Assiut University Hospital Article 2

WELCOME MESSAGE FROM THE HEAD OF CLINICALPATHOLOGY DEPARTMENT – ASSIUT UNIVERSITY Prof. Azza M Ezz Eldin Head of Clinical Pathology Department I would like to extend a warm welcome to the reader of the second issue of Clinical Pathology Department newsletter. On this occasion I would like to give you an idea about our development plans for Assiut University-Clinical Pathology Department. In 2013, a plan for lab development was set by the Clinical Pathology Department. This plan has two main goals. The first goal is to prepare qualified lab personnel while the second one is to improve environmental situations in order to improve the service approved by the department to ultimately achieve patient satisfaction. To achieve these goals, thedepartment launched many projects on its way to get lab accreditation. The first stage of the projectstargeted the development of the following units: blood bank, autoimmune lab in the immunology unit,hemolytic anemia lab in hematology unit and hormone lab in women health hospital. Microbiology labalso included in this stage. In 2015, two more labs were included in the hematology unit (homeostasisand flow cytometry laboratories).The second stage was directed to reconstruction of the infrastructure and preparing a central labservice. We are very excited to announce that this stage is intended to be finished by the end of2017. We hope this will be a forward step into a better future for the clinical pathology department andfor the hospital as well.

ANTIBIOTIC RESISTANCEProf. Hebat Allah Moreover, the misuse and abuse of antibiotics isRashed widespread and not at all confined to theDirector of developing countries. The western countries alsoMicrobiology allow antibiotic prescriptions for common colds.Laboratory Furthermore, the abuse of antibiotics in agriculture to fatten the cattle is now causing theOne cannot deny the spread of resistant strains. This leaves the current antibiotics in a state of uselessness.importance of There is also the problem of people moving allantibiotics in saving over the world in a matter of days or even hours. That being known, the resistance which developsmany lives, but people somewhere can quickly develop somewhere else across the globe.forget to use them with caution. The misuse and There are many ways that we can control thisoveruse of antibiotics ultimately develops issue before it gets out of hand. Other than raising awareness, governments should workbacterial resistance to antibiotics. together to establish international guidelines for antibiotic prescriptions and administration.Although scientists and physicians have warned ght aid in utilizing phages for the treatment ofthe public repeatedly, antibiotic prescriptions in bacterial infections.several countries remain extremely high.Since the making of penicillin during WWII, In some countries, such as India, governmentschemists and scientist have been greatly are urging stricter guidelines for antibioticenthusiastic about creating and discovering new administration and dispensing. It is a prolongedlines of antibiotics. However, killing the bacteria process that will need time, but the sooner thealone is not enough. For an antibiotic to reach the governments take action, the better.market successfully, it needs to be manufacturedin a biologically compatible and safe manner.That being said, despite discovering many newelements, only few of these elements can be usedrealistically.It is essential that doctors as well as patientsunderstand the need for using a specific drug fora specific target. Surely, awareness needs to beraised about the issue that using a non-specificspectrum of antibiotics leads to the developmentof resistance.However, sadly, one of the major issues causingantibiotic resistance is the misuse of antibiotics.In many countries, antibiotics are sold over thecounter, which leads to people treatingthemselves from a common cold or flu by usingantibiotics. The majority of people do notunderstand that the properties of antibiotics areuseless in many cases and the excessive use isonly adding to the resistance in their body. Also,in developing countries, people who are poormay not complete the full dose of an antibiotic,which will also lead to resistance.

IMMUNOPHENOTYPING: A QUITE TRICKY PROCEDURE Prof. Maged Salah molecules “CDs” present on normal cells, and not actual tumor markers. These molecules are not mere MAHMOUD concrete pillars on the cell surface, but they are the products of genes susceptible to up- and down- Professor of Clinical regulation in response to the various stimuli delivered to the cells from their microenvironment, and sample Pathology storage and processing. Immunophenotyping is a Fourthly, the nature of the analyzed sample, the powerful technique used viability of the cells, and the degree of processing for the diagnosis of needed before data acquisition. As a matter of fact, diseases and of particular apoptotic and necrotic cells lose the expression of importance in the diagnosis several molecules once they start their cell death of acute leukemias and program. This is of utmost importance in interpreting lymphomas. It can be data collected from stored samples, refrigerateddone by either immunocytochemistry or flow samples, intracellular molecules that need fixation andcytometry. The latter is being more popular and permeabilization, and much more in samples collectedbecoming increasingly used in many laboratories. by any means of homogenization from solid tissues orDespite the great power of the technique, in certain paraffin-embedded sections. What adds to the problemsituations it can be greatly confusing or even of this type of samples is that necrotic cell debrismisleading given the following facts: causes noise, thus reducing the signal/noise ratio and the quality of results.Firstly, the probe used for detection, which in thiscase is the monoclonal antibodies. These are usually Next, is the interpretation of results in view of a vagueobtained from different commercially available language of the report like “positive” or “negative”sources, which are sold as “monoclonal” but in many without reference to the meaning if positive means forinstances when these monoclonal antibodies are used example 20 or hundred percent, and if negative meansin a Western blot, a clear cross reactivity is observed, zero or a certain figure below a cut-off value. Whatmeaning a cross reactivity with more than a single makes a further confusion is the reporting themolecule or epitope. This is quite understandable by a fluorescence intensities without mentioning their exactsimple look to the procedure by which monoclonal source i.e. from the whole analyzed cells in sample orbodies are raised. The first step is immunization of a from a certain gated population, even how much thislaboratory animal by a small synthetic peptide, usually gated population represents from the whole sample.without checking its homology with other proteins in Moreover, the appearance of several scoring systemsthe proteome of the organism against which the that use arbitrary scores without reference to theseantibody will be raised. As stated before this would “positive” and “negative” scores are based on howresult in cross reactivity with other proteins/epitopes many positive cell percentages, and more important isin the sample that will add a true signal “not noise” that assumed phenotype applies to how many casesand this would not be recognized even by experienced for a certain disease. Also, the emergence of the sooperator. called biphenotypic leukemia as a morphological type that in best conditions denotes ambiguity of diagnosisSecondly, the fluorescent label used to tag this and eventually management plans.“monoclonal” antibody. With the vast array offluorophores available, comparison of their excitation The impressive information afforded byand emission wave lengths shows a considerable immunophenotyping imposed itself as a an importantoverlap. It would be impossible to avoid the “bleed diagnostic and typing requirement for acute leukemia,through” of fluorescence on the fluorescence channels but eventually, the huge literature of flow-cytometricof any given machine available in the market, even immunophenotyping data presented to the scientificwith the use of highly sophisticated dichroic community, with some degree of inconsistency andfilter/mirrors. This issue becomes of more importance lack of consensus agreement, has driven the WHO toand a more likelihood in case of using multicolor gradually stalemate it from the guidelines for theanalysis protocols. classification of acute leukemia.Thirdly, the mere fact that most of the examinedmolecules, with very few exceptions, are normal

Thromboelastography in Clinical Coagulation Management and Transfusion PracticeIn conclusion, understanding the above mentioned Prof. Nabila M.Thabetcomments do not mean at all that we should abandonimmunophentyping, but rather points to the great Professor of Clinical Pathologyimportance of a careful intellectual interpretation ofthe results with thoughtful consideration of the results In the recent years , thromboelastography has becomein the context of integrated clinical and laboratory a popular monitoring device for hemostasis andresults of the case in question. transfusion management in major surgery , trauma and hemophilia. Thromboelastography is performed in whole blood and assesses the viscoelastic property of clot formation under low shear condition. Thromboelastography can be performed with a variety of activator and inhibitors at different concentrations representing the most important factors for different intervals and clot formation variables .furthermore, fibrinogen levels and platelet counts have a major influence on thromboelastographic variables. Aside from clot formation, Thromboelastography has been used to estimate thrombin generation, platelet function, and clot dissolution by fibrinolysis, all of them with some limitations. Thromboelastography has been successfully used for patient coagulation assessment, hemostatic therapy and transfusion in trauma, perioperative care, and assessing bleeding inHuman myeloma cell line showing induction of CD45 hemophilic patients.expression by IL-6 stimulation(Mahmoud et al, Blood 1998, 92 (10): 3887-3897 Thromboelastograp hy based algorithms reduce both transfusion requirements and blood loss in cardiac surgery, liver transplantation, and massive trauma.Human myeloma cell line showing variable levels of Fig (1) represents Thromboelastometry (TEM): (A)expression of a CD19 transgene normal trace and appearance; in hemophilia (B) before(Mahmoud et al, Blood 1999, 94 (10): 3551-3558). and (C) after factor VIII infusion; hypercoaguable status, and (F) thrombocytopenia. Parameter definitions: clotting time (CT) ;Clot formation time (CFT); alpha angle(°); clot formation rate (CFR ) ; maximum clot firmness (MCF)- lysis index (Ly60)- that takes place after maximum firmness (% remaining clot firmness ).

STEM CELLS FOR BLOOD TRANSFUSIONProf. Maha Atwa How we get bloodDirector of Central • Transfusion is the transfer of blood from one person to anotherBlood Transfusion • It is used to replace blood lost due to seriousServices injuries, illness, operations and child birth Researchers are working • Supply depends on donors and is often limited or on a collaborative insufficient research project that aims to generate a limitless and • Worldwide 150,000 woman die each year due to infection-free supply of blood loss from giving birth red blood cells in the lab from human embryonic • There are no good alternatives to carry oxygenstem cells for use in clinical blood transfusion. around the bodyBlood • Donor blood may, rarely, transmit diseases to aEach adult has about five liters of blood making up patientapproximately eight percent of a person’s bodyweight. Blood consists of a fluid known as plasma and • Donor blood must be matched to the patient’sseveral different types of cells; red blood cells, white bloodblood cells and platelets. Red blood cells carry oxygenfrom the lungs to the other tissues; white blood cellsfight infection; and platelets are vital for clotting thatprevents us bleeding to death. Oxygen is essential forall the organs in your body particularly your brain andmuscles. So if you lose a lot of blood or don’t makeenough because of a disease. Oxygen levels can fallso low that you could die.Blood transfusion Stem cell lab making future medicinesBlood transfusions are given to people who have lost Stem cellsblood following a serious accident or surgery and to Human embryonic stem cells and induced pluripotentpeople with life-threatening diseases where the stem cells can make any cell type in your body.normal process of blood cell production has gone Scientists are excited about the possibility that manywrong. However, there is a shortage of blood donors diseases and injuries may be treated by celland despite safety measures patients in need of blood replacement therapies. For example insulin producingtransfusions are at risk of getting infectious diseases cells to treat diabetes; replacing damaged spinal cordand having an immune reaction to blood that isn’t cells after paralysis, or building new bone andtheir own, these problems might be solved using connective tissues to repair joints or bones that havehuman embryonic stem cells that are free from been badly broken. Stem cells can also be used toinfection, can be grown continuously in the lab and make cells that can be used to find and test drugscan be turned into many different cell types, including which will result in better, safer drugs and a reductionred blood cells. in animal testing. How we might use stem cells in the future Study development of disease Scientists study stem cells to understand what controls normal and abnormal development from a fertilised egg to a human being. This will help them understand diseases caused by abnormal cell division, such as cancer and birth defects.

with reviews and audits. A key element was the identification of non-conformances and a Corrective Action System to prevent reoccurrences. Specific quality improvement methodologies were not prescribed. Like ISO 9001QMS .ISO 14001 EMS, ISO 15189 etc……. Test new medicines 5- The Malcolm Baldrige National Quality Award Stem cells can become specialized cells. These specialized cells could replace the scarce source of (1987). dead or donor tissue currently used to test new Awards are given in five categories medicines. This would also reduce the need for animal Manufacturing, service, Small business, Health testing. Care, and Education. Replace damaged cells and treat disease 6- Six Sigma Stem cells are already used in the treatment of It’s a Statistical Methods developed by Motorola extensive burns, and to restore the blood system of Company in Japanese. some patients with leukemia and other blood disorders. Scientists hope stem cells can be used to The Six Sigma concept has developed into a replace cells lost in many other devastating diseases methodology that focuses on process for which there are currently no sustainable cures, e.g. improvement and variation reduction (VR), motor neuron disease, Parkinson’s and liver failure. through the use of a measurement-based strategy.QUALITY PHILOSOPHY AND This strategy is realized through the applicationMANAGEMENT STRATEGIES of a Six Sigma improvement project. This Six Sigma methodology is often accomplished 1- W. Edwards Deming. through the use of sub-methodologies: Define Knowing as a (Quality establisher) he established Measure, Analysis, Improve, and Control 14 concepts for quality. And he invented the (DMAIC). Deming Cycle which known as a PDCA Cycle. There are many levels of these methods Orange 2- Joseph M. Juran (Juran Trilogy). belt, Green belt, Black belt and Master black Belt (Co-author of Quality Control Handbook 1951) (champion) he focused in three components: Planning, Control, and Improvement (PCI). 7- Just in time, Lean Manufacturing, Poka-Yoke, 3- Total quality management (1980). and others. How to solve a problem using SPC Statistical Poka Yoke is a Japanese term literally defined as Process Control (by collect and analyze data) 'mistake proofing'. Developed by (Toyota) Check sheets , Pareto diagrams , Histograms , Company. Poka-Yoke is often used in the context Run charts , Flow charts , Cause and effect of designing devices, typically simple and diagrams , Force field analysis and Scatter inexpensive, that prevent defects from being diagrams made or, if they are made, from moving to the next process. 4- Quality system and standards (1987). To be certified, businesses needed to document Poka-Yoke is fooling proofing, which is the basis their quality system and insure adherence to it of the Zero Quality Control (ZQC) approach, which is a technique for avoiding and eliminating mistakes. Generally this technique is used in manufacturing process but has much wider uses, such as; offices - order and invoice processing, hospitals - drug dispensing, aircraft maintenance - particularly with processes having the potential of inducing catastrophic in-service failures... reduce the billing error . Reduce the cost of waste

MEASUREMENT UNCERTAINTY IN CLINICAL LABORATORIES Eng. Mahmoud A. Eltayeb Knowledge of the uncertainty shows if the result is Chair of Arab accepted within limits defined in specification or Accreditation Cooperation regulation. ARAC Measurement uncertainty and medical laboratory What is measurement accreditation The standard ISO 15189: 2012 [Medical laboratories'measurement uncertainty? — Requirements for quality and competence] In ordinary use the word specifies the requirements for evaluating and 'uncertainty' does not inspire reporting uncertainty of measurement. The problems confidence. However, when presented by these requirements vary in nature used in technical sense as in depending on the technical field. uncertainty' it carries a specific Accreditation bodies are responsible for ensuring themeaning. accredited laboratories meet the requirements of ISOIt is a parameter, associated with the result of 15189.measurement that defines the range of values that Accreditation bodies are harmonizing their implementation of the requirements for expressingcould reasonably be attributed to the measured uncertainty of measurement through the regional organizations and the International Laboratoryquantity. Accreditation Co-operation (ILAC).Uncertainty is defined as the range of values usually Sources of measurement uncertainty ƒ Environmental conditions.centered on the measured value that contains the true ƒ Measuring system ƒ Operator biasvalue with stated probability. ƒ Values assigned to the measurement standard and the reference materials.When uncertainty is defined as above, it indicates ƒ Measurement set up, methods and procedures. ƒ Variations in repeated measurements.confidence interval which is the range of values thatcorresponds to the stated uncertainty, and alsoindicates a confidence level which is the probabilityassociated with the confidence interval. In medical laboratories, measurement uncertainty is concerned only with those sources that arise from within the measuring system i.e. from sample preparation to production of measurement result. Hence, pre- and post-measurement uncertainties are not included in the estimation of measurement uncertainty.Why is measurement uncertainty important? Who evaluates measurement uncertainty?The uncertainty is a quantitative indication of the Uncertainty evaluation is best done by personnel whoquality of the result. It gives an answer to the are thoroughly familiar with the measurement processquestion, how does the result represent the value of within the laboratory and understand the limitations ofthe quantity being measured? It allows users of the the measuring equipment and the influences ofresult to assess its reliability. external factors. Personal should keep records showing the assumptions that were made and sources of information for estimation of component uncertainty values. Basic knowledge of mathematics and statistics is required to determine measurement uncertainty.

Personal should ensure that the measurement process internal quality control and Proficiency testing data, tois under statistical control before determining estimate the standard uncertainty associated with theuncertainty. result.Basic steps for evaluation of measurement ƒ The combined standard uncertainty is calculateduncertainty from the impression component and the biasMeasurement uncertainty can be estimated by two component when bias component is significantdifferent approaches relative to the impression component.a) The bottom-up approach ƒ The impression component data should beThis approach depends on the principles of ISO Guide collected from testing QC material for ato the Expression of uncertainty in measurement minimum period of six months to ensure that(GUM) and based on a comprehensive categorization variations due to different operators, reagents andof the measurement in which each potential source of calibrator lots, recalibrations, routine instrumentuncertainty is identified and quantified. The estimates maintenance are captured. For new methods, aof uncertainty, expressed as standard deviations minimum of 30 replicate determinations of(standard uncertainties), are assigned to individual appropriate QC material is required to calculatecomponents of the procedure which are an interim standard deviation but this ismathematically combined to provide the “combined dependent on the frequency of analysis.standard uncertainty” of the result then the expandeduncertainty is obtained as follows: ƒ The expanded uncertainty is obtained by multiplying the combined standard uncertaintyƒ Identify all uncertainties in the measurement by a coverage factor k in similar to bottom- up process. approachƒ Classify type of uncertainty: ƒ The measurement results and the expanded uncertainty are reported.Type A uncertainty which is evaluated by statistical analysis of series of observations. It is the standard This approach is preferred for routine medical deviation of the mean. laboratory tests and considered more practical than theType B uncertainty which is evaluated by means other than statistical analysis of series of bottom-up approach. However, it is the laboratory’s observations. decision to use the method most appropriate for theirƒ Quantify individual uncertainty by various methods. circumstances and supported by the available data.ƒ Obtain the Combined standard uncertainty by Root Sum Square (RSS method).ƒ Obtain the expanded uncertainty by multiplying combined standard uncertainty by appropriate coverage factor K.o For K=1 the confidence level is 68%o For K=2 the confidence level is 95%o For K=3 the confidence level is 99% Coverage factor 2 is often used for confidence level 95 % . ƒ Document in an uncertainty budget. ƒ Report the measurement results and the expanded uncertainty .b) The top – down approachThe top-down approach uses available laboratory testperformance information, such as method validation,

INSULIN-LIKE GROWTH FACTOR 1 Prof. Hanan Omar Diagnostic test IGF-1 levels can be measured in the blood in 10- Professor of Clinical 1000 ng/ml amounts. As levels do not fluctuate greatly throughout the day for an individual person, It Pathology is used by physicians as a screening test for growth hormone deficiency and excess in acromegaly and Insulin-like growth factor gigantism. 1 (IGF-1), also called Interpretation of IGF-1 levels is complicated by the somatomedin C, is a wide normal ranges, and marked variations by age, protein (consists of 70 sex, and pubertal stage. Clinically significant amino acids in a single conditions and changes may be masked by the wide chain with three intra- normal ranges. Sequential management over time ismolecular disulfide bridges) that in humans is often useful for the management of several types ofencoded by the IGF1 gene with a molecular weight of pituitary disease, under nutrition, and growth7,649 daltons. It has also been referred to as a problems.\"sulfation factor\" and its effects were termed \"nonsuppressible insulin-like activity\" (NSILA) in the As a therapeutic agent1970s. Patients with severe primary insulin-like growthIGF-1 is a hormone similar in molecular structure to factor-1 deficiency (IGFD) may be treated with eitherinsulin. It plays an important role in childhood growth IGF-1 alone or in combination with IGFBP-3.and continues to have anabolic effects in adults. A Mecasermin is a synthetic analog of IGF-1 which issynthetic analog of IGF-1, mecasermin, is used for the approved for the treatment of growth failure. IGF-1treatment of growth failure. has been manufactured recombinantly on a large scale using both yeast and E. coli.Clinical significance ResearchDwarfismRare diseases characterized by inability to make or Agingrespond to IGF-1 produce a distinctive type of growth Signaling through the insulin/IGF-1-like receptorfailure. One such disorder, termed Laron dwarfism pathway is a significant contributor to biologicaldoes not respond at all to growth hormone treatment aging in many organisms. Cynthia Kenyon showeddue to a lack of GH receptors. The FDA has grouped that mutations in the daf-2 gene double the lifespan ofthese diseases into a disorder called severe primary the roundworm, C. elegans. Daf-2 encodes the worm'sIGF deficiency. Patients with severe primary IGFD unified insulin/IGF-1-like receptor. Despite thetypically present with normal to high GH levels, impact of IGF1-like on C. elegans longevity, directheight below 3 standard deviations (SD), and IGF-1 application to mammalian aging is not as clear aslevels below 3 SD. Severe primary IGFD includes mammals lack dauer developmental stages. It is alsopatients with mutations in the GH receptor, post- inconsistent with evidence in humansreceptor mutations or IGF mutations, as previously There are mixed reports that IGF-1 signalingdescribed. As a result, these patients cannot be modulates the aging process in humans and aboutexpected to respond to GH treatment. whether the direction of its effect is positive orPeople with Laron syndrome have strikingly low rates negativeof cancer and diabetes. NeuropathyAcromegaly Therapeutic administration of neurotrophic proteinsIt is a syndrome that results when the anterior (IGF-1) is associated with potential reversal ofpituitary gland produces excess growth hormone degeneration of spinal cord motor neuron axons in(GH). A number of disorders may increase the certain peripheral neuropathies.pituitary's GH output, although most commonly itinvolves a tumor called pituitary adenoma, derived Cancerfrom a distinct type of cell (somatotrophs). It leads to The IGF signaling pathway is implicated in someanatomical changes and metabolic dysfunction caused cancers. People with Laron syndrome have a lessenedby elevated GH and insulin-like growth factor 1 (IGF- risk of developing cancer. Dietary interventions and1) levels. modifications such as vegan diets shown to down

regulate IGF-1 activity, has been associated with If a decrease in IGF-1 is suspected to be due to a morelower risk of cancer. However, despite considerable general decrease in pituitary functionresearch, perturbations specific to cancer are (hypopituitarism), then several other endocrine glandsincompletely delineated and clinical drug trials have and their pituitary regulating hormones will need to bebeen unsuccessful.When is it ordered? evaluated to decide on appropriate treatment. ReducedIGF-1 testing may be ordered, along with a GH pituitary function may be due to inherited defects orstimulation test, when: can develop as a result of pituitary damage following conditions such as trauma, infections, and • A child has symptoms of GH deficiency, such as inflammation. a slowed growth rate and short stature Decreased levels of IGF-1 also may be seen with • Adults have symptoms that a health practitioner nutritional deficiencies (including anorexia nervosa), suspects may be due to a GH deficiency, such as chronic kidney or liver disease, inactive/ineffective decreased bone density, fatigue, adverse changes forms of GH, and with high doses of estrogen. to lipid levels, and reduced exercise tolerance. IncreasedIGF-1: • However, testing for IGF-1 deficiencisis not Elevated levels of IGF-1 usually indicate an routine in adults who have these symptoms; GH increased production of GH. Since GH levels vary and IGF-1 deficiency are only very rare causes of throughout the day, IGF-1 levels are a reflection of these disorders. average GH production, not of the actual amount of GH in the blood at the time that the sample for theAn IGF-1 also may be ordered when a health IGF-1 measurement was taken. This is accurate up topractitioner suspects that someone has an underactive the point at which the liver's capacity to produce IGF-pituitary gland and at intervals to monitor those on 1 is reached. With severely increased GH production,GH therapy. the IGF-1 level will stabilize at an elevated maximumLess commonly, IGF-1 testing may be ordered, along level.with a GH suppression test, when a child hassymptoms of gigantism or when an adult shows signsof acromegaly.When a GH-producing pituitary tumor is found, GH Increased levels of GH and IGF-1 are normal duringand IGF-1 are ordered after the tumor is surgically puberty and pregnancy but otherwise are mostremoved to determine whether the entire tumor has frequently due to pituitary tumors (usually benign).been extracted. IGF-1 also is ordered at regularintervals when someone is undergoing the drug and/or If IGF-1 is still elevated after the surgical removal ofradiation therapy that frequently follow tumor a pituitary tumor, then the surgery may not have beensurgery. fully effective. Decreasing IGF-1 levels duringIGF-1 levels may be ordered at regular intervals for subsequent drug and/or radiation therapies indicatemany years to monitor a person's GH production and that the treatment is lowering GH production. If levelsto watch for pituitary tumor recurrence. of IGF-1 become \"normalized,\" then the person is no longer producing excess amounts of GH. WhenWhat does the test result mean? someone is undergoing long-term monitoring, an A normal level of IGF-1 must be considered in increase in IGF-1 levels may indicate a recurrence of the pituitary tumor.context. Some people can have a GH deficiency andstill have a normal IGF-1 level.DecreasedIGF-1: If the IGF-1 level is decreased, then it is likely thatthere is a GH deficiency or insensitivity to GH. If thisis in a child, the GH deficiency may have alreadycaused short stature and delayed development andmay be treated with GH supplementation. Adults willhave an age-related decrease in production, but lowerthan expected levels may reflect a GH deficiency orinsensitivity.

BIOMARKERS IN MULTIPLE SCLEROSIS: AN UP-TO-DATEOVERVIEWClinical Chimestry Unit KFLC high CSF levels have been reported in MS and considered as highly predictive for CIS conversion toClinical Pathology Departement CDMS.Multiple sclerosis (MS) is a condition where the CNS • Measles-Rubella-Zoster Endothecal Reactionof a person presents a special kind of distributed glial (MRZ Reaction)scars (sclerosis) which are a remaining of a previousinflammatory demyelination. Multiple sclerosis is the MRZ IgG reaction in CSF displays, compared to OCBmost common reason of neurological disability among IgG, a higher specificity for MS diagnosis and higheryoung adults. prognostic value of progression from CIS to CDMS.In multiple sclerosis, localized destruction of myelin • Vitamin D: Vitamin D suppresses Th1 immune response inoccurs in the CNS. Alterations of the immune system multiple levels and enables the production of many neurotrophic factors. 25-Hydroxyvitamin D levels inhave been implicated in this process, by the untreated MS patients correlate inversely with radiologic disease activity.demonstration of myelin-reactive T lymphocytes and • Antibody against potassium channel proteinthe oligoclonal bands (OCB) in CSF reflecting local KIR4.1 It was reported that a subset of MS patientssynthesis of immunoglobulins (figure 1). Patients with have a seropositive anti- KIR4.1.multiple sclerosis have a restricted immune response Biomarkers of demyelination neuroinflammation relapse:with predominately IgG1 subclass. Genetic linkage • Myelin Basic Protein (MBP):studies have indicated a variety of associations, but MBP and its fragments are found in large quantities in the CSF of MS patients during relapse. A significantthe strongest is with HLA-DR2 (human leukocyte correlation of decrease in CSF-MBP, contrast- enhancement in MRI, suggest an association withantigen) genes. During the last decades, the effort of myelin breakdown in MS.establishing satisfactory biomarkers for multiple • αB-Crystalline Immunohistochemical analysis of demyelinatingsclerosis has been proven to be very difficult, due to lesions revealed increased expression of this protein. αβ-Crystalline is a heat-shock protein which formsthe clinical and pathophysiological complexities of aggregates during stress. It is considered as primary target molecule for T-cells in MS. Its mechanism ofthe disease. According to their pathophysiological action encompasses activation of IL-17, IL-10, IL-13, TNF, and Chemokines CCL5 and CCL1.implication in MS pathogenesis, up-to-date • Neuronal Cell Adhesion Molecule (N-CAM)biomarkers are divided into three subgroups, genetic- Constant CSF elevation of N-CAM has been reported immediately after MS relapse, showing negativeimmunogenetic, laboratorial, and imaging. According correlation with clinical improvement.to the clinical application they further subdivided into • Brain-Derived Neurotrophic Factor (BDNF) Lower CSF-BNDF levels in secondary progressivemarkers aid in diagnosis, biomarkers of MS (SPMS) patients comparatively to relapsing remitting MS (RRMS) patients have been reported.demyelination—neuroinflammation relapse, Low BDNF levels are considered to contribute in demyelination and axonal damage progress.biomarkers of prognosis-disability progression andbiomarkers of therapeutical responseBiomarkers aid in diagnosis includes: • HLA-DRB1*1501Is the mainly responsible allele for attributing geneticrisk in MS population. Positive correlation of HLA-DRB1*1501with OCB in the CSF of MS patients wasfound. • OCB IgG in CSFPositive OCB IgG in the CSF of patients withclinically isolated syndrome (CIS) was found toduplicate the risk of progression to clinically definitemultiple sclerosis (CDMS). Their diagnosticsensitivity is high but they lack in specificity.• Kappa Free Light Chains (KFLC) in CSF • Fetuin-A

A calcium regulating surface glycoprotein, protein,s GFAP is a structural protein of the astrocytes whosecoding messenger RNA is overexpressed in MS CSF levels increase in association with gliosis-patients CNS, resulting in its high concentrations in astrocytosis. High CSF values have been found inactive demyelinating lesions. SPMS patients, but rarely in RRMS patients, and seem to correlate well with disability progression. • Cytokines and Adhesion MoleculesInflammatory activity in active demyelinating lesion • OCB IgG, KFLC, MRZ reaction and NAA,lead to the liberation of many different cytokines that NF-H reflect adequately disabilitycan be used as biomarkers of disease activity they progression in MS.include serum levels of IFN-γ-TNF-α, IL-6, IL-10,sICAM-1and sVCAM-1. Biomarkers of therapeutical response: • HLA-DRB1* 10401, 0408, 1601Biomarkers of Axonal loss- neurodegeneration polymorphisms have higher risk for developing neutralizing antibodies against • Soluble Molecule Nogo-A IFN-β.Nogo-A is a CNS myelin component that inhibitsaxonal repair. Its presence in CSF of MS patients • Vitamin D increased serum levels associatedconstitutes a bad prognostic marker of axonal repair. with IFN-β responders.Nogo-A is adequately specific for MS, as it could notbe isolated in other autoimmune or infectious • Fetiun A and NF-L levels are reduced in CSFneurological disorders. and considered biomarkers for good responders to Natalizumab treatment. • N-AcetyloAspartate (NAA)NAA is an aminoacid, highly expressed in neurons. • BDNF increased CSF levels observed inCSF-NAA reduction correlates adequately with Glatiramer Acetate responders, correlatingdisability progression. NAA could be helpful in well with clinical improvement.differential diagnosis between MS and NMO. Biomarkers of differentiation from NMO: • Tau Protein CSF NAA, GFAP, and CSF: serum albumin ratioTau is a cytoskeleton protein whose basic (AR) can also help when there is a possibility forresponsibility is microtubular stabilization. High CSF NMO.levels in MS patients have been reported.Simultaneous elevation in Tau and NF-H values inCSF, in patients with CIS, has a 70% predictive valueof conversion to CDMS, which is superior to thepredictive value of MRI.Biomarkers of prognosis-disability progression: • TOB-1TOB-1 gene has a role against T-cell multiplication,keeping autoreactive cells in a dormant state. Itsdecreased expression leads towards a more intenseimmune response. TOB-1 polymorphisms representan independent factor influencing the progressionfrom clinically isolated syndrome (CIS) to clinicallydefinite multiple sclerosis (CDMS). • Neurofilaments (NFs): Figure 1: The top sample is the normal cerebrospinalNeurofilaments are major axonal cytoskeleton fluid (CSF) and the second lane is the CSFproteins consisting of three subunits (light chain/NF- concentrated 80-fold from a patient with multipleL, intermediate chain/NF-M, and heavy chain/NF-H). sclerosis and the corresponding serum diluted 1:3 isNF-H chains seem to correlate better with disease immediately below. The γ- region of the CSF fromprogression, with significant elevation recorded only this patient has several densely staining oligoclonalin progressive disease forms. bands which are not in the corresponding serum. • Glial Fibrillary Acidic Protein (GFAP)

BIOLOGICAL RISK ASSESSMENTProf. Sohair Kamel Sayed -Slowly growing gram-negative rods or gram- negative coccobacilli;Professor of ClinicalPathology -Slow growth in blood culture bottles (i.e., positive at ≥48 hours), with small gram-negative rods or gramIdentifying potential negative coccobacilli;hazards in the laboratory is Step 2. Identify activities that might causethe first step in performing exposure to the agent or material. 1. The facility (e.g., biosafety level (BSL) -2, BSL-3,a risk assessment. No one open floor plan [more risk] versus separate areas orstandard approach or rooms for specific activities [less risk], sufficient space versus crowded space, workflow, equipmentcorrect method exists for present); 2. The equipment (e.g., in the case of uncertifiedconducting a risk biosafety cabinets (BSCs), cracked centrifuge tubes, improperly maintained autoclaves,assessment; However, several strategies are available, overfilled sharps containers, Bunsen burners); 3. Potential for generating aerosols and droplets.such as using a risk prioritization matrix, conducting a Aerosols can be generated from most routine laboratory procedures but often are undetectable.job hazard analysis; or listing potential scenarios of The following procedures have been associated with generation of infectious aerosols e.g.problems during a procedure, task, or activity. The manipulating needles, syringes and sharps, Manipulating inoculation needles, loops, andprocess involves the following five steps: pipettes and manipulating specimens and cultures 4. Use of sharps;1. Identify the hazards associated with an infectious 5. Improperly used or maintained equipment; agent or material. Examples of possible hazards are decreased dexterity or reaction time for workers wearing2. Identify the activities that might cause exposure gloves, reduced ability to breathe when wearing to the agent or material. N95 respirators, or improperly fitting personal protective equipment (PPE).3. Consider the competencies and experience of laboratory personnel. Step 3. Consider the competencies and experience4. Evaluate and prioritize risks (evaluate the of laboratory personnel. likelihood that an exposure would cause a Age (younger or inexperienced employees might be at laboratory-acquired infection [LAI] and the higher risk); Genetic predisposition and nutritional severity of consequences if such an infection deficiencies, immune/medical status (e.g., underlying occurs). illness, receipt of immunosuppressive drugs, chronic respiratory conditions, pregnancy, nonintact skin,5. Develop, implement, and evaluate controls to allergies, receipt of medication known to reduce minimize the risk for exposure. dexterity or reaction time);Standardization of the risk assessment process can Education, training, experience, competence; Stress,greatly improve the clarity and quality of this process. fatigue, mental status, excessive workload; Perception, attitude, adherence to safety precautions;Step 1. Identify the hazards associated with an and The most common routes of exposure or entry into the body (i.e., skin, mucous membranes, lungs,infectious agent or material. and mouth).The potential for infection, as determined by the mostcommon routes of transmission (i.e., ingestion by Step 4. Evaluate and prioritize risks.contamination from surfaces/fomites to hands and Risks are evaluated according to the likelihood ofmouth; percutaneous inoculation from cuts, needle occurrence and severity of consequences :sticks, nonintact skin, or bites; direct contact withmucous membranes; and inhalation of aerosols).The frequency and concentration of organismsroutinely isolated, as determined by specimen type,•patient data (of individual or the hospital population),epidemiologic data, and geographic origin of thespecimen;Intrinsic factors (if agent is known) as: Pathogenicity,virulence, mode of transmission, infectious dose,Form (stage) of the agent and resistance to antibiotics.Indicators of possible high-risk pathogens that mayrequire continuation of work in a biological safetycabinet (BSC), such as

Likelihood of occurrence: - Gloves for handling all potentially contaminated materials, containers, equipment, or surfaces-Almost certain: expected to occur. - Face protection (face shields, splash goggles worn-Likely: could happen sometime. with masks, masks with built-in eye shield) if BSCs or splash guards are not available. Face protection,-Moderate: could happen but not likely. however, does not adequately replace a BSC. At BSL-2 and above, a BSC or similar containment-Unlikely: could happen but rare. device is required for procedures with splash or aerosol potential.-Rare: could happen, but probably never will. - Laboratory coats and gowns to prevent exposure of• Severity of consequences: street clothing, and gloves or bandages to protect Consequences may depend on duration and nonintact skin frequency of exposure and on availability of vaccine and appropriate treatment. Following are - Additional respiratory protection if warranted by examples of consequences for individual risk assessment Job safety analysis workers:Colonization leading to a carrier state, asymptomatic infection, toxicity,oncogenicity, - One way to initiate a risk assessment is to conduct a allergenicity, infection and disease job safety analysis for procedures, tasks, or activities performed at each workstation or specific laboratoryStep 5. Develop, implement, and evaluate controls by listing the steps involved in a specific protocol and the hazards associated with them and thento minimize the risk for exposure. determining the necessary controls, on the basis of organism suspected. Precautions beyond the• Engineering controls, if possible, first isolate and standard and special practices for BSL-2 may be contain the hazard at its source. indicated in the following circumstances:- Primary containment: BSC, sharps containers, - Test requests for suspected Mycobacterium centrifuge safety cups, splash guards, safer sharps tuberculosis or other mycobacteria, filamentous (e.g., autoretracting needle/syringe combinations, fungi, bioterrorism agents, and viral hemorrhagic disposable scalpels), and pipette aids fevers- Secondary containment: building design features - Suspected high-risk organism (e.g., Neisseria (e.g., directional airflow or negative air pressure, hand washing sinks, closed doors, double door meningitides entry) - Work with large volumes or highly concentrated • Administrative and work practice controls cultures- Strict adherence to standard and special - Compromised immune status of staff microbiologica practices - Training of new or inexperienced staff - Monitoring effectiveness of controls- Adherence to signs and standard operating procedures Risk assessment is an ongoing process that requires at least an annual review because of changes in new- Frequently washing hands and emerging pathogens and in technologies and- Wearing personal protective equipment (PPE) only personnel. in the work area - Review reports of incidents,- Minimizing aerosols exposures,- Prohibiting eating, drinking, smoking, chewing gum illnesses, and near-- Limiting use of needles and sharps, and banning misses. recapping of needles - Identify causes and problems; make- Minimizing splatter (e.g., by using lab \"diapers\" on changes, provide bench surfaces, covering tubes with gauze when follow-up training. opening) - Conduct routine laboratory- Monitoring appropriate use of housekeeping, inspections. decontamination, and disposal procedures - Repeat risk assessment routinely. Implementing \"clean\" to \"dirty\" work flow Following recommendations for medical surveillance and occupational health, immunizations, incident reporting, first aid, postexposure prophylaxis- Implementing emergency response procedures PPE (as a last resort in providing a barrier to the hazard)

YOU CAN'T LIVE A POSITIVE LIFE WITH A NEGATIVE MIND Prof. Sherif Helmy Look for Positive Elements: Events make you grow as a person. In other cases, your loss is Professor of Clinical another person's gain. May be, it will open up Pathology other opportunities. Just focus on a good outcome from all the bad news. Optimism has to be one of the most valuable traits Appreciate the Little Things: Whether it's that you can cultivate and waking up healthy in the morning, going for a it will make you happier picnic or talking to someone you love. We lose a and more popular. It is lot throughout our lives but there are some things most needed when you you can rely on.are going through hard times and when you arefacing up to challenges. Of course it's more Understand the Nature of Change: Don't wastedifficult to remain optimistic when it feels like too much energy trying to fight the change, it iseverything is crashing down around you. inevitable. We go through different stages in our lives, some full of chaos but they won't go onThe Power of Positivity forever. It's just a matter of time.Being positive results in happy changes in yourlife. It means you will attract more people aroundyou and make them feel good about themselvesas they will enjoy your company. This makesthings better for you as you will have the supportof all your friends. At the same time if you areable to remain optimistic then you will be happierbecause you will genuinely believe that things aregoing to get better. You will be more likely totake the good types of risks and to attempt to getyourself out of the situation rather than giving in.How to Remain PositiveRecognize the Value of Positivity: You need torecognize just how valuable it is to be positiveand how unhelpful it is to be negative. This willthen give you the determination to drive outnegative thoughts.Have a Plan: It will make you see a way out andgive you hope leading to optimism. Make sureyou are taking steps to improve matters.Meanwhile have an alternative plan for eachoutcome so that whatever happens you are readyto deal with matters.Face the Worst Case Scenario: Play through theworst possible scenario in your mind. Most likelyit won't be as bad as you thought it would be.You will still be able to cope. Suddenly, youwon’t be afraid anymore.