Clinical and Laboratory Medicine Textbook

Foreword
References
Preface
Contents
About the Editor
1: The Role of Laboratory Medicine in the Clinical Context
	Introduction
	Integration Between Laboratory and Clinic
	Appropriateness in Laboratory Medicine
	Precision Medicine
	Recommended Readings
2: The Laboratory Diagnostic Process
	Introduction
	The Diagnostic Process
	The Laboratory Diagnostic Process
	Laboratory Information and Diagnostic Reasoning
	How to Improve the Laboratory Diagnostic Process
	Quality and Outcome Indicators
	Recommend Readings
3: Elements of Biomedical Laboratory Organization
	Introduction
	Sectors of a Biomedical Laboratory
	The Computer Link
	Organizational Models of the Laboratory Network
	Roles of the Laboratory Staff
4: The Role of Statistics in Laboratory Medicine
	Introduction
	Basic Statistical Tools
		Samples and Populations
		Descriptive Statistics
		Probability Distributions and the Normal Distribution
		Inferential Statistics: Confidence Intervals and Hypothesis Tests
			Confidence Intervals
			Hypothesis Testing
			Correlation and Linear Regression
	Evaluation of Analytical Performance
		Accuracy
		Trueness and Bias
		Limit of Blank (LOB), Limit of Detection (LOD), Limit of Quantification (LOQ)
		Linearity
	Biological Variability
		Comparison of Current Results with Previous Results for the Same Subject: The Critical Difference
		Definition and Use of Reference Intervals
		Individuality Index
		Decision Levels
	Performance of a Diagnostic Test
		ROC Curves
	Recommended Readings
5: Elements of Metrology
	Introduction
	Metrology in Laboratory
	Standardization in Laboratory
		Production of Reference Standards
		Control in the Production of Calibrators
		Method Validation Protocols and Their Instrumental Applicability
			Problems in Standardization of Immunochemistry
	Recommended Readings
6: The Pre-analytical Phase
	Introduction
	Patient-Related Variables
		Biological Variability
		Pre-analytical Variability Related to Preparation and Patient Status
	Sample Variables
		Inappropriate Examination Request or Necessary Examination Not Requested (Appropriateness of Request)
		Patient and Specimen Identification Error
		Container Type Error
		Insufficient Sample
		Coagulated Sample
		Hemolyzed Sample
		Lipemic Sample
		Jaundiced Sample
		Measurement of Serum Indices in the Laboratory
		Sampling Order (Urban Legend?)
		Infusion Route Contamination
		Recommendations for Sampling
		Recommendations for Sample Acceptability
		Transport Problems
		Pre-analytical Processing Problems in the Laboratory
	Pre-analytical Quality Indicators
	Recommended Readings
7: The Quality of Laboratory Results: Sources of Variability, Methods of Evaluation, and Estimation of Their Clinical Impact
	Introduction
	Sources of Result Variability
		Main Sources of Analytical Variability and Their Definition
		Random Error
		Systematic Error
		Biological Variation
			Intraindividual Biological Variation (CVI)
			Interindividual Biological Variation (CVG)
	Definition of APS
		Model Based on the Impact on Clinical Outcome
		Model Based on Biological Variation of the Measurand
		Model Based on State-of-the-Art of the Measurement
	Recommended Readings
8: Principles of Immunochemistry
	Introduction
	The Immunochemical Assay
		The Analyte
		The Binding Molecule
		The Tracer
			Radioactive Tracers
			Enzyme Tracers
				Absorption Signal
					Use of a Chromogenic Substrate
					Use of Two Substrates, One of Which Is Chromogenic
					Use of NAD+ and NADP+ (Cosubstrates That Absorb at 340 nm Only in the Reduced Form)
				Emission Signal
					Use of a Fluorogenic Substrate
					Use of Two Substrates, One of Which Is Luminogenic
			Direct Fluorescent Tracers
			Direct Chemiluminescent Tracers
				Phthalhydrazide
				Acridinium Esters
				Dioxetans
	Architecture of the Immunochemical Assay
		Competitive Methods
		Non-competitive Methods
		Heterogeneous Phase Methods
			Free-Bound Separation Methods
				Non-specific Precipitation
				According to Ab
				Protein A
		Homogeneous-Phase Methods
		Ag-Ab Complex Formation and Equilibrium Reaction
	Immunochemical Methods Without Tracer
		Turbidimetry and Nephelometry
	Relationship Between Analytical Signal and Concentration
		Interpolation and Regression Methods
	Interferences in Immunochemical Methods
	Recommended Readings
9: General Information on Laboratory Tests and Biomarkers
	Introduction to Laboratory Tests and Biomarkers
	The Ideal Characteristics of a Biomarker
	Possible Causes of Biomarkers Increase
	Diagnostic Efficiency and Effectiveness
	Useful Glossary
	Recommended Readings
10: Enzymes and Their Clinical Use
	Introduction
	Factors Influencing the Plasma Concentration of Enzymes
		Release of Enzymes from Cells
		Enzyme Efflux from Damaged Cells
		Impaired Enzyme Production
		Enzyme Clearance
	Choice of Enzymatic Tests
	Muscle Enzymes
		Creatine Kinase (CK)
			Clinical Significance
			Reference Intervals
	Liver Enzymes
		Aminotransferases
			Clinical Significance
			Reference Intervals
		Alkaline Phosphatase
			Clinical Significance
			Reference Intervals
		γ-Glutamyltransferase (GGT)
			Clinical Significance
			Reference Intervals
		Pancreatic Enzymes: Lipase
			Clinical Significance
			Reference Intervals
		Amylase (Pancreatic)
			Clinical Significance
			Reference Intervals
	Bone Enzymes
		Alkaline Phosphatase (Bone Isoform)
			Clinical Significance
			Reference Intervals
		Acid Phosphatase (Tartrate-Resistant Isoform 5b)
			Clinical Significance
			Reference Intervals
	Other Enzymes
		Lactate Dehydrogenase
			Clinical Significance
			Reference Intervals
		Cholinesterase (Pseudocholinesterase)
			Clinical Significance
			Reference Intervals
	Recommended Readings
11: Liver: From Biochemistry to Clinical Biochemistry
	Introduction
	Jaundice
		Bilirubin Metabolism
		Classification of Jaundice
			Jaundice due to increased Bilirubin production
			Jaundice due to Bilirubin Uptake and Conjugation Defect
				Congenital Defects
			Jaundice due to Defective Excretion of Bilirubin or Mechanical Obstruction of the Intra- and/or Extra-hepatic Biliary Tracts
			Neonatal Jaundice
		Diagnosis
	Hepatitis
		Viral Hepatitis
			Hepatitis A
			Hepatitis B
				HBsAg and Anti-HBs
				HBcAg and Anti-HBc
				HBeAg and Anti-HBe
				HBV-DNA
			Hepatitis C
			Hepatitis D
			Hepatitis E
			Iatrogenic Hepatitis
	Steatosis, Fibrosis, and Cirrhosis
		Nonalcoholic Hepatic Steatosis
		Alcoholic Hepatopathy
		Fibrosis
			Diagnostic Investigations
		Cirrhosis
	Alcoholism
		Introduction
		Ethanol Metabolism
		Alcohol-Related Clinical Alterations
		Biomarkers of Alcoholism
			Blood Ethanol
			Urinary Ethanol
			Ethylglucuronide (EtD)
			Carbohydrate Transferrin (CDT)
	Liver Cancers
	Recommended Readings
12: Protein Diagnostics
	Introduction
	Plasma Cell Dyscrasias
		Clinical Relevance
		Separation Technology
			Protein Electrophoresis
			Immunological Typing
		Laboratory Diagnostics
			Serum Protein Electrophoresis
			Monoclonal Component Typing
			Quantification of Serum Monoclonal Component
			Determination of Bence Jones Protein
			Use of Mass Spectrometry
			Measurement of Free Light Chains in Serum
			Measurement of Immunoglobulins in Serum
			Concluding Remarks
	Main Serum Proteins of Clinical Relevance
		Albumin
		α1-Antitrypsin
		Haptoglobin
		β2-Microglobulin
		Ceruloplasmin
		Complement
		Immunoglobulins
		C-Reactive Protein
		Transthyretin (Prealbumin)
	Recommended Readings
13: Biomarkers of Nutritional Status
	Introduction
	Malnutrition
	Assessment of Nutritional Status
		Biomarkers of Nutritional Status
			Albumin
			Prealbumin
			Transferrin
			Retinol Binding Protein
			Urinary Creatinine
	Recommended Readings
14: Dyslipidemias
	Introduction
	Lipoproteins
		Chylomicrons and Chylomicron Remnants
		VLDL and IDL
		LDL
		HDL
		Lp(a)
	Apolipoproteins
	Molecules involved in Lipoprotein metabolism
		LDL Receptor
		Class B Scavenger Receptor Type 1 (SR-B1)
		ATP-Binding Membrane Cassette Transporter A1 (ABCA1)
		ATP-Binding Cassette Transporter G1 (ABCG1)
		ATP-Binding Cassette Transporters G5 and G8 (ABCG5/ABCG8)
		Acylcoa-Cholesterol Acyltransferase (ACAT)
		Lipoprotein Lipase (LPL)
		Hepatic Lipase
		Lecithin Cholesterol Acyltransferase (LCAT)
		Cholesteryl Ester Transfer Protein (CETP)
	Lipoprotein and Lipid Metabolism
		Exogenous Pathway of Lipid Metabolism
		Endogenous Pathway of Lipid Metabolism
		Reverse Cholesterol Transport
	Classification of Dyslipidemias
		Fredrickson Classification
			Type I
			Type IIa
			Type IIb
			Type III
			Type IV
			Type V
		Pathogenetic Classification
			Primary Dyslipidemia
			Combined Familial Hyperlipidemia
				Familial Hypercholesterolemia
				Familial LPL or ApoC-II Deficiency
				Familial ApoB-100 Deficiency
				Familial Dysbetalipoproteinemia
				Familial Hypertriglyceridemia
			Secondary Dyslipidemia
	Dyslipidemia and Cardiovascular Risk
	Diagnosis of Dyslipidemia
		Lipid Profile
			Blood Collection
			Intraindividual Variability
			Measuring Methods
				Total Cholesterol
				LDL-Cholesterol
				HDL Cholesterol
				Triglycerides
				Non-HDL Cholesterol
				Apolipoproteins
				Lp(a)
		Diagnosis of Familial Dyslipidemia
			Familial Hypercholesterolemia
				Heterozygous Familial Hypercholesterolemia
				Homozygous Familial Hypercholesterolemia
				Combined Familial Hyperlipidemia
				Familial Dysbetalipoproteinemia
				Familial Hypertriglyceridemia
	Treatment and Therapy
		Lifestyle Modifications to Improve Lipid Profile
		Drug Therapy
	Recommended Readings
15: Hematological Diagnostics
	Definition of Anemia
	Complete Blood Count (CBC)
		Hemoglobin Measurement
		Hematocrit Measurement
		Cell Counts
		Electrical Impedance
		Flow Cytometry
		Fluorescence Cytometry
		Erythrocyte Indices and Distribution Measurements
			Mean Corpuscular Volume
			Mean Corpuscular Hemoglobin
			Mean Corpuscular Hemoglobin Concentration
			Red Cell Distribution
		Platelet Indices and Platelet Count
			Mean Platelet Volume
			Platelet Distribution Width
			Immature Platelet Fraction
			Plateletcrit
			Other Indexes
		Reticulocytes and related Indices
			Reticulocyte Production Index
			Immature Reticulocyte Fraction
			Reticulocyte Hemoglobin Content
			Reticulocyte Hemoglobin Equivalent
		Differential Leukocyte Count (Leukocyte Formula)
		Microscope Differential Count
		Automated Differential Count
	The Primary Forms of Anemia
		Microcytic Anemias
			Sideropenic and Assimilated Anemia
			Anemia Due to Thalassemia Syndromes
				Gene Complexes, Molecular Expression, Globin Chains
				Embryonic Hemoglobins, Fetal Hemoglobin (HbF), HbF/HbA Switches
				Genetics of Thalassemias
				Molecular Alterations in Thalassemias
				Pathophysiological and General Clinical Aspects of α-Thalassemias
				Clinical Forms of α-Thalassemia
				α-Thalassemia Due to −3.7 Deletion
				α-Thalassemias Due to Nondeletion
				Pathophysiological and General Clinical Aspects of β-thalassemias
				Clinical Forms of β-thalassemia
				Diagnosis of Thalassemia
					Molecular Diagnosis
				Laboratory Diagnosis (Phenotypic) of Thalassemias
		Normocytic Anemias
			Sickle Cell Anemia (Hemoglobinopathy S, Sickle Cell Disease)
			Hemolytic Anemias
				Hereditary Spherocytosis
				Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency
				Unstable Hemoglobins
		Macrocytic Anemias
			Hyporegenerative Macrocytic Anemias/Megaloblastic Anemias
			Causes of Macrocytosis with Normoblastic Erythropoiesis
	Platelet Alterations
		Evaluation of Platelet Function In Vitro with PFA-100
	Recommended Readings
16: Immunohematology
	Introduction
	Historical Premise
	Blood Group Antigens
	Antibody Versus Blood Groups Antigens
	Antibody Antigen Reaction in Erythrocyte Immunohematology
	Erythrocyte Blood Group Antigenic Systems
		ABO, H, and Lewis Blood Groups and Structurally Related Antigens
			H/h System
			I/i System
			Lewis System
		MNSs System
		P System
		RhD RhCE System
		Landsteiner–Wiener (LW) System
		Lutheran System
		Kell/Cellano System
		Duffy System
		Kidd System
		Minor Blood Group Systems
		Platelet and Granulocyte Antigens and Antibodies
		HLA System
	Analytical Aspects of Erythrocyte Immunohematology
		Determination of the ABO Group
		Determination of Type D and Rh Phenotype
		Study of the Antigens Belonging to Other Erythrocyte Blood Group Systems
		The Search for Anti-erythrocyte Antibodies
		Indirect Antiglobulin Test (Indirect Coombs Test)
		Interpreting Results
		Direct Antiglobulin Test (Direct Coombs Test)
		Applications of Molecular Biology to Erythrocyte Immunohematology
	Recommended Readings
17: Hemostasis
	Introduction
	Vascular System
	Hemostatic Balance
	Hemostasis
		Primary Hemostasis
			Vessel Participation
			Platelets
				Phase I: Adhesion (to the Subendothelium)
				Phase II: Shape Change
				Phase III: Activation and Secretion of Granules (Release)
				Phase IV: Aggregation (Between Them)
				Platelet Disorders
		Secondary Hemostasis
			Coagulation Activation Phase
			Thrombin Propagation Phase
			Coagulation Shutdown Phase
				Antithrombin
				Protein C (PC) and Protein S (PS) System
		Fibrinolysis
	Congenital Disorders of Coagulation Factors
	Laboratory Tests for the Study of Hemostasis
		Biological Sample
		Prothrombin Time (PT)
		Activated Partial Thromboplastin Time (aPTT)
		Fibrinogen (Fbg)
		Thrombin Time (TT)
		Mixture Test
	Anticoagulant Therapy
		Heparins and Fondaparinux
		Vitamin K Antagonist (VKA)
		Direct Inhibitors of Factors II and X
		Antiplatelet Therapy
18: Kidney
	Introduction
	Kidney Disease
		Chronic Kidney Disease
		Acute Kidney Injury
			Acute Contrast Media-Induced Nephropathy
	Laboratory Diagnosis of Kidney Diseases
		Standard Urine Test
		Nitrogen (N)
		Urea
		Creatinine
		Estimation of the Glomerular Filtration Rate by Equations
		Low-Molecular-Weight Plasma Proteins
			Cystatin C
		Biomarkers of Tubulo-Interstitial Injury
		NGAL
		Proteinuria
		Albuminuria
	Recommended Readings
19: Physical, Chemical, and Morphological Urine Examination
	Introduction
	Preanalytical Phase
		Sample Collection
		Sample Storage
		Arrival at the Laboratory
	Analytical Phase
		Visual Inspection
			Volume
			Color
			Turbidity
			Foam
		Chemical-Physical Examination
			Albumin/Protein
			Urinary Concentration
				Relative Density
					Test Strip Determination
				Osmolality
				Conductivity
				Creatinine
				Hemoglobin
					Analytical Methods
				Hydrogenionic Concentration (pH)
					Analytical Methods
			Leukocyte Esterase
			Nitrites
			Ascorbate
			Glucose
			Ketones
			Bile Pigments
		Counting and Morphology of the Corpusculate Component
			Analysis of the Corpusculate Fraction
				Level 1: Rapid Tests
				Level 2: Routine Methods
				Level 3: Comparison Methods
				Level 4: Reference Methods
			Principles of Hand Microscopy of Urinary Sediment
			Morphological Evaluation of the Corpusculate Fraction by Light Microscopy
				Identification and Quantification of Erythrocytes
				Leukocyte Identification and Quantification
				Identification and Quantification of Cylinders
					Hyaline Cylinders
					Granular Cylinders
					Leukocyte Cylinders
					Erythrocyte Cylinders
					Epithelial Cylinders
					Lipid Cylinders
					Wax Cylinders
					Pigmented Cylinders
					Cylinders with Bacterial or Fungal Inclusions
					Cylinders with Crystalline Inclusions
					Mixed Cylinders
				Identification and Quantification of Cells
					Lipid Identification
					Identification of Crystals
				Microorganisms
				Contaminants
			Evaluation of the Corpusculate Fraction of Urine by Automated Instrumentation
				Automated Microscopy
				Image Capture
				Cytofluorimetry
	Postanalytical Phase
		The Report of the Chemical-Physical and Morphological Examination of Urine (ECMU)
	Recommended Readings
20: Hydroelectrolytic Disorders
	Introduction
	Pathophysiology
	Water Balance
	Sodium Balance
		Hyponatremia
			Diagnosis and Therapy
		Hypernatremia
			Diagnosis and Therapy
	Potassium Balance
		Hypokalemia
			Diagnosis and Therapy
		Hyperkalemia
			Diagnosis and Therapy
	Recommended Readings
21: Blood Gas Analysis
	Introduction
	Elements of Pathophysiology
		The State of Oxygenation
	The Acid–Base Balance
	Instrumentation
	The Main Variables Measured and Calculated
	The Pre-Analytical Phase
		Patient Preparation
		Blood Sampling Materials
		Site of Arterial Sampling
		Modified Allen Test
		Performing Radial Artery Sampling
		Transport and Storage
	Analysis
	The Postanalytical Phase
		Result Validation
	Quality Control
	The Report
	Blood Gas in Various Situations
		Emergency Room
		Operating Room
		Intensive Care and Coronary Units
		Pneumological Evaluation
		Dialysis Treatments
	Interpretation of Results
		Classical Interpretation
		Stewart’s Quantitative Approach
		The Clinical Approach
	Integrated Management in the POCT
	Recommended Readings
22: Cardiac Biomarkers
	Introduction
	Biomarkers of Myocardial Injury
		Biochemical Characteristics and Biological Function of Troponins
		Clinical Relevance of Troponins Measurement
		Quality Specifications of Troponin Measurement Methods
		Clinical Interpretation of Results Obtained by High-Sensitivity Analytical Methods
	Biomarkers of Cardiac Function
		Biochemical Characteristics and Biological Function of Cardiac Natriuretic Peptides
		Clinical Relevance of Cardiac Natriuretic Peptide Measurement
		Pathophysiological and Clinical Interpretations of Changes in circulating BNP/NTproBNP
	Biomarkers of Myocardial Remodeling and Fibrosis
		Cardiac Fibrosis
		Biomarkers of Collagen Synthesis and Degradation
		Biomarkers of Myocardial Fibrosis
			Galectin-3
			Soluble IL-33 Receptor (sST2)
	Genetic Biomarkers Associated with Cardiovascular Diseases
	Recommended Readings
23: Biomarkers of Stroke
	Introduction
	Definition of Stroke
	Diagnosis and Therapy
	Biomarkers
		Lp-PLA2
		ADMA
		MMP-9
		S100-β
		NMDA Receptor Peptides
		GFAP
		PARK7
		NDKA
	Recommended Readings
24: Thrombophilia
	Introduction
	Hereditary and Acquired Causes of Thrombophilia
	Thrombophilia Screening
		Indications for Performing Thrombophilia Screening
	Laboratory Diagnosis
	Factors Interfering with Thrombophilia Screening
	Recommended Readings
25: Endocrine System
	Introduction
	Hypophysis
		Anatomy
		Adenohypophysis
			Growth Hormone
				Growth Hormone Deficiency
				GH Deficiency in Children
				GH Deficiency in Adults
				Acromegaly
				Laboratory Investigations
					Basal Measurement
						GH
						IGF-1
					Dynamic Measurement
				Diagnosis and Therapy
					GH Deficiency in Children
					GH Deficiency in Adulthood
				Acromegaly
			Prolactin
				Hyperprolactinemia
				Prolactinoma
				Laboratory Investigations
				Diagnosis and Therapy
					Hyperprolactinemia
					Prolactinoma
		Neurohypophysis
			Antidiuretic Hormone
			Oxytocin
				Diabetes Insipidus
					Pituitary Diabetes Insipidus
					Primary Polydipsia
					Gestational Diabetes Insipidus
					Nephrogenic Diabetes
					Inappropriate ADH Secretion Syndrome
				Laboratory Investigations
					24-Hour Urine Test
					Plasma ADH Assay
					Plasma Osmolality Assessment
					Water Deprivation Test
					MRI of the Hypothalamic-Pituitary Region
					Copeptin
				Diagnosis and Therapy
					Diabetes Insipidus
				Inappropriate ADH Secretion Syndrome
	Thyroid
		Anatomy
		Thyroid Hormones
			Biosynthesis and Secretion
			Regulation of Thyroid Hormone Secretion and TSH
			Transport of Thyroid Hormones
			Mechanism of Action of Thyroid Hormones
		Laboratory Investigations
			TSH, fT4, and fT3
			Autoantibodies
		Diagnosis and Therapy
			Primary Hyperthyroidism
			Primary Hypothyroidism
			Thyroiditis
	Parathyroids
		Anatomy
		Parathormone (PTH)
			Synthesis, Secretion, Metabolism, and Mechanism of Action
			Biological Actions
		Regulation of Calcemia and Calcium-Phosphorus Homeostasis
			PTH-Related Peptide
			Phosphorus
			Hypercalcemia
			Hypocalcemia
		Laboratory Investigations
			Calcemia
			Albumin
			Renal Function
			Magnesium
			Phosphate
			PTH
			Vitamin D3
			PTHrP
	Adrenal Gland
		Anatomy
		Adrenal Cortical Hormones
			Biochemistry and Transport
			Metabolism
			Physiology
			Glucocorticoids
			Mineralocorticoids
			Biological Actions
				Glucocorticoids
				Mineralocorticoids
				Androgens
			Hypocorticosurrenalism
			Hypercorticosurrenalism
				Cushing’s Syndrome
				Hyperaldosteronism
			Laboratory Investigations
				Basal Measurements
					Blood
						Cortisol
						Potassium
						Aldosterone and Renin
						ACTH
						DHEA Sulfate
				Urinary Measurements
					Free Cortisol
					Salivary Assays
					Cortisol
					Dynamic Investigations
			Diagnosis and Therapy
				Adrenal Insufficiency
				Cushing’s Syndrome
				Primary Hyperaldosteronism
				Oral Sodium Load Test
				Saline Infusion Test
				Fludrocortisone Suppression Test
				Captopril Test
				Losartan Test
				Secondary Hyperaldosteronism
		Adrenal Medullary Hormones
			Pheochromocytoma and Paraganglioma
				Laboratory Investigations
					Basal Measurements
						Chromogranin A
					Dynamic Investigations
						Diagnosis and Therapy
			Incidentaloma
				Diagnosis and Therapy
	Testis
		Anatomy
		Physiology
			Male Hypothalamic-Pituitary-Gonadal Axis
		Testis Pathologies
			Hypogonadism
			Late-Onset Hypogonadism
		Laboratory Investigations
			Basal Hormone Measurements
				Gonadotropin
				Testosterone
				Inhibin B
				Prolactin
				Dynamic Hormonal Investigations
					Stimulation Test with GnRH
					Human Chorionic Gonadotropin Stimulation Test
		Diagnosis and Therapy
			Hypogonadism
		Germ Cell Tumors of the Testis
	Ovary
		Anatomy
		Physiology
			Female Hypothalamic-Pituitary-Gonadal Axis
			Synthesis and Functions of Steroid Hormones
			Synthesis and Function of Protein Hormones
		Endocrine Disorders of the Ovary
			Hirsutism and Virilization
				Amenorrhea
				Primary Amenorrhea
				Secondary Amenorrhea
		Laboratory Investigations
			Basal Measurement
				Androgen
				Gonadotropin
				Estrogen
				Progesterone
			Dynamic Investigations
				GnRH Testing
				Clomiphene Test
		Diagnosis and Therapy
			Hirsutism
			Primary Amenorrhea
			Secondary Amenorrhea
	Recommended Readings
		Hypophysis
		Parathyroid glands
		Adrenal gland
		Testis
		Ovary
26: Diabetes Mellitus: From Definition to Therapy
	Introduction
	Definition
	Historical Background
	Blood Glucose Regulation
	Classification of Diabetes Mellitus
	Epidemiology
	Etiopathogenesis
		Type 1 Diabetes
			Genetic Factors
			Environmental Factors
			Immunological Factors
				Defect in Lymphocyte Selection in Thymus
				Molecular Mimicry
			Alteration of Suppressor Mechanisms
		Type 2 Diabetes
			Genetic Factors
			Environmental Factors
		Gestational Diabetes
		Other Types of Diabetes Mellitus
	Diagnosis
	Complications
	Monitoring
	Therapy
	Recommended Readings
27: Diabetes Mellitus: The Role of the Laboratory
	Introduction
		Role of the Laboratory in Screening and Diagnosis
		Role of the Laboratory in Surveillance
	Antibodies
		Pancreatic Insula Cytoplasmic Antibodies (ICA)
		GAD Antibodies (GADA)
		Tyrosine-Phosphatase 2 Antibodies (IA-2A)
		Anti-insulin Antibodies (IAA)
		Zinc Transporter 8 Antibodies (ZnT8)
	Glucose
		Fasting Blood Glucose
			Preanalytical Aspects
			Analytical Aspects
			Postanalytical Aspects
		Postprandial Blood Glucose
		Oral Glucose Tolerance Test
			Preanalytical Aspects
			Analytical Aspects
			Postanalytical Aspects
		Blood Glucose Self-Monitoring Using POCT
			Preanalytical Aspects
			Analytical Aspects
			Postanalytical Aspects
		Glycemic Variability
	Ketone Bodies
		Preanalytical Aspects
			Analytical Aspects
	Albuminuria
		Preanalytical Aspects
		Analytical Aspects
		Postanalytical Aspects
		Glycated Hemoglobin
			Preanalytical Aspects
			Analytical Aspects
			Postanalytical Aspects
	Glycated Albumin and Fructosamine
		Preanalytical Aspects
		Analytical Aspects
	Insulin and C-Peptide
		Analytical Aspects
		Postanalytical Aspects
	Recommended Readings
28: Metabolic Syndrome
	Introduction
	Definition
	Pathogenesis
	Diagnosis
	Therapy
	Recommended Readings
29: Hypoglycemia
	Introduction
	Epidemiology
	Symptoms
	Hypoglycemia in Diabetes
	Hypoglycemia without Diabetes
		Drugs
		Chronic and Acute Illnesses
		Hormonal Deficiencies
			Non-insular Tumors
		Endogenous Hyperinsulinism
		Hypoglycemia Factitia
	Diagnosis
	Recommended Readings
30: The Role of Laboratory in Pregnancy
	Introduction
	Preconception Laboratory Test
		Indirect Coombs Test
		TORCH
			Toxoplasmosis
		Others
			Syphilis
			Hepatitis
			Human Immunodeficiency Virus
			Rubella
			Cytomegalovirus
			Herpes Simplex
		Complete Blood Count and Hemoglobin
		Glycemia
		Pap Test
	Ascertainment of Pregnancy
	Pregnancy Laboratory Test
	Gestational Diabetes
	Preeclampsia and Eclampsia
	Prenatal Screening for Down Syndrome
	Recommended Readings
31: Hereditary Metabolic Diseases
	Introduction
	Clinical Aspects
		Definition and Etiology
		Classification
	Clinical Features
	Therapy
	Laboratory Strategies for Screening and Diagnostic Confirmation of IMD
		Diagnostic Confirmation of Clinical Suspicion of IMD
		Neonatal Screening Process
	Recommended Readings
32: Hyperphenylalaninemias, Tyrosinemias, Glycogenosis, Hyperammonemia
	Hyperphenylalaninemias
		Diagnosis and Therapy
		Maternal Phenylketonuria
	Tyrosinemias
	Glycogenosis
		Diagnosis
	Hyperammonemia
		Neonatal Form
		Child Form
		Puberty and Adulthood Forms
	Recommended Readings
33: Circulating Biomarkers in Oncology: Areas of Application, Critical Issues, and Perspectives
	Biomarkers in Oncology: An Evolving Concept
	Critical Issues and Room for Improvement
	Biomarkers in the Blood and in Tissues: A Complementary Approach
	Circulating Biomarkers in Clinical Practice
		Screening of Asymptomatic General Population
		Surveillance of Individuals at Increased Risk
		Differential Diagnosis in Symptomatic Patients
		Initial Diagnostic Workup
		Postoperative Evaluation
		Long-Term Monitoring after Curative Treatment of the Primary Tumor
		Therapy Monitoring in Patients with Advanced or Disseminated Disease
		Measuring Methods
	Biomarkers Associated with Biological Mechanisms
	Recommended Readings
34: Liquid Biopsy
	Introduction
	Liquid Biopsy
	Circulating Tumor Cells
		Technologies for the Isolation of CTCs
		Methods Based on the CTCs Physical Properties
			Immuno-phenotyping Methods
			Methods Based on the Leukocytes Removal
		Molecular Characterization of CTCs
	Circulating Tumor DNA
		Technologies for ctDNA Isolation
		ctDNA Mutational Analysis
	Application of Liquid Biopsy to Non-small-Cell Lung Cancer
	Application of Liquid Biopsy to Other Neoplasms
	Recommended Readings
35: Biological Fluids
	Introduction
	Pathophysiology
	Types of Analysis
		Macroscopic Analysis
		Cytometric Examination
	Pleural Fluid
		Macroscopic Evaluation and Cellular Analysis
		Biochemistry
	Pericardial Fluid
		Macroscopic Evaluation and Cellular Analysis
		Biochemistry
	Ascitic Fluid or Peritoneal Effusion
		Macroscopic Evaluation and Cellular Analysis
		Biochemistry
	Synovial Fluid
		Pathophysiology
		Macroscopic Evaluation, Crystal Detection, and Cellular Analysis
			Bacterial Arthritis
			Rheumatoid Arthritis
			Acute Joint Rheumatism
			Systemic Lupus Erythematosus
			Gout
			Pseudogout or Chondrocalcinosis
			Traumatic Arthropathy
			Villonodular Synovitis
			Primary or Secondary Neoplastic Arthritis
			Prosthetic Infections
		Biochemistry
			Cholesterol and Triglycerides
			Glucose
			Lactic Acid
			Uric Acid
			Enzymes
			C-Reactive Protein (CRP)
	Cerebrospinal Fluid
		Macroscopic Evaluation and Cellular Analysis
		Biochemistry
	Recommended Readings
36: Laboratory Diagnostics in Autoimmune Diseases
	Introduction
	Autoimmune Rheumatic Diseases
	Monitoring of Biological Drugs
		Therapeutic Monitoring of Autoantibodies and TNFα Inhibitor Drugs in Patients Being Treated for Chronic Immune-Mediated Inflammatory Diseases
	Celiac Disease
		Genetics in the Diagnosis of Celiac Disease: Role of HLA DQ2 and DQ8
		Biomarkers and Algorithms for Diagnosis and Monitoring of Celiac Disease
		Quality Characteristics of Anti-transglutaminase Antibodies Assessment
	Autoimmune Liver Diseases
	Recommended Readings
37: Laboratory Diagnostics in Allergic Diseases
	Introduction
	Discovery of Immunoglobulin E
	Mast Cells and Basophils
	Allergens
	Use of Recombinant Allergens in Allergology Diagnostics
	In Vitro Allergy Diagnostics
		Detection of Total IgE
		Detection of Specific IgE
			Cap FEIA on Immunocap
			3gAllergy on Immulite 2000
	Molecular Allergy Diagnostics
		Analytical Methods for Molecular Diagnostics
			Singleplex Molecular Diagnostics
			Multiplex Molecular Diagnostics (Microarrays)
	Conclusions
	Recommended Readings
38: Biomarkers of Bone Remodeling
	Introduction
	Bone Tissue Biochemistry
	Bone Formation Markers
		Bone Alkaline Phosphatase
		Osteocalcin
		Procollagen Type I Terminal Peptides
	Markers of Bone Resorption
		Collagen Cross-Links
		Amino and Carboxy-Terminal Telopeptides of Collagen Type I
		Tartrate-Resistant Acid Phosphatase
	New Biomarkers
		RANK-RANKL-OPG
		Cathepsin K
		Sclerostin
		Fibroblast Growth Factor (Fibroblast-Growth Factor 23, FGF23)
		Genetic Determinants
	Sources of Variability in Bone Remodeling Biomarkers
		Clinical Use of Biochemical Markers of Bone Remodeling
	Biochemical Markers of Bone Remodeling in Different Clinical Conditions Affecting Bone Tissue Metabolism
		Bone Markers in Glucocorticoid-Induced Osteoporosis
		Bone Markers in Immobilization-Induced Osteoporosis
		Bone Markers in Inflammatory Bowel Disease
		Bone Markers in Rheumatoid Arthritis
		Bone Markers in Primary Hyperparathyroidism
		Bone Markers in Cancer Pathologies
		Bone Markers in Paget’s Disease
		Bone Markers in Multiple Myeloma
	Biochemical Markers of Bone Remodeling in Postmenopausal Osteoporosis
		Prediction of Bone Loss
		Fracture Risk Prediction
		Therapy Monitoring
		Assessment of Adherence to Therapy
	Conclusions
	Recommended Readings
39: Alzheimer’s Disease and Other Neurodegenerative Dementias
	Introduction
	Cerebrospinal Fluid Biomarkers
	Alzheimer’s Disease
	Frontotemporal and Vascular Dementias
	Prion Diseases
	Parkinson’s Disease and Synucleinopathies
	Variability and Standardization of CSF Examination
	Recommended Readings
40: In Vivo Clinical Biochemistry
	Introduction
	Magnetic Resonance Spectroscopy Technique: Basic Principles
	In Vitro, Ex Vivo, and In Vivo MR Spectroscopy
		Equipment
			Magnets and Probes
		Detectable Nuclear Species and Corresponding Metabolic Pathways
		Applications in Cells, Tissues (Biopsies), and Extracts
			Cells
			Biopsies
			Extracts
		In Vivo Proton MR Spectroscopy
			Operational Context
			Hardware
			Software
			Patient Preparation
		Proton MR Spectroscopy
		Qualitative and Quantitative Analysis of Proton Spectra
		Brain Metabolites
			Biochemical Characterization and Biological Significance
		Main Findings of Neurological Disorders Evaluated by the 1H-MRS
			Congenital Errors of Metabolism
			Perinatal Hypoxic-Ischemic Encephalopathy
			Neoplastic Pathology and Differential Diagnosis with Radionecrosis and Other Endocranial Masses
			Neurodegenerative Disorders
		Other Applications of Proton MR Spectroscopy
			Prostate
			Breast
	In Vivo Phosphorus MR Spectroscopy
		Skeletal Muscle
		Patient Preparation and Set-Up
		Main Pictures of Musculoskeletal Pathology Evaluated by 31P-MRS Muscle
			Mitochondrial Myopathies
			Muscle Glycogenosis
	Recommended Readings
41: Clinical Biochemistry of the Mind
	Introduction
		Mental Disorders
		Biological Markers of Mental Illness
	Morphological and Functional Exploration Methodologies of the Central Nervous System
		The Concept of Endophenotype
	The Omics Sciences
		Genomics
		Proteomics
		Metabolomics
		Lipidomics
		Epigenomics
	The Study of the Intestinal Microbiota
	Future Prospective
	Recommended Readings
42: Clinical Molecular Biology
	Introduction
	Type of Test and Biological Sample
	Diagnosis of Susceptibility
		Thrombophilia
		Pharmacogenomics
		Guide Therapy in Oncology: The BRCA1/2 Test
	Early Diagnosis
	Diagnosis of Disease
		The Example of an Autosomal Recessive Disease: Cystic Fibrosis
		The Example of Diseases Related to the X Chromosome: Hemophilia A and B
		A Critical Issue in Molecular Testing: Identification of New Mutations
		Bioethical Aspects: Late-Developing Diseases
	Carrier Diagnosis
		Cascade Analysis
		Carrier Screening
	Prenatal Diagnosis
		Prenatal Diagnosis of Non-hereditary Genetic Diseases
		Prenatal Diagnosis of Hereditary Genetic Diseases
		Pre-implantation Diagnosis
	Disease Staging: The Example of Circulating Tumor Cells
	Chronic Myeloid Leukemia, BCR-ABL Gene, and Disease Monitoring
	Recommended Readings
43: Fever of Unknown Origin
	Introduction
	Definition of Fever
	Definition of Fever of Unknown Origin (FUO)
	Causes of FUO
	Diagnosis
	Recommended Readings
44: Biomarkers of Inflammation
	Introduction
	Definition of Inflammation
	Acute Phase Proteins
		C-Reactive Protein
		Erythrocyte Sedimentation Rate
		Procalcitonin
		α-1 Antitrypsin
		β2-Microglobulin
		Fibrinogen
		Amyloid Serum Protein A
	Diagnostic Approach
	Recommended Readings
45: Biomarkers of Sepsis
	Introduction
	Definition of Sepsis
	Epidemiology of Sepsis
	Role of the Laboratory in Sepsis
	Biomarkers of Sepsis
		C-Reactive Protein
		Procalcitonin
		Presepsin
		Adrenomedullin
	Recommended Readings
46: Laboratory Medicine and Exercise
	Introduction
	Acute Effects of Sports Performance on Laboratory Parameters
	Medium- to Long-term Effects of Physical Activity on Laboratory Parameters
	Recommended Readings
47: Clinical Biochemistry of Exercise
	The Benefits of Movement
	Quantification of Energy Expenditure
	Generalities on the Structure and Biochemistry of the Skeletal Muscle
	Clinical Biochemistry of Metabolic Substrates
	Biochemical Parameters for Assessing Athletic Performance
	Biochemical Adaptation
	Doping
	Recommended Readings
48: Preoperative Laboratory Test
	Recommended Readings
49: The Role of Laboratory in Urgency/Emergency
	Introduction
	Altered State of Consciousness
	Asthenia
	Hemorrhagic Diathesis
	Dyspnea
	Abdominal Pain
	Chest Pain
	Major Trauma or Polytrauma
	Burns
	Recommended Readings
50: Biological Drugs
	Introduction
	Biological and Traditional Drugs
	Immunogenicity of Biological Drugs
	Fields of Application of Biological Drugs
	Biological Drugs in Gastroenterology: Crohn’s Disease and Ulcerative Rectocolitis
	Biological Drugs in Rheumatology: Rheumatoid Arthritis and Ankylosing Spondylitis
	Biological Drugs in Dermatology: Psoriasis and Psoriatic Arthropathy
	Biological Drugs in Oncology
	Conclusions
	Recommended Readings
51: Mass Spectrometry in Clinical Biochemistry and Laboratory Medicine
	Introduction
	Therapeutic Dosage of Drugs
	Steroids
	Drugs of Abuse
	Neonatal Screening
	Proteomics
	Recommended Readings
52: Toxicology and Analytical Pharmacology
	Toxicology
		Interaction Among Chemicals
			Tolerance
			Exposure Characteristics
			Metabolism
			The Metabolome and Metabolic Biomarkers
		Dose–Response Relationship
			Variations in Toxic Responses
			Hazards and Toxicological Risks
			Toxicological Evaluation
			The Philosophy of Risk Assessment
		Analytical Toxicology
			Biological Monitoring
	Clinical Toxicology
		Role of the Laboratory
		Analytical Techniques
			Atomic Absorption Spectroscopy (AAS)
			Inductively Coupled Plasma (ICP)
			Molecular Biology Techniques
			Electrophoresis
			Classical Elementary Analysis
			Fluorescence Spectroscopy
			Fourier Transform Infrared Spectroscopy
			Mass Spectrometry
			Nuclear Magnetic Resonance Spectroscopy
			Polarimetry
			Ultraviolet/Visible Spectroscopy (UV–Vis)
			Chromatographic Techniques
			Gas Chromatography (GC)
			Ion Chromatography
			Liquid Chromatography (LC)
	Forensic Toxicology
		Drugs and Psychoactive Substances
			Classic Substances
				Cocaine
				Cannabinoids
				Amphetamines
				Opiates and Derivatives
				Methadone
				Alcohol
			New Psychoactive Substances (NPSs)
		Choice of the Biological Matrix
			Blood
			Urine
			Keratin
				Saliva
			Alternative Matrices: Sweat
		Medico-Legal Value of Toxicological Analyses
		Analytical Procedures
			Screening Analysis
			Confirmation Analysis
	Clinical Pharmacology
		Therapeutic Drug Monitoring
		Requirements for Drugs to be monitored
		Drugs That Meet the Requirements of TDM
		Objectives of TDM
		Appropriateness of Sampling
	Recommended Readings
53: Pharmacotoxicology of Substances of Abuse
	Introduction
	Ionotropic and Metabotropic Mechanisms of Action of Substances of Abuse
	Factors Influencing Substance Abuse
		Pharmacological and Physicochemical Properties of Substances of Abuse
		Personality and Psychiatric Disorders
		Genetic Factors
		Danger of Substances of Abuse
			Physical Damage
			Addiction
			Social Damage
		Damage Assessment
	Main Classes of Substances of Abuse and Mechanism of Action
		Opioids
		Cocaine
		Cannabinoids
		Amphetamines
		Hallucinogens
		Ethyl Alcohol
		Benzodiazepines
		New Psychoactive Substances
			Synthetic Cannabinoids
			Synthetic Cathinones
			Fentanyl
			New Designer Drugs
				Phenethylamines
				Benzofurans
				Triptamines
				Piperazines
	Recommended Readings
54: Applications of “Omics” Sciences in the Laboratory
	Introduction
	“Omics” Sciences, Definitions, and Generalities
	From the Genome Project to the 1000 Genomes Project: Applications of Genomics to Laboratory Medicine
	Detection of Genomic Alterations: The CGH-Array
	Transcriptomics and Gene Expression
	Epigenomics and Regulatory Mechanisms of Gene Expression
	Metagenomics, Microbiome Analysis, and Association with Human Diseases
	Nutrigenomics and Nutrition Medicine
	Pharmacogenomics and Personalized Therapy
	Recommended Readings
55: COVID-19
	Introduction
	SARS-CoV-2
		SARS-CoV-2 Variants
	COVID-19
		Biochemical-Clinical Course
	Diagnosis
		Molecular Tests (NAAT, Nucleic Acid Amplification Test)
		Serological Tests
		Antigen Detection Test
	Monitoring
		Inflammatory Biomarkers
			Cardiac Biomarkers
		Liver Biomarkers
		Renal Biomarkers
	Therapy
	Vaccines
	Recommended Readings
56: From Aging to Healthy Longevity: Innovation in Medicine Including Predictive Medicine and Laboratory Medicine Approaches
	Introduction
	The Homeostatic Balance of the Organism: Genetic and Environmental Factors
	Healthy Aging or Longevity
	Aging as a Multifactorial Disease
	Personalized Medicine and Laboratory Medicine
	The Types of Medicine Referred to as Multiple P
	Concluding Remarks and New Planning in Laboratory Medicine
	Recommended Readings
57: Biobanks of Biomedical Interest
	Introduction
	Human Cells and Tissues for Research
	Definitions of Research Biobank, Research Specimen Collection, Diagnostic Documentation Archive
		Research Biobank
		Sample Collection
		Archives of Diagnostic Documentation
	Biological Resource Centers
	Organizational Criteria
	Structural and Technological Criteria
	Quality Criteria
		Quality Criteria for Tissue Samples
		Quality Criteria for Clinicopathological and Patient Follow-Up Data
	Collection and Sampling of Blood and Other Biological Fluids
	Biobanking Processes
	Privacy and Informed Consent
		Privacy and Data Protection
		Informed Consent
	Access Modalities
	Good Practices for the Use of Stabilized Cell Lines
		Minimum Rules of Conduct for Cellular Handling
		Authentication of Human Cell Lines
	Recommended Readings
58: Health Technology Assessment in Laboratory Medicine
	Health Technology Assessment (HTA): From Theory to Practice
	Methodological and Applicative Aspects of HTA
	The Role of the Laboratory Physician in the Production of Useful Information for HTA
	Critical Aspects of HTA Development in Laboratory Medicine
	Case Study: HTA Evaluation of New Technologies for Quality Control in Hemogasanalysis
		The Research Context
		Methods
		Results
			General and Technical Relevance
			Safety
			Effectiveness
			Economic and Organizational Impact
			Qualitative Dimensions: Impact on Equity, Social, Ethical, and Legal Impact
	Conclusions
	Recommended Readings
Appendices
	Appendix A: Recommendations for the Appropriate Venous Blood Collection
		Introduction
			Steps to Follow for Proper Blood Collection
		Before Collection
			Step 1 – Identify the Patient
			Step 2 – Check That the Patient Is Fasting and Adequately Prepared
			Step 3 – Make Sure to Have All the Materials Needed for the Blood Collection
			Step 4 – Identify the Tubes
		Blood Sampling
			Step 5 – Wearing Gloves
			Step 6 – Apply the Tourniquet
			Step 7 – Select the Puncture Site
			Step 8 – Disinfect the Puncture Site
			Step 9 – Puncture the Vein (Fig. A.3)
			Step 10 – Collect Blood in the First Tube
			Step 11 – Remove the Tourniquet
			Step 12 – Gently Invert the Tubes Immediately After Collection
			Step 13 – Collect Additional Tubes Following the Order of Collection
			Step 14 – Remove the Needle from the Vein and Make Sure the Safety Mechanism Is Activated
			Step 15 – Dispose of the Needle
			Step 16 – Bandage the Puncture Site
			Step 17 – Instruct the Patient to Apply Light Pressure to the Puncture Site and Not to Bend the Arm
			Step 18 – Reverse all Tubes at Least Four Times
			Step 19 – Remove the Gloves
		After Sampling
			Step 20 – Advise the Patient to Rest for 5 Minutes
	Appendix B: Table of Reference and Decisional Values of the Main Biomarkers