The role of CEA, CYFRA21-1 and NSE in monitoring tumor response to Nivolumab in advanced non-small cell lung cancer (NSCLC) patients.

BACKGROUND: CEA, CYFRA21-1 and NSE are tumor markers used for monitoring the response to chemotherapy in advanced adenocarcinoma, squamous cell carcinoma and small-cell lung cancer, respectively. Their role in cancer immunotherapy needs to be elucidated. METHODS: Patients with advanced non-small cell lung cancer (NSCLC) were treated with nivolumab 3 mg/kg every 2 weeks within the Italian Nivolumab Expanded Access Program. Blood samples were collected at baseline, at each cycle up to cycle 5 and then every two cycles until patient's withdrawn from the study. All patients underwent a CT-scan after every 4 cycles of treatment and responses were classified according to RECIST 1.1. The biomarkers serum levels were measured with a chemiluminescent microparticle immunoassay for CEA and with an immuno radiometric assay for CYFRA21-1 and NSE. The markers values at baseline and after 4 cycles were used to analyze the relationship between their variation over baseline and the tumor response, evaluated as disease control rate (DCR: CR + PR + SD), and survival (PFS and OS). RESULTS: A total of 70 patients were evaluable for the analysis. Overall, a disease control was obtained in 24 patients (35.8%, 4 PR + 20 SD). After 4 cycles of nivolumab a CEA or CYFRA21-1 reduction ≥ 20% over the baseline was significantly associated with DCR (CEA, p = 0.021; CYFRA21-1, p < 0.001), PFS (CEA, p = 0.028; CYFRA21-1, p < 0.001) and OS (CEA, p = 0.026; CYFRA21-1, p = 0.019). Multivariate analysis confirmed the ability of CYFRA21-1 reduction ≥ 20% to predict DCR (p = 0.002) and PFS (p < 0.001). CONCLUSION: The reduction in serum level of CYFRA21-1 or CEA might be a reliable biomarker to predict immunotherapy efficacy in NSCLC patients. NSE was not significant for monitoring the efficacy of nivolumab.

Evaluation of adequacy of levo-thyroxine dosage in patients with differentiated thyroid carcinoma: correlation between morning and afternoon TSH determination.

PURPOSE: The aim of this study was to judge the reliability of evaluating thyroid-stimulating hormone (TSH) and free thyroxine (f-T4) in the morning and afternoon in differentiated thyroid carcinoma (DTC) patients. METHODS: We evaluated 153 DTC patients, aged 61 ± 13 years, in active follow-up in our center after primary treatments and under stabilized levo-thyroxine (L-T4) posology. In each patient, morning and afternoon examinations were performed 1-3 months apart. Blood samples were collected at 08:00-09:00 h and 15:00-16:00 h. TSH and f-T4 were evaluated in both samples. Thyroglobulin (Tg), Tg-antibodies and neck ultrasonography were also evaluated. RESULTS: According to clinical and laboratory examinations, 92% of patients were disease-free, 6% had biochemical disease, and 2% structural disease. L-T4 dosages (1.64 ± 0.38 µg/kg b.w.) proved the same on both occasions, despite slight changes in body weight or L-T4 posology in 15% of patients. Free-T4 values were significantly higher in the afternoon (21.5 ± 0.3 pmol/L) than in the morning (18.8 ± 0.4 pmol/L; P < 0.0001), whereas TSH values were statistically unchanged (morning 0.85 ± 0.25 mIU/L; afternoon 0.72 ± 0.20 mIU/L). There was a significant correlation (P < 0.0001) between the two TSH determinations in the same patients. CONCLUSIONS: In DTC patients, follow-up examination consists of clinical and laboratory evaluations. The majority of patients have good disease control. Our study suggests that the adequacy of L-T4 therapy can be monitored equally well either in the morning or in the afternoon. Afternoon examinations can alleviate crowding in hospital ambulatories in the morning.

Prescriptive appropriateness using inhalant and food allergen panels: a comparison between General Practitioners' and Allergists' prescription in Genoa (Italy).

SUMMARY: Background. Prescriptive appropriateness is an actual claim in healthcare, and it also concerns in vitro tests used in the allergy work-up, such as the serum allergen-specific IgE (sIgE) assay. In the Liguria Region, two panels were defined (for inhaled and food allergens) including 12 allergens. Their composition changed over time. Objectives. The aims of the present retrospective study were: i) to evaluate the percentage of positive tests, and ii) to compare the findings of sIgE assay on the basis of the general practictioners' (GPs) or specialist' prescription, considering both the old panels and the new panels. Methods. This retrospective study considered a population of adult patients, which consisted of 2368 subjects (68% females; mean age 50 years; age range: 10-103 years). Serum sIgE were measured by ImmunoCap system. Results. The percentages of positive tests were very low for food allergens and low for inhaled ones (ranging between 5% to 35%). There was change of prevalent prescriptor with new panels. Conclusions. This study underlines the relevance of prescriptive appropriateness in the allergy work-up. The sIgE assay should be limited to those allergens that have a clinical relevance, based on clinical history.

Profiles of Birch Sensitization (Bet v 1, Bet v 2, and Bet v 4) and Oral Allergy Syndrome Across Italy.

BACKGROUND: Birch allergy (BA) is a common pollinosis caused by the allergens Bet v 1, Bet v 2, and Bet v 4. Oral allergy syndrome (OAS) is frequently associated with BA. A gradient of sensitization to birch allergen across Europe has been reported. Therefore, this study aimed to investigate the birch sensitization profile, including OAS, across Italy. METHODS: We performed a retrospective study of 854 patients (391 males, mean age 35.9 years, range 18-93 years): 196 patients were recruited in Genoa, 188 in northern Italy, 359 in central Italy, and 111 in southern Italy. Serum IgE to Bet v 1, Bet v 2, and Bet v 4 was assessed, and OAS was analyzed. RESULTS: With respect to the geographical path Genoa-North-Center-South, the frequency of sensitization to Bet v 1 decreased significantly (P<.0001) from Genoa (95.41%) to southern Italy (58.56%). The frequency of sensitization to Bet v 2 increased significantly (P<.0001) from Genoa (6.12%) to southern Italy (52.25%). The frequency of Bet v 4 also increased significantly (P=.0002) from Genoa (6.12%) to southern Italy (14.41%). The distribution of patients with OAS differed significantly across the areas (P<.0001), the most marked difference ranging between 33.5% in Genoa and 76.9% in northern Italy. The frequency of birch allergens correlated with OAS in central Italy only. CONCLUSIONS: The present study demonstrated a significant difference between sensitization to birch and its clinical expression across Italy.

Serum allergen-specific IgE, allergic rhinitis severity, and age.

BACKGROUND: Allergic rhinitis (AR) is characterized by an IgE-mediated reaction. Aging usually induces a progressive decline of immune system function. There is common belief that both allergic symptoms severity and serum IgE production decline during aging. OBJECTIVE: This study aimed to evaluate the possible impact of age on: i) serum allergen-specific IgE levels in a large sample of subjects, and ii) AR symptom severity in a group of mono-allergic patients. METHODS: Serum allergen-specific IgE to birch, Bet v 1, Parietaria, and Dermatophagoides pteronyssinus were measured by immunofluorometric assay (IFMA) in a sample of 8098 subjects. AR symptom severity was assessed by visual analogue scale (VAS) in a sub-group of 531 mono-allergic patients. RESULTS: The analysis of variance showed that IgE to Bet v 1, birch, and Dermatophagoides pteronyssinus significantly decreased considering the age, whereas IgE to Parietaria did not significantly decline in respect of the age. Considering the global sample of mono-allergic patients, elderly subjects (over 65 years old) tended to have lower IgE levels, but had significantly lower VAS rating, and significantly less sensitizations than adult subjects (18-65 years old). In both adult and elderly patients VAS strongly correlated with IgE values. CONCLUSIONS: Allergen-specific IgE levels tend to reduce with aging, but with differences between types of allergy. The IgE decrease is usually associated with reduced AR symptom severity. Elderly AR patients seem to have a different phenotype/endotype in comparison with adult AR ones, characterized by milder symptoms, lower IgE production, and less sensitizations. However, a close positive relationship between IgE values and VAS scores is shared by both adult and elderly AR patients, confirming the close link between allergy and symptoms that persists also in the elderly.

Severe vitamin D deficiency is associated with frequently observed diseases in medical inpatients.

INTRODUCTION: Vitamin D deficiency consequences may go beyond altered calcium homeostasis and musculoskeletal disease. Medical inpatients are often vitamin D-deficient, but little information is available about the relation of vitamin D status with extra-skeletal disorders in this population. METHODS: We analysed the relationship between the concentrations of 25-hydroxyvitamin D [25(OH)D], the marker of vitamin D status, and the conditions most commonly causing admission in 115 consecutive medical inpatients. RESULTS: Sixty-five subjects (56.5%) had severe vitamin D deficiency [25(OH)D < 8 ng/ml]. Age (ß = -0.35, p = 0.01) and hepatic disease (ß = -0.21, p = 0.02) were significant correlates of 25(OH)D levels. Compared with patients with ≥ 8 ng/ml 25(OH)D, those with < 8 ng/ml 25(OH)D had significantly higher parathyroid hormone (PTH) concentrations [123 (92.7-208.2) ng/l vs. 88 (68.5-129.5) ng/l, p < 0.001], were significantly more likely to have arterial hypertension (OR 2.76, 95% CI 1.16-6.58), heart failure (HF) (OR 2.49, 95% CI 1.14-5.47), cerebrovascular disease (OR 3.23, 95% CI 1.41-7.39), and infections (OR 2.44, 95% CI 1.02-5.87), and stayed in hospital significantly longer (10 days vs. 7.5 days, p = 0.01). Only the probability of having an infection remained significantly higher in cases with severe vitamin D deficiency after adjustment for age (OR 2.41, 95% CI 1.03-5.68) and persisted after further correcting for presence of hepatic disease and PTH values (OR 2.66, 95% CI 1.03-6.88). A significant association between PTH and HF (OR 2.32, 95% CI 1.05-5.09) and length of hospitalisation (ß = 0.22, p = 0.04) emerged in the fully adjusted regression models. CONCLUSIONS: Severe vitamin D deficiency is associated with commonly presenting extra-skeletal diseases in medical inpatients. With the exception of infections, this association is mainly driven by age. Additional studies are needed to determine whether vitamin D testing on admission may help stratifying specific categories of patients by clinical severity.

Calcitonin assay in wash-out fluid after fine-needle aspiration biopsy in patients with a thyroid nodule and border-line value of the hormone.

Assaying calcitonin (CT) in the wash-out fluid from fine-needle aspiration biopsies (CT-FNAB) could be useful in the diagnosis of medullary thyroid carcinoma (MTC). The aim of this study was to correlate serum CT with cytology and CT-FNAB. Twenty-seven subjects (age range 27-75 yr) were studied. FNAB was performed in a thyroid nodule (no.=16) or lymph-node (no.=1 previously operated on for MTC) or in the prevalent nodule of multinodular goiters (no.=10). CT-FNAB values obtained in 37 subjects with normal serum CT (<10 ng/l) who underwent FNAB for thyroid nodules served as a negative control. In these subjects, CTFNAB values were 8.2+/-6.4 ng/l (range 2-30 ng/l). In patients with a thyroid nodule under evaluation for MTC, serum CT and CT-FNAB values were 14.5+/-3.9 ng/l (range 10-24 ng/l) and 16.4+/-29.8 ng/l (range 2-144 ng/l), respectively. In 4 patients, CT-FNAB values were higher than the highest values found in our negative controls (30 ng/l), but cytology results were compatible with a benign thyroid lesion and pentagastrin testing was negative. In 3 cases with CT-FNAB <30 ng/l, cytology was indicative of an indeterminate or probably follicular malignant lesion and histology was negative for MTC. None of the other subjects in whom pentagastrin testing was conducted showed serum CT values >100 ng/l. Our data do not show any correlation between CT-FNAB and serum CT. In conclusion, borderline CT values in patients with thyroid nodules are not rare. Our experience suggests that CT-FNAB does not have the same importance as that reported in the literature for thyroglobulin and PTH assay in wash-out fluid after FNAB in malignant thyroid and hyperfunctioning parathyroid lesions.

Allergen-specific IgE: comparison between skin prick test and serum assay in real life.

BACKGROUND: The most common sensitizing allergens in in the area of Liguria region (Northwestern Italy) are pollens, mainly Parietaria and cypress, house dust mites, i.e. Dermatophagoides, and pets. IgE assessment is a crucial step in allergy diagnosis. It may be performed by skin prick test (SPT) or serum IgE (sIgE) assay. Therefore, this study compared these two methods in a real-life setting. METHODS: This retrospective study included 793 subjects, who were referred to the Allergy Department for respiratory allergy during 2014. Inclusion criteria were i) documented diagnosis of allergic rhinitis (AR), and/or allergic asthma, and/or allergic conjunctivitis. SPT and sIgE assay were performed for 5 allergens, such as Dermatophagoides pteronyssinus (D1), cat (E1), Parietaria officinalis (W19), cypress (T23), and dog (E5), as they are the most common in our geographic area. RESULTS: Using a positive SPT result as the target condition, remarkably high and statistically significant values of AUC, ranging from 0.84 to 0.94, were found. On the basis of the Youden index the following optimal classification threshold values were also computed: D1 = 0.22, E1 = 0.26, W19 = 0.61, T23 = 0.25, E5 = 0.34. These values allowed to define a set of sensitivity/specifity estimates ranging from 0.75 to 0.93 and from 0.83 to 0.93, respectively. CONCLUSIONS: The present study shows that SPT and sIgE are two tests that are rather concordant, but with different sensitivity and specificity distinct for each allergen. In clinical practice, both tests should be used depending on clinical history features and obtained findings.

Colistin and rifampicin in the treatment of multidrug-resistant Acinetobacter baumannii infections.

OBJECTIVES: The increased incidence of nosocomial infections by multidrug-resistant organisms has motivated the re-introduction of colistin in combination with other antimicrobials in the treatment of infections. We describe the clinical and microbiological outcomes of patients infected with multidrug-resistant Acinetobacter baumannii who were treated with a combination of colistin and rifampicin. PATIENTS AND METHODS: Critically ill patients with pneumonia and bacteraemia caused by A. baumannii resistant to all antibiotics except colistin in medical and surgical intensive care units were enrolled. Clinical and microbiological responses and safety were evaluated. RESULTS: Twenty-nine patients (47 +/- 14 years and APACHE II score 17.03 +/- 3.68), of whom 19 were cases of nosocomial pneumonia and 10 were cases of bacteraemia, were treated with intravenous colistin sulphomethate sodium (2 million IU three times a day) in addition to intravenous rifampicin (10 mg/kg every 12 h). All A. baumannii isolates were susceptible to colistin. The mean duration of treatment with intravenous colistin and rifampicin was 17.7 (+/-10.4) days (range 7-36). Clinical and microbiological responses were observed in 22 of 29 cases (76%) and the overall infection-related mortality was 21% (6/29). Three of the 29 evaluated patients (10%) developed nephrotoxicity when treated with colistin, all of whom had previous renal failure. No cases of renal failure were observed among patients with normal baseline renal function. No neurotoxicity was noted. CONCLUSIONS: Colistin and rifampicin appears to be an effective and safe combination therapy for severe infections due to multidrug-resistant A. baumannii.

Absence of thyrotropin-induced increase in leptin levels in patients with history of differentiated thyroid carcinoma undergoing recombinant human thyrotropin testing.

BACKGROUND: Some extra-thyroid effects of TSH have been described in vitro and in vivo. TSH has recently been suggested to induce interleukin-6 secretion by adipocytes. Leptin is the main protein secreted by adipose tissue. OBJECTIVE: The aim of our study was to evaluate the acute effect of the recombinant human TSH (rhTSH)-induced TSH surge on serum leptin levels in thyroidectomized patients undergoing levothyroxine (L-T4) suppressive therapy for differentiated thyroid carcinoma (DTC). DESIGN: A cohort of 15 female DTC patients was evaluated. Standard rhTSH testing was performed. Leptin, TSH, thyroid hormones, and thyroglobulin were measured before and 3, 6, and 9 days after rhTSH testing. Some metabolic parameters were also evaluated at the baseline. RESULTS: Baseline leptin levels were 12.2+/-3.2 microg/l. Only body mass index (BMI) correlated significantly (p<0.05) with leptin levels. After rhTSH administration, TSH levels increased significantly (p<0.001), while thyroid hormones remained unchanged. Twenty hours after the last rhTSH administration, leptin (11.8+/-3.0 microg/l) levels were unchanged. The maximal TSH level was negatively related with BMI (p<0.05), but no correlation between maximal TSH and leptin levels after rhTSH was noted. CONCLUSIONS: Our in vivo experimental model suggests that an acute TSH increase after rhTSH testing is ineffective in changing circulating leptin levels.

Circulating levels of cytokines (IL-6 and IL-1beta) in patients with intermittent claudication, at rest, after maximal exercise treadmill test and during restore phase. Could they be progression markers of the disease?

AIM: Inflammation is considered to be one of the main mechanisms for the development and progression of peripheral arterial disease (PAD). Many studies have demonstrated that maximal exercise enhances the acute inflammatory response in claudicant patients, but no one has assessed the duration of this acute inflammatory activation. The aim of this study was to assess of the inflammatory pattern in claudicants and of the inflammatory response after maximal exercise and during the recovery from calf pain. METHODS: Eleven patients with moderate claudication (MC) (age: 60.5+/-5.8 years; body mass index [BMI]: 27.5+/-4.6; absolute claudication distance [ACD]: 165.4+/-38), 10 patients with severe claudication (SC) (age: 60.3+/-5 years; BMI: 27+/-4.5; ACD: 91+/-11.3) and 8 healthy subjects (age: 59.4+/-6.8; BMI: 28.7+/-4.16) underwent to maximal treadmill test (speed 2.5 km/h, slope 15%). At rest, just after stop of the exercise (appearance of calf pain in patients, and 6 min of treadmill in controls) the circulating levels of interleukin (IL)-1beta and IL-6 have been measured. STATISTICAL ANALYSIS: variance of mean values, Bonferroni t-test, split plot variance model, variance of d stop-before and stop-recovery have been utilized. P<0.05 has been considered the significant cut-off of the differences. RESULTS: The maximal exercise excited significant (P<0.01) inflammatory activation in all patients: MC (rest IL-1beta: 1.55, 3.3 at stop; rest IL-6: 5.97, 8.38 at the stop); SC (rest IL-1beta: 2.97, 5.72 at stop; rest IL-6: 6.98, 9.99 at the stop). During recovery, MC showed a reduction of the inflammatory activation, whilst SC showed further increase (IL-1beta: 7.55; IL-6: 11.94). CONCLUSION: The study confirms the higher inflammatory activation in claudicants and its enhancement after maximal exercise. During recovery, we found two kinds of response: type 1 (controls and MC), in which inflammation subsides, and type 2 (SC) characterized by further inflammatory increase. This trend is not univocal: 3 MC showed a type 2 response and 2 SC showed a type 1. In conclusion, inflammatory activation may depend not only on the degree of endothelial damage, but also on the individual inflammatory attitude, better assessed after maximal exercise than baseline values. This individual inflammatory responsiveness, considering the role of the rest measurement of markers of inflammation recently discussed, could be a useful marker for aggressive PAD.

Low molecular mass proteins and urinary enzymes in amniotic fluid of healthy pregnant women at progressive stages of gestation.

OBJECTIVES: Amniotic fluid alpha1-microglobulin (alpha1-m) and beta2-microglobulin (beta2-m) levels, as well as N-acetyl-beta-D-glucosaminidase (NAG) and alanine aminopeptidase (AAP) activities, were measured in the course of uncomplicated pregnancies to assess their variations as gestation progresses. DESIGN AND METHODS: Samples were obtained from 141 healthy pregnant women divided into three groups on the basis of gestational stage. Quantitative estimation of proteins was performed immunometrically and enzyme activities were determined spectrophotometrically. RESULTS: It was found that, during pregnancy, alpha1-m and beta2-m concentrations as well as AAP activity significantly decrease, although their reduction patterns vary. Controversial results were found for NAG activity: the normalization of values for amniotic fluid creatinine significantly changed the reduction pattern of this enzyme. No statistically significant differences were found between male and female fetuses for amniotic fluid values of the biochemical substances studied. CONCLUSIONS: The behavior observed for alpha1-m, beta2-m, and AAP might be linked to the progressive development and maturation of fetal renal tubular function. Amniotic fluid total NAG activity seems not to depend only on fetal urinary excretion.

An immunological evaluation of type II diabetic patients with periodontal disease.

Peridontal disease is a frequent complication of diabetes, and diabetic subjects often exhibit decreased immune response with increased susceptibility to infection. We evaluated the possible relationship between immune response and periodontal disease in 40 type II diabetic patients, mean (+/- SD) age 59 +/- 8 years and mean disease duration 17 +/- 4 years, with good metabolic control (mean fasting plasma glucose, 10.5 +/- 3.8 mM/L, mean HbA1c 8.1 +/- 1.66%), and in 40 age and gender-matched controls. Interproximal alveolar bone loss (ABL), as the percentage of bone loss from the cement enamel junction (CEJ) to the apex, was measured with a modified Schei ruler at the deepest point on the mesial/distal surface of the teeth, except third molars, on a panoramic radiograph. Immunological evaluation involved study of NADPH neutrophil superoxide production, neutrophil chemotaxis, lymphocyte subpopulations, immunoglobulins and complement. Diabetic patients showed significant differences compared with controls regarding ABL (30.6 +/- 14.7% versus 17.6 +/- 4.3%; p < 0.0001) and the T-helper/T-suppressor ratio (2.3 +/- 1.0% versus 1.8 +/- 0.8%; p < 0.05). Other parameters of cell-mediated immunity and humoral immune response did not show any significant variations. No correlation between immunological and radiographic analysis parameters were found. Further studies are needed to verify the exact role played by immunological factors in type II diabetic patients with periodontal disease.

Netilmicin effect on urinary retinol binding protein (RBP) and N-acetyl-beta-D-glucosaminidase (NAG) in preterm newborns with and without anoxia.

The study aim was to evaluate urinary excretion of Retinol Binding Protein (RBP), compared with urinary excretion of N-acetyl-beta-D-glucosaminidase (NAG), in preterm infants with anoxia and netilmicin treatment. Urinary RBP and NAG were evaluated in 83 preterm newborns divided in 4 groups: 37 healthy preterm newborns (controls); 14 with neonatal anoxia; 16 treated with ampicillin + netilmicin; 16 with neonatal anoxia and treated with ampicillin + netilmicin. RBP was determined by an automated nephelometric technique and NAG by a colorimetric method on 5-h urine samples in the first week of life. Results showed that urinary excretion of RBP (average from first week values) was 1.06+/-0.67 g/mol creatinine (mean +/- SD) in controls, 1.99+/-1.41 in antibiotic-treated newborns, 3.99+/-4.57 in anoxic newborns and 3.75+/-3.48 in anoxic newborns under antibiotic treatment. When gestational age was not considered, a marked effect of anoxia (P<0.001) and a borderline effect of netilmicin (P<0.059) on RBP excretion were detected by ANOVA. However when gestational age was also considered by analysis of covariance, it appeared as the strongest predictor of RBP excretion (P<0.001), while the effect of netilmicin was no longer significant (P=0.181). The effect of anoxia persisted, although less remarkable (P=0.010). Conversely anoxia did not affect urinary NAG excretion, which was rather correlated with gestational age and netilmicin administration. The authors conclude that RBP and NAG urinary excretion may be used to discriminate between neonatal anoxia and netilmicin treatment, respectively as etiologic factors of renal tubular damage in the newborn.

Renal tolerability of teicoplanin in a case of neonatal overdose.

The literature does not contain reports regarding teicoplanin overdose in newborns. In a neonate with a history of recent postasphyctic acute renal failure which recovered within 7 days of life, antibiotic therapy with teicoplanin was started for sepsis due to Staphylococcus hominis. However, for 5 days the dosage was excessive (20 mg/kg twice daily instead of an initial dose of 16 mg/kg and then doses of 8 mg/kg once daily). Once this error had been noted, therapy was immediately suspended. Clinically the newborn had improved and blood culture at the end of the therapy was negative. Biohumoral tests revealed constantly normal levels of serum creatinine, serum cystatin C and blood nitrogen. Urinary parameters of tubulotoxicity were also within normal values. Urinary epidermal growth factor was increased. Teicoplanin was well tolerated at the renal level in the newborn even in this case of excessive dosage.

Tubular proteins and enzyme content in the amniotic fluid.

Amniotic fluid is the product of many substances and fetal urine is considered to be one of the principal components. Only a few reports have been published describing the concentration of microglobulins and urinary enzymes in the amniotic fluid. We determined the levels of alpha 1-m, beta 2-m, AAP and NAG, in 154 samples of amniotic fluid (103 early determinations and 51 late determinations) as a function of gestational age. We observed a statistically significant decrease in concentration of alpha 1-m (P < 0.001), beta 2-m (P < 0.01) and AAP (P < 0.001) when early and late amniotic fluid samples were compared. A statistically significant increase of NAG (P < 0.01) and creatinine (P < 0.01) was also found. A significant correlation was observed between alpha 1-m and beta 2-m, and between AAP and NAG, respectively. The potential role of urinary enzyme and microglobulin determination in amniotic fluid as an index of fetal kidney development, is discussed.

Coagulation and plasma fibronectin parameters in HELLP syndrome.

OBJECTIVES: HELLP syndrome (hemolysis, elevated liver enzymes and low platelets) has a high fetal mortality and maternal morbidity, partly due to its late diagnosis. In order to facilitate earlier diagnosis, we studied the changes occurring in natural coagulation inhibitors, fibronectin and haptoglobin as potential early markers of endothelial damage, coagulation cascade activation and intravascular hemolysis. METHODS: The study compared antithrombin (AT-III), protein C and S activity, plasma fibronectin, 'prothrombin time' and 'partial prothrombin time' (AST, ALT), lactate dehydrogenase (LDH), bilirubin and serum haptoglobin in 17 asymptomatic controls, 19 preeclampsia patients and 11 HELLP syndrome patients. RESULTS: HELLP syndrome patients had higher fibronectin and D-dimer values, lower AT-III and protein C activity, a lower platelet count and higher LDH than healthy controls; only 25% had raised bilirubin. Serum haptoglobin was lower in HELLP syndrome. CONCLUSIONS: Early on in HELLP syndrome, there is probably a pro-coagulatory imbalance in the placental microcirculation. Endothelial damage causes tissue thromboplastin release and coagulation cascade activation due to collagen exposure; the vascular lesion increases thromboplastin in the bloodstream and triggers distant coagulation processes, suggesting compensated disseminated intravascular coagulopathy. Measuring plasma fibronectin and coagulation inhibitors should be supported by testing haptoglobin as a marker of intravessel hemolysis to differentiate conventional preeclampsia from HELLP.

Predictive markers of pre-eclampsia in hypertensive disorders of pregnancy.

OBJECTIVE: The aim of this work is to assess the most widespread methods currently proposed and two new markers for predicting the development of pre-eclampsia in pregnant women with hypertension. METHODS: The study involved 212 pregnant Caucasian women: 104 normotensive, 68 pregnancy-induced hypertensive and 40 chronic hypertensive. Blood and urine were sampled between 28 and 30 weeks gestation. All 108 hypertensive pregnant women, at the time of sampling, demonstrated proteinuria below 0.3 g/24 h. The following laboratory tests were performed: fibronectin, antithrombin-III, alpha-1-microglobulin, U-N-acetyl-beta-glucosaminidase, uric acid and albumin excretion rate. Student's t-test, discriminant analysis and chi2 (chi-square) test were used as statistical methods. A P value less than 0.05 was considered significant. RESULTS: After discriminating analysis, only three of the six variables analyzed were able to discriminate patients who would develop pre-eclampsia from the remaining hypertensive pregnant women: microalbuminuria, uric acid and fibronectin (chi2 = 29.122, P < 0.01). CONCLUSIONS: In agreement with previous studies, albumin excretion rate appeared to be the best predictive test for pre-eclampsia in hypertensive pregnant women, giving a higher positive predictive value and specificity (87.5 and 98.9%, respectively).

Markers of tubular damage in pre-eclampsia.

BACKGROUND: The aaim of this study is to investigate the tubular damage markers in pre-eclampsia and in pregnancy induced hypertension (PIH). METHODS: This transversal study involved 111 women admitted to the Department of Obstetric and Gynaecology, University Hospital, Padua (Italy) and was conducted from the 24th week until delivery: 23 had normal pregnancies, 54 manifest pre-eclampsia, and 34 manifested pregnancy-induced hypertension (PIH) without superimposed pre-eclampsia. The following laboratory tests were performed: U-alpha 1 microglobulin, U-NAG, uric acid and microalbuminuria. The four groups were compared using the Mann-Whitney test and the Kruskall-Wallis test for multiple comparisons. A value of p < 0.05 was considered as statistically significant. RESULTS: As for the markers of tubular damage, the values for urinary NAG were significantly lower in the control group (0.97 U/mmol Creat) than in the pre-eclampsia group (2.89 U/mmol Creat), and the PIH group (2.12 U/mmol Creat) (p < 0.01). Values for urinary alpha 1-microglobulin were higher in the pre-eclampsia group (4.03 U/mmol Creat) than in the control (0.74 U/mmol Creat), and PIH groups (1.88 U/mmol Creat) (p < 0.01). As for the markers of glomerular damage, the values of microalbuminuria were higher in the pre-eclampsia group (134 micrograms/min) than in the control (9.4 micrograms/min), and PIH groups (10 micrograms/min), (p < 0.05). Uric acid, the marker of glomerular and tubular damage, was higher in the pre-eclampsia group (0.27 mmol/L) than in the control (0.20 mmol/L), and PIH groups (0.24 mmol/L), (p < 0.05). CONCLUSIONS: In pre-eclampsia there is a tubular and glomerular damage to point out by an increased urinary excretion of NAG. In pre-eclampsia, an increase of urinary alpha 1-microglobulin excretion may be considered to be partly due to the overloading of the tubule and partly due to a mixed glomerular and tubular lesion.

[Determination of blood cystatin C in pregnant women during labor and in their newborns]. / Determinazione della cistatina C sierica in gestanti al momento del parto e nei loro neonati.

INTRODUCTION: Human cystatin C is a basic low molecular mass protein (M(r) = 13,359) freely filtered by the glomerulus and almost completely reabsorbed and catabolized by the proximal tubular cells. In this study, we determined maternal and neonatal serum cystatin C levels both in a group of healthy pregnant women and in their newborns over the first five days of life. PATIENTS AND METHODS: Fifty healthy pregnant women, aged from 19 to 40 years, were selected. Newborns (31 males, 19 females) demonstrated the 1-min Apgar score ranging between 8 and 10, and the 5-min between 9 and 10. Their gestational age (GA) ranged between 37 and 43 weeks. Cystatin C was determined by using the cystatin C PET kit (Dako, Milano, Italy). We also determined serum creatinine and urea in all patients by using the Ektachem enzymatic assay (Ortho Diagnostic Division, Milano, Italy). RESULTS: In pregnant women, serum cystatin C was 1.52 +/- 0.39 mg/L, ranging from 0.69 to 2.30 mg/L. Serum creatinine was 58.9 +/- 11.5 mumol/L, and serum urea was 3.117 +/- 0.729 mmol/L. In newborns, serum cystatin C was at birth 2.29 +/- 0.52 mg/L, ranging from 1.17 to 4.84 mg/L. Subsequently, cystatin C significantly decreased over the first five days of life. Serum creatinine was at birth 80.08 +/- 14.26 mumol/L. By using analysis of variance (ANOVA) we found a statistically significant difference between maternal and neonatal cystatin C (p < 0.001) as well as between maternal and neonatal creatinine (p +/- 0.001). However, no correlation has been demonstrated by simple linear regression between maternal and neonatal cystatin C (r = 0.05), while maternal and neonatal creatinine significantly correlated (r = 0.45). CONCLUSIONS: Our preliminary findings suggest that cystatin C does not cross the placental barrier. Thus, in the neonate cystatin C serum levels may solely derived from himself.