Increased erythroferrone levels in malarial anaemia.

We assessed the diagnostic potential of erythroferrone as a biomarker for iron homeostasis comparing iron deficiency cases with anaemia of inflammation and controls. The dysregulation of the hepcidin axis was observed by Latour et al. in a mouse model of malarial anaemia induced by prolonged Plasmodium infection leading to increased erythroferrone concentrations. In line with that, we found significantly higher erythroferrone levels in cases with malaria and anaemia in an African population, compared to asymptomatic controls. Therefore, our findings extend the previous ones of the mouse model, suggesting also a dysregulation of the hepcidin axis in humans, which should be further corroborated in prospective studies and may lay the basis for the development of improved treatment strategies according to ERFE concentrations in such patients.

Exploring the host factors affecting asymptomatic Plasmodium falciparum infection: insights from a rural Burkina Faso study.

BACKGROUND: Asymptomatic Plasmodium falciparum parasitaemia forms a reservoir for the transmission of malaria disease in West Africa. Certain haemoglobin variants are known to protect against severe malaria infection. However, data on the potential roles of haemoglobin variants and nongenetic factors in asymptomatic malaria infection is scarce and controversial. Therefore, this study investigated the associations of iron homeostasis, inflammation, nutrition, and haemoglobin mutations with parasitaemia in an asymptomatic cohort from a P. falciparum-endemic region during the high transmission season. METHODS: A sub-study population of 688 asymptomatic individuals (predominantly children and adolescents under 15 years, n = 516) from rural Burkina Faso previously recruited by the NOVAC trial (NCT03176719) between June and October 2017 was analysed. Parasitaemia was quantified with conventional haemocytometry. The haemoglobin genotype was determined by reverse hybridization assays targeting a selection of 21 HBA and 22 HBB mutations. Demographics, inflammatory markers (interleukins 6 and 10, hepcidin), nutritional status (mid upper-arm circumference and body mass index), and anaemia (total haemoglobin, ferritin, soluble transferrin receptor) were assessed as potential predictors through logistic regression. RESULTS: Malaria parasites were detected in 56% of subjects. Parasitaemia was associated most strongly with malnutrition. The effect size increased with malnutrition severity (OR = 6.26, CI95: 2.45-19.4, p < 0.001). Furthermore, statistically significant associations (p < 0.05) with age, cytokines, hepcidin and heterozygous haemoglobin S were observed. CONCLUSIONS: According to these findings, asymptomatic parasitaemia is attenuated by haemoglobin S, but not by any of the other detected genotypes. Aside from evidence for slight iron imbalance, overall undernutrition was found to predict parasitaemia; thus, further investigations are required to elucidate causality and inform strategies for interventions.

Retrospective validation of a ß-trace protein interpretation algorithm for the diagnosis of cerebrospinal fluid leakage.

BACKGROUND: Cerebrospinal fluid (CSF) leakage is a rare condition that can potentially lead to the development of serious complications. In the last decade, ß-trace protein (ß-TP) has been shown to be a valuable immunological biomarker that allows prompt and non-invasive identification of CSF leakage. At our institution, the measurement of ß-TP has been included in the diagnostic work-up of CSF leakage for more than 10 years. According to our diagnostic algorithm, the presence of CSF in secretion is excluded when ß-TP values are <0.7 mg/L, whereas ß-TP values ≥1.3 mg/L indicate the presence of CSF in secretion. ß-TP values between 0.7 and 1.29 mg/L indicate the presence of CSF if the ß-TP ratio (ß-TP secretion/ß-TP serum) is ≥2. This study aimed to validate this diagnostic algorithm using clinically defined nasal/ear secretions. METHODS: We performed a retrospective statistical analysis of three ß-TP interpretation strategies using data of 236 samples originating from 121 patients with suspect CSF leakage received at our laboratory between 2004 and 2012. RESULTS: The highest odds ratio was obtained when the proposed algorithm has been used for the interpretation of ß-TP results, showing a sensitivity of 98.3% and a specificity of 96%. Positive and negative predictive values were 89.2% and 99.4%, respectively. CONCLUSIONS: Our data suggest that the proposed ß-TP interpretation algorithm is a valuable tool for the diagnosis of CSF leakage in the clinical practice.

Hb Bakersfield (HBA1: c.151_152insGGAGCC): The Insertion of Arg-His Between Codons 49 and 50 of the α1-Globin Chain Leads to Increased Oxygen Affinity.

We describe an insertion variant on the α1-globin gene (HBA1) identified in a 49-year-old woman of Jurassian ancestry presenting with macrocytosis and erythrocytosis. The variant resulted in a peak of 15.5% of the total hemoglobin (Hb) on high performance liquid chromatography (HPLC). Stability and oxygen affinity testing revealed that the variant was stable and had an increased oxygen affinity. Molecular genetic testing detected the heterozygous sequence variant Hb Bakersfield [α50(CE8)His→0; Arg-Ser-His- inserted between 49(CE7) and 51(CE9) of α1; HBA1: c.151_152insGGAGCC (p.Ser50_His51insArgSer)] in the index patient, one of her sons, as well as in two of her grandchildren, who showed a similar hematological pattern.

Increased endothelial microparticles and oxidative stress at extreme altitude.

PURPOSE: Hypoxia and oxidative stress affect endothelial function. Endothelial microparticles (MP) are established measures of endothelial dysfunction and influence vascular reactivity. To evaluate the effects of hypoxia and antioxidant supplementation on endothelial MP profiles, a double-blind, placebo-controlled trial, during a high altitude expedition was performed. METHODS: 29 participants were randomly assigned to a treatment group (n = 14), receiving vitamin E, C, A, and N-acetylcysteine daily, and a control group (n = 15), receiving placebo. Blood samples were obtained at 490 m (baseline), 3530, 4590, and 6210 m. A sensitive tandem mass spectrometry method was used to measure 8-iso-prostaglandin F2α and hydroxyoctadecadienoic acids as markers of oxidative stress. Assessment of MP profiles including endothelial activation markers (CD62+MP and CD144+MP) and cell apoptosis markers (phosphatidylserine+MP and CD31+MP) was performed using a standardized flow cytometry-based protocol. RESULTS: 15 subjects reached all altitudes and were included in the final analysis. Oxidative stress increased significantly at altitude. No statistically significant changes were observed comparing baseline to altitude measurements of phosphatidylserine expressing MP (p = 0.1718) and CD31+MP (p = 0.1305). Compared to baseline measurements, a significant increase in CD62+MP (p = 0.0079) and of CD144+MP was detected (p = 0.0315) at high altitudes. No significant difference in any MP level or oxidative stress markers were found between the treatment and the control group. CONCLUSION: Hypobaric hypoxia is associated with increased oxidative stress and induces a significant increase in CD62+ and CD144+MP, whereas phosphatidylserine+MP and CD31+MP remain unchanged. This indicates that endothelial activation rather than an apoptosis is the primary factor of hypoxia induced endothelial dysfunction.

[Outcome studies with regard to medical laboratory testing]. / Outcome - Studien im Zusammenhang mit Laboranalysen.

Outcome studies and health technology assessment and appraisals have become more and more prominent in regard to the utility of laboratory testing in clinical medicine. In the past years many valuable and useful studies have been published that demonstrate an increasing value of laboratory testing in a variety of clinical situations or for a good number of disease diagnosis and monitoring. An excellent outcome using laboratory testing can only be achieved when the tests (methods) have an outstanding performance in terms of sensitivity, specificity, imprecision and robustness. Further, not only has the test per se to be outstanding, it is also of uttermost importance that the clinical setting, in which the test is performed, fits and that the preanalytic requirements are fulfilled as well as that the statistical rules are followed. The laboratory test has to be incorporated into an integrated approach respecting in a weighted attempt as many as possible aspects of health care.

Detection of germline rearrangements in patients with α- and ß-thalassemia using high resolution array CGH.

Approximately 80% of α-thalassemia mutations are deletions in the α-globin cluster on chromosome 16 and about 10% of ß-thalassemia mutations are deletions in the ß-globin gene cluster on chromosome 11. Larger deletions involving the ß-globin gene cluster lead to (δß)-, (γδß)-, (εγδß)-thalassemia, or hereditary persistence of fetal hemoglobin (HPFH). Array comparative genomic hybridization (CGH) was applied to screen for deletions in the α- and ß-globin gene clusters not detected by routine gap-PCR. In total, in 13 patients with hypochromia and inclusion bodies (IBs) the α-globin gene cluster was analyzed and in 13 patients with increased fetal hemoglobin levels with or without hypochromia the ß-globin gene cluster was examined. All samples were subsequently investigated by multiplex ligation-dependent probe amplification (MLPA). In 9 out of 13 patients deletions of the α-globin gene cluster were identified; 5 of these deletions remove the entire α-globin cluster and extend to the telomere. Additional sequencing of the remaining 4 patients revealed polyadenylation mutation in 1 of them. 7 deletions were identified in the ß-globin gene cluster in 13 patients. Additional sequencing of the remaining 6 patients revealed mutations in one of the γ-globin gene promoters in 3 of them and a KLF1-mutation in 1 of them. Array CGH is a reliable method to screen for deletions in thalassemia and hemoglobinopathy. The method offers the advantage of a high resolution with the possibility to characterize breakpoints on sequence level.

Angioedema: patients experience and treatment relief.

Angioedema is defined as a swelling of the skin, mucosa and submucosa of the respiratory tract. It may also impair the intestinal epithelium and other mucous membranes. It can be potentially life-threatening if the upper respiratory tract is involved. In these cases emergency treatment is often required in particular if the pharynx and larynx are swollen. Beside the well-known etiologies of allergic angioedema, many forms of nonallergic angioedema are known and in the majority of these forms increased plasma and tissue concentrations of bradykinin play a critical role.

Reduced expression by SETBP1 haploinsufficiency causes developmental and expressive language delay indicating a phenotype distinct from Schinzel-Giedion syndrome.

BACKGROUND: Mutations of the SET binding protein 1 gene (SETBP1) on 18q12.3 have recently been reported to cause Schinzel-Giedion syndrome (SGS). As rare 18q interstitial deletions affecting multiple genes including SETBP1 correlate with a milder phenotype, including minor physical anomalies and developmental and expressive speech delay, mutations in SETBP1 are thought to result in a gain-of-function or a dominant-negative effect. However, the consequence of the SETBP1 loss-of-function has not yet been well described. METHODS: Microarray-based comparative genomic hybridisation (aCGH) analyses were performed to identify genetic causes for developmental and expressive speech delay in two patients. SETBP1 expression in fibroblasts obtained from one of the patients was analysed by real-time RT-PCR and western blotting. A cohort study to identify nucleotide changes in SETBP1 was performed in 142 Japanese patients with developmental delay. RESULTS: aCGH analyses identified submicroscopic deletions of less than 1 Mb exclusively containing SETBP1. Both patients show global developmental, expressive language delay and minor facial anomalies. Decreased expression of SETBP1 was identified in the patient's skin fibroblasts. No pathogenic mutation of SETBP1 was identified in the cohort study. CONCLUSION: SETBP1 expression was reduced in a patient with SETBP1 haploinsufficiency, indicating that the SETBP1 deletion phenotype is allele dose sensitive. In correlation with the exclusive deletion of SETBP1, this study delimits a milder phenotype distinct from SGS overlapping with the previously described phenotype of del(18)(q12.2q21.1) syndrome including global developmental, expressive language delay and distinctive facial features. These findings support the hypothesis that mutations in SETBP1 causing SGS may have a gain-of-function or a dominant-negative effect, whereas haploinsufficiency or loss-of-function mutations in SETBP1 cause a milder phenotype.

Homozygous nonsense mutation in WNT10B and sporadic split-hand/foot malformation (SHFM) with autosomal recessive inheritance.

Split-hand/foot malformation (SHFM) is a limb malformation affecting the central rays of the hands and/or feet. Isolated SHFM occurs within families but more often sporadically. Since most families with more than one patient show dominant inheritance with reduced penetrance, sporadic SHFM is generally considered to be due to dominantly inherited new mutations. Recently, recessive inheritance of SHFM was proposed in a highly consanguineous family with a homozygous missense mutation in WNT10B. Nevertheless, the assumption of a second locus was necessary to explain the observed phenotypes in this family. To date, no other family and no case of sporadic SHFM with WNT10B mutations are known. By examining WNT10B in a patient with sporadic SHFM, we identified a homozygous 4-bp duplication resulting in a premature termination codon. Nine heterozygous relatives show no sign of SHFM. These findings have profound implications for genetic counseling. Obviously, sporadic SHFM may show recessive rather than dominant inheritance resulting in a 25% recurrence risk for sibs instead of a very low-recurrence risk as generally presumed. Likewise, there is a very low-recurrence risk for offspring of patients (unless there is consanguinity) instead of an estimated risk between 30% and 50%. It can be concluded that sporadic SHFM is not always a dominant trait. To determine the recurrence risk, patients affected with sporadic SHFM should be tested for mutations in WNT10B.

Deletion of 7q11.21-q11.23 and infantile spasms without deletion of MAGI2.

We report on the clinical and cytogenetic findings and on the array-based characterization of an interstitial 7q11.21-q11.23 deletion initially recognized by standard karyotyping in a 15-month-old female patient. Beginning at the age of 3 months and 2 weeks the patient had severe infantile spasms. Recently, it was reported that infantile spasms are associated with deletion of the MAGI2 gene on chromosome 7q11.23. Nevertheless, not all patients reported with deletions of MAGI2 developed infantile spasms and at least one reported patient with a deletion 7q11.23 without missing the MAGI2 gene was diagnosed with infantile spasms. Molecular karyotyping of our patient confirmed a large 13 Mb deletion encompassing the 7q11.21-q11.23 region without involvement of MAGI2. Critical review of published data and the results of our patient underline the importance to map precisely the deletion boundaries of further patients to reevaluate the significance of MAGI2 hemizygosity in the pathogenesis of infantile spasms.

Interstitial deletion 1q42 in a patient with agenesis of corpus callosum: Phenotype-genotype comparison to the 1q41q42 microdeletion suggests a contiguous 1q4 syndrome.

Interstitial deletions of 1q4 are rare and present with different deletion breakpoints and variable phenotype. We report on the clinical and molecular cytogenetic findings in a girl with minor anomalies, midline defects including prenatally ascertained agenesis of the corpus callosum, epilepsy and developmental delay. A de novo 5.45 Mb deletion almost exclusively located within 1q42 was found to cause this phenotype, which shows significant overlap with the microdeletion 1q41q42 syndrome reported in a few patients except for the agenesis of the corpus callosum. However, deletions in patients with the 1q41q42 syndrome mainly extend into the 1q41 region with a region of overlap including the DISP1 gene involved in the SHH pathway, which is not part of the 1q42 deletion in our patient. We suggest that an interaction of genes involved in pathways of embryonic development rather than haploinsufficiency of single genes in the so-called critical regions is causing complex malformation syndromes due to cytogenetic microaberrations in the 1q4 region.

A new stable alpha chain variant: Hb Basel [alpha14(A12)Trp-->Leu (alpha1)].

We describe a heterozygosity for a new missense mutation on the alpha1-globin gene of an 18-year-old woman of Portuguese ancestry with severe hypochromic anemia and iron deficiency. Hemoglobin (Hb) analysis by high performance liquid chromatography (HPLC) found a prominent peak constituting about 12% of total Hb. Sequencing of the globin genes of the index patient found the mutation alpha14(A12)Trp-->Leu (alpha1), HBA1:c.44G

Familial 14.5 Mb interstitial deletion 13q21.1-13q21.33: clinical and array-CGH study of a benign phenotype in a three-generation family.

We report on the clinical and cytogenetic findings as well as the array-based characterization of an interstitial familial 13q21 deletion initially recognized by standard karyotyping. Although 13q deletions are known to imply a wide variability of clinical consequences, the deletion carriers of the familial deletion in three generations did not reveal a relevant phenotype. The breakpoints and the deletion size in all three carrier individuals were determined by molecular karyotyping confirming a large 14.5 Mb deletion encompassing the 13q21.1-13q21.33 region identical in all three carriers. Gene paucity and the lack of dosage-sensitive genes in the delineated region might explain the apparently innocuous nature of this chromosomal anomaly. The example of this family presents evidence for describing the chromosomal region 13q21.1-13q21.33 as a large euchromatic variant or benign copy number variation without phenotypic consequences. Our data underline the importance of a phenogenetic approach combining clinical and laboratory evidence in the interpretation of segmental chromosomal anomalies especially in genetic counseling related to prenatal diagnosis.

Body mass index, blood pressure, and serum cholesterol in young Swiss men: an analysis on 56784 army conscripts.

QUESTIONS UNDER STUDY: This study aimed to investigate the prevalence of excess bodyweight and high blood pressure in young Swiss men and to evaluate the associations of these disorders with serum cholesterol in this important population. METHODS: The study investigated a large cohort of 56784 Swiss army conscripts aged 18-25 years from 2004 through to 2007. RESULTS: From the investigated men, 2231 (3.9%) were underweight with a body mass index (BMI) <18.5 kg/m2, 42681 (75.2%) were normal weight (BMI 18.5-24.9 kg/m2), 9562 (16.8%) were overweight (BMI 25.0-29.9 kg/m2), and 1811 (3.2%), 402 (0.7%) and 96 (0.2%) had obesity classes I, II or III, respectively. The prevalence of blood pressure within the hypertensive range significantly increased through these categories of BMI (12.5%, 23.9%, 37.6%, 49.7%, 56.7%, and 54.2%), as did serum levels of cholesterol (3.8 +/- 0.6, 4.0 +/- 0.7, 4.4 +/- 0.8, 4.7 +/- 0.9, 4.7 +/- 0.9, and 4.8 +/- 1.1 mmol/l). Serum cholesterol also increased through categories of blood pressure (4.0 +/- 0.7 mmol/l in normotensive subjects and 4.1 +/- 0.7, 4.2 +/- 0.8, and 4.5 +/- 0.9 in those with blood pressure in the ranges of pre-hypertension, and hypertension stages 1 and 2, respectively); excess body weight and blood pressure in the hypertensive range were associated with serum cholesterol in a mutually independent manner. CONCLUSIONS: Prevalence rates of excess bodyweight and of elevated blood pressure are high in young Swiss men, and these entities are strongly interrelated. Excess body weight and high blood pressure are independently associated with high serum cholesterol in this population. Excess bodyweight and associated risk factors should receive increased attention in young Swiss men.

Stability of hematological analytes depends on the hematology analyser used: a stability study with Bayer Advia 120, Beckman Coulter LH 750 and Sysmex XE 2100.

AIM: With the availability of newer hematology analysers, novel measurement techniques are being introduced into daily routine. As analyte stability may differ according to the employed measurement technique, the aim of this study was to assess the stability of hematologic analytes on different hematology analysers. METHODS: We investigated the effect of storage time and storage temperature on sample stability on three newer analytical systems (Advia 120, Bayer Diagnostics; XE 2100, Sysmex and LH 750, Beckman Coulter). Samples were obtained from 64 healthy volunteers and stored at room temperature as well at 4-8 degrees C in order to conduct analysis at different timepoints up to 72 h after blood was drawn. Sample stability was assessed by the graphical truncated normal sequential test. A parameter was considered stable, when its average change was smaller than one coefficient of variation CV (%) of the assessed method, allowing a 5% risk of error. RESULTS: Red blood cell counts, mean corpuscular hemoglobin (MCH) and hemoglobin are least affected by storage temperature and showed stability for at least 48 h, depending on analyser utilized. While reticulocytes, mean corpuscular volume (MCV), hematocrit and leukocyte counts were more stable at 4-8 degrees C, thrombocytes exhibited a better stability at RT. The white blood cell (WBC) subpopulations changed over time with a decrease in eosinophils and lymphocytes and an increase in neutrophils at 4-8 degrees C. Further, the stability pattern of WBC subpopulations was significantly different among the 3 investigated analysers with some analytes only displaying a stability of 4 h. CONCLUSIONS: Analyte stability of hematological parameters varies not only according to the investigated parameter but also according to storage temperature and the employed measurement system. Depending on the analyte sample stability differences among the different analytical systems are considerable.

[Improved sensitivity in detecting renal diseases by combined urinanalysis (proteins and cellular components)]. / Verbesserte Sensitivität bei Nieren- und Harnwegserkrankungen durch Kombination von Teststreifen, automatisiertem bzw. standardisiertem Urinsediment und differenzierter Proteinbestimmung im Urin.

New technologies and methods allow better diagnosis of renal and urinary tract diseases. On one hand the safe handling of renal biopsies and on the other hand the precise measurement of test strips and urinary sediment analysis obtained by automatic reading devices, flow cytometry (UF-100) or video imaging (Iris) and/or the cost effective cell chamber systems (KOVA), and the measurement of cystatin C in the serum and the differentiated protein analyses in urine, make possible earlier and better diagnoses. The exclusive analyses of the traditional urinary sediment and creatinin values are considered not being sufficient to exclude a renal disease. The follow-up with precise values allow for early intervention in case of failure of therapy (i.e. urinary tract infection) or deterioration of an underlying disease.

[Selective application of tumor markers PSA]. / Gezielter Einsatz des Tumormarkers PSA.

UNLABELLED: Tumor markers are being used in the early detection of cancer disease, diagnostics, prognosis, therapy and disease follow-up. A lot of clinical studies would not be nowadays possible without tumor markers. As in clinical practice the informative value of results is limited (by limited sensitivity and/or specificity) those markers should be selectively used, i.e. in such clinical setting where there is a clear benefit. Prostate specific antigen (PSA) has become the most important tumor marker in oncology. Its importance ranges from early detection of prostate cancer until therapy decision making in hormone refractory cancer. To prevent initial PSA- "terrorism" in early detection the patient must be well informed about risk of prostate cancer and therapeutic options inclusively possible side effects. Does the man at risk agree further evaluation by biopsy has to be performed directly above a PSA-cut-off 4.0 ng/ml. A high percentage of free PSA is not allowed to prolong diagnostic procedure. On the opposite, in PSA range 3.0-3.9 ng/ml and free-to-total PSA ratio less than 12% a prostate biopsy is also indicated. The diagnostic "grey zone" 4.0-10 ng/ml does not exist any more. Further follow-up should be done if the estimated life expectancy exceeds 10 years and should be performed in the PSA-range 2.0-3.9 ng/ml annually, in the PSA-range 1.0-1.9 ng/ml biannually and in the PSA range less that 1.0ng/ml triennially. About 3-25% of newly detected cancers are clinically insignificant. Models based on PSA, Gleason Score and tumor load of biopsies are helpful in identifying these men for "active surveillance" in curative intent. IN CONCLUSION: "Not every early detected cancer must be cured, but cancer where cure is necessary, must be early detected!" After primary therapy (operation/radiotherapy) one third of men will document a PSA only relapse. 30% of them will develop clinical symptoms and possible die from disease. PSA and especially PSA doubling time is a promising marker to identify these men at risk for whom salvage-radiotherapy, salvage prostatectomy or hormonal therapy can be an option. However the benefit in survival must be weight against a possible loss in quality of life.

[Old and new iron parameters in iron metabolism and diagnostics]. / Alte und neue Eisenparameter - Bedeutung im Eisenstoffwechsel und in der Diagnostik.

Iron is an element which is essential to life but also potentially toxic. Therefore, clever mechanisms exist in the human body for uptake, transport and storage of iron. Hepcidin, which seems to be the master protein for regulation of intestinal iron absorption, is known for a short time. The expression of hepcidin is not only influenced by iron levels but also by mediators of inflammation and growth factors of erythropoiesis. Hence hepcidin plays also a crucial role in the development of anemia of chronic disease and iron overload due to ineffective erythropoiesis. Serum ferritin is a reliable parameter to estimate the storage iron. It is an acute phase protein which is elevated during infections and inflammations, though. In these situations, measurement of soluble transferrin receptors is a useful tool to differentiate between iron deficiency and anemia of chronic disease. Newer parameters as erythrocyte zink protoporphyrin or percentage of hypochromic erythrocytes (%HYPO) are suited to detect a functional iron deficiency. Early diagnosis of iron overload is essential to prevent organ damage. Serum ferritin and transferrin are useful parameters to screen for iron overload. If no clear reason for a secondary iron overload can be found, the search for a hereditary haemochromatosis is recommended. Most of these hereditary haemochromatoses are a result of mutations in the HFE gene (homozygous state for Cys282Tyr or compound heterozygosity for Cys282Tyr/ His63Asp) which can be detected by PCR technique. Liver biopsy is still the gold standard for quantification of storage iron. However, a method of increasing importance for quantification of iron overload is magnetic resonance imaging with new approaches as for example T2*.