Types and Frequency of Errors in the Pre-Analytical Phase in the Clinical Laboratory - Single Center Study from Bosnia and Herzegovina.

BACKGROUND: The pre-analytical phase, which includes all preparatory actions to the analytical procedure, is part of the process during which there is the greatest possibility of laboratory errors. This study was conducted to investigate the frequency and types of laboratory errors during work in the clinical laboratory as well as the frequency and types of laboratory errors in the pre-analytical phase of laboratory work. METHODS: The retrospective, descriptive study covered the period from 01/01/2016 to 12/31/2016 within which the presence of 5 different indicators of quality of work, i.e., pre-analytical errors, was monitored: improperly drawn blood, coagulated blood sample, hemolyzed blood sample, improperly marked referral for analysis, and insufficient sample for analysis. RESULTS: The most common error in the pre-analytical phase of our study was "coagulated sample", followed by: "improperly drawn blood", "improperly marked referral", "insufficient sample for analysis", and "hemolyzed sample". Using the chi-squared test, a statistically significant difference was found in the frequency of occurrence of certain types of indicators in different departments (p < 0.005). CONCLUSIONS: Reduction of these errors can be achieved through analyzing and correcting the reasons for them, education, and by joint action of experts and international organizations, continual training of staff as well as to following the adopted guidelines and standards.

Determination of Six Sigma Metric in Control of Enzymes Determination in Human Serum.

BACKGROUND: Clinical Chemistry is the backbone of medical treatment, diagnostics, and prevention. The laborato-ries are trying to improve the quality and to reduce diagnostic errors and processing time and safeguard trace-ability of all laboratory procedures to ensure patient safety. Six sigma belongs to statistical quality control and provides a new methodology for measuring and improving process performance in laboratory. METHODS: Activities of AST, ALT, CK, LDH, Amy, and γ-GT were determined by standard kinetic methods on a Vitros 5600 biochemistry analyzer. Two daily quality controls (Verifier I and Verifier II) were run over 60 days. Total percent CV was calculated from routine daily QC. Between-instrument bias was also calculated from daily QC. RESULTS: The calculated sigma metrics for AST were 6.9 and 3.8; for ALT 9.3 and 5.6; for CK 6.6 and 5.3; LDH 5.2 and 5.2; for γ-GT 4.9 and 2.7; and for amylase 8.7 and 7.1. Analytical performance for AST, ALT, CK, LDH, and Amylase is world class. On the other hand, γ-GT analytical performance is poor. CONCLUSIONS: Six Sigma benefits from earlier quality management approaches that creates new challenges for medical laboratories.

Interpretation of Erythropoietin and Haemoglobin Levels in Patients with Various Stages of Chronic Kidney Disease.

BACKGROUND: The production of erythrocytes is regulated by the hormone erythropoietin (EPO), which maintains the blood haemoglobin (Hb) levels constant under normal conditions. Human EPO is a glycoprotein hormone and its synthesis is controlled by the hypoxia-inducible transcription factor. The aim of this study was to establish EPO and Hb levels in patients with chronic kidney disease (CKD), as well as in control subjects, and to investigate the relationship between these parameters. METHODS: This cross-sectional, observational study included 356 subjects with CKD divided into 4 subgroups according to their glomerular filtration rate (GFR). The control group consisted of 206 age and sex matched healthy subjects with GFR rate ≥90 mL/min/1.73 m2. EPO, Hb and serum creatinine levels were determined by using immunochemical and spectrophotometric methods. GFR was determined using the MDRD formula. RESULTS: The CKD patients had significantly lower levels of haemoglobin (p<0.0005) and hematocrit (p<0.0005) compared to control group. Our results showed that Hb levels decreased, whereas serum creatinine increased with the increasing renal failure. The CKD patients in all four groups had significantly lower (p<0.0005) Hb levels, and significantly higher (p<0.0005) creatinine levels compared to the control group. The median EPO in group I and II were significantly higher (p=0.002; p=0.018), while median EPO in group III and IV were significantly lower (p=0.03; p=0.011) compared to the control group. CONCLUSIONS: In patients with CKD, GFR positively correlated with Hb and EPO, while the correlation between GFR and serum creatinine was negative.

ELISA Test for Analyzing of Incidence of Type 1 Diabetes Autoantibodies (GAD and IA2) in Children and Adolescents.

INTRODUCTION: Anti GAD (antibodies on glutamic acid decarboxylase) and anti-IA2 antibodies (against tyrosine phosphatase), today, have their place and importance in diagnosis and prognosis of Type 1 diabetes. Huge number of patients with diabetes mellitus type 1 have these antibodies. Insulin antibodies are of critical importance in diagnosis of diabetes mellitus type 1 for pediatric population. MATERIALS AND METHODS: During 2014, the samples of 80 patients from Clinical Center University Sarajevo (CCUS) Pediatrics clinic's, Endocrinology department were analyzed on anti-GAD and IA2 antibodies. The samples of serums of all patients were analyzed with ELISA tests using Anti GAD ELISA (IgG) kites from EUROIMMUN company. These are quantitative in vitro tests for human antibodies against decarboxylase of glutamine acid (GAD) and IA2, in serum or EDTA plasm. RESULTS: During the period of one year, in CCUS's Organizational unit, Institute for Clinical Immunology, 80 samples of patients with anti GAD and IA2 antibodies were analyzed. Out of total number of samples, 41 were male patients, or 51% and 39 female, or 49%. The youngest patient was born in 2012, and the oldest in 1993. Age average was represented by the patients born in 2001. Share of positive results for IA2 antibodies and GAD antibodies was 37% for IA2 antibodies, and 63% for GAD antibodies. DISCUSSION: During an autoimmune - mediated Diabetes mellitus type 1 leads to T-cell mediated destruction of beta cells of pancreatic islets, reduced production of insulin and glucose metabolism. Studies have shown that these bodies are the most intense single marker for identifying persons with increased risk for diabetes development.

The Relation of Erythropoietin Towards Hemoglobin and Hematocrit in Varying Degrees of Renal Insufficiency.

INTRODUCTION: Hypoxia is a basic stimulant in production of erythropoietin (EPO). The primary function of erythrocytes is the transport of oxygen to tissues. Erythropoietin stimulates erythropoiesis which leads to increased production of erythrocytes- their total mass. This increases the capacity of the blood to carry oxygen, reduces the hypoxic stimulus and provides a negative feedback of stopping EPO production. The aim of this study was to establish a quantitative relationship between the concentration of erythropoietin, hemoglobin and hematocrit in different values of renal insufficiency. MATERIAL AND METHODS: The survey was conducted on 562 subjects divided into two groups: with and without renal insufficiency. EPO, hemoglobin, hematocrit, serum creatinine and additional parameters iron, vitamin B12, and folic acid were determined by using immunochemical and spectrophotometric methods and glomerular filtration rate (GFR) was calculated as well. RESULTS: EPO values (median) grow to the first degree of renal insufficiency, as compared to EPO values of healthy subjects, this increase is statistically significant, p=0.002. With further deterioration of renal function the values of EPO between all pathological groups are decreasing, and this decrease is statistically significant between first and second degree of renal insufficiency (RI) p<0.001. In the group of healthy subjects EPO is correlated rho = -0.532, p <0.0005 with hematocrit. The correlations are negative and strong and can be predicted by regression line (EP0 = 41.375- Hct * .649; EPO = 61.41-Hb * 0.355). In the group of subjects with the first degree of renal insufficiency EPO is in correlation with hematocrit rho=-0.574, p<0, 0005. It is also correlated with hemoglobin rho=-0.580, p< 0.0005. The correlation is negative (EP0= 42.168- Hct * 0.678). In the group of subjects with the third degree of renal insufficiency EPO is in correlation with hemoglobin rho=0.257, p=0.028. The correlation is medium strong and positive. In the group of subjects with third and fourth degree of renal insufficiency EPO is not in correlation with hemoglobin and hematocrit p>0.05. CONCLUSION: Renal dysfunction, depending on the level of RI effects differently on the biosynthesis of EPO in a diseased kidney, and consequently it also has a different effect on biosynthesis of HB in bone marrow and its content in the blood.

Immunophenotype lymphocyte of peripheral blood in patients with psoriasis.

INTRODUCTION: Regulatory T cells (Treg) play a central role in the immunopathogenesis of psoriasis. Immunoregulatory T cells (Tregs) are involved in important homeostatic mechanism for maintaining tolerance and preventing autoimmunity, and autoimmune diseases. The aim of this study was to examine the role of Tregs cells in the pathogenesis of psoriasis, and determine the range value for Treg cells (CD4+ CD25+) in the peripheral blood of patients with psoriasis compared to the severity of disease. MATERIAL AND METHODS: The study included 51 patients diagnosed with psoriasis and 25 healthy individuals. Phenotype profile of peripheral blood lymphocytes was determined by flow cytometry, and assessment of severity of disease was determined on the basis of PASI score (e.g. Psoriasis Area and Severity Index). RESULTS: Proportion of CD4+CD25+T cells in the control group was significantly higher than in the patients with psoriasis [6,4% ±(5,4-7,6) vs. 4,1% (3,1 -5,8)-Mann-Whitney U test, p <0.001]. In the present study we did not find a statistically significant correlation between the levels of CD4+CD25+cells, in patients with psoriasis, compared to the severity of disease-PASI. (i.e. Pearson correlation, r = 0.197, p = 0.194). CONCLUSION: The stratification of patients, according to the severity of the clinical course was not possible on the basis of Treg cells' level. ROC curve analysis of the optimal cutoff (PASI=10) and the CD4+CD25+, which distinguishes between patients and healthy individuals was 5% of CD4+CD25+ of the total number of CD4+ lymphocytes with specificity of 69% and sensitivity of 84%.

Assessments of the socioeconomic status and diet on the prevalence of dental caries at school children in central bosnian canton.

AIM: The main aim of this research was to determine the influence of socioeconomic status and residence/living conditions on the status of oral health (e.g. health of mouth and teeth) in primary school students residing in Canton Central Bosnia. METHODS: The study was designed as a cross-sectional study. Our research included two-phased stratified random sample of 804 participants. The quantitative research method and newly designed survey instrument were utilized in order to provide data on the oral health of the examined children. The alternate hypothesis foresaw that "there were significant statistical differences between the levels of incidence of dental caries in comparison to the incidence in children of different socioeconomic status. RESULTS: The Chi square () of 22.814, degree of freedom (Df) = 8, coefficient of contingency of 0.163 and T-test (Stat) of-0.18334 showed that there were no significant statistical differences at p < 0.05 level between the primary school children from urban and rural areas. The obtained results showed that the caries indexes in elementary schools in Central Bosnia Canton were fairly uniform. Research showed that there were a difference in the attitudes towards a regular dental visits, which correlated with social-educational structure of the children's' families. CONCLUSION: According to the results, we can see that the socioeconomic status of patients had an effect on the occurrence of dental caries and oral hygiene in patients in relation to the rural and urban areas, because we can see that by the number of respondents, the greater unemployment of parents in both, rural and urban areas, caused a host of other factors, which were, either, directly or indirectly connected with the development of caries.

Financial aspects and the future of the pharmaceutical industry in the United States of america.

INTRODUCTION: The U.S. pharmaceutical industry is defined by the U.S. Census Bureau as "companies engaged in researching, developing, manufacturing and marketing of medicines and biological for human or veterinary use". Besides its main role in improving human health, the US pharmaceutical industry represents one of the most critical, key decision makers' lobbying prone and competitive sectors in the economy. The cost in the environment of very limited government price regulation remains one of the major problems fuelling aggregate health care cost inflation. Pharmaceuticals have created huge benefits for public health and economic productivity by the means of saving lives, increasing life expectancy, reducing illness related suffering, preventing surgeries and decreasing hospital stays. PURPOSE: The goal of this review paper is to show the present conditions and future trends of the pharmaceutical industry in the U.S. METHODOLOGY: THIS PAPER REPRESENTS A THOROUGH LITERATURE REVIEW OF THE MULTIFACETED SOURCES INCLUDING: studies, books, peer reviewed journals, U.S. government sources (i.e. U.S. Census Bureau, U.S. Bureau of Economic Analysis, etc.). DISCUSSION: In the thirty years pharmaceutical companies have consistently developed and launched new medicines, bringing hope to sick or - at risk patients. They also usually provide above the average financial returns for its shareholders. U.S. pharmaceutical companies had as their goal to discover blockbuster drugs. Blockbuster drugs are generally defined as drugs that solve medical problems common to hundreds of millions of people and, at the same time generate large sales increases and profits for the pharmaceutical companies. The main approach of these companies includes huge investments in research and development (R&D), innovation, marketing and sales. The trend analysis shows that for the most part the era of blockbuster drugs is nearing an end. CONCLUSION: Numerous blockbuster drugs will be coming off patent in the next few years, opening the way to generics and eliminating a major source of the industry's profits. Still, there is plenty of room for improvement in the medications people take while there is no shortage of human suffering to alleviate. It is doubtful whether big pharmaceutical firms will be able to pursue these goals within the old model of developing exclusive new drugs that can be sold further in the future. In the past, medicines for the ailments that were never before addressed, like anti-cholesterol or anti-depression drugs were developed. Currently, and in the future, it is expected that only blockbuster modifications will be developed. This phenomenon is expected to create market saturation, which will significantly reduce profits. The business model that drove the major drug makers' success is not working anymore. Pharmaceutical companies must create new ways and to bring new ideas. The survivors will be those that market strategies supported by innovative approaches and winning capabilities.

The effects of dipeptidyl peptidase-4 inhibitors in treatment of obese patients with type 2 diabetes.

INTRODUCTION: Dipeptidyl peptidase-4 (DPP-4) inhibitors are a new class of antihyperglycemic drugs that block degradation ofincretin hormones. GOAL: To assess the effects oftreatment with DPP-4 inhibitors on glucoregulation and body weight in obese patients with type 2 diabetes mellitus. PATIENTS AND METHODS: The study included 9 females and 9 males with type 2 diabetes (n=18), BMI=31.24 +/- 2,26 kg/m2, mean age 58 +/- 6,8 years. The patients have been thoroughly evaluated before treatment, and 6 months after treatment with DPP-4 inhibitor (sitagliptin) in combination with metformin. RESULTS: After 6 months of treatment with DPP-4 inhibitors in combination with metformin HbAlc (-1,49%)., FBG (-3.75 mmol/L) and PBG (-5.79 mmol/L) significantly reduced (p=0.000). Mean body weight also significantly reduced (-12.5%; p=0.000). Reduction of mean fasting insulin was 5.46 mIU/L or 27% (p=0.000). Mean HOMA-IR change was -1.64 (p=0.000). Also there was significant decreasing of systolic blood pressure (p=0.001), cholesterol (p=0.004), triglycerides (p=0.001), LDL (p=0.002) and increasing of HDL (p=0.002). Hypoglycaemia was not registered in any of the patients. CONCLUSION: These results show that in obese patients with type 2 diabetes, DPP-4 inhibitors treatment in combination with metformin was associated with improvements in glycaemic control, and a reduction in body weight.

Detection methods of immunoglobulin IgG in CSF and serum.

INTRODUCTION: This study represents a new approach to the extended analysis of correlation of findings of oligoclonal bands on gels and the level of intrathecal synthesis of immunoglobulin G in the central nervous system. Previous studies have shown that there is no correlation at this level as well as the number of tape or finding does not correlate with the forecast effect of therapy or patient outcome. AIMS OF THE STUDY: To determine the correlation of level of immunoglobulins IgG in CSF with the number of oligoclonal bands on the gel. MATERIAL AND METHODS: The retrospective study based on data processed in Clinical Immunology Clinical Center University of Sarajevo. Patients were assumed of multiple sclerosis according to clinical findings and magnetic resonance imaging. All CSF and serum samples were processed by nephelometry, isoelectric focusing on the gel. Statistical analysis of results was also performed by using SPSS statistical analysis program. RESULTS: Analyses were performed on 254 samples of cerebrospinal fluid and serum of patients from neurological clinic, suspected of multiple sclerosis. We concluded that there is no correlation between the level of intrathecal synthesis obtained by Reibergram with the number of oligoclonal bands on gels. We think that the reason could be a small sample of patients analyzed and it leaves room for future analysis on a larger sample. DISCUSSION AND CONCLUSION: For most patients with established MS we found intrathecal humoral response, type two, and the number and arrangement of IgG bands generally does not change during the disease, because they reflect long-term non-specific immune stimulation rather than a specific immune response that during infectious disease changes (quantitatively and qualitatively).

Reibergram and oligoclonal bands in diagnosis of multiple sclerosis.

INTRODUCTION: In this study authors have analyzed the correlation between the IgG immunoglobulins in cerebrospinal fluid and the findings of oligoclonal bands on gel. Immunoglobulin IgG in cerebrospinal fluid (CSF) can be detected in neurological diseasses (infections and inflammatory neurological diseases and in demyelinating diseases, like multiple sclerosis (MS)). Quantitative IgG in CSF can be expressed by different formulae Reiber (Reiber and Felgenhauer 1987), Tourtellotte (Tourtellotte 1970), Schuller (Schuller and Sagar 1983) and IgG Index (Link and Tibbling 1977). In this study we used Reibergram. Qualitative CSF IgG can be measured by electrophoresis and isoelectric focusing (IEF). We used IEF for analysig CSF and seum because of its higher sensitivity. AIMS OF THE STUDY: To determine the correlation of immunoglobulins IgG positivity in CSF with the finding of oligoclonal bands on the gel. MATERIAL AND METHODS: The retrospective study based on data processed in OJ Clinical Immunology KCUS. Patients were suspicious of multiple sclerosis according to clinical findings and magnetic resonance imaging. All CSF and serum samples were processed by nephelometry, isoelectric focusing on the gel. Statistical analysis of intrathecal synthesis was also performed according to Reibergram. RESULTS: Analyses were performed on 76 samples of cerebrospinal fluid and serum of patients from neurological clinic, suspected of multiple sclerosis. We received following results: 42 samples tested had type 1.25 samples tested showed type 2.3 samples had type 3.5 samples had type 4.1 sample had a fifth type. When we compare these results with values obtained by intrathecal synthesis of which is determined by Reibergram we obtained the following values: 16 samples had intrathecal synthesis of 20%-60%, 9 samples had a negative value of intrathecal synthesis of 10% or less. DISCUSSION AND CONCLUSION: For most patients with established MS we found intrathecal humoral response, type two, and the number and arrangement of IgG bands generally does not change during the disease, because they reflect long-term non-specific immune stimulation rather than a specific immune response that during infectious disease changes (quantitatively and qualitatively).

Serum lipids and lipoproteins among students of the University of Sarajevo.

INTRODUCTION: This study researched the distribution of desirable, borderline and high-risk values of certain lipid status parameters in healthy young individuals. AIM: The purpose of this study was to research the statistical distribution of desirable, borderline and high-risk values of certain lipid status parameters in healthy young individuals (i.e. medical university students). MATERIAL AND METHODS: In this research we tested 112 students studying at the University of Sarajevo, of both genders and 20-30 years of age. RESULTS: Total serum cholesterol was minimally elevated in 7.1% of tested students, elevated with high risk in 2.7% and triglycerides were minimally elevated in 1.8%. Presence of elevated LDL cholesterol was found to be 2.7% minimally and 1.8% with high risk. HDL cholesterol was minimally decreased in 1 tested student. DISCUSSION: Standard biochemical methods were used to determine the values of total cholesterol, triglycerides and HDL-cholesterol. The level of LDL cholesterol was also calculated. CONCLUSION: Our results point to the need for performing gradual laboratory diagnostic procedures for routine check-ups of university students.

Financial aspects of the immunosuppressive therapy.

INTRODUCTION: In this study the authors have analyzed the costs associated with the immunosuppressive therapy in patients who underwent organ transplantation in two countries: the United States of America and Bosnia and Herzegovina (i.e. the entity Federation B&H). AIMS OF THE STUDY: The goal of this paper is to compare and contrast the costs of the immunosuppressive therapy in two countries against the total costs of the organ transplantation. Further, the costs, dosages and effectiveness of the particular types of immunosuppressant were also analyzed. Problem of the Study: Immunosuppressive medications are essential in preventing kidney transplant rejection. Most available pharmaco-economic information to date is for induction and maintenance therapies, while the data on the financial impacts of the rejection are still limited. Immunosuppressive regiments are expensive in the socio-economic environment of limited resources and constraints. MATERIAL AND METHODS: This academic article has utilized the publicly available sources of information from the Federation Entity of B&H, (i.e. Federal Department of Insurance and Reinsurance) in period 2006 to 2010, as well as peer-reviewed academic articles, books, private and government data from the United States of America from 2006 to 2010, including projections for 2011. RESULTS: In the U.S. the cost of the immunosuppressive medications for the major types of organ transplantations typically range from US $19,300 to $34,600 per year based on commonly prescribed doses at average wholesale prices. In the Federation entity of B&H in 2009, the average cost per patient in F.B&H in 2010 was 6,009.00 KM (U.S.$4,292.00), which represents an absolute cost decrease of 740 KM or 11.00%, when compared to the higher average cost per patient in 2009, which was 6,749.00 KM (US $4,821.00). DISCUSSION: The process of finding the ideal medication regiments to minimize morbidity and mortality, while maximizing quality of life and optimizing the cost is the major challenge to the transplantation community. Pharmaco-economic analysis can provide valuable insight toward achieving of these, rather difficult goals. CONCLUSION: A sensitive pharmaco-economic analysis must be undertaken in order to achieve the best results in the world of limited/constrained resources and increasing demands for the expensive and quality of life improving immunosuppressive therapy in organ transplantation.