Download Talk 3: Malignancy as a cause of PUO

Clinicolaboratory Integration
Bridging The Gap
7th Conference Of the
Laboratory Medicine in Alexandria
Alexandria Medical Syndicate
In collaboration with
Faculty of Medicine, Alexandria University
which will be held in
Main hall, Alexandria Faculty of Medicine
Convention Center
26 -28 september 2012
Conference Board
Conference President
Prof. Dr. Mohamed Rafik Khalil
Prof. Dr. Myriam Abou Seif
Conference Coordinator
Prof. Dr. Moustafa Rizk
Prof. Dr. Safaa Mohy El Din
Conference General Secretary
Prof. Dr. Mohamed Ibrahim Sayed
Prof. Dr. Ahmed Fathy El Koraie
Scientific Committee (by alphabetical order)
Prof. Dr.
General Information
 Target Audience
Laboratory physicians
General Practitioners
Surgeons
Oncologists
Anesthiologists
Nephrologists
Hepatologists
Haematologists
Diabetologists
 Main Topics
Session I: Peri-operative Lab Assessment
Session II: Updates in Diabetes Diagnostics
Session III: Updates in Renal Diagnostics
Session IV: Clinical Utility of Biological Fluids Analysis
Session V: RecentTrends in Haematoncology
Session VI: Elusive tumor; A Challenge for Pathologist
Session VII: Immunopathology ; Recent Advances
Session VIII: Lab Approach to hepatitis
Session IX: Future Lab
Session X: Quality in Lab
Post-conference Workshop: ( separate registration )
Pyrexia of Undetermined Origin
 Overview
This is the 7th conference of laboratory medicine in Alexandria aiming at bridging the gap between
lab physicians and clinicians by providing most recent highly selected lab techniques and their
clinical value
 Learning Objectives
After completing this educational activity, the audience will be able to:
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Review recommended laboratory measures and other assessment, with respective targets related
to each topic
Integrate evidence based guidelines to ask for and interpret different Lab techniques
Outline a collaborative inter-professional approach to better use laboratory techniques and foster
best practices in the delivery of care.
 Conference Format :
Almost each session will include :
 State of art lecture
 Standard guidelines of practice
 Clinical case scenarios
 Debate (whenever applicable )
 Participating Departments :
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Clinical Pathology, Faculty of Medicine,Alexandria University
Medical Biochemistry, Faculty of Medicine, Alexandria University
Medical Microbiology and Immunology, Faculty of Medicine, Alexandria University
Parasitology, Faculty of Medicine, Alexandria University
Pathology, Faculty of Medicine, Alexandria University
Surgery, Faculty of Medicine, Alexandria University
Oncology, Faculty of Medicine, Alexandria University
Anaesthia, Faculty of Medicine, Alexandria University
Hepatology, Faculty of Medicine, Alexandria University
Nephrology, Faculty of Medicine, Alexandria University
Haematology, Faculty of Medicine, Alexandria University
Neurology, Faculty of Medicine, Alexandria University
Rheumatology, Faculty of Medicine, Alexandria University
Tropical Medicine, Faculty of Medicine, Alexandria University
Chemical Pathology, Medical Research Institute, Alexandria University
Microbilology, High Institute of Public Health, Alexandria University
Alexandria Fever hospital
 Venue
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The conference will be held in main hall Alexandria Faculty of Medicine convention center
 Language
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The official language is English
All lectures and presentations will be held in the English language only
There will be no translation available.
 Badge
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All participants, and exhibitors must wear their name badges to have access to congress
and social events. No exceptions will be made.
 Registration Hours
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Registration desk will be ready on Wednesday 26th September at 9:00 am
Registration desk will be ready on Thursday 27th September at 9:00 am
Registration desk will be ready on Friday 28thSeptember at 9:00 am
 Scientific Program Hours
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Scientific activities will start on Wednesday 26th September at 10:00 am
Scientific activities will start on Thursday 27th September at 9:00 am
Scientific activities will start on friday 28th September at 9:00 am
 Food & Beverage
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Lunch is served to all congress participants on the allocated time.
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Coffee Break is served to all congress participants on the allocated time.
Main sponsors
Smart Medical Equipment
Mira Lab
Organizing Committee in charge
Prof. Dr. Ahmed Fathy El Koraie
Dr. Menna Magdy
Miss Manal Baioumy
Mr. Taher Derbala
Dr. Hassan Foula
Scientific Program
Day 1 ( 26th September 2012 )
Session I: Peri-operative Lab Assessment
10:00-11:30
Chair persons ( by alphabitical order ):
Prof. Dr. Abd El Fatah Hamouda
Prof. Dr. Magda Sultan
Prof. Dr. Nadia Mokhles
Prof. Dr. Nagwa El Kobeya
Prof. Dr. Safaa Hussein
 Guidelines for perioperative hematological assessment
(10:00 – 10:20 )
Prof. Dr. Hala Sultan - Clinical Haematology – Alexandria University
 State-of-the-art; Updates in Electrolyte Assessment Perioperatively
(10:20 – 10:40 )
Dr. Hazem Farag - Medical Biochemistry – Alexandria University
 Assessment of liver & kidney functions
( 10:40 – 11:00 )
Dr. Yasmin Amr -Medical Biochemistry – Alexandria University
 Should or should we not use peri-operative antibiotic prophylaxis?
( 11:00 – 11:20 )
Prof. Dr. Nesreen Fathy - Microbiology and immunology – Alexandria University
 Case Presentation
( 11:20 – 11:30 )
Prof. Dr. Emad Abd El Monem–Anesthesia & Postoperative Critical care – Alexandria
University
Opening Ceremony
( 11:30 – 12:00 )
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Talk of Prof. Dr. Mohamed Rafik Khalil ( 11:30 – 11:35 )
Talk of Prof. Dr. Myriam Abou Seif ( 11:35 – 11:40 )
Talk of Prof. Dr. Ashraf Saad Galal ( 11:40 – 11:45 )
Honoring Celebration for the pioneers in Laboratory Medicine
Coffee Break
( 12:00 - 12:30 )
Session II: updates in diabetes
12:30 – 13:45
Chair persons ( by alphabetical order ):
Prof. Dr. Ghada El Helaly
Prof. Dr. Nagwa Lasheen
Prof. Dr. Passint Moez
 State of the art lecture :Lab diagnosis of insulin resistence :clinical value
( 12:30 – 12:50 )
Prof. Dr. Ali Abd el Rehim – Diabetes and Metabolism – Alexandria University
 HbA1c versus glucose testing : A comparison
( 12:50 – 13:10 )
Prof. Dr. Passint Moez - Clinical pathology – Alexandria University
 Diabetic foot infection, Challenges in microbiological assessment
( 13:10 – 13:30 )
Prof. Dr. Shewekar Abd El Salam - Microbiology and Immunology – Alexandria University
 Case Report
( 13:30–13:45 )
Dr. Raghda Saad Zaghloul – Clinical Pathology – Alexandria University
Session III: Updates in Renal Diagnostics
14:00-15:30
Chair persons :
Prof. Dr. Jylan Fadaly
Prof. Dr. Moustafa Rizk
 Updates in renal pathology
( 14:00 – 14:20 )
Prof. Dr. Nahed Baddour – Pathology – Alexandria University
 State of art lecture: Urinary Proteomics : a promising diagnostic laboratory tool
( 14:20 – 14:40 )
Prof. Dr. Ahmed Fathy El Koraie -Clinical Nephrology – Alexandria University
 Urinary anion gap
( 14:40 – 15:00 )
Dr. Doreen Younan Nazeh - Clinical Pathology – Alexandria University
 Plasma NGAL and Cytatin C versus creatinine clearance as a biomarker for AKI
( 15:00 – 15:20 )
Prof. Dr. Moustafa Rizk - Clinical Pathology – Alexandria University
 Case presentation
( 15:20 – 15:30 )
Prof. Dr. Dalal El Kaffash- Clinical Pathology – Alexandria University
Lunch
( 15:30 )
Day 2 ( 27th September 2012 )
Session IV: Biological Fluids
09:00 – 10:30
Chair Persons :
Prof. Dr. Malak Mahmoud Abd El Hai
Prof. Dr. Sabah Abd El Hady
Prof. Dr. Osama Nasr EL Din
Prof. Dr. Mohamed Fouad Boraey
 Cytopathological examination for biological fluids
(09:00 – 09:20 )
Prof. Dr. Manal Nasr – Pathology – Alexandria University
 Updates in microbiological assessment of biological fluids
(09:20 – 09:40 )
Dr. Hadir Okasha -Microbiology and Immunology – Alexandria University
 Role of biological fluid biomarkers in Oncology
(09:40 – 10:00 )
Dr. Doaa Abd El Monsef - Medical Biochemistry – Alexandria University
 Standards of biological fluid examination – Good practice &Pitfalls
(10:00 – 10:20 )
Prof. Dr. Dalal Kaffash - Clinical Pathology – Alexandria University
 Case presentation
( 10:20 – 10:30 )
Dr. Mohamed Abd El Hady - Neurology – Alexandria University
Session V: Recent Trends in Hemato-oncology
10:30 – 12:00
Chair Persons ( by alphabetical order ):
Prof. Dr. Magdy El Bordiny
Prof. Dr. Nahla Hamed
Prof. Dr. Zeinab Mourad
 New classification of acute myeloid leukemia and precursor related neoplasms : unresolved
issues
( 10:30 – 10:50 )
Prof. Dr. Magdy El Bordiny – Clinical Pathology – Alexandria University
 Pifalls in flowcytometric interpretation
( 10:50 – 11:10 )
Prof. Dr. Nahla Farahat – Clinical Pathology – Alexandria University
 Approach to diagnosis of multiple myeloma
( 11:10 – 11:30 )
Prof. Dr. Mohamed Abdel Rahman – Clinical Pathology – Military Academy
 Value of Lab prognostic markers in cases of chronic lymphoproliferative disorders
( 11:30 – 11:50 )
Prof. Dr. Ashraf El Ghandour – Haematology – Alexandria University
 Case presentation
( 11:50 – 12:00 )
Prof. Dr. Akram Deghedy – Clinical Pathology – Alexandria University
Coffee Break
( 12:00 – 12:30 )
Session VI : Elusive Tumors ;A Challenge For Pathologists
12:30- 14:00
Chair Persons :
Prof. Dr. Azaa Risk
Prof. Dr. Abbas Omar
Prof. Dr. Malak Zoheir
Prof. Dr. Ahmed Tarek
 Contemporary use of Immunohistochemistry in the interpretation of undifferentiated
malignant tumors
( 12:30 – 12:50 )
Prof. Dr. Eman Abd El Zaher – Pathology – Alexandria University
 Metastasis of unknown primary: an immunohistochemical approach
(12:50 –13:10 )
Prof. Dr. Bassma El Sabaa – Pathology – Alexandria University
 Immunohistochemistry in the differential diagnosis of small blue round cell tumors
( 13:10 – 13:30 )
Prof. Dr. Mona Abdel-Hadi - Pathology – Alexandria University
 Prognostic and therapeutic implications of immunohistochemistry
(13:30 – 14:00 )
Prof. Dr. Nevin El Deeb – Pathology – Alexandria University ( 15min. )
Prof. Dr. Mohamed Farouk – Oncology – Alexandria University ( 15min. )
Session VII: Immunopathology Recent Advances
14:00-15:30
Chair Persons:
Prof. Dr. Osama Ebada
Prof. Dr. Amina Hassab
Prof. Dr. Manal Tayel
Prof. Dr. Mohamed Adel Ata
Prof. Dr. Myriam Abou Seif
 Lab workup for a couple for renal transplant
( 14:00 – 14:30 )
Prof. Dr. Mohamed Ibrahim - Clinical Pathology – Alexandria University
 Auto immune disorders of GIT
( 14:30 – 15:00 )
Prof. Dr. Amira Fiad – Clinical Pathology – Alexandria University
 Rheumatological disorders: Lab recent advances
( 15:00 – 15:30 )
Prof. Dr. Mona Wagdy - Clinical Pathology – Alexandria University
Coffee Break
( 15:30 – 16:00 )
Session VIII: Hepatitis markers
16:00-17:30
Chair Persons :
Prof. Dr. Faika Ghoneim
Prof. Dr. Ola Abd El Kader
Prof. Dr. Mervat El Azzouni
Prof. Dr. Mohamed Naguib Shawky
Prof. Dr. Mohamed Abbass El Barrawy
 Viral hepatitis
(16:00 –16:20)
Prof. Dr.Amira Amer– Microbiology – Alexandria University
 Autoimmune hepatitis
( 16:20 – 16:40 )
Prof. Dr. Amina Hassab – Clinical Pathology – Alexandria University
 Biomarkers of liver disease
(16:40 –17:00 )
Prof. Dr. Iman Diab - Medical Biochemistry – Alexandria University
 Fibrosis markers versus Standard pathological evaluation of liver cirrhosis – Pros & Cons
( 17:00 – 17:20 )
Prof. Dr. Nahed Baddour – Alexandria University
 Case presentation: Parasitological hepatitis
( 17:20 – 17:30 )
Prof. Dr. Rasha Fadaly – Parasitology – Alexandria University
Lunch
( 17:30 )
Third Day: 28th September 2012
Session IX: Future Lab
9:00-10:40
Chair Persons:
Prof. Dr. Soheir Morchedi Hamam
Prof. Dr. Iman Diab
Prof. Dr. Pacint Moez
Prof. Dr. Bossina Massoud
Prof. Dr. Moustafa Ibrahim Mourad
 The universe of genetic testing
(09:00 – 09:20)
Prof. Dr. Hoda Elassi – Genetics – Alexandria University
 Proteomics over view
( 09:20 – 09:40 )
Prof. Dr. Hanan Nomier - Medical Biochemistry – Alexandria University
 DNA Microarray and cancer
( 09:40 – 10:00 )
Prof. Dr. Mona Moustafa - Medical Biochemistry – Alexandria University
 Pharmacogenomicsinsight in therapeuticdrug monitoring
( 10:00 – 10:20 )
Dr. Rasha Nassra - Medical Biochemistry – Alexandria University
 The Ongoing evolution of diagnostic testing in microbiology
( 10:20 – 10:40 )
Dr. Noha Abo Saeda – Microbiology and Immunology – Alexandria University
Session X: Quality in Lab Reporting; A Clinical View
10:40-12:00
Chair Persons:
Prof. Dr. Ahmed Zaki
Prof. Dr. Ahmed Tork
Prof. Dr. Medhat Saber Ashour
 Pillars of reliable key performance indicators dashboard
( 10:40 – 11:00 )
Prof. Dr. Rania El Sharkawy - Chemical Pathology – Alexandria University
 Poka-yoke in a medical lab
( 11:00 – 11:20 )
Prof. Dr. Ola El Gaddar - Chemical Pathology – Alexandria University
 What is right quality control
( 11:20 – 11:40 )
Prof. Dr. Ragaa Abd El Kader - Chemical Pathology – Alexandria University
 Quality in lab Reporting
( 11:40 – 12:00 )
Prof. Dr Salwa Hamdy - Chemical Pathology – Alexandria University
Coffee Break & Gomaa Prayer
( 12:00 – 14:00 )
Post-conference workshop
Pyrexia of Undetermined Origin
Chair Persons :
Prof. Dr. Hesham El Dekhs
Prof. Dr. Salama Sadaka
Prof. Dr. Manal Tayel
Prof. Dr. Eman Helmy Hegazy
Prof. Dr. Aleya Abd El Gawad
Talk 1: Role of infections as a cause of PUO
( 14: 00 – 14:30 )
By: Prof. Khaled Mohey Eldin
Professor of Tropical Medicine, Faculty of Medicine.
Talk 2: Collagenic diseases as a cause of PUO
( 14:30 – 15:00 )
By: Prof. ManalTayel
Professor of Rheumatology, Faculty of Medicine.
Talk 3: Malignancy as a cause of PUO
( 15:00 – 15:30 )
By: Prof. Ashraf ELmasry
Professor of Oncology, Faculty of Medicine.
Coffee Break
( 15:30 – 16:00 )
Talk 4: Workup for a case of PUO (guidelines)
( 16:00 – 16:30 )
By: Dr. Rim Harfoush
Assistant Professor, Department of Medical Microbiology and Immunology, Faculty of Medicine.
Talk 5: Leptospirosis; case report in Fever Hospital
( 16:30 : 17:00 )
By: Dr. Eman Ragab El Shehey
Microbiology specialist, Alexandria Fever Hospital
Talk 6: Fever in Parasitic diseases
( 17:00 – 17:30 )
By: Dr. Maha Reda Gaafar
Assistant Professor of parasitology , Faculty of Medicine.
Lunch
( 17:30 )
Abstracts
Guidelines for Peri-operative Assessment
Traditionally, routine investigations prior to surgery are considered an important element of pre-anesthetic evaluation
to determine the fitness for anesthesia and surgery. The prevalence of unrecognized disease that impacts upon surgical
risk is low in healthy individuals. Nevertheless, clinicians often perform laboratory tests in this group of patients out of
habit and medicolegal concern, with little benefit . Preoperative tests should not be performed unless there is a clear
clinical indication. An approach of selective testing reduces cost without sacrificing safety or quality of surgical care.
In an attempt to rationalize this issue, guidelines have been systematically developed after analysis of studies, best
evidence available, and consensus of expert professionals. Preoperative diagnosis-based guidelines provide basic
recommendations for laboratory and other tests . The recommendations can be accepted as such or can be modified
based on local need and individual practice, to ensure highest quality of surgical care.
Updates in Electrolyte Assessment Perioperatively
Patients undergoing surgery must be assessed for their operative risk for both the specific procedure and the general
anaesthetic agent.
Specific diseases should alert the physician to the need for further preoperative work-up or modifications in the
postoperative management.
Peri-operative fluid and electrolyte balance is a subject which has received
a considerable attention from clinicians
and physiologists and is a major issue that needs to be considered as a part of perioperative management. However it
remains a controversial and recurring topic of interest. Moreover, the prevention of clinically significant electrolyte
disturbances is one of the cornerstones of contemporary anesthetic and surgical care.
Electrolyte disturbances are especially problematic after certain types of surgery, such as transsphenoidaladenomectomy, intestinal surgeries and surgeries requiring the use of large volumes of irrigating solutions
and in certain types of patients undergoing surgery such as those with renal failure, or cardiac diseasesrequiring the use
of diuretics….etc.
So, electrolyte assessment has special indications and clinicians should consider the risk-benefit ratio of any ordered
laboratory test including those for electrolytes.
Perioperative Liver and Kidney Function Tests
Assessment of liver and kidney functions come on top of the list of perioperative lab investigations. Abnormalities in
kidney and liver functions can be of prognostic value regarding the outcome of the operation. In addition, they should
alert the physician to the need of further preoperative workup, choice of proper anesthetic and drugs that would
minimize hepatotoxicity and nephrotoxicity, intraoperative assessment of fluid and electrolyte changes and
postoperative modification of management.
The risk of surgery in patients with hepatic dysfunction should be assessed preoperatively using the Child-Pugh or
Model for End-Stage Liver Disease (MELD) severity scoring systems. Management of patients should be determined
according to the score of severity.In addition to common perioperative liver function tests, the LiMAx test is a new
liver function test for predictingpostoperative outcome in liver surgery that has shown credibility.
As for the kidney, in addition to routine kidney function tests, in both serum and urine, cystatin C has been proposed as
a promising renal function marker that has shown superiority and can be added to the routine workup of the regular
kidney functions tests that are measured in both serum and urine.
Some new approaches in management of liver and kidney perioperative dysfunction include introduction of of
branched chain aminoacidstodecrease the incidence of hepatic encephalopathy,administration of medullary tubular
growth factors such as include insulin-like growth factor I, epidermal growth factor, and tumour necrosis factor have
been suggested to accelerate the rate of recovery after acute renal failure that can be induced due to surgical stress, and
administration of a high calorie diet with adequate protein instead of the regular low protein diet routinely given to
renal patients, and this is in case of nutritionally deprived renal patients undergoing major surgeries such as resection
anastomosis.
Pros and Cons of Perioperative Antibiotic Prophylaxis.
Surgical site infections account for 15% of nosocomial infections and are associated with prolonged hospital stays and
increased costs. Examples of measures intended to prevent wound infection that attempt to modify host and local
tissue factors, include preoperative optimization of co-morbid illness, control of the operative environment, proper
cleansing of the skin and use of aseptic surgical technique. Antibiotic prophylaxis is considered as the only one
relatively minor effort with high efficacy and evidence based significant efficiency. Antibiotic prophylaxis has been
found to reduce post-surgical infections, which can lengthen hospital stay, worsen pain, prolong recovery, and lead to
other complications. Recommendations for using antibiotic prophylaxis have been developed by many hospitals,
accrediting bodies, and national organizations. While prophylaxis generally is thought to be safe, unnecessary
administration of antibiotics is undesirable; more doses or more powerful antibiotics are not always better. An
appreciation of some of the nuances of prophylaxis is desirable to improve patient care and safety. The use of
prophylactic antibiotics for “dirty” or contaminated sites have been supported still, some authors did not recommend
their use in cleaner cases. The argument against prophylaxis for clean procedures, based on the intrinsically low rate of
infection without antibiotic treatment, is overly simplistic as the morbidity and cost of even infrequent infection can be
a good justification. Choice of prophylactic perioperative antibiotic has been usually delegated to anesthesiologists,
with consideration that the appropriate prophylactic antibiotic should be effective against microorganisms anticipated
to cause infection; achieve adequate local tissue levels with minimal side effects; and be relatively inexpensive,
though it does not likely have to select virulent organisms. The microbial context of the wound and the hospital
environment may influence the choice of antibiotic, but coverage should primarily target those organisms known to
cause postoperative infection.
NGAL, CYSTATIN C VERSUS CREATININE CLEARENCE AS A
BIOMARKER IN PEDIATRIC ACUTE KIDNEY INJURY
Acute kidney injury (AKI), previously known as acute renal failure, after cardiac surgery is one of the most serious
complications during the postoperative period. Although the incidence of post-operative AKI is relatively low, it is
associated with strikingly high mortality rates during hospitalization, usually exceeding 50%.N-Acetyl-Bglucosaminidase (NAG), a proximal tubule lysosomal enzyme, is among the most extensively studied and best
characterized urinary enzymes. It has proven to be a sensitive and robust indicator of AKI.Cystatin-C (Cys-C) is a 13
kDa protein that is believed to be one of the mostimportant extracellular inhibitors of cysteine proteases.Urinary Cys-C
levels have been found to be elevated in individuals with known tubular dysfunction.Mishra et al. initially in
experimental and later in clinical setting showed NGAL as a promising early biomarker for AKI. Since then, many
investigators have studied its utility in AKI diagnosis and in a variety of other clinical settings.
Cytopathologic Examination of Biologic Fluids: Guide Lines
The main goal of cytopathologic examination of biologic fluids is the detection of malignancy .Sometimes,
specification of inflammatory reaction as TB may be faced in other situations. Biologic fluids include pleural effusion,
pericardial, ascetic fluids, urine, CSF as well as fluid collection of any cystic pathologic lesion. The sensitivity and
specificity of such method varies greatly, because in comparison to biopsy cytologic results are less confirmed ,may
be only suggestive, and sometimes false negative in other wise proved cancer cases. Despite these disadvantages, the
easy way, cheap and facility of repetition makes this procedure the first choice in any laboratory investigation of fluids.
Combining the routine cytologic examination with other additional techniques
such as
immunohistochemistry,flowcytometry and culture microbiology were tried in many previous studies in trial to increase
the diagnostic value of it.
Microbiological Assessment of Biological Body Fluids
Infection of normally sterile body fluids usually result s in severe morbidity and mortality. Therefore rapid and
accurate assessment of these samples is important to successful patient management, especially with the increased use
of prostheses, immunosuppressive therapy regimens and long term care of individuals with debilitating chronic
disease, which also increases the risk of true infection with commensal organisms, making accurate diagnosis difficult.
Role of Biological Fluid Biomarkers in Oncology
Cancer continues to be a major cause of worldwide morbidity and mortality among men and women. Cancer
biomarkers can be DNA, mRNA, proteins, metabolites, or processes such as apoptosis, angiogenesis or proliferation.
Such biomarkers can be found in a variety of body fluids and tissues. Fluid sampling has advantages over imaging and
invasive biopsy as it is widely accepted, readily repeated, convenient, noninvasive, and low cost. Biomarkers in body
fluids have the potential to detect a wide variety of primary tumors and metastases located throughout the body. Fluid
biomarkers include a variety of components in blood, urine, saliva, CSF, pleural, peritoneal fluid, and other fluids that
reflect the presence of a tumor in the body.
New Classification of Acute Myeloid Leukemia and Precursor Related Neoplasms
: Unresolved Issues
The World Health Organization (WHO) classification of lympho-hematopoietic neoplasms is increasingly based on
genetic criteria. Here. The category of AML with recurrent genetic abnormalities was expanded to account for 60% of
AML by adding three distinct entities, i.e., AML with t(6,9), inv(3), or t(1;22), and two provisional entities, i.e., AML
with mutated NPM1 or CEBPA. These changes have greatly modified the approaches to diagnosis and prognostic
stratification of AML patients. Mmyelodysplasia (MD)-related cytogenetic abnormalities, history of myelodysplasia or
myelodysplasia/myeloproliferative neoplasm, and multilineage dysplasia, the category of "AML with multilineage
dysplasia" was re-named AML with MD-related changes. Finally, we describe the unique characteristics of myeloid
proliferations associated with Down syndrome and blasticplasmacytoid dendritic cell neoplasm.
Contemporary Use of Immunohistochemistry in the Interpretation of
Undifferentiated Malignant Tumors
Not uncommonly, pathologists are confronted with neoplasms that have few distinguishing microscopic characteristics
and, therefore, appear to be "undifferentiated." The differential diagnostic considerations in such cases are many, and
special studies are almost always necessary to reach a definite conclusion.
An extensive array of antibodies is available to the surgical pathologist to facilitate characterization of tumors without
histologically specific features. A highly select panel of immunostains, based on the histopathologic impression of the
tumor, can be extremely useful to narrow the diagnostic considerations, if not definitively identify the tumor.
This presentation will address approaches to these dilemmas that are particularly suited to the use of immunodiagnosis.
Metastasis of Unknown Primary, Role of the Pathologist
In spite of the increasing sophistication in the diagnostic workup for malignancies, detailed investigations fail to reveal
a primary site of origin for a subset of patients with metastatic cancer. This is often referred to as carcinoma of
unknown primary origin (CUP) or occult primary malignancy. The diagnosis of carcinoma of unknown primary thus
generates anxiety among patients and caregivers, who may feel that the evaluation has been incomplete. The
pathologist has an indispensable role in the evaluation of cancer of unknown primary origin. The help of a pathologist
familiar with cancer of unknown primary origin can in many cases solve dilemmas and put the patient on the road to
cure.
The Role of Immunohistochemistry in the Differential Diagnosis of Small Round
Blue Cell Tumors
Small round blue cell tumor (SRCT) is the name given to a group of highly malignant neoplasms that occur mostly in
the pediatric age group. This term could also apply to some adult neoplasms. The name is derived from the primitive,
highly cellular nature of these lesions, which typically present a vast sea of dark-blue nuclei on hematoxylin-based
stains. These tumours are often indistinguishable by light microscopy and their diagnosis, which is often based on
clinical features, may be difficult for those tumors presenting in an unusual clinical context.
In an attempt to reach the correct diagnosis, a panel of antibodies that recognize various tumour-associated markers
will be highlighted.
Prognostic and Therapeutic Implications of Immunohistochemistry
The identification of new accurate methods and techniques for determining the presence or overexpression of certain
molecules and receptors in cancer patients in the last years was revolutionary, as it has led to improvement in disease
free survival and, in some situations, improvement in overall survival in cancer patients. Immunohistochemistry (IHC)
is a major ancillary technique that has been used by histopathology laboratories to study the antigenic profile of tumors
in order to classify them as well as to identify predictive markers of prognosis and targets of therapy in patients' tissues
This talk will go briefly through the evidence-based information regarding the use of the most common markers as
prognostic and therapeutic indicators in cancer patients.
Anion Gap
The term "anion gap" usually implies serum anion gap. The "urine anion gap" is a different measure, principally used
to determine whether the kidneys are capable of appropriately acidifying urine.
Urine anion gap is an 'artificial' and calculated measure that is representative of the unmeasured ions in urine. Usually
the most important unmeasured ion in urine is NH4.
The urine anion gap is calculated using measured ions found in the urine. It is used to aid in the differential diagnosis
of metabolic acidosis.
The Universe of Genetic Testing
The tremendous technological advancements over the past decade have empowered the discovery of novel disease
concepts and rapidadvancement in medical sciences with emergence of entirely new scientific fields. Hence the need of
developing an advanced genetic lab with diverse research and diagnostic facilities becomes imperative.
Genetics medicine has become undoubtedly integral part of clinical practice. Although most genetic diseases are only
treated symptomatically, except for the group of inborn errors of metabolism that can be controlled by diet restriction
or relatively cured by enzyme replacement therapy, the accurate diagnosis of a certain genetic disorder must be
confirmed by the suitable genetic test analysis, for correct diagnosis and for genetic counseling and family screening of
familial mutation. The genetic diagnosis can be at many levels: the cytogenetics, molecular cytogenetics, gene level
diagnosis and or diagnosis at the protein level (enzyme defect or hormonal deficiency).
The exponential growth of biomedical science and technology has enabled system biology studies allowing the study
of disease through incorporating genomic, transcriptomic, proteomic and phenomic aspects. This is possible through
integrated multidisciplinary clinical approach acting on an advanced technologic and bioinformatic platform, aiming
for improving clinical workup at diagnostic, prognostic and therapeutic levels.
Proteomics Overview
Proteomics is the investigation of the protein products encoded by genes. The role of genetics in certain human disease
has been studied by the use of genomics which is the study of the known sequence of the entire human genome.The
study of proteomics is much more important than genomics due to the following reasons: Protein expression is equal
to and even more important than genomics because proteins determine what is currently occurring within a cell while
the genes indicate what a cell might be capable of performing. Moreover many posttranslational changes occur to the
protein, as influenced by other proteins & enzymes that cannot be easily predicted by knowledge at the genomic level.
The advances in proteomic technology facilitated the study for new diagnostic biomarker especially in cancer patients.
Proteomics techniques gave a promise to patients that disease diagnosis and monitoring can be done away from the
actual site of disease most often serum , urine or cerebrospinal fluid.It may also be beneficial in the field of treatment
as drug can be tailored to accommodate the variation in enzymes and other proteins involved in drugs action &
metabolism among individuals
Biomarkers of Liver Disease
Liver fibrosis is defined as the building up of excessive amount of extracellular matrix, also known as scar tissue, in
the liver parenchyma. While reviewing fibrosis as a component of the pathogenesis of a disease, it is important to
remember that the process of fibrogenesis is also a component of the normal healing response to various kinds of
injury.With great advancements in the therapeutic modalities used for the treatment of chronic liver diseases,
theaccurate assessment of liver fibrosis is a vital need for successful individualized management of disease activity
inpatients.
For the past 50 years liver biopsy has been considered tobe the gold standard for staging of liver fibrosis.
Thistechnique allows physicians to obtain diagnostic informationnot only on fibrosis, but also on many otherliver
injuring processes, such as inflammation, necrosis,steatosis, hepatic deposits of iron or copper. However,many recent
studies clearly highlight several crucialdrawbacks of liver biopsy, including variable accessibility,high cost, sampling
errors and inaccuracy due tointer- and intra-observer variability of pathologic interpretations. In addition, there is a
small but importantrisk of liver biopsy-associated morbidity and mortality. In recent years, interest in identifying and
describingliver fibrosis by using non invasive surrogate markershas been on the rise. Serum markers of liver
fibrosisoffer an attractive, cost effective alternative to liverbiopsy for both patients and clinicians. In addition tobeing
substantially less invasive, there are practically nocomplications, little or no sampling errors and smallobserver related
variability. Moreover, measurementsmay be performed repeatedly, thus, allowing for adynamic monitoring of fibrosis.
Although no single ideal marker exists, several markershave been identified as possible useful indicators offibrosis
when used in conjunction with each other.Biomarkers of fibrosis are commonly divided intoDirect and Indirect
markers. Direct markers are fragmentsof the liver matrix components produced byhepatic stellate cells (HSC) during
the process of ECMremodeling. Indirect markers include molecules releasedinto the blood due to liver inflammation,
moleculessynthesized/regulated or excreted by the liver, and markersof processes commonly disrupted due to liver
functionimpairment, such as insulin resistance. Direct and indirect markers may be used alone or- more commonly - in
combination with each other, toproduce composite scores. The calculation of suchscores can be relatively simple or
can be based on complicatedformulas (e.g. those underlying Fibrotest/Fibrosure).Direct biomarkers include:
Procollagen type I carboxy terminal peptide (PICP) and Procollagen type III amino-terminal peptide(PIIINP),
Metalloproteinases (MMPs), Tissue inhibitors of matrix metalloproteinases (TIMPs), Transforming growth factor-b1
(TGF-b1), Hyaluronic acid (HA), YKL-40 (chondrex) and Connective tissue growth factor (CTGF).
Indirect biomarkers include: AST/ALT ratio, The PGA index, The AST-to-Platelet Ratio Index (APRI), the Forns
index, the HepaScore, the FIB-4 score, The FIBROSpect II test and The FibroTest and FibroSre.
DNA Microarray and Cancer
Cancer is a highly complex disease which can encompass multiple genomic alterations, including point mutations,
translocations, gene amplifications, epigenetic modifications, deletions, aberrant splicing, and altered gene expression.
These genomic perturbations drive cancer cell survival by altering the mechanism for cell cycle control, DNA repair,
differentiation, apoptosis, tumor vascularization, and metabolism. .
Since its development in the mid-1990s, DNA microarray technology has revealed a great deal about the genetic
factors involved in a number of diseases, including multiple forms of cancer. Early on, microarrays were used to
identify differences in gene expression between normal cells and their cancerous counterparts. It is now possible, with
microarray products, to perform extensive analysis of tumor genomes, including whole genome chromosomal copy
number analysis, systematic gene resequencing, and RNA expression analysis.Through the use of these tools,
researchers can achieve a more complete picture of the genesis and evolution of cancer, with the goal of ultimately
improving the diagnosis and treatment of the disease.
Pharmacogenomics Insight in Therapeutic Drug Monitoring
Decoding the DNA of patients could predict whom most likely to benefit from therapy, whilst sparing others from
unnecessary treatment. Genomic information will be one more data point for physicians to consider when they select
among several treatment options.While pharmacogenomics can be an invaluable tool clinically for predicting efficacy
and reducing serious side effects of certain drugs, the situation for others is more complicated as cost versus benefit is
an important consideration. Clinical pharmacogenomics provide a promising way to the adoption of personalized
pharmacotherapy. Genetic variations, however, are currently identified using methods that are characteristically time
consuming, operator dependent and relatively costly, hampering the routine clinical application of pharmacogenomic
testing in daily pharmacotherapy. The recently emerging bedside point-of-care (POC) genetic assay has offered rapid,
easy-to-use and a more affordable solution to achieving the benefit of drug therapy more safely and effectively .The
current cost of sequencing a patient’s complete genome, is generally prohibitive to routine use; however, as the wholegenome sequencing cost is becoming affordable and the entire genome data are becoming more clinically available, the
question is raised of whether POC genetic testing can resist and compete with full genome-sequencing developments.
Could pharmacogenomics /POC genetic testing persuade clinicians to consider the indispensable role of genetics and to
integrate pharmacogenomics into routine medical practice?
The Ongoing Evolution of Diagnostic Testing in Microbiology
The advent of the molecular biology era in the 1950s and the subsequent emergence of new technologies positively
impacted on all areas of biology. New discoveries in molecular biology and experimental tools were developed over
the next 60 years that have revolutionized the study of microbiology. Previously, microbiology relied on
classic microbiology techniques, which had remained relatively unchanged since the discoveries of Louis Pasteur in the
1800s. More recently, new advances resulting in "omic" technologies have exploded the areas of genomics,
transcriptomics, and proteomics and revealed many fundamental processes driven by both pathogens and commensals.
By extending our understanding of the process of bacterial pathogenesis at the molecular level new strategies for
their treatment and prevention can be developed. Proteomic technologies, along with other methods for global gene
expression analysis, play an important role in understanding the mechanism(s) of bacterial pathogenesis.
Pillars` of Reliable Key Performance Indicators Dashboard
Indicators addressing health system quality in terms of patient-centered care from the patient’s perspective are crucial
in evaluating the performance of an organization as well as the quality of healthcare services provided. Recent
attention has focused on validity, reliability and feasibility for different approaches in developing performance
indicators for the purposes of quality improvement. A key performance indicators dashboard is a performance
management tool that uses charts, reports and a collection of other data visualization and charting elements to provide
organizational managers with an overview of how the company is performing vs. key pre-determined targets. The
information provided by the dashboard shall be intuitive and insightful. Developing a reliable indicators dashboard that
actually monitors the performance and helps in decision making is a challenge that has to be jeopardized.
Quality Lab Reporting
For most clinical situations, the standard reporting mechanism used by laboratories should meet the needs of patients
and clinicians in the community.
Clinical decisions are often made or influenced significantly by lab results.
Lab results can represent up to 70-80% of all health care information for patients and providers.
Key component of longitudinal Electronic Health Record.
The laboratory, an integrated and essential service within a hospital, has an obligation to ensure the laboratory report,
whether hardcopy or electronic, appears in the organization’s patient medical record in the intended format and with all
required elements.
The laboratory must provide useful clinical data. Data must be legible, accurate, reported in clearly designated units of
measurement, and promptly reported to persons authorized by law to receive and
use medical information. Reference intervals (normal ranges) must be readily available to clinicians, preferably on the
test report itself.
Several questions have to be answered:
When errors are detected in patient test reports, does the laboratory promptly notify the responsible clinicians and issue
a corrected report?
Does the laboratory have procedures for immediate notification of a physician when results of certain tests fall within
established "alert" or "critical" ranges?
Has the laboratory defined turnaround times for each of its tests, and does it have a policy for notifying the requester
when testing is delayed?
Diagnostic Challenges in Pyrexia of Unknown Origin (PUO)
Pyrexia of unknown origin (PUO) remains one of the major diagnostic challenges for the clinician. It identifies a
syndrome of fever that does not resolve spontaneously, in which the cause remains elusive after an extensive
diagnostic workup. Four types of PUO have been proposed: classic, nosocomial, neutropenic and HIV associated.
Although infection, malignancy and collagen vascular disease remain the 3 most important causes of PUO, the relative
importance of different disease entities with each of these major categories has changed because of improvements in
serodiagnosis, culture techniques and radiologic imaging modalities. A detailed clinical history and meticulous
physical examination remains the mainstay of the approach to management of patients with PUO. There is no set of
"routine" investigations that patients with PUO should be subjected to. Instead, diagnostic testing should be
individualized and guided by abnormalities found on clinical examination and simple laboratory testing.
Fever in Parasitic Diseases
Fever is a symptom for most of the parasitic diseases, either helminthes or protozoa. Through this talk, there will be a
discussion about the most common parasitic causes of fever and their new laboratory techniques for diagnosis.
Furthermore, there will be a discussion of a case history of cerebral malaria as an example of a parasite producing
pyrexia of unknown origin.
Prof. Dr. Ahmed Nagdi Abdelaal
Prof. of Medical Biochemistry – Faculty of Medicine – Alexandria University
1976 : 1979 Demonstrator Medical Biochemistry ( MBBCH )
1979 : 1984 Assistant Lecturer of Medical Biochemistry ( MS )
1984 : 1989 Lecturer of Medical Biochemistry
1989 : 1994 Assistant Professor of Medical Biochemistry
1994 : 2008 Professor of Medical Biochemistry
2008 : 2011 Head of Medical Biochemistry Department
Prof. Dr. Iglal Shola
Prof. of Clinical Pathology – Faculty of Medicine – Alexandria University
1976 : 1978 Demonstrator of Clinical Pathology
1978 : 1988 Assistant Lecturer of Clinical Pathology
1988 : 1993 Lecturer of Clinical Pathology
1993 : 1998 Assistant Professor of Clinical Pathology
1998 Professor of Clinical Pathology