Valoración de la función tiroidea durante la gestación: intervalos de referencia de tirotropina y tiroxina no unida a proteína durante el primer trimestre

Background and objectivesThe physiological changes that occur during pregnancy affect the physiology of the thyroid gland. Consequently, interpretation of thyroid function markers during pregnancy requires trimester-specific reference intervals. The aims of our study were to: 1) establish first-trimester reference intervals for biochemical markers of thyroid function [thyroid-stimulating hormone (TSH) and free thyroxine (T4)] and 2) to establish the prevalence of autoimmune thyroid disease in pregnant women resident in Cartagena (Murcia, Spain).Patients and methodA total of 441 women between weeks 11 and 13 of pregnancy were included in this study. A blood sample was extracted from all women to measure TSH, free T4 and antithyroid antibodies. Reference intervals for TSH and free T4 were determined in 400 pregnant women without autoimmune thyroid disease or known thyroid disease.ResultsAutoimmune thyroid disease was detected in 23 pregnant women (5.2%) who showed TSH levels higher than those in pregnant women without thyroid autoimmunity. First-trimester reference intervals were as follows: TSH: 0.130–3.710 mUI/L; free T4: 0.89–1.50 ng/dL. These reference intervals differed from the non-pregnant reference intervals used in our laboratory.ConclusionsThe reference intervals established are useful to evaluate thyroid function in women between 11 and 13 weeks of pregnancy. Interpretation of thyroid function requires intervals established in a reference population without autoimmune thyroid disease and with the methodology usually used to analyze these markers.     

Closing the Gaps in Paediatric Reference Intervals: The CALIPER Initiative

Screening, diagnosis and monitoring of paediatric diseases relies on the measurement of a spectrum of disease biomarkers in clinical laboratories to guide important clinical decisions. Physicians rely on the availability of suitable and reliable reference intervals to accurately interpret laboratory test results with data collected during medical history and physical examination. However, critical gaps currently exist in accurate and up-to-date reference intervals (normal values) for accurate interpretation of laboratory tests performed in children and adolescents. These gaps in the available paediatric laboratory reference intervals have the clear potential of contributing to erroneous diagnosis or misdiagnosis of many diseases of childhood and adolescence. Most of the available reference intervals for laboratory tests were determined over two decades ago on older instruments and technologies, and are no longer relevant considering the current testing technology used by clinical laboratories. It is thus critical and of utmost urgency that a more acceptable and comprehensive database be established. There are however many challenges when attempting to establish paediatric reference intervals. Paediatric specimen collection is a major concern for health care providers as it is frequently difficult to obtain sufficient volumes of blood or urine from paediatric patients. Common reference intervals have not been widely implemented due to lack of harmonisation of methods and differences in patient populations. Consequently, clinical laboratory accreditation organisations and licensing agencies require that each laboratory verify or establish reference intervals for each method. To provide such reference intervals requires selection criteria for suitable reference individuals, defined conditions for specimen collection and analysis, method selection to determine reference limits and validation of the reference interval. The current review will provide a brief introduction to the current approach to establishment of reference intervals, will highlight the current gaps in data available in paediatric populations, and review a recent Canadian initiative, CALIPER (Canadian Laboratory Initiative on Paediatric Reference Intervals), to establish a comprehensive database for both traditional and emerging biomarkers of paediatric disease.     

The case for common reference intervals

The current paradigm for pathology reference intervals is for each laboratory to determine its own interval for use with each test offered by the laboratory. It is our contention that this approach does not best serve the medical community, especially at a time when electronic databases of health information are being expanded and integrated. We also believe that this approach is not performed well in many laboratories and is excessively expensive in practice. In contrast, we believe that the preferable option is to develop and apply common reference intervals throughout Australia and New Zealand, together with common reporting formats and assay standardisation wherever this is possible.

We are aware that these are neither trivial nor simple issues, however we believe that failure to achieve this goal where technically possible will be a failure of the pathology profession to meet the challenges of the modern health community.

     

RCPAQAP First Combined Measurement and Reference Interval Survey

Reference intervals are commonly considered to allow for between-laboratory bias. The RCPAQAP Liquid Serum Chemistry Program has collected data on laboratory measurements as well as reference intervals. This allows assessment of the between-laboratory variation in results, reference intervals and the information transmitted by the combination of these factors. For the majority of common chemistry analytes, the between-laboratory variation in reference intervals is greater than the variation in results. Additionally the reference interval variation is generally not related to bias between the results. Use of common reference intervals, either as an average of the current intervals in use, or the intervals proposed by the AACB Harmonisation Group, improved the variation seen in the information produced by different laboratories.     

Prerequisites for use of common reference intervals

The theory of reference values was developed more than 30 years ago, but its application in most clinical laboratories is still incomplete today. This is for several reasons, the most relevant ones being the lack of standardisation of the analytical methods, resulting in method-dependent values, and the difficulty in recruiting the proper number of reference subjects for establishment of reference intervals. With the recent progress in method standardisation the first problem is reducing while the second can be addressed optimally via multicentre collaborative studies that aim to establish common reference intervals. To be effective this approach requires the following prerequisites: 1) the existence of a reference measurement system for the analyte; 2) field methods producing results traceable to the reference system; and 3) a carefully planned multicentre reference interval study. Such a procedure will produce results traceable to the reference measurement system for a large number of reference subjects, under controlled pre-analytical conditions. It will also enable a better understanding of the various sources of population variability, if there is the need for partitioning of a reference interval or if there are any limitations to adopting the established reference intervals on a national or global scale. Once reference intervals are determined, clinical laboratories can adopt a common reference interval provided: 1) the population that the laboratory services is similar to the one studied; 2) methods producing traceable results are used; and 3) analytical quality is within defined targets of precision and bias. Moreover, some validation of the interval using a small sample of reference individuals from the laboratory's population is advisable.     

Rectangular tolerance regions and multivariate normal reference regions in laboratory medicine

Reference intervals are widely used in the interpretation of results of biochemical and physiological tests of patients. When there are multiple biochemical analytes measured from each subject, a multivariate reference region is needed. Because of their greater specificity against false positives, such reference regions are more desirable than separate univariate reference intervals that disregard the cross-correlations between variables. Traditionally, under multivariate normality, reference regions have been constructed as ellipsoidal regions. This approach suffers from a major drawback: it cannot detect component-wise extreme observations. In the present work, procedures are developed to construct rectangular reference regions in the multivariate normal setup. The construction is based on the criteria for tolerance intervals. The problems addressed include the computation of a rectangular tolerance region and simultaneous tolerance intervals. Also addressed is the computation of mixed reference intervals that include both two-sided and one-sided limits, simultaneously. A parametric bootstrap approach is used in the computations, and the accuracy of the proposed methodology is assessed using estimated coverage probabilities. The problem of sample size determination is also addressed, and the results are illustrated using examples that call for the computation of reference regions.     

A study of behavioural responses of non-human primates to air transport and re-housing

More long-tailed macaques (Macaca fascicularis) than any other primate are imported into the UK for research, and journey times may be of up to 58 h. Whilst a number of studies have examined the stress associated with transport, these have typically involved laboratory rodents and livestock, and little is known of its effect on non-human primates. This paper reports the results of a study of behavioural changes in a group of long-tailed macaques transported by air from standard breeding conditions and then re-housed in standard laboratory primate conditions. The animals were studied prior to their departure, immediately after their arrival, and 3 weeks after that. Data were collected on individual time budgets using focal animal sampling and on hierarchy using a feeding trial. The data were analysed for changes in behavioural repertoires and for social perturbation that would be reflected in hierarchical changes. Changes in behaviour occurred which reflected heightened levels of stress in the study group. It was also clear that although there was some adjustment of behaviour, after an initial change on arrival at the new establishment, there was no return to levels observed at the breeding facility within the first month. This study demonstrates that, as a whole, the process of international air transport and re-housing in laboratory conditions may result in the compromising of the welfare of the study animals.     

Accreditation and the use of validated/recognised methods to analyse human semen

Accreditation of laboratories who perform diagnostic semen analysis in Australia and New Zealand is a requirement of the healthcare system. Within the accreditation process laboratories are required to set ISO standards within their policies and procedures. In order to achieve their aims, laboratories need to be able to measure a number of defined semen parameters both accurately and repetitively, especially around the lower limit of the reference intervals. The methods documented in the WHO-manual are used almost universal as the laboratory standard. Some laboratories incorporate minor method variations into their procedures. As part of the ISO requirements all variations require validation using internally approved processes that are documented and that incorporate appropriate statistical analysis and comparison of results. Validation is an ongoing process and regular review is essential. Evidence of the validation must be available for review by external auditors during accreditation. Where any validated variant method returns results that are significantly different to any method within the WHO-manual, the laboratory needs to develop its own, in-house reference interval for that method.     

Population-based biochemistry, immunologic and hematological reference values for adolescents and young adults in a rural population in Western Kenya

Background

There is need for locally-derived age-specific clinical laboratory reference ranges of healthy Africans in sub-Saharan Africa. Reference values from North American and European populations are being used for African subjects despite previous studies showing significant differences. Our aim was to establish clinical laboratory reference values for African adolescents and young adults that can be used in clinical trials and for patient management.

Methods and Findings

A panel of 298, HIV-seronegative individuals aged 13–34 years was randomly selected from participants in two population-based cross-sectional surveys assessing HIV prevalence and other sexually transmitted infections in western Kenya. The adolescent (<18 years)-to-adults (≥18 years) ratio and the male-to-female ratio was 1∶1. Median and 95% reference ranges were calculated for immunohematological and biochemistry values. Compared with U.S-derived reference ranges, we detected lower hemoglobin (HB), hematocrit (HCT), red blood cells (RBC), mean corpuscular volume (MCV), neutrophil, glucose, and blood urea nitrogen values but elevated eosinophil and total bilirubin values. Significant gender variation was observed in hematological parameters in addition to T-bilirubin and creatinine indices in all age groups, AST in the younger and neutrophil, platelet and CD4 indices among the older age group. Age variation was also observed, mainly in hematological parameters among males. Applying U.S. NIH Division of AIDS (DAIDS) toxicity grading to our results, 40% of otherwise healthy study participants were classified as having an abnormal laboratory parameter (grade 1–4) which would exclude them from participating in clinical trials.

Conclusion

Hematological and biochemistry reference values from African population differ from those derived from a North American population, showing the need to develop region-specific reference values. Our data also show variations in hematological indices between adolescent and adult males which should be considered when developing reference ranges. This study provides the first locally-derived clinical laboratory reference ranges for adolescents and young adults in western Kenya.     

Locomotor impairment of gravid lizards: is the burden physical or physiological?

Pregnancy is associated with reduced locomotor performance in several reptile species, but the reasons for this reduction remain unclear. Previous authors generally have assumed that the decreased maternal mobility is due to the physical burden of the clutch, but our data on a viviparous Tasmanian scincid lizard (Niveoscincus microlepidotum) suggest a different interpretation. Running speeds of gravid female skinks decrease during gestation (as litter mass increases), but this locomotor impairment is due to physiological changes associated with pregnancy, rather than simple physical burdening. Maternal running speeds are unrelated to litter masses, and do not increase in the week after parturition. Females with very large abdominal fat‐bodies (due to ad libitum feeding in the laboratory), equivalent in mass to the litter, nonetheless run rapidly. If the locomotor ‘costs’ of reproduction reflect all‐or‐none physiological changes associated with pregnancy, then the magnitude of such costs may correlate only weakly with the actual level of reproductive investment. Because life‐history models predict that the relationship between fecundity and ‘cost’ has important evolutionary consequences, our results highlight the need to clarify the causal basis for locomotor impairment in gravid reptiles.     

Design considerations for proteomic reference materials

In order to improve the repeatability, comparability, and accuracy of MS-based proteomic measurements, there has been considerable international effort to develop appropriate reference materials. Although the majority of reference materials are developed to support measurement quality of routine assays, the development of reference materials for a diverse and changing research field such as proteomics represents unique challenges. In order to define common measurement components and common features of typical proteomic samples, the metrology underpinning proteomics must be considered due to the diversity and changing nature of the field. Reference materials can then be designed around common aspects in order to produce reference materials with the broadest applicability. Reference materials are needed to support both qualitative and quantitative proteomic measurements, involving different design considerations. Consensus and validated statistical approaches to describe the confidence in qualitative measurement, such as protein identification, needs to be established. Common sources of measurement bias also need to be considered in proteomic reference material design.     

Normal Laboratory Reference Intervals among Healthy Adults Screened for a HIV Pre-Exposure Prophylaxis Clinical Trial in Botswana

Introduction

Accurate clinical laboratory reference values derived from a local or regional population base are required to correctly interpret laboratory results. In Botswana, most reference intervals used to date are not standardized across clinical laboratories and are based on values derived from populations in the United States or Western Europe.

Methods

We measured 14 hematologic and biochemical parameters of healthy young adults screened for participation in the Botswana HIV Pre-exposure Prophylaxis Study using tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) (TDF2 Study). Reference intervals were calculated using standard methods, stratified by gender, and compared with the site-derived reference values used for the TDF2 study (BOTUSA ranges), the Division of AIDS (DAIDS) Grading Table for Adverse Events, the Botswana public health laboratories, and other regional references.

Results

Out of 2533 screened participants, 1786 met eligibility criteria for participation in study and were included in the analysis. Our reference values were comparable to those of the Botswana public health system except for amylase, blood urea nitrogen (BUN), phosphate, total and direct bilirubin. Compared to our reference values, BOTUSA reference ranges would have classified participants as out of range for some analytes, with amylase (50.8%) and creatinine (32.0%) producing the highest out of range values. Applying the DAIDS toxicity grading system to the values would have resulted in 45 and 18 participants as having severe or life threatening values for amylase and hemoglobin, respectively.

Conclusion

Our reference values illustrate the differences in hematological and biochemical analyte ranges between African and Western populations. Thus, the use of western-derived reference laboratory values to screen a group of Batswana adults resulted in many healthy people being classified as having out-of-range blood analytes. The need to establish accurate local or regional reference values is apparent and we hope our results can be used to that end in Botswana.     

Thyroid Physiology in Pregnancy

ObjectiveVarious physiological changes occur in maternal thyroid economy during pregnancy. This review focuses on the events taking place during gestation that together strongly influence maternal thyroid function.MethodsScientific reports on maternal thyroid physiology in pregnancy.ResultsDuring the 1^st trimester, human chorionic gonadotropin (hCG) induces a transient increase in free thyroxine (FT4) levels, which is mirrored by a lowering of thyroid-stimulating hormone (TSH) concentrations. Following this period, serum FT4 concentrations decrease of approximately 10 to 15%, and serum TSH values steadily return to normal. Also starting in early gestation, there is a marked increase in serum thyroxine-binding globulin (TBG) concentrations, which peak around midgestation and are maintained thereafter. This event, in turn, is responsible for a significant rise in total T4 and triiodothyronine (T3). Finally, significant modifications in the peripheral metabolism of maternal thyroid hormones occur, due to the expression and activity of placental types 2 and 3 iodothyronine deiodinases (D2 and D3, respectively).ConclusionIn line with these variations, both free thyroid hormone and TSH reference intervals change throughout pregnancy, and most scientific societies now recommend that method-and gestation-specific reference ranges be used for interpreting results in pregnancy.The maternal iodide pool reduces during pregnancy because of increased renal clearance of iodine and transfer of iodine to the feto-placental unit. This results in an additional requirement of iodine during pregnancy of ~ 100% as compared to nonpregnant adults. In accordance, the recommended iodine intake in pregnancy is 250 μg/day. A daily iodine intake below this threshold poses risks of various degrees of thyroid insufficiency for both the mother and the fetus. (Endocr Pract. 2014;20:589-596)     

Haematological and biochemical reference intervals for farmed channel catfish

The reference intervals for biochemical variables and red blood cell indices of healthy intensively bred channel catfish Ictalurus punctatus were determined. The blood variables were determined using standardized clinical methods. The reference intervals (25th and 75th percentiles) were established using a non-parametric method. Reference intervals for plasma glucose, serum total protein, sodium, potassium, calcium, magnesium, chloride concentration, primary and secondary red blood cell indices were established. The haematological and biochemical reference intervals established may allow important clinical decisions about channel catfish.     

Minireview: physiological and pharmacological properties of vanadium

Vanadium is distributed extensively in nature. It is a trace element and is present in almost all living organisms including man. Even though vanadium was originally recognized for its ability to inhibit membrane Na+-K+-ATPase, various laboratory studies now document that this element has the capacity to affect the activity of various intracellular enzyme systems and may modify their physiological functions. Vanadium may be an essential element for normal development and may play an important role in various homeostatic mechanisms, and thus vanadium deficiency may prove to be an important concern. Abnormalities in biological disposition of vanadium may be involved in the pathogenesis of certain neurological disorders or cardiovascular diseases. While the essentiality of this element for living organisms is yet to be established with certainty, vanadium has become an increasingly important element and is used extensively in various heavy industries such as steel, oil, etc.; thus, the incidence of exposure to toxic levels of vanadium to industrial workers has been an increasing concern for toxicologists. To date, little information is available on the physiological or pharmacological actions of vanadium; hence, it is difficult to reach any definitive conclusion concerning its biological significance, essentiality and its role in pathological states. An attempt has been made in this review to broadly document what is known of various biological actions of vanadium.     

Terminal monosaccharide expression on amniotic glycoproteins as biomarkers of fetus maturity

Glycotypes, particularly those that terminate with sialic acid and fucose are known to play a fundamental role in human development, during implantation, growth and differentiation of fetal tissues. The present review describes changes in the exposition of terminal sialic acid and fucose isoforms in the amniotic fluid glycoconjugates, α1-acid glycoprotein and fibronectin during critical stages of pregnancy, i.e. second and third trimester, perinatal period, delivery and post-date pregnancy. The distinct amniotic glycoforms are suggested to be implicated in regulatory processes to ensure homoeostasis during pregnancy and to protect the fetus. These may have the potential of becoming additional laboratory makers in obstetrics to monitor pregnancy.     

Assessing the use of known mutagens to calibrate the Salmonella typhimurium mutagenicity assay: I. Without exogenous activation

There has been an increasing need in genetic toxicology to progress from strictly qualitative tests to more quantitative tests. This, in turn, has increased the need to develop better quality assurance and comparative bioassay methods. In this paper, two laboratories tested 10 Salmonella mutagens in order to determine the usefulness of selected chemicals as potential reference materials to calibrate the Salmonella assay. If variance within a bioassay is sufficiently low and the rankings of the compounds are of acceptable consistency, the chemicals later could be evaluated for use as standard control compounds, as audit materials, and as standard reference materials for comparative bioassay efforts. The results demonstrated that the chosen chemicals (with the possible exception of dimethylcarbamylchloride) provide such consistent results in the Salmonella mutagenicity bioassay that they can be used for semi-quantitative calibration and as possible bioassay controls, special audit chemicals, and potentially as reference standards in comparative bioassay efforts. Reference standards, whether used as audit materials or in comparative bioassays, must be used concurrently with the test substances of interest; used without bias; used in a standardized, highly controlled bioassay; and be tested across an appropriate dose range. The study also shows that when these compounds are used as reference standards much care must be given to the number and spacing of doses if highly reproducible slope values are to be generated. We recommend use of a pilot test to establish a dose range for definitive tests and the placement of doses for the definitive tests within the first half of the linear dose-response curve. For appropriate comparisons, one should replicate the tests using the defined dose range and analyze the results in a non-biased statistical manner.     

Cold exposure does not decrease serum leptin concentration,but increases energy intake and thermogenic capacity in pregnant Brandt's voles (Lasiopodomys brandtii)

In most mammals, maternal body mass and fat mass increase during pregnancy due to hyperphagia. These physiological changes provide the fetus with energy and nutrients and prepare the mother for the high energetic demands of lactation. In the present study, metabolic changes in response to cold and pregnancy were examined in female Brandt's voles (Lasiopodomys brandtii). At 23±1 °C, the voles increased body mass and deposited body fat during pregnancy. However, at 5±1 °C pregnant voles did not deposit body fat even though energy intake increased above the level in the warm. Serum leptin concentration increased during pregnancy and was not influenced by cold exposure. Thermogenic capacity, as indicated by uncoupling protein 1 (UCP1) content in brown adipose tissue (BAT), increased in cold-exposed pregnant voles. The number and mass of fetuses were not affected by cold exposure. Our data may indicate the importance of an increased serum leptin concentration for a successful outcome of the pregnancy and also the independence of leptin secretion from body fat in pregnant voles. It also implies the need to develop central leptin resistance with respect to control of energy balance for pregnant voles.     

Age-specific reference intervals for routine biochemical parameters in healthy neonates,infants, and young children in Iran

Age and sex need to be considered in the establishment of reference intervals (RIs), especially in early life when there are dynamic physiological changes. Since data for important biomarkers in healthy neonates and infants are limited, particularly in Iranian populations, we have determined age-specific RIs for 7 laboratory biochemical parameters. This cross-sectional study comprised a total of 344 paediatric participants (males: 158, females: 186) between the ages of 3 days and 30 months (mean age: 12.91 ± 7.15 months). Serum levels of creatinine, urea, uric acid, calcium, phosphate, vitamin D and high-sensitivity C-reactive protein (hs-CRP) were measured using an Alpha classic-AT plus auto-analyser. We determined age-specific RIs using CLSI Ep28-A3 and C28-A3 guidelines. No sex partitioning was required for any of the biomarkers. Age partitioning was required for kidney function tests and phosphate. The serum concentration of urea and creatinine increased with age, while phosphate and uric acid decreased with age. Age partitioning was not required for serum calcium, vitamin D, and hs-CRP, which remained relatively constant throughout the age range. Age-specific RIs for 7 routine biochemical markers were determined to address critical gaps in RIs in early life to help improve clinical interpretation of blood test results in young children, including neonates. Established age partitions demonstrate the biochemical changes that take place during child growth and development. These novel data will ultimately better disease management in the Iranian paediatric population and can be of value to clinical and hospital laboratories with similar populations.     

Computer evaluation of reference limits.

Reference limits are necessary for medical laboratory to provide objective information on health in concrete characteristics. With respect to changeability of some factors influencing upon homeostasis, reference limits must be determined and redetermined in each clinical laboratory with the high degree of the internal quality control system. The presented program computing reference limits and providing expert consultations facilitates solution.