[Personalized medicine and healthcare: where are we now, where should we go?]

The authors of this manuscript are representatives of different subdisciplines of medicine, all of them are experienced researchers. As of their origin, they are practicing doctors from the primary care and from the clinical/hospital setting, diagnostics experts, researchers from healthcare management, health economics, representatives of patients' rights and patient organizations. They are all devoted to the implementation of personalized medicine and personalized healthcare in Hungary. The current manuscript - also meant to be a keynote message provoking further discussion in the medical community - is devoted to correcting for two false ideas. One is that personalized medicine is not yet ready for practical applications, it is merely a research area of futurologists. The other false idea is that only (or mainly) the lack of financial resources hinders the introduction of personalized healthcare in Hungary. Orv Hetil. 2023; 164(6): 202-209.

A közfinanszírozott laboratóriumi szolgáltatások egészségpolitikai tapasztalatai Magyarországon egészségbiztosítási adatok elemzésével

Bevezetés: A laboratóriumi vizsgálatok iránti igény fokozódik, a prevenció, a pontosabb diagnosztika, a terápia indikálásának eldöntése, a terápia eredményességének monitorozása érdekében. Célkitűzés: Elemzésünk célja az Egészségbiztosítási Alap laboratóriumi előirányzatának egészség-gazdaságtani elemzése. Adatok és módszer: Elemzésünkhöz a Nemzeti Egészségbiztosítási Alapkezelő (NEAK) finanszírozási adatbázisát használtuk. Az elemzés a 2002 és 2018 közötti időszakot öleli fel. Vizsgáltuk a laboratóriumi előirányzat éves összegét, az esetszámokat és a beavatkozások számát, a különböző tulajdonviszonyú laboratóriumi szolgáltatók részesedését az egészségbiztosítási gyógyító-megelőző kasszából. Eredmények: A laboratóriumi vizsgálatok finanszírozására rendelkezésre álló forrás 2005 és 2015 között érdemben nem változott, az időszak jelentős részében a 21–22 milliárd Ft/év sávban mozgott. Mind az esetszámban, mind a beavatkozások számában látunk érdemi visszaesést 2006 és 2008 között. Az utóbbi években az esetszám évi 14–15 millió körül, míg a beavatkozások száma évi 180 millió körül állandósult. A forprofit vállalkozások részesedése az egészségbiztosítási forrásokból a 2010. évi 29,0%-ról 2018-ban 10,6%-ra csökkent, míg az állami intézmények részesedése a 2010. évi 27,1%-ról 2018-ban 78,7%-ra nőtt. Következtetés: A laboratóriumi aktivitás az elmúlt években stabilizálódott. A szakmai szabályok esetlegesen még szükséges pontosításával, a kódok karbantartásával a laboratóriumi ellátásokra fordított összegek tovább növelhetők a most már zömében köztulajdonban lévő laboratóriumi szolgáltatók irányában. Orv Hetil. 2020; 161(12): 468–473.

[Measurement of natriuretic peptides in heart failure: the good laboratory and clinical practice]

Cardiac natriuretic peptides (BNP, NT-proBNP) play a pivotal role in cardiovascular homeostasis, mainly due to their roles in vasodilatation, natriuresis, diuresis and due to their antiproliferative properties. Proper measurement of the natriuretic peptide levels may help differentiate between respiratory and cardiac forms of dyspnea, diagnose early forms of heart failure, evaluate severity of heart failure (prognosis) and monitor the efficacy of therapy. In many countries natriuretic peptide levels are being used as one of the earliest diagnostics tools to evaluate the involvement of the heart. Current theoretical and clinical data confirm the importance of natriuretic peptides in routine healthcare. These roles are clearly described in international recommendations and guidelines. In the current review the authors discuss the problems of the measurement of natriuretic peptides in Hungary, including several aspects related to laboratory medicine, cardiology and health economy.

[Investigation of adolescents' bone metabolism in the western part of Transdanubia]

Childhood reference range based on the age is not available in Hungary, therefore the diagnosis and therapy of bone metabolic diseases of childhood are subject to difficulties. The aim of this work is to provide information about the adolescents' results of bone mineral density and bone biomarkers.

SUBJECTS AND METHODS

Measurements were performed in 169 healthy adolescents (98 girls, 71 boys, age: 17.0+/-1.2 years). Bone mineral content (BMC) and bone mineral density (BMD) of the lumbar spine were measured using Double X-ray Absorptiometry (DXA, LUNAR, GE Health Care, USA) and Z-score values were analyzed using different reference population. In the serum, bone biomarkers osteocalcin (OC) and beta-crosslaps (beta-Cl) were measured by a fully automated, electrochemiluminescence immunoassay method (Elecsys-2010, Roche). Data were analyzed according to gender and the Tanner stage and grade system. Associations between body mass index (BMI), calcium intake, consumption of soft drinks and coke, and physical exercise were investigated.

RESULTS

BMC values for both age groups were significantly elevated in boys of the Tanner stage V. (15-16 years: 62.9+/-14.3 g; 17-19 years: 69.8+/-9.3g) than in girls (58.1+/-10.4; 61.6+/-8.5 g) (p<0.001). BMD values were higher in girls, than in boys (1.17+/-0.12 g/cm 2 vs. 1.13+/-0.11 g/cm 2) (p<0.05). OC and beta-Cl levels showed negative correlation with age in both gender (p<0.01), while OC and beta-Cl levels were higher in boys, than in girls (p<0.001). Elevation of BMC and BMD values were associated with increase of BMI in both gender (p<0.05), but the biomarkers in thin girls were higher, than in overweight girls (p<0.05). Authors obtained excellent correlations between the BMD-Z-score values compared to the German standard and to their own population (girls: r=0.97, boys: 0.88), but the absolute values significantly differed from one another. 80% of adolescents are on a diet with insufficient calcium intake, while 38% of them do not play sport regularly. Excessive intake of soft drinks was determined in 60% of adolescents. In the case of insufficient calcium intake (4.7%, 6/127), low bone mass was measured using the Z-score of the German reference values. Among children with adequate calcium intake, BMD assessed by DXA was normal.

CONCLUSION

These data help to determine normal reference values among healthy high school students. Further studies are needed in wider range of young population for the establishment of Hungarian reference values of bone markers.

[Multidrug resistance: diagnostic approaches and difficulties]

During the mid sixties scientists recognized that tumour cells can be resistant to a variety of chemotherapeutical drugs of different chemical structure simultaneously. They named this phenomenon multidrug resistance (MDR). Following this observation, number of in vitro and in vivo experiments proved that transmembrane proteins of the cell membrane are responsible for the mechanism. Many details of the underlying biochemical mechanisms were explored during the past decade. Nowadays the importance of MDR is well appreciated in different walks of medical science. MDR is an important problem during the treatment of many haematological conditions and solid organ tumors. Also, MDR is an important factor during immunosuppressant therapy of the transplanted patients. In spite of extensive research there are many uncertainties around MDR. This brief review describes the present options in the investigation of MDR. Based upon the MDR genotyping and expression level the likelihood of drug resistance may be predicted with reasonable accuracy. Additional information may be obtained by measuring the P-glycoprotein expression on the cell surface and the outward transport of test molecules from the cells. Although the tests described above provide significant help in predicting MDR or in the confirmation of existing MDR there is no consensus about the laboratory diagnosis.

[Macroprolactinemia in the differential diagnosis of hyperprolactinemia]

INTRODUCTION

Biologically active prolactin and the inactive fraction of macroprolactin can be present in hyperprolactinaemic sera. The reaction of routinely used prolactin assays with macroprolactin is variable.

AIMS

The present study was undertaken to analyse the leading clinical signs of hyperprolactinemia in macroprolactinemia and true hyperprolactinemia and to assess the prevalence of macroprolactinemia in hyperprolactinemic females.

METHODS

1571 consecutive female patients were investigated for hyperprolactinemia. Prolactin was measured before and after precipitation of macroprolactin by polyethylene glycol in 285 hyperprolactinemic (> 520 mlU/l) patients. Since not a single case of macroprolactinemia (recovery < 40%) was found in the range of 520-700 mlU/l, only in women with prolactin > 700 mlU/l (N = 254) entered the study.

RESULTS

In 59 patients (23%) macroprolactinemia was found. In women, the occurrence of macroprolactinemia increased with advancing age (p < 0.05). "A priori" clinical signs indicating hyperprolactinemia occurred less frequently in patients with macroprolactinemia than in those with true hyperprolactinemia. Pituitary microadenoma was found in 9.8% of macroprolactinemia vs. 31.6% in true hyperprolactinemia (p < 0.01); galactorrhea: 4% in macroprolactinemia vs. 19% in true hyperprolactinemia, (p < 0.05); infertility: 17% in macroprolactinemia vs. 44% in true hyperprolactinemia (p < 0.05). In 8 out of 59 women with macroprolactinemia, true hyperprolactinemia appeared simultaneously (15.3%). Occurrence of polycystic ovaries syndrome was more frequent in the true hyperprolactinemia (12%) that in macroprolactinemia (4.5%).

CONCLUSIONS

It has been shown that macroprolactin does not occur in mild hyperprolactinemia. In women, the occurrence of macroprolactinemia increases with age. "A priori" clinical signs indicating hyperprolactinemia and pituitary abnormality are less frequent in macroprolactinemia than in true hyperprolactinemia. The diagnosis of macroprolactinemia should be used only, when the PRL levels fall to the normal range after precipitation. To avoid diagnostic and therapeutic pitfalls the screening for macroprolactin of all patients with prolactin > 700 mlU/L is recommended.

Activation of porcine oocytes via an exogenously introduced rat muscarinic M1 receptor

Thirty hours after the beginning of in vitro maturation, porcine oocytes were microinjected with mRNA coding for the rat muscarinic M1 receptor. They were then incubated for 15 h to allow sufficient time for completing maturation, translation of the mRNA, and insertion of the receptor into the plasma membrane. They were then treated with acetylcholine, the receptor's agonist, and its effect on inducing various activation-related changes was examined. Acetylcholine treatment triggered the release of Ca2+ from internal stores that could be blocked by atropine, the receptor's antagonist. The Ca2+ release was probably mediated via a G protein, since prior injection of guanosine 5'-O-(2-thiodiphosphate) (GDP-beta-S) totally inhibited the effect of the agonist. Pertussis toxin (PT) had no effect on the Ca2+ transients induced by acetylcholine, suggesting that the signal transduction pathway involved a PT-insensitive G protein. Electron microscopy revealed that in the injected oocytes, acetylcholine induced cortical granule exocytosis. The oocytes were released from meiotic arrest as evidenced by the decrease in H1 kinase activity measured in the oocytes during the histone H1 kinase assay. After resuming meiosis they entered interphase: 58.8% of the injected oocytes formed pronuclei after incubation with the agonist. Injection without subsequent acetylcholine treatment, or acetylcholine incubation without prior injection with the receptor mRNA, did not cause these changes. The results provide further evidence that the components of a G protein-mediated signal transduction pathway exist in porcine oocytes and that the activation of this pathway via an exogenously supplied G protein-coupled receptor results in a full complement of oocyte activation events. Whether this pathway transduces the activating signal at sperm-induced oocyte activation requires further examination.

[Diagnostic value of thyroid antibodies]

Thyroid antibodies against thyroglobulin, the microsomal fraction and TSH receptor have been investigated in 150 patients (41 of them with Graves'disease, 24 of them with Hashimoto thyroiditis, 21 of them with subacute thyroiditis and 34 cases with treated hypothyroidism). 30 patients having thyroid disease without immune etiology served as a control group. As compared with the control group, significant differences were detected in the titers of microsomal and TSH-receptor antibodies in Graves' disease, microsomal and thyroglobulin antibodies in Hashimoto thyroiditis, while significantly higher antibody titers were measured against the microsomal fraction antibodies in hypothyroidism. In subacute thyroiditis, no significant elevation of any of the three antibodies was demonstrated. The diagnostic values of antibodies were investigated; in Graves disease, the antibody against TSH receptor is the most sensitivity method (70%), while in Hashimoto thyroiditis the highest sensitivity (87,5%) is exhibited by the determination antibody against the microsomal fraction. The relationship between the thyroid hormone values and the antibody titer was investigated too. In Hashimoto thyroiditis with hypothyroid state significantly elevated microsomal antibodies were found, as compared with the euthyroid state. It may be concluded that in cases suspect of Graves disease, determination of antibody against of TSH receptor is recommended. In case of normal value, finding the antibody against microsomal fraction can confirm the diagnosis. In further conclusion, antibody measurements are rarely informative in subacute thyroiditis. In cases suspect of other thyroid diseases of immune origin, measurement of the antibodies against the microsomal fraction may be helpful, while the discriminative value of the thyroglobulin antibody is more limited.

Transcriptional organization and expression of noIXWBTUV, a locus that regulates cultivar-specific nodulation of soybean by Rhizobium fredii USDA257

Rhizobium fredii is a nitrogen-fixing bacterial symbiont of soybean and a number of other legume species. We have studied the transcriptional organization of a Sym plasmid locus that restricts the host range of R. fredii USDA257 at both the host species and cultivar level. The genes of this host-specificity locus, noIXWBTUV, are transcribed from three promoters. Two of these, which are upstream of noIW and noIBTUV, are oriented face to face and initiate transcription at sites that are 14 bp apart. The third lies upstream from noIX. The noIW promoter is constitutive, whereas the noIB and noIX promoters are inducible by flavonoid signals. We have attempted to express genes from this locus in Escherichia coli systems, both in vivo and in vitro. We detected the insert- and orientation-specific expression of two genes, noIX and noIW, but we were unable to obtain expression of noIBTUV. Antiserum raised against NoIT nevertheless detected an abundantly expressed polypeptide of the predicted size in protein extracts of USDA257. This observation, as well as RNA dot blot data from a series of mutants, indicates that noIBTUV is expressed as a single transcriptional unit in R. fredii. Immunological detection of NoIT, and of a second protein, NoIX, was strictly dependent on flavonoid induction. The NoIX protein was larger than the size predicted from the previously published nucleotide sequence, and this led to resequencing and revision of the open reading frame.

[Clinical significance of the ultrasensitive TSH assay]

The authors attempted to answer the question whether the low thyroid stimulating hormone (TSH) levels measurable by the TSH ultrasensitive DELFIA kit have any clinical significance and whether they are more informative than the results obtained by the supersensitive TSH assay. No measurable TSH was detected in 111 sera among 896 random specimens, by using a supersensitive fluorimetric kit. These 111 sera were further investigated, TSH was measured by an ultrasensitive assay, in addition, the levels of the peripheral hormones (total T4, total T3, T3-uptake, free T4, free T3), were also determined. On basis of the latter, the patients were classified as having subclinical (n = 28) or manifest (n = 80) hyperthyroidism. The TSH levels of the patients affected by manifest hyperthyroidism were found significantly (p < 0.0001) lower than those encountered in subclinical hyperthyroidism. The groups were then further divided to homogeneous clinical subgroups (patients treated with thyrostatic drugs, untreated patients, toxic adenoma, Graves' disease) and the results were analyzed. It can be stated that the ultrasensitive test safely distinguishes manifest and subclinical disease in all subgroups (range of sensitivity: 90.0-94.7%). Specificity for the diagnosis of subclinical hyperthyroidism was 66.7% for the untreated subgroups, irrespective of aetiology, while in treated patients the value of specificity was 10%. In Graves' disease, specificity was 100%, in toxic adenoma 0% (the number of patients, however, was very small in these homogeneous subgroups). These results suggest that although the ultrasensitive method furnishes more information than the supersensitive test, its exclusive application would not be appropriate in characterizing thyroid function because of the broad range of individual scatter.

Mapping and genetic organization of pTiChry5, a novel Ti plasmid from a highly virulent Agrobacterium tumefaciens strain

Agrobacterium tumefaciens Chry5, a wild-type strain originally isolated from chrysanthemum, is unusually tumorigenic, particularly on soybean. We have mapped the Chry5 Ti plasmid by genomic walking and restriction endonuclease analysis, and have located its virulence, T-DNA, plasmid incompatibility, and L,L-succinamopine utilization loci. Southern analysis has revealed that about 85% of the Chry5 Ti plasmid is highly homologous to another Ti plasmid, pTiBo542. Although all the functions that we have located on pTiChry5 are encoded by pTiBo542-homologous regions, the two Ti plasmids differ in their genetic organization. The overall patterns of restriction sites in the plasmids also differ, with the exception of an approximately 12 kb segment of the virulence region, where the BamHI sites appear to be conserved. Complementation analysis has shown that deletion of a DNA segment which flanks the oncogenic T-DNA results in severe attenuation of virulence. This region also contains a sequence that is repeated in the Chry5 genome outside the Ti plasmid, and that is widely distributed in the Rhizobiaceae.

[New strategy for thyroid function testing]

The authors used a new protocol, based upon a supersensitive TSH assay, to examine the thyroid status of 1720 patients. Based upon the serum hormone levels, the patients were divided into different clinical groups. The biochemical relationship between the different hormone levels, and the rate of occurrence of various thyroid diseases were studied. 76.1% of the new patients hadn't received any previous treatment. 15.5% of those patients who had received treatment had hyperthyroidism, while 8.4% of those had hypothyroidism. 76% of the new patients, 38.3% of those who had hyperthyroidism, and only 29.7% of those who had hypothyroidism, were euthyroid. Undetectable TSH levels (< 0.03 mU/L) where observed in 51.8% of the new hyperthyroid patients, and in 33.8% of those who had subclinical hyperthyroidism. Similar results were obtained with those who had been previously treated for hyperthyroidism. The new protocol has the following advantages: it's more convenient to the patients, it's quick, it's economical. With this method it is possible to reduce the assays per patient by 31%. The algorithm was supplemented with results of free hormone levels. By doing this the authors were able to measure free-T4 and T3 hormone levels of 150 more patients. According to the authors, the free-T4 test is more informative than the free-T4-index, especially in the border-line cases and in treated hyperthyroidism. Primarily the free-T3 test is most necessary when examining patients treated with methimasol.

[Diagnostic value of CA 19-9 and CEA in gastrointestinal pathology]

The diagnostic values of CA 19-9 and CEA were evaluated in 187 cases (including 31 gastric, 41 colorectal, 12 pancreatic, 7 hepatobiliar and 5 hepatocellular carcinomas). These tumor markers were compared to the other laboratory parameters [hemoglobin, erythrocyte sedimentation rate, serum bilirubin, ASAT (aspartate amino transferase), ALAT (alanine amino transferase) GGT (gamma glutamil transpeptidase), ALP (alkaline phosphatase)]. The specificity of CA 19-9 was 89.5%, while the sensitivity of this tumor markers was 91.7% in pancreatic carcinoma, 54.8% in gastric carcinoma and 43.9% in colorectal carcinoma. The sensitivity of CEA only in colorectal patients was higher than that of CA 19-9 (specificity 73.9%, sensitivity 64.5%). Although the CA 19-9 and CEA are not known to give any cross-reaction with each other, simultaneous measurement and evaluation of these two tumor antigens did not result in a better diagnostic sensitivity. After undergoing a gastrointestinal carcinoma operation, CA 19-9 indicated the appearance of tumor recidiva with a 62% sensitivity. Calculated together with CEA the sensitivity elevated to 88.9%. In most of the patient with benign cholostasis, the CA 19-9 and CEA values were out of the normal range (53.3% and 36.4% respectively), so these tumor markers are not suitable to differentiate between benign and malign cholostasis. According to the authors, CA 19-9 is the most useful diagnostic tool to differentiate between pancreatic carcinoma and pancreatitis chronica (both group without cholostasis), as well as for monitoring the patients after surgery of a gastrointestinal cancer.