gDNA of the MUT gene, we detected 42 mutations, 29 of which were novel mutations. These included five frameshift mutations (insertion, deletion, or duplication of a single nucleotide), five sequence modifications in consensus splice sites, six nonsense and 12 missense mutations, and a large genomic deletion including exon 12. We explored how the 12 novel missense mutations might cause the observed phenotype by mapping them onto a three-dimensional model of the human MCM generated by homology with the P. shermanii enzyme. In this work we update the spectrum of MCM mutations (n=84), and then discuss their prevalence and distribution throughout the coding sequence in relation to the enzyme structure.

Retinoids increase alpha-1 acid glycoprotein expression at the transcriptional level through two distinct DR1 retinoic acid responsive elements.

In the present study, we analyzed the influence of retinoic acids on the expression of alpha-1 acid glycoprotein (AGP). We show that in rat primary hepatocytes, 9-cis retinoic acid and all-trans retinoic acid increase AGP gene expression at the transcriptional level. Transient transfections of rat primary hepatocytes with a reporter construct driven by the rat AGP gene promoter indicated that retinoids regulate AGP gene expression via the -763/-138 region of the AGP promoter. Furthermore, cotransfection experiments with retinoic acid receptor alpha (RARalpha) and retinoid X receptor alpha (RXRalpha) expression vectors in NIH3T3 cells demonstrated that both RXRalpha/RXRalpha homodimer and RXRalpha/RARalpha heterodimer are competent for ligand-induced transactivation of the AGP promoter. Unilateral deletion and site-directed mutagenesis identified two retinoic-acid responsive elements (RARE), RARE-I and RARE-II, which interestingly correspond to a direct repeat of two TGACCT-related hexanucleotides separated by a single bp only (DR1-type response element). Cotransfection assays showed that RXRalpha and RARalpha activate AGP gene transcription through these two elements either as a homodimer (RXRalpha/RXRalpha) or as a heterodimer (RXRalpha/RARalpha). The RXRalpha/RXRalpha homodimer acts most efficiently through the RARE-I response element to promote AGP transactivation, whereas the RXRalpha/RARalpha heterodimer mediates transactivation better via the RARE-II responsive element.

Cerebrospinal fluid lactate and pyruvate concentrations and their ratio in children: age-related reference intervals.

BACKGROUND: Lactate (L) and pyruvate (P) concentrations in cerebrospinal fluid (CSF) and the L/P ratio have diagnostic value in numerous primary and acquired disorders affecting the central nervous system, but age-related reference values are not available for children. METHODS: We analyzed CSF and blood lactate and pyruvate concentrations and their ratio in a 4-year retrospective survey of a children's hospital laboratory database. Reference intervals (10th-90th percentiles) were established from data on 197 hospitalized children. A recent regression modeling method was used to normalize and smooth values against age. The model equation of best fit was calculated for each variable. RESULTS: Slight age-related variations were shown by the model, with an increase in lactate, a decrease in pyruvate, and a resulting increase in the L/P ratio with increasing age. However, the SD did not vary with age. We defined the upper limit of the reference intervals as the 90th percentiles, which from birth to 186 months of age varied continuously from 1.78 to 1.88 mmol/L (6%), 148 to 139 micro mol/L (6%), and 16.9 to 19.2 (14%) for lactate, pyruvate, and the L/P ratio, respectively. At a threshold of 2 (in Z-score units), the sensitivity for a subgroup of inborn errors of metabolism (respiratory chain disorders) was 73%, 42%, and 31% for lactate, pyruvate, and the L/P ratio, respectively. CONCLUSIONS: In children, CSF lactate and pyruvate concentrations and their ratio appear to vary slightly with age. Average 90th percentile values of 1.8 mmol/L, 147 micro mol/L, and 17, respectively, could be used in infants up to 24 months of age. In older children, age-adjusted reference intervals should be used, especially when values are close to the 90th percentile.

Biochemical markers of neonatal sepsis: value of procalcitonin in the emergency setting.

BACKGROUND: We evaluated procalcitonin (PCT) assay in the emergency diagnosis of neonatal bacterial infection, especially in preterm infants, relative to C-reactive protein (CRP) and fibrinogen. METHODS: One hundred and twenty neonates (32 preterm), of whom 21 were infected, were tested. RESULTS: Concentrations of PCT, CRP and fibrinogen in uninfected infants were not affected by gestational age at birth. Concentrations of CRP and PCT increased rapidly during the first 24 h of life, while fibrinogen concentrations increased gradually from birth. All marker concentrations were significantly greater in neonates with bacterial infection. Receiver-operating characterstic analysis showed that optimum cut-off values for fibrinogen, CRP and PCT were 3.0 g/L, 7.5 mg/L and 2.5 microg/L respectively, for the diagnosis of sepsis at birth. CONCLUSIONS: Determination of PCT is of value in excluding bacterial infection in neonates since it has a negative predictive value of 93%.