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Introduction: During the COVID-19 pandemic thyroid gland alteration/dysfunction has been emerged as a possible endocrine complication. The present review is focused on inflammatory and autoimmune thyroid complications triggered by SARS-CoV-2 infection by searching through databases like MEDLINE and Scopus up to April 2021. Areas covered: Beside the occurrence of ‘non-thyroidal illness’ in severe clinical conditions, alterations of thyroid function and structure may occur during COVID-19 as a consequence of either direct or indirect effects of SARS-CoV-2 infection on the gland. On the one hand, SARS-CoV-2 uses ACE2 as a receptor to infect the host cells and ACE2 is highly expressed by follicular thyroid cells. On the other hand, COVID-19 is associated with a systemic inflammatory and immune response, involving Th1/Th17/Th2 lymphocytes and proinflammatory cytokines, which resembles the immune activation that occurs in immune-mediated thyroid diseases. COVID-19-related thyroid disorders include destructive thyroiditis and onset or relapse of autoimmune thyroid disorders, leading to a broad spectrum of thyroid dysfunction ranging from thyrotoxicosis to hypothyroidism, that may worsen COVID-19 clinical course and affect prognosis. Expert opinion: Physicians should be aware of the possible occurrence of thyroid dysfunction during and after SARS-CoV-2 infection. Further longitudinal studies are warranted to evaluate potential long-term sequelae.

Currently, few evidences have shown the possible involvement of autoimmunity in patients affected by coronavirus disease 2019 (COVID‐19). In this study, we elucidate whether severe acute respiratory syndrome coronavirus disease 2 (SARS‐CoV‐2) stimulates autoantibody production and contributes to autoimmunity activation. We enrolled 40 adult patients (66.8 years mean age) admitted to Alessandria Hospital between March and April 2020. All the patients had a confirmed COVID‐19 diagnosis and no previously clinical record of autoimmune disease. Forty blood donors were analyzed for the same markers and considered as healthy controls. Our patients had high levels of common inflammatory markers, such as C reactive protein, lactate dehydrogenase, ferritin, and creatinine. Interleukin‐6 concentrations were also increased, supporting the major role of this interleukin during COVID‐19 infection. Lymphocyte numbers were generally lower compared with healthy individuals. All the patients were also screened for the most common autoantibodies. We found a significant prevalence of antinuclear antibodies, antineutrophil cytoplasmic antibodies, and ASCA immunoglobulin A antibodies. We observed that patients having a de novo autoimmune response had the worst acute viral disease prognosis and outcome. Our results sustain the hypothesis that COVID‐19 infection correlates with the autoimmunity markers. Our study might help clinicians to: (a) better understand the heterogeneity of this pathology and (b) correctly evaluate COVID‐19 clinical manifestations. Our data explained why drugs used to treat autoimmune diseases may also be useful for SARS‐CoV‐2 infection. In addition, we highly recommend checking patients with COVID‐19 for autoimmunity markers, mainly when deciding on whether to treat them with plasma transfer therapy. Study Highlights WHAT IS THE CURRENT KNOWLEDGE ON THE TOPIC? ☑ Recent data sustain the idea that autoimmune phenomena exist in patients with coronavirus disease 2019 (COVID‐19), but other investigations are necessary to define the possible link between severe acute respiratory syndrome coronavirus disease 2 (SARS‐CoV‐2) infection and autoimmune disease onset. WHAT QUESTION DID THIS STUDY ADDRESS? ☑ In this monocentric study, we demonstrated how SARS‐CoV‐2 infection could be associated with an autoimmune response and development of autoantibodies. WHAT DOES THIS STUDY ADD TO OUR KNOWLEDGE? ☑ Patients with COVID‐19 having an increased level of inflammatory markers and strong autoantibodies positivity (i.e., antinuclear antibodies and antineutrophil cytoplasmic antibodies) presented the worst clinical outcome. HOW MIGHT THIS CHANGE CLINICAL PHARMACOLOGY OR TRANSLATIONAL SCIENCE? ☑ These results suggest that the drugs normally used to treat autoimmune diseases should also be considered during SARS‐CoV‐2, improving public health. In addition, before starting a transfer plasma therapy, it is important to also evaluate the autoimmunity conditions of the patients with COVID‐19. Transferring antibodies or trying to neutralize them should be done with precaution. It is possible that the risk of developing or increasing the autoimmune response may enhance.

Objectives: To improve the appropriateness in the autoantibody test requests for proper diagnosis of systemic rheumatic autoimmune diseases, celiac disease and anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitides. Methodology: Review of recommendations proposed by the Study Group in Autoimmunology (GDS-AI) of the Italian Society of Clinical Pathology and Laboratory Medicine (SIPMeL) and the European Society For Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHaN) Results: This document aims to bring to the attention of general practitioners the recommendations proposed by National and International study group to improve the appropriateness in the autoantibody test requests expecially in sytemic autoimmune and celiac disease. Conclusions: Autoimmunity is a specialistic laboratory area where the costs are extremely high compared to other diagnostics: it would therefore be very helpful and economically advantageous to align the clinicians on appropriate requests and the laboratory on useful diagnostics. In Autoimmunology, diagnostic appropriateness remains a complex and debated topic from the management, professional and economic point of view.

Receptor autoimmunity is one of the ways in which autoimmune diseases appear in humans. Graves’ disease, myasthenia gravis, idiopathic membranous nephropathy, and autoimmune acute encephalitis are the major autoimmune diseases belonging to this particular group. Receptor autoimmune disease are dependent on the presence of autoantibodies directed against cell-surface antigens, namely TSH receptor in thyrocytes, acetylcholine receptor in neuromuscular junction, phospholipase 2 receptor in podocytes, and NMDA receptor in cortical neurons. In this article we outline the distinctive features of receptor autoimmunity and the specific relationship between the autoimmunology laboratory and the presence/concentration of autoantibodies. Some immunological features distinguish receptor autoimmunity. Anti-receptor autoantibody pathologies are considered T cell-dependent, B-cell-mediated autoimmune disorders: the knowledge about the presence of circulating and/or localized autoantibodies to target organs and identification of autoantigens involved in the autoimmune reaction is of paramount importance. Due to the close correlation between the concentration of anti-receptor autoantibodies, the autoimmune target of some cell-surface receptors and the intensity of symptoms, the measurement of these immunoglobulins has become central to diagnose autoimmune diseases in all affected patients, not just in clinically dubious cases. The measurement of autoantibodies is also relevant for differential diagnosis of autoimmune and non-autoimmune forms with similar symptoms. From the methodological point of view, quantitative immunoassay methods of measurement should be preferred over semi-quantitative ones, for the capacity of the first class of methods to define precisely the reference ranges and decision levels overcoming the measurement uncertainty of semi-quantitative methods.

Nel novembre 2017, il Gruppo di Studio in Autoimmunologia (GdS-AI) della SIPMeL ha organizzato un convegno nazionale a Santa Margherita Ligure per formulare e discutere alcune proposte per una scelta saggia nell’ambito della diagnostica autoimmune di laboratorio. Delle 19 proposte presentate da 5 gruppi di lavoro e sottoposte alla valutazione e discussione in aula con i partecipanti al Congresso, ne sono state scelte 5, una per ciascuno dei 5 gruppi di patologia che erano stati inseriti nel programma. In questa rassegna vengono presentate le proposte Choosing Wisely relative alla diagnosi immunologica del morbo di Graves, della gastrite autoimmune, delle miositi infiammatorie autoimmuni, del diabete di tipo 2 e della miastenia gravis.

E rilevante la mancanza di studi in letteratura sulla reale utilita dei sistemi PoCT in eventi complessi, quali i disastri e le grandi emergenze, nonostante l’analisi dei processi sanitari nelle grandi catastrofi degli ultimi anni abbia confermato la necessita di un uso proattivo del PoCT in queste circostanze. All’interno degli standard di cura in condizioni di crisi delineati dall’Institute of Medicine, non vi e ancora sufficiente attenzione sulle modalita di impiego dei sistemi PoCT e non vengono previste procedure specifiche di intervento diagnostico nell’ambito del percorso terapeutico. Non appaiono infatti adeguati i modelli di intervento elaborati in tempo di pace o in condizioni ordinarie, data la diversita del contesto; per questo sta emergendo il piu largo concetto di punto di necessita, in luogo del punto di cura. Tuttavia la Medicina di Laboratorio non e stata ancora chiamata a chiarire il campo e il contesto d’azione dell’attivita diagnostica in vitro in queste particolari condizioni. Il principale scopo dell’articolo e definire per la prima volta alcune raccomandazioni relative ai criteri, ai modelli flessibili e alle strategie da attuare in condizioni di crisi: in particolare si fa riferimento ad alcune caratteristiche dei dispositivi (robustezza e tipologia di prestazioni), alle necessita dell’innovazione tecnologica e all’emergente esigenza di test diversi e mirati. Viene inoltre rivisto il concetto di leadership del coordinatore PoCT (con riferimento al set di abilita, all’analisi dell’esposizione al rischio e al piano di emergenza), sostenuta la necessita di nuove procedure per la formazione e l’addestramento (telemedicina, risorse web e impiego di smartphone) e infine riservata particolare attenzione alle strategie per la garanzia di qualita dei risultati dei test di laboratorio, dato il prevedibile incremento di potenziali rischi di errore nelle situazioni di crisi.

Objective In patients with a history of lymphoma, each lymphadenopathy should be carefully evaluated. The aims of this study were to evaluate (i) the usefulness of high-resolution ultrasonography (US), US-guided fine-needle aspiration cytology (FNAC) and flow cytometry phenotyping (FCP) together in the diagnosis of recurrent lymphoma, and (ii) whether these tools were independent predictors of correct results. Design Retrospective cohort study with stepwise forward logistic regression analysis of results. Setting Tertiary referral centre. Participants A total of 151 patients with history of lymphoma who developed a cervical mass during follow-up. Methods On neck US, a lymphadenopathy was shown in 129 (85.4%) patients (median age 57 years, range 18-78 years), and US-guided FNAC combined with FCP were immediately performed. All patients had surgical excision and subsequent histological examination of the enlarged node(s), to establish lymphoma subclassification. Results Final histology confirmed recurrence in 82 (63.6%) patients. According to the logistic regression analysis, FNAC and FCP were independent predictors of correct results (p=0.009 and 0.028, respectively) and did not interfere with each other. The sensitivity, specificity and accuracy of the combination of all of the tools were 98.8%, 100%, and 99.2%, respectively, and the area under the receiver operating characteristic curve was 0.902 (95% CI: 0.797-0.896). Conclusion This minimally-invasive procedure is easily performed and should be recommended for all patients with cervical lymphadenopathy and a history of lymphoma, avoiding the need of core-biopsy or surgical excision if recurrence was excluded. This article is protected by copyright. All rights reserved.

Background The aims of this study were: (1) to calculate reliable thyroid stimulating hormone (TSH) reference intervals using laboratory databases; (2) to evaluate the relationship between TSH, sex and age values in different large Italian populations. Methods The TSH values stored in the laboratory information system of clinical laboratories of four Italian city hospitals, including 146,801 TSH measurements (with the respective age and sex data of individuals) were taken in consideration. Assuming a log-normal distribution, to log-transformed TSH values were applied the Dixon’s iterative principle in order to exclude the outliers. At the end of this iterative process 142,821 log-transformed TSH results remained. The four clinical laboratories measured serum TSH concentrations using the same TSH immunoassay method (Access TSH 3rd IS, using UniCel DxI platform). Results The TSH reference interval calculated in the present study (0.362–5.280 mIU/L) is similar to that suggested by the manufacturer for the Access TSH 3rd IS assay (0.45–5.33 mIU/L). TSH values in females were significantly higher than in males (females: mean=2.06 mIU/L; standard deviation [SD]=1.26 mIU/L; n=101,243; males: mean=1.92 mIU/L; SD=1.19 mIU/L; n=41,578; p Conclusions The results of the present multicenter study confirm that data mining techniques can be used to calculate clinically useful reference intervals for TSH. From a pathophysiological point of view, our results suggest that some Northern populations of Italy might still suffer some harmful effects on the thyroid gland due to mild to moderate iodine intake deficiency. Specific clinical trials are needed to confirm these results.

L’insufficienza surrenalica (IS) e una condizione clinica, potenzialmente pericolosa per la vita, determinata dalla diminuita produzione o azione degli ormoni glucocorticoidi, accompagnata o meno da carenza di mineralcorticoidi o androgeni surrenalici. E dovuta a un’alterazione dell’asse ipotalamo-ipofisi-surrene, per cause surrenaliche [insufficienza surrenalica primaria (ISP) o morbo di Addison], ipofisarie (insufficienza surrenalica secondaria) o ipotalamiche (insufficienza surrenalica terziaria). La prevalenza dell’ISP in Europa e di circa 100 casi per milione, l’incidenza 5 casi per milione/anno, con una frequenza maggiore nella quarta decade di vita e nel sesso femminile. Oggi l’82% dei casi di ISP ha eziologia autoimmune, il 9% infettiva e il 9% da altre cause. L’IS si differenzia in una forma acuta, che costituisce un’emergenza clinica con le manifestazioni proprie dello shock ipovolemico, e una forma cronica, caratterizzata da sintomi e segni che si aggravano progressivamente in base al grado e alla velocita di distruzione del surrene: astenia generalizzata, anoressia, calo ponderale, ipotensione, ipoglicemia, iperpigmentazione cutanea, amenorrea e diminuzione della libido, anemia e depressione. Le presenti raccomandazioni pratiche della Societa Italiana di Patologia Clinica e Medicina di Laboratorio riprendono quelle della Endocrine Society del 2016 preparate utilizzando il sistema Grade. Le raccomandazioni principali ribadiscono che: (1) la misura basale di cortisolo sierico totale (CST), l’indice di cortisolo libero (ICL) e il cortisolo salivare del mattino (CSM), associati alla misura della corticotropina (ACTH), rappresentano i test di ingresso per la diagnosi di ISP (test combinato basale); (2) rilevare un valore elevato di renina attiva, associato a un valore basso-normale di aldosterone suggerisce l’esecuzione del test combinato basale; (3) rilevare un valore basso di deidroepiandrosterone solfato (DHEAS) suggerisce l’esecuzione del test combinato basale; (4) rilevare un valore di $\text{CST}

The skeleton is the most common site of metastasis for breast cancer and the periodic measurement of circulating bone turnover markers (BTMs) can be useful. The aim of this study was to prospectively evaluate the diagnostic accuracy of a panel of BTMs in the early detection of bone metastases (BMs).We reviewed the medical records of 297 postmenopausal women with early stage luminal-type invasive ductal carcinoma (IDC). Twenty-six patients who developed isolated BMs during follow-up and 24 randomly selected controls were studied. The two groups were matched according to age, final disease staging, and follow-up. All patients underwent periodic measurement of total and bone-specific (BSAP) alkaline phosphatase, CTX, ICTP, osteocalcin, NTX, PINP, and TRACP5b.Only BSAP, CTX, PINP, and TRACP5b were significantly (p0.05) associated with the group, and the logistic regression analysis excluded CTX from the model. The AUC (ROC curve) for TRACP5b alone, which was the most accurate marker, and for the combination of BSAP+PINP+TRACP5b was 0.784 (95% CI: 0.651-0.916) and 0.889 (95% CI: 0.798-0.981), respectively.According to our results, the measurement of these three markers together should be performed in all postmenopausal patients with luminal-type IDC, when an early diagnosis of BMs is required.

Standardization and harmonization are complementary tools to achieve higher testing quality in laboratory medicine. Both are of great relevance and are strongly needed in autoimmune diagnostics, due to the impressive advance in basic research and technological development observed in this diagnostic field in recent years that has led to the introduction of many new tests and new analytical methods. It is, therefore, essential that this strong innovative thrust is translated into clinical practice in a coordinated way to avoid confusion and the risk of potentially harmful errors for the patient. However, while standardization of antibody assays is a very complex task, harmonization of procedures and behaviors is a more feasible target and should necessarily include all the phases of the total testing process-in the pre-analytical phase, appropriateness of test requests, harmonization of autoantibody terminology, and adoption of uniform nomenclature for laboratory tests; in the analytical phase, harmonization of measurements, and sharing of test profiles and diagnostic algorithms; and in the post-analytical phase, harmonization of data reporting, and criteria for interpreting immunoserological results, especially harmonization of units, reference intervals, decision limits, and definition and notification of critical values. We here provide and discuss some examples of harmonization initiatives related to anti-nuclear antibodies, TSH receptor, and anti-thyroid peroxidase antibodies and to antibodies associated with autoimmune hepatitis and with celiac disease. These initiatives could be the starting steps to achieve a wider consensus and a closer interaction among stakeholders in the path of autoimmune diagnostics harmonization to enhance clinical effectiveness and provide greater patient safety.

Background: Thyroid stimulating hormone (TSH) receptor autoantibodies (TRAb) are pathogenetic and diagnostic hallmarks of Graves’ disease (GD). Three varieties of TRAb have been described: stimulating (S-TRAb), blocking (B-TRAb), and apoptotic (A-TRAb) autoantibodies. Very recently, the first immunoassay method (Immulite TSI assay, Siemens Healthcare Diagnostics) declared to measure serum S-TRAb concentration, has been made available in an automated commercial platform. The aim of the study was to evaluate the ability of this new test to identify patients suffering from GD, in comparison with two current IMA methods for total TSH receptor autoantibodies (T-TRAb) measurement. Methods: Sera of 383 subjects [72 patients with untreated GD, 55 patients with autoimmune thyroiditis (AIT), 36 patients with multinodular non-toxic goiter, 100 patients with other non-thyroid autoimmune diseases (NTAD) and 120 healthy subjects (HS)] were evaluated. Results: The threshold obtained by receiver operating characteristic (ROC) analysis was 0.54 IU/L, very similar to that proposed by the manufacturer (0.55 IU/L). Thyroid-stimulating immunoglobulins (TSI) were positive in all GD patients and negative in all but three controls (clinical sensitivity and specificity of 100% and 98.7%, respectively). Passing and Bablok regression analysis and Bland-Altman plot showed an acceptable agreement between TSI Immulite assay and other two immunoassay methods (Cobas/Elecsys, Roche and TRAK RIA, BRAHMS Thermo Scientific). Conclusions: The diagnostic performance of fully automated Immulite TSI assay in GD patients is at least comparable to that of current TRAb immunoassays (IMAs) suggesting the possibility of including such assay in rapid and cost-saving diagnostic and monitoring algorithms. However, our results do not provide full evidence that this assay is specific for S-TRAb only, and future studies comparing Immulite TSI assay to stimulating activity are required.

The prognosis of breast cancer is strongly influenced by the stage of the disease; therefore, it is essential that breast cancer lesions be diagnosed at the earliest stages. There is an urgent need to identify different biomarkers with a high accuracy for the early detection of this cancer to facilitate clinical management of the disease. A wide number of substances named serum tumor markers can be detected in the serum of patients with breast cancer, including tumor-associated proteins, cytokines, stimulating or inhibiting factors, autoantibodies to antigen tumor-associated substances and miRNAs. Despite ASCO and NACB recommendations, the routine use of breast cancer tumor markers by a significant proportion of oncologists is common, particularly after primary treatment of early tumors. The new promising circulating markers are HER2/neu, Trx 1, CSF1, autoantibodies against these tumor-associated antigens, and miRNAs, which are non-coding RNA molecules that regulate the translation of mRNA and control a number of biological processes, including oncogenic cells proliferation. The expression of single miRNA results in a miRNA signature, and is considered a potential biomarker for early breast cancer. However, additional studies are needed to identify its real usefulness.

In this review we analyze all aspects of total testing process regarding the measurement of antithyroid peroxidase, antithyroglobulin and antithyrotropin receptor autoantibodies. The main critical points related to the preanalytical, analytical and postanalytical steps of autoimmune thyroid disease diagnostics are considered, focusing on harmonization of autoimmune thyroid tests request, retesting intervals, terminology of thyroid autoantibodies, measurement units and definition of reference limits. Harmonization in thyroid autoantibody testing is a relevant example of feasible harmonization in autoimmunology.

Follicular cell-derived and medullary thyroid carcinomas constitute a biological continuum progressing from the highly curable well-differentiated forms to the rare aggressive and undifferentiated forms. A progressive dedifferentiation translates in a more aggressive tumor behavior and worse prognosis especially in patients with locally advanced or metastatic disease.

Differentiated thyroid cancer (DTC) is the most common endocrine cancer, and its incidence has increased in recent decades. Initial treatment usually consists of total thyroidectomy followed by ablation of thyroid remnants by iodine-131 depending on post-operative risk stratification. As thyroid cells are assumed to be the only source of thyroglobulin (Tg) in the human body, circulating Tg serves as a biochemical marker of persistent or recurrent disease in DTC follow-up. Currently, standard follow-up of DTC comprises Tg measurement and neck ultrasound combined, when indicated, with an additional radioiodine scan. Measurement of Tg after stimulation by endogenous or exogenous thyrotropin (TSH) is suggested to detect occult disease with maximum sensitivity due to the suboptimal sensitivity of older Tg assays. However, the development of new highly sensitive Tg assays with improved analytical sensitivity and precision at low concentrations now allows detection of very low Tg concentrations reflecting minimal amounts of thyroid tissue without the need for TSH stimulation. Use of these highly sensitive Tg assays has been incorporated into more recent clinical guidelines; thus, the cornerstone in current guidelines for long-term follow-up is by measuring serum basal (i.e. unstimulated) Tg, and most patients can be followed by this method. However, some thyroid cancer patients have serum anti-thyroglobulin antibodies (TgAb), both at diagnosis and after treatment, when follow-up is started. As these antibodies interfere technically in the immunological methods measuring Tg, current guidelines cannot be implemented in the follow-up of TgAb-positive patients. However, many studies have indicated that following the concentration of TgAb in serum could serve as a “surrogate marker” for recurrence of the thyroid carcinoma. Additionally, in recent years, complementary laboratory methods such as Tg mini-recovery test and Tg measurement by tandem mass liquid spectrometry were proposed to overcome interferences when measuring Tg. The present chapter reviews the biological basis, advances and challenges in Tg and TgAb measurement techniques, as well as their impact on clinical management of DTC patients.

Background:The total testosterone (T) cutoffs clinically adopted to define late-onset hypogonadism (LOH) do not consider the differences that exist between different analytical platforms, nor do they consider the body mass index (BMI) or age of the patient. We aimed at providing method, age and BMI-specific normal values for total T in European healthy men.Methods:A total of 351 eugonadal healthy men were recruited, and total T was measured with four automated immunometric assays (IMAs): ARCHITECT i1000SR (Abbott), UniCel DxI800 (Beckman Coulter), Cobas e601 (Roche), IMMULITE 2000 (Siemens) and liquid chromatography-tandem mass spectrometry (LC-MS/MS). Reference ranges (RRs) were calculated for each method.Results:Passing and Bablok regression analysis and Bland-Altman plot showed an acceptable agreement between Abbott and LC-MS/MS, but a poor one between LC-MS/MS and the other IMAs. Age-specific T concentrations in non-obese (BMI 2) men were greater than in all men. The total T normal range, in non-obese men aged 18–39 years, measured with LC-MS/MS was 9.038–41.310 nmol/L. RRs calculated with LC-MS/MS statistically differed from the ones calculated with all individual IMAs, except Abbott and among all IMAs. Statistically significant differences for both upper and lower reference limits between our RRs and the ones provided by the manufacturers were also noticed.Conclusions:We calculated normal ranges in a non-obese cohort of European men, aged 18–39 years, with four commercially available IMAs and LC-MS/MS and found statistically significant differences according to the analytical method used. Method-specific reference values can increase the accuracy of LOH diagnosis and should be standardly used.

Purpose Thyrotropin receptor (TSHR) autoantibodies (TRAbs) are a hallmark of Graves’ disease (GD). The aim of this study was to evaluate the diagnostic accuracy of a new third generation automatic fluorescence enzyme immunoassay for TRAb measurement in GD, in comparison with two current IMAs. Methods Sera of 439 subjects (57 patients with untreated GD, 34 with treated GD, 15 with GD and Graves’ orbitopathy, 52 with multinodular non-toxic goiter, 86 with Hashimoto’s thyroiditis, 20 with toxic adenoma or toxic multinodular goiter, 55 with non-thyroid autoimmune diseases and 120 normal controls) were tested for TRAbs with the ELiA™ anti-TSH-R assay (ThermoFischer Scientific, Uppsala, Sweden), the TRAK™ RIA, Brahms (Thermo Scientific, Hennigsdorf, Germany) and the Immulite™ TSI assay (Siemens Healthcare, Llanberis, UK). Results Sensitivity and specificity of the ELiA™ anti-TSH-R assay, TRAK™ RIA and Immulite™ TSI assay were 94.7% and 99.6, 100 and 98.2%, 100 and 98.2%, respectively. Spearman’s coefficient and Passing-Bablok regression showed a satisfactory correlation between EliA™ and TRAK™ [rho: 0.925; 95% CI: 0.883-0-953. Intercept: − 0.875 (95% CI: − 2.411 to 0.194); slope: 1.086 (95% CI: 0.941 to 1.248)], and between ELiA™ and TSI™ [rho: 0.947; 95% CI: 0.912 0.969. intercept: 1.085 (95% CI: 0.665 to 2.116); slope 1.315 (95% CI:1.116 to 1.700)]. Conclusions The diagnostic performance of ELiA™-TSH-R assay is comparable to that of some current TRAb assays. It may be adopted into clinical practice for the differential diagnosis of hyperthyroidism, to screen for transient hyperthyroidism, and to monitor disease activity and treatment effects.

Il Gruppo di Studio in Autoimmunologia (GdS-AI) della Societa Italiana di Patologia Clinica e Medicina di Laboratorio (SIPMeL), dopo 14 anni dalla ultima edizione, ha ritenuto opportuno revisionare e integrare le “linee guida per l’impiego di test per autoanticorpi nucleo-citoplasmatici nella diagnosi e nel monitoraggio delle malattie autoimmuni sistemiche”, con l’aggiunta di nuove tematiche, la modifica di precedenti raccomandazioni e la rivalutazione di aspetti controversi del precedente documento. Per l’elaborazione di questa edizione, la valutazione della “qualita delle evidenze” e l’espressione della “forza delle raccomandazioni” sono state definite secondo il metodo GRADE (Grading of Recommendation Assessment, Development and Evaluation), frutto dell’attivita avviata nel 2000 da un gruppo di lavoro internazionale che aveva come scopo la definizione di un metodo rigoroso ed esplicito per la produzione di raccomandazioni cliniche. Il documento e articolato in 18 raccomandazioni, suddivise in 4 sezioni; ognuna di esse e introdotta da un quesito clinico con scelta e valutazione formale degli outcome a esso correlati, seguito dalla valutazione sistematica della letteratura scientifica e della qualita delle prove reperite. La definizione formale della forza delle raccomandazioni, espressa come “forte” o “debole”, e stata assegnata per consenso da tutti i membri del GdS-AI della SIPMeL. Questa revisione delle linee guida, nel fornire una sintesi sullo stato attuale dei test per la ricerca degli autoanticorpi anti-antigeni intracellulari, formula una serie di raccomandazioni rivolte soprattutto all’appropriatezza della richiesta, alla metodologia analitica da utilizzare, all’interpretazione e alla modalita di refertazione dei risultati. Infine, il documento affronta problematiche ancora aperte, quali l’utilizzo di nuovi termini e acronimi per denominare i test autoanticorpali in uso nella diagnostica delle malattie reumatiche autoimmuni e la standardizzazione dei metodi di dosaggio degli autoanticorpi.

Circulating endothelial cells (CEC) and their progenitors (EPC) are restricted subpopulations of peripheral blood (PB), cord blood (CB), and bone marrow (BM) cells, involved in the endothelial homeostasis maintenance. Both CEC and EPC are thought to represent potential biomarkers in several clinical conditions involving endothelial turnover/remodeling. Although different flow cytometry methods for CEC and EPC characterization have been published so far, none of them have reached consistent conclusions, therefore consensus guidelines with respect to CEC and EPC identification and quantification need to be established. Here, we have carried out an in depth investigation of CEC and EPC phenotypes in healthy PB, CB and BM samples, by optimizing a reliable polychromatic flow cytometry (PFC) panel. Results showed that the brightness of CD34 expression on healthy PB and CB circulating cells represents a key benchmark for the identification of CEC (CD45neg/CD34bright/CD146pos) respect to the hematopoietic stem cell (HSC) compartment (CD45dim/CD34pos/CD146neg). This approach, combined with a dual-platform counting technique, allowed a sharp CEC enumeration in healthy PB (n = 38), and resulting in consistent CEC counts with previously reported data (median = 11.7 cells/ml). In parallel, by using rigorous PFC conditions, CD34pos/CD45dim/CD133pos/VEGFR2pos EPC were not found in any healthy PB or CB sample, since VEGFR2 expression was never detectable on the surface of CD34pos/CD45dim/CD133pos cells. Notably, the putative EPC phenotype was observed in all analyzed BM samples (n = 12), and the expression of CD146 and VEGFR2, on BM cells, was not restricted to the CD34bright compartment, but also appeared on the HSC surface. Altogether, our findings suggest that the previously reported EPC antigen profile, defined by the simultaneous expression of VEGFR2 and CD133 on the surface of CD45dim/CD34pos cells, should be carefully re-evaluated and further studies should be conducted to redefine EPC features in order to translate CEC and EPC characterization into clinical practice.

Over the past two decades, we have witnessed an extraordinary change in autoimmune diagnostics, characterized by the progressive evolution of analytical technologies, the availability of new tests, and the explosive growth of molecular biology and proteomics. Aside from these huge improvements, organizational changes have also occurred which brought about a more modern vision of the autoimmune laboratory. The introduction of automation (for harmonization of testing, reduction of human error, reduction of handling steps, increase of productivity, decrease of turnaround time, improvement of safety), consolidation (combining different analytical technologies or strategies on one instrument or on one group of connected instruments) and integration (linking analytical instruments or group of instruments with pre- and post-analytical devices) opened a new era in immunodiagnostics. In this article, we review the most important changes that have occurred in autoimmune diagnostics and present some models related to the introduction of automation in the autoimmunology laboratory, such as automated indirect immunofluorescence and changes in the two-step strategy for detection of autoantibodies; automated monoplex immunoassays and reduction of turnaround time; and automated multiplex immunoassays for autoantibody profiling.

La sindrome di Cushing e un complesso di segni e sintomi determinato da un’esposizione cronica a elevati livelli di glucorticoidi circolanti di cui si distinguono una forma esogena (iatrogenica) e una forma endogena. La maggior parte dei casi di sindrome di Cushing ACTH-dipendente e rappresentata dalla malattia di Cushing, ovvero da tumori ipofisari che producono ACTH, mentre le forme di sindrome di Cushing ACTH-indipendente sono riconducibili a tumori surrenalici, in prevalenza benigni, che producono cortisolo. La presentazione clinica e, in genere, caratterizzata da obesita centrale, strie rubrae, acne, irsutismo, astenia muscolare e osteoporosi, disfunzioni gonadiche (nel maschio ipogonadismo ipogonadotropo, nella femmina cicli oligo- o anovulatori), ipertensione arteriosa, alterazioni metaboliche (diabete mellito e iperlipidemia), disturbi neuropsichiatrici (depressione e psicosi), anche se le forme subcliniche sono piu frequenti di quelle conclamate e si riscontrano nel 5–20% dei casi di incidentaloma surrenalico. La revisione della letteratura successiva alle linee guida della Endocrine Society ha confermato nel complesso le raccomandazioni del 2008: diagnostic odd ratio e number needed to diagnose dimostrano che il cortisolo libero urinario, il cortisolo salivare notturno e il cortisolo sierico totale dopo test al desametasone 1 mg overnight raggiungono performance diagnostiche e analitiche molto soddisfacenti e comparabili. Le presenti raccomandazioni pratiche della Societa Italiana di Patologia Clinica e Medicina di Laboratorio riprendono quelle della Endocrine Society del 2008, privilegiando tuttavia il ruolo della raccolta di almeno 2 campioni di cortisolo salivare notturno, determinato con metodo immunometrico e con attenta valutazione del relativo cut-off, o con metodo LC-MS/MS. Si conferma l’importanza di standardizzare la fase della raccolta della saliva utilizzando un dispositivo adeguato e istruzioni dettagliate per il paziente. Si ribadisce di non eseguire per lo screening della sindrome di Cushing i seguenti test: cortisolo sierico e ACTH plasmatico, prelevati casualmente nel corso della giornata, 17-chetosteroidi urinari, test di tolleranza all’insulina, test alla loperamide e test al DST 8 mg.

Il Gruppo di Studio in Autoimmunologia della SIPMeL ha riveduto e aggiornato le linee guida gia proposte nel 2005 alla luce delle evidenze scientifiche comparse negli ultimi 10 anni per l’inquadramento diagnostico e il monitoraggio del paziente celiaco. L’identificazione della non celiac gluten sensitivity come entita nosologica a se stante ha reso inoltre necessari alcuni chiarimenti su aspetti diagnostici e classificativi. L’attuale versione ripropone sotto forma di raccomandazioni le indicazioni per un appropriato utilizzo dei test sierologici oggi disponibili, dei test genetici in grado di definire l’appartenenza ai gruppi a rischio e dei diversi quadri istologici, definendo gli step diagnostici e interpretativi in maniera diversificata a seconda della motivazione della richiesta (diagnosi, monitoraggio, gruppi a rischio) e dell’eta dei pazienti. Le raccomandazioni sono il risultato delle piu recenti evidenze disponibili in letteratura, del consenso tra i componenti del gruppo di studio e del lavoro interdisciplinare tra patologi clinici, immunologi e anatomo-patologi e ha l’obiettivo di supportare il lavoro del medico nell’approccio quotidiano alla diagnosi delle patologie glutine-associate.

Thyrotropin (TSH) is the most accurate marker of thyroid dysfunction in the absence of pituitary or hypothalamic disease. Studies on TSH reference intervals (RIs) showed wide inter-individual variability and prompted an intense debate about the best estimation of TSH RIs. We performed a population study on TSH RIs, using current data stored in the laboratory information system (LIS), at the Hospital Department of Laboratory Medicine, Pordenone (Italy), historically an area of mild–moderate iodine deficiency with a relatively high goiter prevalence. 136,650 individuals constituted the final sample. A TSH immunoassay was performed on fasting serum samples with the Dimension Vista 1500 analyzer (Siemens Healthineers). We adopted the Kairisto’s procedure to analyze TSH data downloaded by the LIS, applying the indirect strategy for deriving RIs. TSH RIs of the entire population were 0.32–3.36 mIU/L with a distribution skewed towards higher values. RIs were 0.26–3.61 mIU/L for females, and 0.32–3.01 mIU/L for males. Unlike other studies, TSH median levels progressively decreased from 0–4 to 85–104 years in the overall population, both in male and in female subgroups, showing an inverse correlation between TSH and age in all groups. This study is the first to analyze a high percentage (40%) of individuals from an ethnically homogenous Caucasian population. The results obtained emphasize the opportunity to define the TSH RIs according to age, gender and race, in addition to assay methods, and provide further insight about the possible role of iodine status.

Purpose In the last two decades, thyroglobulin autoantibodies (TgAb) measurement has progressively switched from marker of thyroid autoimmunity to test associated with thyroglobulin (Tg) to verify the presence or absence of TgAb interference in the follow-up of patients with differentiated thyroid cancer. Of note, TgAb measurement is cumbersome: despite standardization against the International Reference Preparation MRC 65/93, several studies demonstrated high inter-method variability and wide variation in limits of detection and in reference intervals. Taking into account the above considerations, the main aim of the present study was the determination of TgAb upper reference limit (URL), according to the National Academy of Clinical Biochemistry guidelines, through the comparison of eleven commercial automated immunoassay platforms. Methods The sera of 120 healthy males, selected from a population survey in the province of Verona, Italy, were tested for TgAb concentration using eleven IMA applied on as many automated analyzers: AIA-2000 (AIA) and AIA-CL2400 (CL2), Tosoh Bioscience; Architect (ARC), Abbott Diagnostics; Advia Centaur XP (CEN) and Immulite 2000 XPi (IMM), Siemens Healthineers; Cobas 6000 (COB), Roche Diagnostics; Kryptor (KRY), Thermo Fisher Scientific BRAHMS, Liaison XL (LIA), Diasorin; Lumipulse G (LUM), Fujirebio; Maglumi 2000 Plus (MAG), Snibe and Phadia 250 (PHA), Phadia AB, Thermo Fisher Scientific. All assays were performed according to manufacturers’ instructions in six different laboratories in Friuli-Venezia Giulia and Veneto regions of Italy [Lab 1 (AIA), Lab 2 (CL2), Lab 3 (ARC, COB and LUM), Lab 4 (CEN, IMM, KRY and MAG), Lab 5 (LIA) and Lab 6 (PHA)]. Since TgAb values were not normally distributed, the experimental URL (e-URL) was established at 97.5 percentile according to the non-parametric method. Results TgAb e-URLs showed a significant inter-method variability. Considering the same method, e-URL was much lower than that suggested by manufacturers (m-URL), except for ARC and MAG. Correlation and linear regression were unsatisfactory. Consequently, the agreement between methods was poor, with significant bias in Bland–Altman plot. Conclusions Despite the efforts for harmonization, TgAb methods cannot be used interchangeably. Therefore, additional effort is required to improve analytical performance taking into consideration approved protocols and guidelines. Moreover, TgAb URL should be used with caution in the management of differentiated thyroid carcinoma patients since the presence and/or the degree of TgAb interference in Tg measurement has not yet been well defined.

Il Gruppo di Studio in Autoimmunologia della SIMeL ha svolto un’indagine per rilevare le caratteristiche strutturali, le tecnologie impiegate, i volumi di attivita diagnostica e gli aspetti di governo clinico dei Laboratori italiani di autoimmunologia nell’anno 2012. I dati sono stati raccolti utilizzando un questionario distribuito in forma elettronica nel mese di gennaio 2013 a 315 Laboratori di autoimmunologia italiani. Il questionario comprendeva 38 domande relative alle caratteristiche del Laboratorio di autoimmunologia, alle dimensioni del bacino di utenza, al numero di esami di autoimmunologia effettuati, alla fase analitica (strumentazione, test anticorpali e metodi), alla definizione degli intervalli di riferimento. Infine, l’ultima serie di quesiti intendeva esplorare le modalita di refertazione, l’utilizzo di commenti interpretativi e il rapporto con il mondo clinico, sia ospedaliero sia del territorio. 235 (74,6%) Laboratori hanno risposto in tutto o in parte alle domande. I Laboratori che operano nel settore di autoimmunita in Italia sono per l’87% inseriti in ospedali pubblici e per il 13% in strutture private. La meta circa (48%) esegue tra i 10.000 e i 50.000 esami/anno di autoimmunologia e il 30% piu di 50.000. Solo il 7% dei Laboratori esegue meno di 5000 esami e questi sono per lo piu Laboratori privati. Tra i metodi analitici, l’immunofluorescenza indiretta e utilizzata nel 97% dei Laboratori, i metodi immunoenzimatici sono impiegati nel 96% dei Laboratori e l’immunochemiluminescenza nel 62%. Il 63% dei partecipanti dichiara di inserire un commento interpretativo nel referto. Il 5% utilizza solo commenti codificati, il 9% solo commenti personalizzati e il 49% un commento predefinito o personalizzato a seconda del risultato. In generale, esistono buoni rapporti di collaborazione con i clinici ospedalieri e con i medici di medicina generale e attivita di consulenza viene fornita dal 57% dei Laboratori, sia pubblici sia privati. L’elevato numero di risposte ricevute fa ritenere che i dati raccolti e analizzati siano del tutto rappresentativi della realta organizzativa dei Laboratori italiani e costituiscano un’eccellente fotografia dello stato attuale dell’attivita diagnostica autoimmunologica nel nostro Paese.

Il feocromocitoma e un tumore neuroendocrino di derivazione dalla cresta neurale, in grado di sintetizzare e secernere catecolamine e loro metaboliti. Si tratta di una neoplasia rara con un’incidenza nella popolazione generale di 2–8 casi/milione/anno. I feocromocitomi si localizzano nella midollare del surrene in circa il 90% dei casi, ma si possono trovare anche in altri tessuti derivati dalle cellule della cresta neurale, dove prendono il nome di paragangliomi. La presentazione clinica del feocromocitoma e molto variabile e comprende una costellazione di sintomi e segni riconducibili alla produzione delle catecolamine e dei loro metaboliti: ipertensione (parossistica o persistente), sudorazione, pallore, cefalea, cardiopalmo, ansia, dispepsia, parestesie, disturbi visivi, dolore toracico e addominale. Per la diagnosi di feocromocitoma la determinazione delle metanefrine plasmatiche libere o urinarie frazionate, determinate con tecniche cromatografiche, e stata raccomandata come esame di prima linea nelle recenti linee guida pratiche dell’Endocrine Society. Il dosaggio di questi metaboliti presenta infatti un’alta sensibilita per cui un risultato negativo permette di escludere un feocromocitoma a differenza del dosaggio delle catecolamine e del loro principale metabolita urinario, l’acido vanilmandelico. Le recenti linee guida dell’Endocrine Society suggeriscono inoltre di eseguire il prelievo di sangue per il dosaggio delle metanefrine plasmatiche dopo 30 minuti di riposo, in posizione supina, usando intervalli di riferimento ottenuti nelle medesime condizioni. Per concentrazioni di metanefrine intermedie, si suggerisce la determinazione della cromogranina A e, per i rari casi in cui la determinazione delle metanefrine plasmatiche libere, delle metanefrine urinarie frazionate e della cromogranina A non siano diagnostici, il test di soppressione alla clonidina. Si raccomanda di non eseguire la determinazione dell’acido vanilmandelico urinario e delle catecolamine plasmatiche e urinarie.

Indirect immunofluorescence (IIF) plays an important role in immunological assays for detecting and measuring autoantibodies. However, the method is burdened by some unfavorable features: the need for expert morphologists, the subjectivity of interpretation, and a low degree of standardization and automation. Following the recent statement by the American College of Rheumatology that the IIF technique should be considered as the standard screening method for the detection of anti-nuclear antibodies (ANA), the biomedical industry has developed technological solutions which might significantly improve automation of the procedure, not only in the preparation of substrates and slides, but also in microscope reading.We collected 104 ANA-positive sera from patients with a confirmed clinical diagnosis of autoimmune disease and 40 ANA-negative sera from healthy blood donors. One aliquot of each serum, without information about pattern and titer, was sent to six laboratories of our group, where the sera were tested with the IIF manual method provided by each of the six manufacturers of automatic systems. Assignment of result (pos/neg), of pattern and titer was made by consensus at a meeting attended by all members of the research team. Result was assigned if consensus for pos/neg was reached by at least four of six certifiers, while for the pattern and for the titer, the value observed with higher frequency (mode) was adopted. Seventeen ANA-positive sera and six ANA-negative sera were excluded. Therefore, the study with the following automatic instrumentation was conducted on 92 ANA-positive sera and on 34 ANA-negative sera: Aklides, EUROPattern, G-Sight (I-Sight-IFA), Helios, Image Navigator, and Nova View. Analytical imprecision was measured in five aliquots of the same serum, randomly added to the sample series.Overall sensitivity of the six automated systems was 96.7% and overall specificity was 89.2%. Most false negatives were recorded for cytoplasmic patterns, whereas among nuclear patterns those with a low level of fluorescence (i.e., multiple nuclear dots, midbody, nuclear rim) were sometimes missed. The intensity values of the light signal of various instruments showed a good correlation with the titer obtained by manual reading (Spearman's rho between 0.672 and 0.839; P0.0001 for all the systems). Imprecision ranged from 1.99% to 25.2% and, for all the systems, it was lower than that obtained by the manual IIF test (39.1%). The accuracy of pattern recognition, which is for now restricted to the most typical patterns (homogeneous, speckled, nucleolar, centromere, multiple nuclear dots and cytoplasmic) was limited, ranging from 52% to 79%.This study, which is the first to compare the diagnostic accuracy of six systems for automated ANA-IIF reading on the same series of sera, showed that all systems are able to perform very well the task for which they were created. Indeed, cumulative automatic discrimination between positive and negative samples had 95% accuracy. All the manufacturers are actively continuing the development of new and more sophisticated software for a better definition in automatic recognition of patterns and light signal conversion in end-point titer. In the future, this may avert the need for serum dilution for titration, which will be a great advantage in economic terms and time-saving.

Molti pazienti, pur presentando sintomi e segni suggestivi per una connettivite, non possono essere agevolmente classificati in una delle malattie autoimmuni sistemiche universalmente riconosciute: lupus eritematoso sistemico, sclerodermia, polimiosite, dermatomiosite, artrite reumatoide, sindrome di Sjogren. Con il termine sindromi overlap reumatiche autoimmuni (autoimmune rheumatic overlap syndromes) si indica un gruppo di malattie caratterizzate dalla sovrapposizione nello stesso paziente, contemporaneamente o in periodi diversi, di quadri clinici di almeno due malattie autoimmuni sistemiche. Qualsiasi combinazione tra le diverse connettiviti puo essere osservata. La diagnosi delle sindromi overlap reumatiche autoimmuni e importante ai fini prognostici e per migliorare la gestione clinica del paziente. Questo articolo e una rassegna delle sindromi overlap reumatiche autoimmuni associate a specifici marker autoanticorpali, quali la connettivite mista, la sindrome da anticorpi anti-tRNA-sintetasi, la sclerosi sistemica-polimiosite e il lupus eritematoso-sindrome di Sjogren. Particolare enfasi viene dedicata al significato diagnostico dei marcatori sierologici specifici, all’importanza della ricerca degli autoanticorpi nelle malattie reumatiche autoimmuni e, infine, alla necessita di stabilire definiti profili autoanticorpali da ricercare nella diagnosi di queste sindromi.

Background Methods to detect anti-nucleosome antibodies (ANuA) have been available for more than 10 years and the test has demonstrated its good sensitivity and high specificity in diagnosing systemic lupus erythematosus (SLE). Despite these data produced through clinical and laboratory research, the test is little used. Objective To verify the diagnostic performance of methods for measuring ANuA and to compare them with those for anti-dsDNA antibodies. Data sources A systematic review of English and non-English articles using MEDLINE and EMBASE with the search terms “nucleosome”, “chromatin”, “anti-nucleosome antibodies” and “anti-chromatin antibodies”. Additional studies were identified checking reference lists in the selected articles. Study selection We selected studies reporting on anti-nucleosome tests performed by quantitative immunoassays, on patients with SLE as the index disease (sensitivity) and a control group (specificity). A total of 610 titles were initially identified with the search strategy described. 548 publications were subsequently excluded based on abstract and title. Full-text review was undertaken as the next step on 62 publications providing data on anti-nucleosome testing; 25 articles were then excluded because they did not include either SLE patients or a control group, and 37 articles were selected for the metanalysis. Finally, a sub-metanalysis study was conducted on the 26 articles providing data on both ANuA and anti-dsDNA antibody assays in the same series of patients. Data extraction Extraction of data from selected articles was performed by two authors independently, using predefined criteria: the number of patients with SLE as the index case, and the number of healthy or diseased controls; specification of the analytical method used to detect anti-nucleosome and anti-dsDNA antibodies; the cut-off used in the study; and the sensitivity and specificity of the assay. Demographic and clinical data on the population investigated (adults or children; lupus patients with or without nephritis; patients with active or inactive disease) were also recorded and analyzed in a separate evaluation. Results The systematic review and metanalysis showed that the overall sensitivity of the ANuA assay is 61% (confidence interval-CI, 60–62) and the specificity 94% (CI, 94–95). The overall positive likelihood ratio is 13.81 (CI, 9.05–21.09) and the negative likelihood ratio 0.38 (CI, 0.33–0.44). The odds ratio for having SLE in ANuA-positive patients is 40.7. The comparative analysis on anti-dsDNA antibodies conducted on the 26 studies which provided data for both antibodies showed that ANuA have greater diagnostic sensitivity (59.9% vs 52.4%) and a specificity rating only slightly higher (94.9% vs 94.2%). The probability that a subject with positive ANuA have SLE is 41 times greater than a subject with negative ANuA, while for anti-dsDNA the probability is 28 times greater. These figures are even more impressive in children, in whom ANuA have an odds ratio for the diagnosis of SLE of 146, compared to 51 for anti-dsDNA antibodies. In selected studies, ANuA ( p p = 0.256) were significantly associated with disease activity measured by the international score systems. However, neither antibody appears to correlate with kidney involvement. Conclusions Data from the metanalysis have shown that ANuA have equal specificity but higher sensitivity and prognostic value than anti-dsDNA antibodies in the diagnosis of SLE. Despite a certain heterogeneity among the various studies, the use of ANuA appears more efficacious than anti-dsDNA.

To evaluate whether vitamin D levels are related to the risk of developing autoimmune diseases and whether supplementation with vitamin D can modify the course of the diseases.We reviewed the most relevant papers published from January 1973 to October 2011, using Medline and EMBASE and the search terms "vitamin D"; "autoimmune disease"; "autoimmunity"; "rheumatoid arthritis"; "systemic lupus erythematosus"; "scleroderma"; "systemic sclerosis"; "type 1 diabetes"; "multiple sclerosis"; and "undifferentiated connective tissue disease". We selected studies on the environmental, genetic and epidemiologic association of vitamin D with autoimmune diseases. Using the strategy described, we identified 1268 articles. 331 articles were eliminated on the basis of the title and another 703 on the basis of the abstract, since they were considered irrelevant for the purposes of the study. Full-text examination was performed on the remaining 234 studies, and a further 15 studies were excluded from the review, since the results had been confirmed or superseded by more recent research. Finally, a systematic review was conducted on 219 articles concerning cross-sectional data on: vitamin D levels and autoimmune diseases; interventional data on vitamin D supplementation in autoimmune diseases; prospective data linking vitamin D level or intake to autoimmune disease risk.Physiopathology studies confirm that hypovitaminosis D, in genetically predisposed subjects, can impair self tolerance by compromising the regulation of dendritic cells, of regulatory T-lymphocytes and of Th1 cells. Cross-sectional studies show that levels of vitamin D30 ng/mL are present in a significant percentage, not only in patients with autoimmune disease, but also in healthy subjects (30-77%), and link profound deficiency (10 ng/mL) with aggravation of symptomatology, while genetic studies associate polymorphism of vitamin D receptors to various autoimmune diseases. Among experimental studies on humans, only those on type-1 diabetes prove that the risks are significantly reduced in infants treated with vitamin D after the 7th month (OR 0.71, 95% CI, 0.60 to 0.84) and that a dose-response effect exists.Basic, genetic, and epidemiological studies indicate a potential role of vitamin D in the prevention of autoimmune diseases, but randomized and controlled trials are necessary to establish the clinical efficacy of vitamin D supplementation in ill or at-risk subjects.

Objectives Pleural effusion recognizes heterogeneous etiology and pathogenesis and requires invasive diagnostic procedures. Usually, after pleural fluid analysis, 30–50% of patients with malignant pleural effusion exhibit negative pleural cytology, and the sensitivity of image-guided pleural needle-aspiration biopsy ranges between 60% and 70%. With the aim of differentiating between benign (BPE) and malignant (MPE) pleural effusions, several tumor markers have been assayed in the pleural fluid and the majority of studies focus on pleural carcinoembryonic antigen (p-CEA). The aims of this study were to evaluate (i) the diagnostic accuracy of p-CEA of patients with pleural effusions undergoing video-assisted thoracoscopic surgery (VATS) for diagnostic purpose, (ii) the relationship between p-CEA and serum CEA (s-CEA), and (iii) the usefulness of the p-CEA/s-CEA ratio in the diagnosis of malignant pleural effusions (MPE). Design & methods We prospectively enrolled in the study 134 consecutive patients with pleural effusions, scheduled for having VATS and biopsy. The final diagnosis, based on histopathology of the VATS-guided specimens, was available for all patients. p-CEA and s-CEA was assayed with a chemiluminescence immunoassay method (CLIA), applied on the Maglumi 2000 Plus automated platform (SNIBE, Shenzen, China). Results The sensitivity and accuracy of p-CEA was significantly higher than that of pleural cytology at the same specificity comparing BPE with MPE and BPE with non-small lung cancer. The sensitivity of p-CEA and PC together reached 100% (BPE vs. NSCLC) and 91.5% (BPE vs. MPE excluding mesothelioma), respectively. Conclusions The p-CEA measurement in patients with pleural effusion of uncertain etiology is a safe and cost-effective procedure, everywhere easily available, which may help clinicians in selecting patients for further evaluations. An elevated p-CEA level in a patient with pleural effusion and negative pleural cytology suggests the need of more invasive procedure (e.g. VATS-guided biopsies), whilst low p-CEA may support a follow-up.

Different imaging tools, circulating endocrine markers, and fine-needle aspiration (FNA) cytology are of great importance in the diagnosis and follow-up of different thyroid and parathyroid diseases. Sometimes, however, they are conflicting or inconclusive: interestingly, measuring endocrine markers (i.e. thyroglobulin, calcitonin, parathyroid hormone) in fluids from FNA proved to be a very useful complementary diagnostic tool in such cases. The determination of endocrine markers in fluids other than serum/plasma has been developed in the last years. Although studies have reported overall satisfactory results, a good standardization of procedures has not yet been reached, and further efforts should be made in order to better define pre-analytical, analytical, and post-analytical aspects. Here we reviewed critically the literature on the measurement of FNA endocrine markers, focusing on laboratory issues, such as preparation of the sample, choice of solution, and technical features of determination of these markers. Indeed, information for use of FNA-Tg, FNA-CT, and FNA-PTH in clinical practice was also provided.