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Ghazal K, Brabant S, Prie D, Piketty ML. Hormone Immunoassay Interference: A 2021 Update. Ann Lab Med 2022; 42:3-23. [PMID: 34374345 PMCID: PMC8368230 DOI: 10.3343/alm.2022.42.1.3] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/08/2021] [Accepted: 07/21/2021] [Indexed: 12/17/2022] Open
Abstract
Immunoassays are powerful qualitative and quantitative analytical techniques. Since the first description of an immunoassay method in 1959, advances have been made in assay designs and analytical characteristics, opening the door for their widespread implementation in clinical laboratories. Clinical endocrinology is closely linked to laboratory medicine because hormone quantification is important for the diagnosis, treatment, and prognosis of endocrine disorders. Several interferences in immunoassays have been identified through the years; although some are no longer encountered in daily practice, cross-reaction, heterophile antibodies, biotin, and anti-analyte antibodies still cause problems. Newer interferences are also emerging with the development of new therapies. The interfering substance may be exogenous (e.g., a drug or substance absorbed by the patient) or endogenous (e.g., antibodies produced by the patient), and the bias caused by interference can be positive or negative. The consequences of interference can be deleterious when clinicians consider erroneous results to establish a diagnosis, leading to unnecessary explorations or inappropriate treatments. Clinical laboratories and manufacturers continue to investigate methods for the detection, elimination, and prevention of interferences. However, no system is completely devoid of such incidents. In this review, we focus on the analytical interferences encountered in daily practice and possible solutions for their detection or elimination.
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Affiliation(s)
- Khaldoun Ghazal
- Assistance Publique Hopitaux de Paris, Department of Functional Explorations, Necker Enfants Malades Hospital, Paris-Centre University, Paris Cedex, France
| | - Severine Brabant
- Assistance Publique Hopitaux de Paris, Department of Functional Explorations, Necker Enfants Malades Hospital, Paris-Centre University, Paris Cedex, France
| | - Dominique Prie
- Assistance Publique Hopitaux de Paris, Department of Functional Explorations, Necker Enfants Malades Hospital, Paris-Centre University, Paris Cedex, France
| | - Marie-Liesse Piketty
- Assistance Publique Hopitaux de Paris, Department of Functional Explorations, Necker Enfants Malades Hospital, Paris-Centre University, Paris Cedex, France
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Yin Y, Zhao F, Hu Y, Lu L, Qiu L. Consideration triggered by the choice of heterophilic antibody interference detection tests in measuring ACTH for a teenager boy with a rare adrenal disease. Clin Chim Acta 2021; 519:210-213. [PMID: 33991519 DOI: 10.1016/j.cca.2021.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 04/14/2021] [Accepted: 05/10/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Plasma ACTH is an important marker for Cushing syndrome; inaccurate measurement of ACTH concentrations due to the serum heterophile antibody may mislead diagnosis by physicians. We describe the case of a teenage boy with a rare adrenal disease who presented falsely increased ACTH concentrations (20.3 pg/ml; Siemens Immulite). METHODS Low dose dexamethasone inhibition test showed no inhibition of serum cortisol. While biochemical evidence suggested ACTH-dependent Cushing, the imaging tests suggested otherwise. Hence, further tests for interference identification, including test platform replacement, sample dilution, PEG precipitation, and use of blocking antibodies, were conducted. RESULTS The measurements of the same patient sample on three different analytical platforms suggested ACTH concentrations below 5 pg/ml. Serial dilutions of serum samples revealed nonlinearity, PEG recovery resulted in ACTH concentrations dropping to < 5 pg/ml, and interferences in plasma were blocked by a heterophilic blocking reagent (21.2 vs < 5 pg/ml), suggesting that assay interference performed on Siemens Immulite led to false-positive ACTH. Finally, the boy was diagnosed with a rare type of ACTH-independent Cushing syndrome. CONCLUSIONS The inaccurate evaluation of ACTH misled the physicians, increasing treatment time and diagnostic testing. Thus, an anti-interference workflow should be established between physicians and laboratories to avoid such cases in the future.
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Affiliation(s)
- Yicong Yin
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing 100730, PR China
| | - Fang Zhao
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing 100730, PR China
| | - Yingying Hu
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing 100730, PR China
| | - Lin Lu
- Department of Endocrinology, Key Laboratory of National Health Commission, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing 100730, PR China.
| | - Ling Qiu
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing 100730, PR China.
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Adrenal insufficiency: Physiology, clinical presentation and diagnostic challenges. Clin Chim Acta 2020; 505:78-91. [PMID: 32035851 DOI: 10.1016/j.cca.2020.01.029] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 01/24/2020] [Accepted: 01/27/2020] [Indexed: 12/21/2022]
Abstract
Adrenal insufficiency (AI) is a serious condition, which can arise from pathology affecting the adrenal gland itself (primary adrenal insufficiency, PAI), hypothalamic or pituitary pathology (secondary adrenal insufficiency, SAI), or as a result of suppression of the hypothalamic-pituitaryadrenal (HPA) axis by exogenous glucocorticoid therapy (tertiary adrenal insufficiency, TAI). AI is associated with an increase in morbidity and mortality and a reduction in quality of life. In addition, the most common cause of PAI, autoimmune adrenalitis, may be associated with a variety of other autoimmune disorders. Untreated AI can present with chronic fatigue, weight loss and vulnerability to infection. The inability to cope with acute illness or infection can precipitate life-threatening adrenal crisis. It is therefore a critical diagnosis to make in a timely fashion, in order to institute appropriate management, aimed at reversing chronic ill health, preventing acute crises, and restoring quality of life. In this review, we will describe the normal physiology of the HPA axis and explain how knowledge of the physiology of this axis helps us understand the clinical presentation of AI, and forms the basis for the biochemical investigations which lead to the diagnosis of AI.
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Shi J, Dhaliwal P, Zi Zheng Y, Wong T, Straseski JA, Cervinski MA, Shajani-Yi Z, DeMarco ML. An Intact ACTH LC-MS/MS Assay as an Arbiter of Clinically Discordant Immunoassay Results. Clin Chem 2019; 65:1397-1404. [DOI: 10.1373/clinchem.2019.306365] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 08/19/2019] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
Measurement of plasma adrenocorticotropic hormone (ACTH) is key in the differential diagnosis of hypothalamic-pituitary-adrenal disorders. Two-site sandwich immunoassays dominate clinical testing of ACTH in North America; however, discordant results between manufacturers have been repeatedly reported. To resolve the discrepancy, we developed a liquid chromatography–tandem mass spectrometry (LC-MS/MS) assay for the intended measurand, biologically active intact ACTH (iACTH).
METHODS
The multiple reaction monitoring LC-MS/MS assay was designed to selectively measure full-length iACTH, as well as ACTH analogs and fragments (i.e., ACTH1–24 and ACTH18–39). Epitope assignment of the Roche Elecsys antibodies was performed by MALDI-TOF mass spectrometry. A method comparison between Roche Elecsys and Siemens Immulite ACTH immunoassays was performed and clinically concordant/discordant results identified. In a subset of these samples, the iACTH concentration was determined using the LC-MS/MS method.
RESULTS
The lower limit of the measuring interval of the iACTH LC-MS/MS assay was 9 pg/mL (2 pmol/L). The assay was linear from 9 to 1938 pg/mL (2 to 427 pmol/L). Epitope mapping revealed that the Roche capture and detection antibodies bound residues 9–12 and 36–39 of ACTH, respectively. The iACTH LC-MS/MS analysis demonstrated that for discordant results between 2 immunoassays studied, only the Roche results were highly positively correlated with the iACTH concentration.
CONCLUSIONS
Immunoprecipitation of biologically active ACTH molecules followed by LC-MS/MS analysis enabled selective detection of iACTH and relevant biologically active fragments in plasma. Applied to the investigation of clinically discrepant results, this method can act as an arbiter of the concentration of iACTH present.
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Affiliation(s)
- Junyan Shi
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | - Pawan Dhaliwal
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | - Yu Zi Zheng
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | - Terry Wong
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | | | - Mark A Cervinski
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon NH and The Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Zahra Shajani-Yi
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine and Vanderbilt University Medical Center, Nashville, TN
| | - Mari L DeMarco
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
- Department of Pathology and Laboratory Medicine, St. Paul's Hospital, Providence Health Care, Vancouver, Canada
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Qian S, Smith J, Wijeratne N, Kevat D. ACTH measurements in Cushing's syndrome: the need for caution and communication. Pathology 2019; 51:769-771. [PMID: 31640888 DOI: 10.1016/j.pathol.2019.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 07/14/2019] [Accepted: 08/01/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Sarah Qian
- Department of Endocrinology and Diabetes, Western Health, St Albans, Vic, Australia
| | - Joel Smith
- Department of Biochemistry, Dorevitch Pathology, Heidelberg, Vic, Australia
| | - Nilika Wijeratne
- Department of Biochemistry, Dorevitch Pathology, Heidelberg, Vic, Australia; Department of Medicine, Monash University, Clayton, Vic, Australia
| | - Dev Kevat
- Department of Endocrinology and Diabetes, Western Health, St Albans, Vic, Australia; School of Public Health, Monash University, Melbourne, Vic, Australia.
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Morita K, Ogawa M, Kimura M, Okawa Y, Oki Y, Edo N, Tsukamoto K, Ishikawa T. Falsely elevated plasma ACTH levels measured by the Elecsys assay related to heterophilic antibody in a case of secondary adrenocortical insufficiency. Endocr J 2019; 66:563-569. [PMID: 30944263 DOI: 10.1507/endocrj.ej19-0023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A 49-year-old woman with membranous nephropathy was referred to our hospital during the tapering of oral prednisolone, because of suspicion of primary adrenal insufficiency based on a plasma ACTH level of 399.1 pg/mL in the Elecsys assay and a serum cortisol level of 3.1 μg/dL. A rapid ACTH stimulation test revealed a suboptimal response, whereas a prolonged ACTH simulation test showed a sufficient increase in her urinary free cortisol. Also, big ACTH was not detected by gel exclusion chromatography. Therefore, we speculated that ACTH levels were falsely elevated due to some interference substances. Pretreatment of her plasma with either polyethylene glycol precipitation or a heterophilic blocking tube substantially reduced her ACTH values. When either the Immulite ACTH II or the TOSOH II ACTH was tried instead of the Elecsys ACTH, her plasma ACTH values turned out to be lower and appropriate for her clinical status. These results indicated that heterophilic antibodies interfered only with the Elecsys ACTH assay presumably by bridging the capture and tracer antibodies. To our knowledge, this is the first case in which the Elecsys ACTH assay yielded falsely elevated results. Regardless of the measurement system used, if there is a discordance between assay results and clinical findings, it should be considered to adopt additional procedures and/or another assay.
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Affiliation(s)
- Koji Morita
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo 173-8606, Japan
| | - Masumi Ogawa
- Division of Metabolism, Department of Internal Medicine, Self-Defense Forces Central Hospital, Tokyo 154-8532, Japan
| | - Michiko Kimura
- Department of Laboratory Medicine, Teikyo University School of Medicine, Tokyo 173-8606, Japan
| | - Yuta Okawa
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
| | - Yutaka Oki
- Department of Family and Community Medicine, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
| | - Naoki Edo
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo 173-8606, Japan
| | - Kazuhisa Tsukamoto
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo 173-8606, Japan
| | - Toshio Ishikawa
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo 173-8606, Japan
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Heterophile Antibody to Adrenocorticotropin Hormone Interfering with the Investigation of Cushing's Syndrome. Indian J Clin Biochem 2019; 34:234-236. [PMID: 31093000 DOI: 10.1007/s12291-018-0770-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 06/09/2018] [Indexed: 10/14/2022]
Abstract
The practice of medicine depends on the accuracy of biochemical assays. The high prevalence of incidental masses on imaging necessitates a correct biochemical diagnosis before proceeding to radiological studies. Hormonal assays, tumour markers, and markers of cardiac injury are particularly susceptible to heterophile antibody interference which may lead to inaccurate and misleading results, inappropriate investigation and/or treatment, patient concern and potential harm. A case of heterophile antibody interference in the measurement of ACTH in a patient with Cushing's syndrome resulting in unnecessary invasive investigation is presented. Close collaboration and communication between laboratory and clinical staff is essential where laboratory results and the clinical picture are not congruent.
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Greene LW, Geer EB, Page-Wilson G, Findling JW, Raff H. Assay-Specific Spurious ACTH Results Lead to Misdiagnosis, Unnecessary Testing, and Surgical Misadventure-A Case Series. J Endocr Soc 2019; 3:763-772. [PMID: 30963134 PMCID: PMC6446888 DOI: 10.1210/js.2019-00027] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 02/15/2019] [Indexed: 11/19/2022] Open
Abstract
The proper clinical evaluation of pituitary and adrenal disorders depends on the accurate measurement of plasma ACTH. The modern two-site sandwich ACTH immunoassay is a great improvement compared with older methods but still has the potential for interferences such as heterophile antibodies and pro-opiomelanocortin (POMC) and ACTH fragments. We report the cases of five patients in whom the diagnosis or differential diagnosis of Cushing syndrome was confounded by erroneously elevated results from the Siemens ACTH Immulite assay [ACTH(Immulite)] that were resolved using the Roche Cobas or Tosoh AIA [ACTH(Cobas) and ACTH(AIA), respectively]. In one case, falsely elevated ACTH(Immulite) results owing to interfering antibodies resulted in several invasive differential diagnostic procedures (including inferior petrosal sinus sampling), MRI, and unnecessary pituitary surgery. ACTH(Cobas) measurements were normal, and further studies excluded the diagnosis of Cushing syndrome. In three cases, either Cushing disease or occult ectopic ACTH were suspected owing to elevated ACTH(Immulite) results. However, adrenal (ACTH-independent) Cushing syndrome was established using ACTH(AIA) or ACTH(Cobas) and proved surgically. In one case, ectopic ACTH was suspected owing to elevated ACTH(Immulite) results; however, the ACTH(Cobas) findings led to the diagnosis of alcohol-induced hypercortisolism that resolved with abstinence. We have concluded that ACTH(Immulite) results can be falsely increased and alternate ACTH assays should be used in the diagnosis or differential diagnosis of clinical disorders of the hypothalamic-pituitary-adrenal axis.
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Affiliation(s)
- Loren Wissner Greene
- Department of Medicine, New York University School of Medicine, New York, New York.,Department of Obstetrics and Gynecology, New York University School of Medicine, New York, New York
| | - Eliza B Geer
- Multidisciplinary Pituitary and Skull Base Tumor Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Gabrielle Page-Wilson
- Neuroendocrine Unit, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York
| | - James W Findling
- Endocrinology Center and Clinics, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Community Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Hershel Raff
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.,Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin.,Endocrine Research Laboratory, Aurora St. Luke's Medical Center, Aurora Research Institute, Milwaukee, Wisconsin
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9
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Analytical interference in the corticotropin immunoassay in patients with adrenal adenomas. ENDOCRINOL DIAB NUTR 2018; 65:127-129. [DOI: 10.1016/j.endinu.2017.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 11/21/2017] [Accepted: 11/25/2017] [Indexed: 11/19/2022]
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Abstract
A laboratory test has three phases, pre-analytical, analytical and post-analytical. The purpose of this review is to highlight an issue concerning the analytical phase of one of the most widely deployed groups of in vitro diagnostic tests using a common technology - namely immunoassay.Immunoassay entails an inherently high error rate and, therefore, has the potential for inaccurate and misleading results susceptible to misinterpretation and/or diagnostic misapplication by clinicians. An approach based on Bayesian inference (without mathematics or equations) - illustrated by examples - is presented; this may help clinicians in discerning potentially erroneous results even when they appear plausible and not unreasonable.Essentially, false positive results are most likely to occur when the disease prevalence/incidence is low. False negative results become more prominent when the prevalence/incidence of disease increases. When concern is raised, available follow-up laboratory tests should be initiated to establish with confidence the diagnostic reliability or unreliability of such results.
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Yener S, Demir L, Demirpence M, Mahmut Baris M, Simsir IY, Ozisik S, Comlekci A, Demir T. Interference in ACTH immunoassay negatively impacts the management of subclinical hypercortisolism. Endocrine 2017; 56:308-316. [PMID: 28247312 DOI: 10.1007/s12020-017-1268-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 02/13/2017] [Indexed: 11/26/2022]
Abstract
PURPOSE Low plasma corticotropin is considered a useful parameter for the diagnosis of subclinical hypercortisolism in patients with an adrenal incidentaloma. However, immunoassays are vulnerable to interference from endogenous antibodies. In this study, subjects who underwent Hypothalamus-pituitary-adrenal axis evaluation for the assessment of subclinical hypercortisolism were evaluated. The objective of the study was to ascertain whether antibody interference in corticotropin immunoassay affected the diagnostic work-up and clinical decisions. METHODS The 437 consecutive patients with incidentally discovered adrenal adenomas were included in this single centre study. Patients who had a combination of a nonsuppressed corticotropin concentration (>4.4 pmol/L) and a non-suppressed cortisol concentration after 1 mg overnight dexamethasone suppression test (>50 nmol/L) were selected. Eight eligible subjects without specific features of Cushing's syndrome were identified and recruited for interference studies and follow-up. Nine controls including one patient with unilateral adrenalectomy and one patient with Cushing's disease were recruited as well. MEASUREMENTS Eligible subjects and controls were subjected to hormonal tests and investigations for suspected interference. Interference studies included measurement of corticotropin on a different analytical platform, serial dilutions, polyethylene glycol precipitation and heterophilic antibody analysis. Patients were followed with clinical and laboratory parameters for a median duration of 30 (12-90) months. RESULTS Antibody interference was identified in four patients. Rheumatoid factor was responsible for the interference in one patient. Clinical management of the patients was affected by the erroneous results. Interference tests were negative in control subjects. CONCLUSIONS Erroneous results associated with analytical interference negatively impacted on clinical decision making in this patient group. This should be considered particularly in conditions such as subclinical hypercortisolism which decisions depend on laboratory investigations mainly. Analytical interference could explain the high variability observed both in field measurements from patients who were expected to have lower corticotropin concentrations and in subclinical hypercortisolism prevalence reported by different studies. Many problems can be resolved by ensuring good communication between clinical and laboratory staff.
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Affiliation(s)
- Serkan Yener
- Department of Endocrinology, Dokuz Eylul University Faculty of Medicine, Narlidere, 35340, Izmir, Turkey.
| | - Leyla Demir
- Department of Clinical Biochemistry, Katip Celebi University Faculty of Medicine, Izmir, Turkey
| | - Mustafa Demirpence
- Department of Endocrinology, Tepecik Education and Research Hospital, Konak, Izmir, Turkey
| | - Mustafa Mahmut Baris
- Department of Radiology, Dokuz Eylul University Faculty of Medicine, Narlidere, 35340, Izmir, Turkey
| | - Ilgin Yildirim Simsir
- Department of Endocrinology, Ege University Faculty of Medicine, Bornova, 35040, Izmir, Turkey
| | - Secil Ozisik
- Department of Endocrinology, Dokuz Eylul University Faculty of Medicine, Narlidere, 35340, Izmir, Turkey
| | - Abdurrahman Comlekci
- Department of Endocrinology, Dokuz Eylul University Faculty of Medicine, Narlidere, 35340, Izmir, Turkey
| | - Tevfik Demir
- Department of Endocrinology, Dokuz Eylul University Faculty of Medicine, Narlidere, 35340, Izmir, Turkey
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