Chest pain is one of the leading presentations in the Emergency Department (ED), and the historically conservative approach to avoid missing a potential acute myocardial infarction (AMI) has led clinicians to admit or prolong the ED dwell time of many more patients than are subsequently found to have an AMI. This consequently leads to crowding in the ED, which is associated with adverse outcomes for all patients, with or without AMI.

Approximately 30 per cent of chest pain related ED visits will have a final diagnosis of a myocardial infarction (MI). Clinicians are obligated to exclude myocardial ischemia with a high degree of certainty. To manage costs and the adverse effects of overcrowding in the ED, it is of high priority to be able to rapidly and safely discharge patients with a sufficiently low probability for acute coronary syndrome (<0.5 per cent – 1 per cent).

The 2012 third universal definition of a MI is the detection of a rise and/or fall of cardiac troponins with at least one value above the 99th percentile upper reference limit (URL) in addition to at least one of the following: 1) symptoms of ischaemia; 2) new electrocardiogram (ECG) changes of ST-T segments, new left bundle branch block or development of pathological Q waves; 3) imaging evidence of new regional wall motion abnormality or loss of viable myocardium; and/or 4) identification of an intracoronary thrombus by angiography or autopsy. 

To diagnose AMI, myocardial injury must be accompanied by clinical indicators of an ischemic mechanism. On the contrary, an AMI cannot be present in the absence of myocardial injury. Hence, a MI is easier to rule out than to rule in. In addition, sufficient time must be allowed for the release of myocardial structural proteins (i.e. cardiac troponins, cTn) into the circulation in measurable quantities to be detectable post-myocardial injury. Therefore, the absence of high-sensitivity troponin (hsTn)>99th percentile URL and ≥6 hours after the onset of ischemia has conventionally been used to rule out MI. 

In the 1960s, aspartate transaminase (AST) was the first biomarker widely used in diagnosing AMI, followed by creatine kinase (CK) and lactate dehydrogenase (LDH) by the 1970s, all of which were not specific to cardiac muscle and hence detection of these were not specific to myocardial injury. Myoglobin, found in the heart and striated skeletal muscles, was later developed in 1978 as a cardiac biomarker as its serum level rises following acute myocardial injury. This was replaced in the era of electrophoresis advancement during which cardiac isoenzymes CK-MB, LDH 1 and 2 could be detected. 

Troponin is a complex within the contractile apparatus of cardiac and skeletal myocytes discovered in 1965. It was detectable with a reliably sensitive radioimmunoassay developed in the late 1980s. Several generations of troponin assays have since been developed, each reportedly with increasing diagnostic utility as well as the ability to rule out MI. Cardiac troponin (cTn) is a collective term referring to serum troponins T and I, which are isoforms highly sensitive and specific to cardiac myocytes, the sensitivity for detection of which approaches 100 per cent when sampled 6 – 12 h after acute onset of chest pain. Therefore, to reliably rule out AMI, patients with acute chest pain have had repeat troponin samples 6 – 12 h after the initial assessment. Consequently, patients were increasingly admitted for observation.

The latest generation of hsTn assays is defined as assays that have a coefficient variant (CV) of 10 per cent or less, at the 99th percentile URL, with the ability to detect cTn levels in at least 50 per cent of the reference normal population. Compared with earlier-generation assays, hsTn can establish biochemical evidence of myocardial injury at a much lower concentrations (10- to 100-fold lower) and thus earlier after the onset of ischemia. It is also able to discriminate small changes in concentration starting within the normal reference range, above the limit of detection (LoD) of the assay but below the URL. Small dynamic increases (delta values) are associated with a higher probability of subsequent rises above the URL and future major adverse cardiac events (MACE); whereas stable concentrations of hsTn in the detectable range below the URL are associated with structural heart disease, atherosclerosis risk factors, and a higher risk of future MACE. Consequently, non-detectable or very low hsTn concentrations identify patients with lower cardiovascular risk. 

Of the emerging applications for hsTn, the rapid rule-out of MI in the ED is the application most likely to be incorporated by clinicians. Accelerated diagnostic protocols (ADP) utilising hsTn can facilitate earlier triage while maintaining an acceptable negative predictive value (NPV). For example, the ADP developed by Meller et al (2015) utilising high-sensitivity troponin T (hsTnT) identified 35-40 per cent of patients to be at extremely low risk of MACE and hence ideal candidates for early outpatient management. 

ST-elevation myocardial infarction (STEMI) is an ECG diagnosis in the context of a patient with typical cardiac chest pain, and clinicians do not wait for biochemical evidence of myocardial damage before emergency revascularisation is instituted. Non-ST-elevation myocardial infarction (NSTEMI), on the other hand, can be ruled out as early as four hours after symptom onset with existing hsTn assays, allowing shorter ED or inpatient stay for patients without raised levels of troponin and earlier intervention for those with a confirmed AMI. 

ADPs incorporating the clinical history, electrocardiogram, and cTn concentrations provide a framework to rapidly evaluate and triage chest pain patients suspicious for ischemia. The National Institute for Health and Care Excellence (NICE) updated guidelines in 2016 on the evaluation of patients with suspected AMI recommended clinicians to consider ruling out MI if a patient has very low concentrations of cTn at presentation. They further recommended clinicians to apply the LoD as a threshold below which MI can be safely ruled out at presentation, provided patients are deemed to be at low risk of MI by an appropriate risk stratification system. Evidence from studies including both the Thrombolysis in Myocardial Infarction (TIMI) score and the Global Registry of Acute Coronary Events (GRACE) score were considered. Having cTn concentrations embedded in both scores were initially derived and validated in patients with confirmed MI for prognostication, but over time, these scores have been implemented to risk stratify patients with suspected MI as well. Although NICE ultimately recommended the TIMI risk score, it was yet to be validated with hsTn, using LoD at presentation alone. 

In 2018, Carlton et al found when a hsTnT of <5ng/L (LoD) was applied alongside a TIMI score of 0 and a non-ischaemic ECG, the sensitivity and NPV were extremely high, at 99.5 per cent and 99.6 per cent respectively. For the high-sensitivity Troponin I, (hsTnI), using the LoD (<2ng/L) and a TIMI score of 0 alongside a non-ischaemic ECG, the sensitivity was 98.9 per cent and NPV was 99.5 per cent. These strategies would identify 17.9 per cent and 21 per cent of low-risk patients respectively. 

The European Society of Cardiology (ESC) has previously advocated the use of a 0/3-hour algorithm in conjunction with the ECG and GRACE (Global Registry of Acute Coronary Event) risk score in clinical practice. However, a recent meta-analysis by Pickering et al (2017) have concluded that a single hsTnT concentration below the LoD in combination with a non-ischemic ECG provided excellent NPV (99.3 per cent) and sensitivity (98.7 per cent) for MI, hence may successfully rule out AMI in patients presenting to EDs with possible ACS without the need for additional risk score. Indeed, the ESC now advocates use of the LoD at presentation in conjunction with ECG, but do not recommend the addition of clinical risk scores. Nevertheless, application of clinical risk score is still widespread in most settings, probably due to the perceived assurance it provides diagnostically. 

One of the most widely used risk scores, the history, ECG, age, risk factors, troponins (heart) score, was developed and validated in a population with suspected ACS. A recent meta-analysis of 11,217 patients demonstrated that this score had a sensitivity of just 96.7 per cent, below the threshold of 99 per cent, which most ED clinicians deem acceptable. It is unclear whether this score risk stratifies better than with hsTn alone, hence comparative studies between risk stratification thresholds of hsTn alone or in combination with risk scores are required to determine if patient safety can be improved. 

The evolution of hsTn-based rule-out strategies in the ED is aimed at reliably excluding myocardial injury as early as possible through staged measurement of hsTn in conjunction with other clinical assessments for the probability of MI. Emerging components include movement of serial hsTn samples to earlier time points, addition of criteria for an absolute delta hsTn changes between measurements, and integration of very low decision limits well below the 99th percentile URL at the early time points. For example, the ESC 2015 practice guidelines also included an alternative (Class I) strategy, reducing the sampling interval from three to one hour when a validated hsTn assay with 0/1- hour algorithm is used. Such an algorithm incorporates all three components listed above, including a very low cut-off applied at the initial hsTn value aimed at excluding MI after the first sample in patients who arrive >three hours after symptom onset, and a delta criteria for patients with dynamic 

hsTn concentrations subjecting them to additional testing. These reports have shown that using very low hsTn on the first sample can reasonably exclude MI in 40-50 per cent of low-risk patients having presented >two hours from symptom onset. Similarly, a comparative study by Chapman et al (2017) between the High-STEACS (High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome) 0/3/6-hr algorithm and the standard ESC 0/3-hr algorithm to rule out MI, also value added on the use of a very low 0-hour cut-off to facilitate earlier rule-out, and a delta criterion to exclude increasing values with absolute concentrations below the URL among patients requiring three-hour sampling. 

Boeddinghaus et al (2017) moved the serial sample in the 0/3- hour algorithm forward to one hour and comparing the ESC alternative 0/1-hour strategy with other approaches using either a single cut-off at 0 hours or the one-hour strategy. They found that each of these approaches performed similarly in delivering an NPV >99 per cent, comparing favourably with the ESC 0/3- hour algorithm (NPV, 98.4 per cent) among patients presenting >two hours after symptom onset. However, among early presenters, the NPV (98.5 per cent) and sensitivity (94.2 per cent) were lowered with the use of the single 0-hour cut-off (5 ng/L). Hence, it is of utmost importance that very early presenters should have serial testing to support an acceptable NPV, as should patients with other high-risk indicators. 

Although others have also advocated the use of the LoD as necessary to support an acceptable sensitivity with a single sample, a study by Carlton at el (2016) showed that use of LoD (1.2ng/L) ruled out fewer patients (18.8 per cent discharge rate), albeit with higher sensitivity of 99.0 per cent (95 per cent CI, 96.8 per cent – 99.7 per cent) and NPV of 99.5 per cent (95 per cent CI, 98.4 per cent – 99.9 per cent). 

Undoubtedly, there remain several challenges in translating this diagnostic innovation into cost-effective healthcare with improved patient outcomes. Firstly, increased sensitivity of hsTn assays are usually accompanied with reduced specificities and low positive predictive values (PPV) for MI. Although there would be a lower likelihood of a missed MI, these assays would not be suitable for early rule-in decision-making. In other words, clinicians would need to be more prudent and cautious with positive tests given the advent of such assays. Secondly, the reduced specificity and low PPV for MI accompanying the improved analytical precision of the assays leads to greater rate of invasive investigation, i.e. coronary angiography without a proportionate increase in coronary lesion-specific therapy, i.e. revascularisation, although the improved analytical precision enables earlier clinical decision to admit or discharge a patient with suspected ACS. Thirdly, hsTn assays are impractical in the primary care setting due to the long turnaround times for results despite its usefulness in the context of low or intermediate clinical suspicion of MI, provided sufficient time has passed since symptom onset. Also, it is problematic for general practitioners to receive results in a timely manner for execution of an appropriate clinical response. Lastly, improved test precision without a greater discretion in clinical decision making and test interpretation may result in increased costs and inefficiencies, i.e. increased investigative burden of patients tested positive due to the many non-coronary causes of elevated troponin. 

With emerging studies published worldwide optimising the potential application of hsTn, knowledge gaps have still remained to date. For example, there is lack of data among early presenters to provide confidence around and/or lead to revision of current algorithms. Future algorithms may possibly integrate the actual timing of sampling instead of assigning specific time points as per all current algorithms. The time-related rate of rise may become more crucial than the absolute or relative changes. Perhaps coupling hsTn with clinical probability tools such as cardiovascular risk scores or imaging such as CT coronary angiogram can improve diagnostic performance for ACS rule-out. Prospective randomised studies implementing these testing strategies are warranted in view that current studies are mostly observational with reported outcomes based on management according to local standards of care. In view of low cut-offs and small delta criteria optimising NPV but lowering PPV, future studies should also be directed at determining higher delta criteria to rule in MI. These issues should be addressed in the near future as we move toward evidence-based best practice. 

In conclusion, hsTn has greater utility in the early rule-out of MI, potentially at 0-hour presentation for low risk cases clinical outcomes are also improved due to less likelihood of missed AMI in patients presenting with chest pain in the ED. Nevertheless, specificity and PPV remains its main shortfall as hsTn does not differentiate AMI from other non-coronary causes of myocardial necrosis. hsTn should be always be used in tandem with clinical judgement to enable appropriate interpretation of these assays. Lastly, consensus and continuous education in every institution employing hsTn are essential for clinical practice changes in testing strategies to harness the full potential of hsTn in further improving resource efficiency and patient safety.

Infectious diseases are illness involving two organisms: a human being as a host and a microorganism as a causative agent. To manage infectious diseases doctors must consider both, otherwise it will not address all the biological characteristics of infectious diseases. Current approach of infectious diseases management is using antimicrobial agents to eradicate pathogens. The aims of antimicrobial agent administration are to eradicate or decrease the pathogens concentration below dose of infection. The microbe should be killed by drugs, which are available in the market. However, there are huge accumulated data of pathogens resistance against antimicrobial agents. In addition, the antimicrobial agent effect is influenced by the characteristic of the patients, since its administration does not mean the drugs will be able to reach the target organ, where the microbes are present, properly. 

Mutation of the microbes is a random event, which eventually results in the change of the entire characteristics of the microbes, which is more exaggerated by the horizontal gen transfer. For a long time, it has been known that these mechanisms are responsible for the rise of antimicrobial resistance in microbes, though it is not uniformed in bacteria, fungus, and viruses (Richardson, 2017). A human as a host has been documented with genetic variation also. However, direct evidence of interaction between the two events of evolution in the microbes and humans may not yet be conclusive. 

Multi drug resistant organisms (MDRO), a technical definition that is not uniform, refers to microbes that are resistant to many antimicrobial agents from different classes and inhibitory mechanisms. MDRO infections have clinical manifestations that are like infections caused by susceptible pathogens, with an exception in several cases. Options for treating patients with MDRO infections are often extremely limited, because of the shortage of antimicrobial agents left. On the other hand, the pipeline of antimicrobial invention has been in a droughty condition. It will result in increased lengths of stay, costs, and mortality. All together it will produce an interflow of infectious diseases management impediments (CDC, 2006). 

There are two issues of MDRO management in the healthcare setting, containment for its transmission and treatment for infected patients. Containment of the MDRO transmission includes the community and healthcare associated transmission. Transmission of MDRO is a big concern since, by nature, the genetic determinants of drug resistance can be transmitted from bacteria in the various genus and species. It means that if we have extended-spectrum beta-lactamases (ESBL) producing Escherichia coli in the community or healthcare, we may expect that the ESBL associated genes spread to other Enterobacteriaceae in the same region. The same situation occurs in methicillin resistant Staphylococcus aureus (MRSA), vancomycine resistant Enterococci (VRE), or carbapenem-resistant enterobacteriaceae (CRE) cases (Reinheimer et al., 2016). 

Multifaced approaches are needed to contain the MDRO transmission in the healthcare setting (Backman et al., 2011; Barnes et al., 2014). Current recommendation for containment of the MDRO transmission includes several strategic planes i.e.: implementing antibiotics stewardship, focus on infection prevention fundamentals, enhance the role of microbiology laboratory, minimise the use of invasive medical devices, and enhancement of environmental cleaning and disinfection strategies. Antibiotics stewardship is a systematic programme that aims to ensure the prudent antibiotics prescription in bacterial infection cases. This will result in the reduction of selection pressure for bacteria that will eventually prevent the emerging of MDRO. Infection prevention fundamental for MDRO is related with the contact precaution procedure implementation, such as: hand washing and hygiene. One of the most important factors is to make sure that the infection prevention programme is in place and implemented. Microbiology laboratory is the unit that can detect the presence of MDRO in the hospital. It is always a case that prompts notification to the infection control officers, and clinicians will help to contain MDRO transmission. Minimisation of invasive medical device is another key factor of MDRO containment, through the daily basis review of the necessity of medical device use, such as: central line and urine catheters. 

Implementing the MDRO transmission prevention programme is challenging. Factors that may contribute to the failure of such strategic plans are: poor human resource education and training (Dumyati et al, 2017); lack of involvement and communication among clinicians, nurses, infection control officers, microbiology laboratory, and healthcare management in implementing the programme; lack of surveillance infrastructure and implementation, including active surveillance culture to identify patients who are colonised with a targeted MDRO; monitoring of MDRO transmission base on the positive culture results of patients, which may not reflect the real transmission and circulation of MDRO (CDC, 2006). 

Treating a MDRO bacterial infection case is challenging. This problem may be correlated with the situation that several — if not all — classes of antibiotics are resistant. There is limited choice for clinicians to kill bacteria by using common antibiotics. Although antibiotics is not the only answer, the effectivity of nutrition/energy balance, maintaining immune-protective barrier, preserving the flora normal, and other immunological intervention are not as effective as antimicrobial approaches. 

One of the issues of antibiotics therapy for MDRO is whether to use monotherapy or combination of several antibiotics. It is controversial and inflicts debates from experts. The favouring opinion to the combination therapy is based on several considerations, such as: there is an in vitro and animal data that several antibiotics may have synergism effect to kill bacteria; it is a reasonable approach to prevent resistance of bacteria against other antibiotics; and it also increases the probability of appropriate empirical coverage. On the other hand, experts prefer to recommend antibiotic monotherapy based on several reasons: the cost, toxicity, and antagonism between combined antibiotics; studies combined different antibiotic combinations, which is not able to show the efficacy of specific antibiotic combination; and patients included in RCTs are not representative of the patient population seen in general practice (Paul and Leibovici, 2013). Furthermore, there is no comprehensive meta-analysis study that truly favours combination therapy. 

However, it was interesting that the combination antibiotics therapy has been prescribed, at least occasionally, in 114/115 (99.1 per cent) hospitals, in France, Greece, Italy, Slovenia, Spain and selected hospitals in the U.S., which were involved in a cross-sectional, Internet-based questionnaire survey. It seems that combination therapy was the preferred treatment strategy for infections caused by carbapenem resistant Gram-negative bacteria (CRGNB) among hospital representatives, even though high-quality evidence for carbapenem-based combination therapy is lacking (Papst et al., 2018).

The controversies of antibiotic treatment in MDRO bacterial infected patients indicated that the problem of MDRO is obvious. The best approach must be a pre-emptive action to prevent generation and transmission of MDRO in the society and healthcare facilities. However, the three steps of MDRO check points e.g.: prevent generation, containment of transmission, and treatment of the patient is a vicious circle of antibiotics resistant. We need comprehensive action at every step of the way.

Symbiotic relationship between microbial flora in human body and our body plays a key role in maintaining a healthy life. Microbiota of our body protects us against pathogens, supports our immune system and plays a role in the synthesis of certain necessary micronutrients. Human microbiota is composed of bacteria, fungi and viruses, and their number exceeds 10 trillion in total. This number is 100 times more than the number of other cells in our body. Researchers are able to determine the microbial diversity and rates in our body in a surprising accuracy with new-generation sequencing technique. Such developments have been the turning point in the understanding of relationship between microbiota and human health. Majority of today’s studies are about gastrointestinal system and genitourinary system. While being less frequently, microbial communities in organs such as nose, nasopharynx, auditory canal, eyes and skin have been investigated. 

Human intestinal microbiota is the most studied microbial community; it is complex and intensely related to its host (human). Intestinal microbiota is thought to have a role in many pathological conditions in human, and evidence supporting such theory is increasingly improving. 

Human intestinal microbiota goes through a few developmental processes until gaining its final shape. First, foetus intrauterine is invaded by bacteria coming from mother’s intestinal system and vagina. Next, it is subjected to mother’s vaginal microbes during vaginal birth. Furthermore, it is known that breast milk is not sterile and host bacteria such as Streptococcus, Staphylococcus, Propionibacterium, and Bifidobacterium. In early postnatal period, intestinal microbiota is rich of Bifidobacteria, but they become less towards age 2 and child’s intestinal microbiota becomes similar to adult’s intestinal microbiota. Among children born by caesarean section, intestinal microbiota is different from children born by vaginal delivery in the first three to four months; this difference can be explained by reasons such as that children born by caesarean section don’t contact mother’s vaginal microbiota, mother’s use of antibiotics and late breast-feeding. 

Content of intestinal microbiota is affected by factors such as diet, smoking, age, body-mass index, haemoglobin level and antibiotics use. Diet is also thought to be the main source of intercommunity intestinal microbiota difference. Intestinal microbiome is capable of synthesising certain matters, which permeate into general circulation and affect organ systems. Indeed, some of the researchers call internal microbiome an actual endocrinal organ. Bacteria in intestinal microbiota can secrete agents such as serotonin, gamma-amino butyric acid, histamine, acetylcholine, dopamine and noradrenaline into circulation. 

Importance of short-chained lipid acids presented as end product due to fermentation of carbohydrates by bacteria in the anaerobic environment of intestines has been emphasised in recent years. These are acetic acid, propionic acid and butyric acid. Great part of these products is absorbed by intestines and five to 10 per cent of them are discarded with faeces. Intestinal microbiota protects intestines against the pathogenic invasion of bacteria by getting into competition for nutrients or producing antimicrobial proteins or peptides (bacteriocin). 

It has been long known that microbiota of female reproductive system is very diverse. Traditionally, research used to focus on vaginal microbiota; however, evidence has been collected in the last 10-20 years on the fact that female reproductive systems including uterus are not sterile. It has been increasingly clarified that microbiota extends beyond uterine cavity, and according to some of the researchers, there may be bacteria found also in fallopian tubes of healthy women. Studies have recently begun on the relationship between reproductive system microbiota and fertilisation and successful pregnancy. So far, the relationship between clinically apparent infection and inflammation and impaired reproductive function has been clearly identified. Inflammation due to pathogenic invasion causes proinflammatory cytokines and growth factors to be secreted from immune system cells. Slight changes in microbiome may cause ambiguous changes in tissues, but such changes may be clinically important. 

Lactobacillus which has probiotic attributes and prevents reproduction of other bacteria is prevalent in normal vaginal microbiota. Lactobacillus produces high amount of H2O2 and prevents other members of microbiota from becoming prevalent in tissue. 

Reproductive system’s microbiota is not only composed of free bacteria clusters. These bacteria mostly form three-dimensional biofilm structures. These structures function as a protective cover; they involve polysaccharides, nucleic acids and proteins. These biofilm structures prevent immune system from recognising the pathogens and reduce positive effects of antibiotics. 

Biofilms usually form in vagina but can extend towards endometrial cavity and even fallopian tubes. Even though biofilms’ role in pathogens of reproductive system is not fully known, what we need to have in mind is that the relationship between microbiome and reproductive system cannot be identified only with presence or absence of certain bacteria. 

Microbiome can affect gametogenesis. It has been shown that some bacteria impair follicular development and suppress follicular response to gonadotropins. 

Studies on vaginal microbiota of healthy women have been carried out under the management of human microbiome project. Samples were taken from three different areas (introitus, mid-vagina and posterior fornix) of vaginas of 113 healthy, volunteer women, and these samples were analysed with the 16S rRNA sequencing. 

The samples taken from the same individual at different times differed scarcely by type of bacteria, and a very little difference was found between the samples from different individuals. The samples taken from different areas of vagina did not differ by type of bacteria, and Lactobacillus was prevalent. The fact that samples taken from the same individual at different times showed very little difference is the indicator that vaginal flora is stable. Vaginal microbiota is simpler than other parts of body in terms of content in a healthy woman; so, even small shifts may cause disease symptoms. 

It has been believed that ascending colonisation of upper genital system via vagina is associated only with pathological conditions until recently. Uterine cavity has been considered sterile for a long time due to cervical mucus involving high levels of proinflammatory cytokines, immunoglobulins, and antimicrobial peptides and functioning as a protective barrier. However, upward bacteria transport is possible in a healthy reproductive system. For example, when we placed radio-labeled 1-2 ml human serum albumin in the posterior fornix of vagina, these were observed in uterus two minutes later. 

As shown in a few studies, human follicular liquid can be cultured and hosts microbes. Follicular liquid was obtained during transvaginal oocyte retrieval in some of these studies, during laparoscopy in others. It has not been clarified whether bacteria are present in follicles before the retrieval of bacteria cultured from the follicular liquid or whether follicular liquid is contaminated during aspiration. It has been found that follicular liquid contains microbes similar to the ones in vaginal microbiota. These include Lactobacillus, Bifidobacteria, Enterobacteriaceae, Streptococcus and Staphylococcus. This finding reinforces the assumption that follicular liquid is not contaminated during oocyte aspiration and is colonised beforehand. 

As mentioned before, parts (follicular liquid, endometrial cavity) playing a role in reproductive system and considered to have been sterile in the past have been understood not to be sterile and to have idiosyncratic microbiotas in molecular studies. 

In bacterial vaginitis, reduction of Lactobacillus (Döderlein rods) dominance causes increased bacteria diversity (Gardnerella, Mycoplasma, and Prevotella). This increased diversity in bacterial vaginitis increases tendency to gynaecological infections such as Chlamydia, Neisseria gonorrhoea, Trichomonas, Human papilloma virus (HPV) and herpes simplex type-2. It is known that hydrogen peroxide produced by Lactobacillus have viricidal quality, and decreased Lactobacillus in bacterial vaginitis increases tendency to HIV infection. Again, subclinical endometritis was observed in 27 per cent of the patients with vaginal chlamydia infection and 26 per cent of the patients with vaginal gonorrhoea infection. 

Similarly, to vaginal microbiome, it seems possible that imbalances in uterine microbiome can increase tendency to disorders such as infertility and pregnancy complications. Impaired uterine microbiome can cause early-late abortions, preterm labour and postpartum endometritis, affecting the reproductive system. Follicular fluids were studied during the oocyte retrieval for IVF, and differences were found in the composition of follicular fluid by diseases (polycystic ovary, endometriosis) and whether there is implantation. 

In a study conducted on endometrial microbiota, the patients in which more than 90 per cent of endometrium’s bacteria content were composed of Lactobacillus were compared with the patients in which the rate was less than 90 per cent, and implantation, clinical pregnancy, ongoing pregnancy and live birth rates of the patients with Lactobacillus dominance (more than 90 per cent) were found significantly higher than the other group. 

If we were to accept effect of vaginal, uterine and follicular fluid microbiome on infertility, we would need to investigate possible treatment options. For instance, prophylactic antibiotics usage before embryo transfer in IVF cycles may reduce amount of microbial colonisation in upper genital tracts and be effective in pregnancy rates. Yet, contradictory research results have been reported to date. 

As mentioned before, the most distinct characteristic of a healthy vaginal microbiome is the relative multitude of Lactobacillus. Beneficial effects of probiotic supplement on human health have been increasingly receiving recognition by physicians. Given the abundance and effects of microorganisms in reproductive system, it seems reasonable that beneficiary effects of probiotics might be positive on the reproductive system health. Since majority of bacteria in human body is present in intestines, great part of studies has investigated oral probiotics intake on intestinal health to date. 

For the first time, Hilton et al. (1992) reduced the risk of relapse by seven times by giving 250 grams of yoghurt containing Lactobacillus acidophilus a day orally to the patients with recurring vulvovaginitis complaint. Later, it was shown that Lactobacillus rhamnosus inhibited the reproduction of Gardnerella vaginalis and candida albicans through high glycogen metabolism and lactic acid production in vitro. In recent years, several studies have been conducted on benefits of probiotic supplement and beneficial effects of probiotics directly on reproductive health are yet to be proven; however, orally-taken Lactobacillus rhamnosus and Lactobacillus fermentum have been shown to be hygienizing vaginal flora among 82 per cent of women with a vaginal dysbiosis history. Supporting the treatment with Lactobacillus rhamnosus and Lactobacillus reuteri following the antibiotics usage in bacterial vaginitis was reported to be increasing vagina-specific Lactobacillus iners and Lactobacillus crispatus. Based on these observations, certain bacterial strains can be utilised to regulate pre-conception vaginal microbiota, but further studies are required to find the ideal combination, dosage and way of application. 

It was stated that probiotics might contribute to a healthy immune system as well as its contributions to the formation of a healthy microbiota in intestines. This result was based on the presence of quality meta-analyses supporting that probiotics can be used against conditions such as infectious diarrhoea, antibiotics-related diarrhoea and irritable bowel syndrome. 

There are many studies in the literature concluding negative impact of impaired vaginal microbiota on fertility. However, studies on upper genital system’s (endometrium, fallopian tubes, follicular liquid) microbiota which has been accepted to be sterile until recently are limited, and no study was observed in the literature on the treatment of upper genital system’s impaired microbiota with probiotics. On the other hand, based on the assumption that vaginal microbiota can affect upper genital system’s microbiota via adjacency, it can be concluded that probiotics used for impaired vaginal microbiota would indirectly affect upper genital system in a positive way.

Itchy, scaly, painful, unseemly and all-round unpleasant, fungal skin and nail infections are a scourge of our times. They are caused predominantly by dermatophytes, but also by yeasts and moulds. The pathogens spread easily via contaminated surfaces such as clothes, shoes, showers, floors and carpets, as well as by direct contact. Fungal skin and nail infections are characteristically long-lasting, recurring and difficult to cure. Identification of the causative pathogen is essential for selecting the most effective treatment. The classical diagnostic methods of pathogen culturing and microscopy are, however, time-consuming and unreliable. Direct pathogen detection by PCR-based methods provides fast and accurate identification of the causative agent, enabling prompt implementation of targeted therapy. Multiplex testing by DNA microarray provides exceptionally high diagnostic efficiency, allowing as many as 56 dermatomycosis pathogens to be determined in a single reaction. 

Dermatomycosis

Fungal infections of the skin, hair and nails, known as dermatomycoses, are extremely common, affecting around 20- 25 per cent of the population worldwide. Elderly people and immunocompromised patients are especially at risk. Infections caused exclusively by dermatophytes are referred to as dermatophytoses or tinea. Tinea pedis, which occurs on the soles of the feet and between the toes, is the most common dermatophyte infection, followed by tinea unguium, which affects the nails. Rarer forms can occur on the neck, back, trunk, arms, legs, groin, hands, scalp, face or beard hair. Nail infections caused by dermatophytes or yeasts/moulds are called onychomycoses and are typically accompanied by deformation of the nail. 

Dermatophytes encompass fungi of the genera Trichophyton, Epidermophyton, Nannizzia, Paraphyton, Lophophyton, Microsporum and Arthroderma. Dermatophytes are classified according to the major host and infection source into anthropophilic (human source), zoophilic (animal source) or geophilic (soil source) species. Around 70 per cent of human dermatophyte infections are caused by anthropophilic species. Trichophyton rubrum, in particular, is the most frequent cause of fungal skin infections worldwide. Zoophilic dermatophytes are commonly transmitted by pets, which are often asymptomatic. These infections can cause severe inflammatory reactions in humans. Geophilic infections are less frequent in humans and typically occur in outdoor workers. 

Human pathogenic yeasts and moulds include Candida spec., Scopulariopsis brevicaulis, Fusarium spec. and Aspergillus fumigatus. Moulds and yeasts cause opportunistic infections, benefitting from damage to the skin or nail caused by an existing dermatophyte. In immunocompromised individuals, local fungal infections may develop into systemic mycosis. 

Diagnostic Strategy

Dermatomycoses can be difficult to diagnose clinically, as they are heterogeneous and may resemble other dermatoses such as eczema, psoriasis, erysipelas, or autoimmune diseases such as Lichen ruber planus. In addition, diagnosis can be hampered by bacterial infections of the injured skin, ongoing treatments with corticosteroid-containing compounds or secondary contact allergies. 

Nevertheless, accurate identification of the culpable pathogen is a prerequisite for selecting the most suitable medication, since different antifungal drugs have different activity spectra. Selecting effective treatment at the outset is especially important given the oftentimes long duration of therapy. In the case of nail infections, for example, successful treatment can take many months. 

Classical laboratory diagnostics for dermatomycoses encompass detection of the pathogen by culture and/or morphological identification by microscopy. However, this procedure requires time, patience and expertise. Successful pathogen culturing, for example, can take up to six weeks. The procedure is also prone to uncertain or incorrect findings. In mixed infections, slowly growing species may be overgrown or overlooked. Furthermore, antifungal therapy started before the sampling can hinder the culture. 

Direct Pathogen Detection

A faster and more reliable method for identification of the causative agent is PCR-based detection by DNA microarray, which identifies the pathogens directly by means of their genetic material. Nucleic acid-based detection can close the diagnostic gap of microscopy/culture and increase the sensitivity and specificity of mycological diagnostics. Molecular genetic detection also significantly shortens the time to diagnosis from weeks to hours. 

The novel EUROArray Dermatomycosis provides direct detection and differentiation of the most important dermatomycosis pathogens in one test. The assay simultaneously detects 50 dermatophyte species and provides species identification for 23 of these as well as for six yeasts and moulds (Table 1). The direct detection ensures accurate results, even in cases of difficult-to-culture dermatophytes, mixed infections or dermatomycoses that have already been treated. 

The EUROArray procedure is extremely easy to perform (Figure 1) and takes just three hours. Ready-to-use reagents and the small number of pipetting steps ensure a minimal work load. The analysis is performed on DNA isolated from patient sample material, such as skin scales, nail shavings or hair stubs. Defined gene sections of the pathogens are first amplified by multiplex polymerase chain reaction (PCR) and at the same time fluorescently labelled. The PCR products are then hybridised to complementary probes in the microarray system and detected using a special scanner (Figure 2). The evaluation and interpretation of results as well as the archiving of data are fully automated and thus objective. No in-depth knowledge of molecular biology is required to perform the test. The swift and unambiguous test result enables prompt therapeutic intervention and may also provide a pointer to the source of infection, in the case of zoophilic infections often a pet. 

Clinical Evaluation

An evaluation study was performed using 409 clinical samples. The EUROArray Dermatomycosis yielded a good agreement with the pre-characterisation. In many cases, additional pathogens that were not included in the pre-characterisation were detected. The additional findings were confirmed by further independent tests or sequencing. Thus, the study confirmed the reliability and the broad detection capabilities of the EUROArray. 

Perspectives 

The incidence of fungal skin and nail infections is increasing worldwide and is expected to continue to rise. Growth in vulnerable populations, such as the elderly and those with chronic diseases like diabetes mellitus, may fuel the upsurge further. Furthermore, the geographic distribution of dermatophytes species and the epidemiology of infections is changing due to factors such as migration, travel, drug therapy, lifestyle and socioeconomic conditions. This necessitates a broad diagnostic analysis in cases of infection. Molecular genetic methods such as the EUROArray Dermatomycosis are ideally suited for this application, providing rapid, comprehensive and reliable results. This enables timely, pathogen-specific treatment, increasing the chances of curing the fungal disease.

The third stand-alone edition of the MEDLAB Exhibition and Congress is all set to connect and empower the international medical laboratory industry and will focus on developing the value of laboratory medicine in shaping the future of healthcare. The event will take place between February 4 to 7, 2019, at the Dubai World Trade Centre. 

A must-attend annual event for the medical laboratory community, MEDLAB will welcome over 19,610 professionals and more than 678 companies from around 46 countries. The event brings together thousands of professionals, right from manufacturers to key opinion leaders who congregate to shape the future of the industry. 

The exhibition offers access to high-performance devices at cost-effective prices that enable in better decision-making. It prides itself on bringing innovation from all continents to support the advancement of patient care. With this agenda, the event will showcase an array of the latest laboratory medicine solutions such as cutting-edge equipment, diagnostic tests, instruments, reagents, and disposables, among other items. 

Pioneering Growth

One of the only exhibitions that provides access to a variety of audiences, right from distributors to medical laboratory professionals, MEDLAB has established itself as a one-stop-shop for generating viable leads and doing business within the MENA region. 

The 2018 edition of the show demonstrated the significance to the diagnostics industry worldwide, with a seven per cent increase in overall attendees from 2017. Understanding this niche market’s goals and challenges, the event benefited from a uniquely targeted campaign to enforce the theme of unifying the laboratory and clinicians, in order to improve patient care. The event welcomed 678 exhibitors and hosted 12 country pavilions, 46 exhibiting countries, 124 product categories, 17 (12 Laboratory and five Clinical) conferences, and 6,726 delegates. 

While the first stand-alone event in 2017 hosted over 575 exhibitors from 38 countries, including representation from 12 country pavilions. Welcoming 20,420 attendees from 129 countries, the event allowed medical lab professionals the opportunity to meet, learn and do business with their relevant target audience. 

Having introduced bespoke tracks to bridge the gap between lab professionals and clinicians, it was evident that the event fulfilled a critical need in the market, as four out of 11 tracks were sold out ahead of the first stand-alone show. 

Bridging the Gap 

Furthermore, MEDLAB hosts the region’s only CME-accredited multi-disciplinary Congress. It is committed to supporting the education of all faculty and medical lab professionals and offers conference tracks that put emphasis on the core lab and specialist lab units. 

MEDLAB Congress 2019 will host 11 multi-disciplinary conferences that will provide education as well as management solutions to help advance skills and improve laboratory functions. These will provide up to 31.5 CME credits and fresh insights from industry pioneers to build key skills as well as increase the quality of care. 

Focusing on the implementation of quick and safe selection, performance and evaluation of results of new and established laboratory tests, the Congress has established itself as a learning and sharing platform for all medical laboratory workers to advance professionally and develop adaptive solutions for daily practice in the lab. 

This year, the conferences will cover a wide range of topics from reviewing of basic laboratory procedures to identifying advanced mechanisms that will cater to the knowledge demand of every attendee. It will be led by a strong scientific committee, ensuring that current issues and innovation are at the centre of all programmes. 

This edition, MEDLAB will explore the “Lab of the Future” as the UAE prepares to adopt the use of Artificial Intelligence (AI) in the medical laboratory. Reportedly, AI is predicted to add US$182 billion to UAE’s economy by 2035 with the healthcare industry taking a US$22 billion slice of the gains.

The conference will explore the potential for AI to transform the medical laboratory industry in the UAE through improved efficiencies and how the diagnosis can be revolutionised through futuristic technologies such as data robots and “bloodless blood tests”. The conference is a must-attend to understand how innovation and emerging digital health technologies will revolutionise the medical laboratory. 

The event will host other conferences such as Laboratory Management, which will open with a plenary session to talk about the laboratory beyond 2020. It will be followed by two sessions – the leadership session that will focus on managerial issues and the lab operations  session, which will address technical skills and methods designed for laboratory technicians. 

Also, the newly introduced Immunology conference will provide delegates with a unique opportunity to engage with immunology field experts. This new track will discuss the latest trends and issues concerning the widespread utilisation of immunological techniques for healthcare advancement. Also new, the Cytogenetics & IVF conference is aimed at improving services in the growing number of fertility centres and genetic labs in the region. It will feature developments in prenatal diagnosis to chromosome biology in epigenetics and evolution. 

While the Haematology & Blood Transfusion conference will bring together leaders within the field of haematology and blood transfusion science to provide a broader overview of current key developments and best practices, supported by evidence-based education.

Leading the Way 

Last year also saw the introduction of the “Heads of Lab Masterclass”, a roundtable discussion facilitating senior laboratory decision-makers to meet and discuss both public and private laboratory concerns and challenges, providing leading manufacturers direct insight into the lab to offer viable solutions. The session received a great response and is back again this year. The topic is “Laboratory Medicine: Challenges and Opportunities” and will feature exceptional leaders in the laboratory.

The masterclass will discuss current and anticipated healthcare developments that may affect the future of laboratory medicine and how to deal with these changes, asses global and regional competition and provide an insight into technologies and solutions for the operational organisation of clinical laboratory services such as consolidation, integration, and networks.

 The next edition of MEDLAB Asia Pacific and Asia Health is all set to take place from March 26 to 28. The event, which will be held at the Suntec Singapore Convention & Exhibition Centre, is one of Southeast Asia’s premier international laboratory and healthcare exhibitions. The 2019 edition will host 14 inter-disciplinary scientific conferences, eight international pavilions, over 200 product categories, and more than 250 exhibitors. 

The 2018 edition of the event hosted over 57 per cent healthcare and laboratory-specific dealers and distributors, alongside senior decision-making end users, enabling them to connect with new suppliers, business partners and customers looking to do business in Southeast Asia. It received over 250 exhibitors from 24 countries worldwide, including representation from 11 country pavilions. 

Welcoming 4,358 attendees from 62 countries (eight per cent increase from the 2017 edition), the concentrated and targeted event allowed all medical lab and healthcare professionals the opportunity to meet, learn and do business with their relevant audience. The conferences at the event experienced seven per cent year-on-year growth with 2,834 delegates attending the 15 multi-disciplinary CME-accredited conferences. Having introduced dedicated tracks to bridge the gap between lab professionals and clinicians, the event’s clinical tracks were attended by lab professionals, doctors, general practitioners, oncologists, obstetricians, gynaecologists and other specialists throughout the show days. 

For instance, the newly introduced Healthcare Procurement Conference, supported by the Procurement and Supply Institute of Asia - PASIA, focused on the recent Asian trends in buying for hospitals and other healthcare facilities. Attended by over 150 delegates, the conference hosted over 20 of the leading distributors from across the APAC to attend, speak and provide best practice on procurement regulations in the medical device and equipment industry. 

Enhancing Skills 

Now in its sixth year, MEDLAB Asia Pacific will provide a platform for leading companies to showcase current technologies and smart innovations in the field of laboratory and diagnostics. Furthermore, it will feature a multi-track, fully accredited, conference programme providing unparalleled education and management solutions to help labs excel. With a number of expert speakers and laboratory professionals in attendance, the event provides an opportunity to explore the current technology and science driving today’s diagnostics and patient care. 

MEDLAB Asia Pacific is renowned for offering integral opportunities for the industry to showcase the latest laboratory management and diagnostics technologies to a worldwide audience, to advance their skills and improve lab services in today’s highly competitive market. 

The MEDLAB Asia Pacific Congress is the among one of the few dedicated medical laboratory scientific events in Asia providing multidisciplinary education for medical lab professionals, enhancing skills, productivity, and quality for sustainable care. 

The Congress brings together clinical laboratory professionals from different types of laboratories and is attended by laboratory managers and leaders, clinical technicians, consultants, scientists who can connect and share their experiences and collective knowledge on all aspects of laboratory medicine and clinical research. In 2019, the event will also introduce roundtable discussions to advance technical, mechanical and diagnostic skills of laboratory technicians. 

New Features 

The upcoming edition has a whole host of new features such as the Artificial Intelligence Future in Health Zone, Patient Safety Zone, Hosted Buyer Programme, Innovation Zone, Business Matchmaking, and Oncology Zone. 

The Hosted Buyer Programme is designed to connect international suppliers at MEDLAB Asia Pacific with prospective buyers across the region. Hosting high-level buyers with a considerable budget for new purchases, the programme will ensure not only a monetary return on investment (ROI) for suppliers but also an invaluable ROI for the time spent at the event. 

While the Business Matchmaking portal will see suppliers being partnered with buyers, both trade and clinicians, based on their requirements. Product interest and purchasing power will be considered to further ensure a line-up of worthwhile meetings, that is both cost effective and time efficient for attendees.

In recent years, the NHS in the United Kingdom has seen a dramatic rise in the number of inpatients and subsequent bed occupancy levels. This has resulted in an unprecedented operational challenge to hospitals, especially when combined with the current need for streamlining and generating cost/efficiency savings across all aspects of healthcare; resulting in increased staffing pressures and negatively impacting upon patient experience. In response to these pressures, there is increasing evidence that ambulatory emergency care (AEC) services can play an instrumental role in reducing the inpatient burden; improving patient management and enhancing the overall patient experience.

The ethos of AEC is the identification and management of patients with acute medical conditions that should not require overnight admission. Estimates demonstrate that ambulatory treatable conditions managed through conventional admission streams account for up to £1.42 billion of the national NHS budget per year. A predicted 50 per cent reduction in patient length of stay (LoS) could save the NHS an additional £683.8 million.
At the James Paget University Hospital, we previously utilised a small assessment u bay within the Acute Medical Unit (AMU) to provide limited AEC services, in conjunction with a nurse-led DVT clinic. The existing set-up was not capable of meeting service demand or providing operational benefits. This presented an opportunity to re-design and implement fundamental work process changes to existing patient management streams, resulting in the establishment of an Ambulatory Care Unit (AmbU) with the specific intention of improving patient experience, outcomes and flow. 

When beginning the process of redesigning ambulatory care pathways, it was evident at an early stage that utilising POCT diagnostics could hold the key to significantly reducing the overall patient LoS. It is now widely accepted that the reduced specimen turn-around-times provided by POCT can potentially help to reduce the time in which patient clinical review is undertaken; in turn, offering improved patient outcomes, increased patient satisfaction, and importantly, a possible reduction in costs.

However, when POCT is provided as a stand-alone solution, it is often unable to generate desired improvements unless accompanied by system process changes, as laboratory test turn-around times may not be the rate limiting step in a patient management process. By changing the processes and overall system in which POCT is utilised, new approaches to patient management can be engineered; particularly those focusing on patient-centred care, as integrated, multi-analyte POCT devices are well suited to increasing patient involvement in the decision-making process and reducing the patient’s perceived sense of waiting.

Additionally, the majority of current health systems are based upon pathology testing within a centralised laboratory and are not configured to utilise POCT effectively; for this reason, process change and innovation is required to decentralise traditional testing methodologies – aligning service delivery and work-flow to ensure real-time availability of results to affect patient management.

Consequently, James Paget University Hospital formed a working agreement with Abbott Point-of-Care to provide the i-STAT platform and Emerald CEL-DYN full blood count analyser for an initial 3-month pilot; coupled with service redesign expertise provided by Operasea Limited – experts in Six Sigma improvement methodology.

Operasea assisted the Trust-based project team in exercises including extensive project planning, stakeholder salience analysis and ‘process activity mapping’ (PAM) to understand how the current system actually worked; in turn identifying an evidence-based ideal future-state, capable of fulfilling demand and leverage points on which to focus to catalyse change. Additionally, we utilised ‘failure mode and effect analysis’ (FMEA); obtaining multiple stakeholder inputs to identify, quantify, prioritise and resolve potential issues in terms of severity, occurrence and detection – adding additional items as and when identified to provide on-going project governance.

By undertaking the redesign of AEC services in this manner, we were able to define ‘value’ within the system (reducing LoS) and focus upon what really mattered to achieve this. This meant that process optimisation required close interdepartmental collaboration with the Emergency Department, a conscious breakdown of the traditional emergency floor NHS silo and integration of our AEC services into the existing emergency care set-up (A&E and Acute Medical Unit); and so complying with national best practice guidance. Furthermore, this will provide a foundation to meet improvement objectives defined by the Institute of Medicine, stating that all healthcare systems should provide patient-centred, timely and efficient care in a safe, effective and equitable manner.

Redesigned AEC pathways within the Trust supported the attainment of these objectives through the use of national guidance to enable early identification of suitable patients, such as those with chest pain, cellulitis or suspected pulmonary emboli; expedited investigations; and appropriate treatment/discharge planning. The pathways were controlled and defined by condition-specific patient management algorithms and the involvement of senior decision makers (Consultant, Registrar or Nurse Practitioner) at the first point of patient clinical contact. Work processes have been specifically designed to integrate the role of Nurse Practitioners as the key staff group within the unit to provide strong leadership and accurate, early patient assessments.

During the pilot, the newly developed AmbU model (operational on weekdays only between 08:00 and 18:30) demonstrated dramatic improvements in patient flow through the AMU, despite an overall 7.61% year-on-year increase in Trust medical admission activity. The process change reduced the length of stay (LoS) from 1.04 to 0.8 bed days within the AMU, despite only 26.06% of patients being managed through AmbU. Mean LoS for this patient cohort has reduced by 40.80% from an established baseline of 250 minutes. As expected, we have seen an 8.22% increase in the number of same-day discharges (zero LoS admissions) in AMU; with an associated decrease of 8.93% in 1, 2 and 3 day LoS patient admissions – equating to 59 saved bed days during the pilot period.

Following the success of the pilot study, the project team has delivered further evidence-based expansion and development of services through a permanent, dedicated AmbU area designed to structurally enhance the processes and pathways.  A ‘business as usual’ state was achieved through a business case demonstrating clinical, operational and financial benefits – the latter equating to £1.098 million per annum. This was enabled through enhanced staffing levels, extended 7-day working hours, and an enhanced POCT test cluster including the Abbott i-Stat (electrolytes and blood gasses), Sysmex XN-450 (full blood count), and Radiometer AQT 90 Flex (D-dimer). 

The overall changes to process and adoption of the ambulatory model, along with integration of POCT and evidence-based Six Sigma service redesign, has allowed the James Paget University Hospital to provide emergency medical patients with a standardised and sustainable model of efficient, high quality care delivery. By increasing both staff and patient engagement, we have delivered improved operational performance and clinical outcomes. In turn, this has maximised operational benefits and successfully reduced the LoS for this patient cohort, whilst supporting safe discharge and appropriate follow-up; underpinned by rapid assessment through senior decision makers and timely diagnostic results.

The primary goal of transfusion medicine is to ensure a safe transfusion of blood and blood products to patients. To achieve quality service in transfusion medicine, laboratory professionals ought to follow international guidelines set forth by AABB (formerly known as the American Association of Blood Banks), FDA (US Food and Drug Administration), CAP (College of American Pathologists), GMP (Good Manufacturing Practices) and JCI (Joint Commission International). 

Blood transfusion services are commonly divided into two areas: donors at Blood Banks and recipients at hospitals. 

The quality journey starts with the donation process, followed by the immediate storage of blood units, components preparation within six hours after collection and accurate labeling for ABO and Rh grouping. Facility design should include separate areas for donor selection, blood collection, blood processing, storage, and laboratory facilities.

Essentials of quality at blood banks shall cover quality control procedure for reagents, blood units, blood products, equipment management, calibration of temperature storage devices, continuous temperature monitoring system and alarms. External quality assurance programme is important to monitor accuracy of laboratory testing. Avoiding mis-identification risk before and during transfusion is considered the most important safe practice to minimise transfusion reactions.

Compliance with international standards is not adequate to show excellence in Transfusion Medicine Services. Most blood banks need to think outside the box and start implementing quality improvement models such as Six Sigma and Lean tools.

Implementing Six Sigma in Transfusion Medicine will help laboratory professionals reduce variation in processes and start counting their errors, defects and deviations. Calculating the Sigma metric will help laboratory professionals monitor their improvement in accuracy and increase process capability in order to reduce variation. Converting all errors in Transfusion Medicine Services yearly into defects per million opportunities, (DPMO) will help blood bank professionals monitor the level of Sigma Metric that the blood bank has. Implementing Six Sigma Model of DMIAC (Define, Measure, Improve, Analyse and Control) will improve the services in transfusion services.

Implementing Lean is important to accelerate the process flow between different processes and reduce the wasted resources in process time, inventory, and defects. Implementing Lean helps blood banks in streamlining their processes, eliminating the “no value-added activities” and accelerating the workflow. Lean provides a platform for sustainable and continuous process improvement. Poor layouts of blood bank processes and working stations can cause increased congestion, stress for staff, increased turn-around time, error potential as well as decreased capacity and efficiency. Reduction in RBC and plasma product wastage had been reported by hospitals that implemented the Lean Six Sigma improvement model.

The Kanban Model is one tool of Lean Management system that triggers a notification system. Once the notification system is activated, it will trigger a response to start another process. A good example is an inventory notification card for low supply of certain blood products or low supply of certain reagents. 

The Kanban model can be used to turn the working environment into a visual instructive by using visual cues. Visual cues are used to reduce the amount of wasted time that is spent on searching, looking, waiting and asking for things such as reagents, patient records, blood products or consumables. Using coloured labels, coloured test tube racks, TV monitors, signage and white boards are good examples of Kanban model.

5S Model, which is another model of Lean Management System, can help transfusion service facilities to organise the workspace by the tool sort, set in order, shine, standardise and sustain. Mistake-Proofing (Poka-Yoke) tool is a third type of Lean Management system. It can be utilised to reduce human errors inside blood banks. The use of Bar Coding to match a patient with the blood unit is a good example of Poka-Yoke. In addition, Mistake-Proofing is best utilised by blocking the laboratory analyser from testing patient samples after any failure in calibration or quality control runs.

To summarise, implementing quality improvement models in Transfusion Services such as Lean and six Sigma models can increase Blood Bank efficiency and capacity, enhance process effectiveness, reduce overall costs, better utilise blood products, eliminate error potential and improve patient outcomes. 

References available on request.

From pollen to peanuts and pets, allergies are on the increase worldwide. Around 40 per cent of the population in industrialised countries now suffers from at least one allergic ailment. Children, in particular, are frequently affected by atopic eczema, hay fever and allergic asthma. Moreover, many individuals are polysensitised, making diagnosis challenging. In vitro tests for specific IgE antibodies play an essential role in allergy diagnostics, identifying the causative substance with a simple blood test. Cutting-edge allergy tests based on individual allergen components (proteins, also called defined partial allergens) provide the most in-depth analysis and allow primary sensitisations to be differentiated from cross reactions. This accurate diagnosis is crucial for selecting the most suitable specific immunotherapy and for assessing the risk of severe allergic reactions. In the case of food allergies, precise identification of the allergy trigger can prevent patients from needlessly restricting their diet.

Triggers of Allergic Sensitisation
In a type I hypersensitivity, specific IgE antibodies against a normally innocuous substance such as a pollen, food or insect venom are formed. Once an individual is sensitised, symptoms can manifest shortly after the next contact with the allergen. If a systemic allergic reaction occurs, serious or even life-threatening complications such as anaphylactic shock can develop. Atopy describes a hereditary disposition to developing allergic reactions such as allergic asthma, rhinitis or dermatitis, including atopic eczema.

Inhalation allergies can be triggered by seasonal allergens, such as pollens from trees, grasses and weeds, or by all-year-round indoor allergens, such as house dust mites, domestic animals and mould spores. Symptoms of inhalation allergy include rhinitis, conjunctivitis and allergic asthma. Allergic rhinitis is becoming more frequent worldwide, with a prevalence of 10 to 40 per cent in different regions.

Food allergies manifest with symptoms such as burning or itching in the oral cavity, nausea, gastrointestinal spasms, diarrhoea and skin rashes. Severe attacks can also lead to asthma, breathlessness, increased heart rate, panic attacks, confusion and in rare cases anaphylaxis. The most common foods causing allergic reactions are peanuts, soy, wheat, shellfish, fish, milk, eggs and tree nuts. Allergy to sesame is an emerging concern. Primary food sensitisations have a prevalence of 5 to 10 per cent in babies and infants and 1 to 5 per cent in adults.

Insect venom reactions can occur minutes to hours after the insect sting. Systemic reactions include urticaria, swelling, itching and redness at sites other than the puncture, swelling of the throat or tongue, difficulty breathing, nausea, gastrointestinal cramps, neurological deficiencies with confusion, dizziness and gait disorder, as well as raised pulse and fall in blood pressure. Insect venom reactions can also lead to anaphylactic shock and thus be life-threatening. The prevalence of insect venom allergy is estimated to be 1 to 7 per cent, for example, in central Europe.

In vitro Diagnostics
In vitro tests complement conventional diagnostic methods such as the skin-prick test and are essential for optimal patient management and therapy decision-making. 

Measurement of total IgE serves as a general screening test to indicate if an allergic reaction may occur. This test aids the differentiation of allergic and intrinsic asthma, allergic and vasomotor rhinitis, or atopic and seborrheic dermatitis. Total IgE can be determined quickly and reliably, in patient serum using ELISA.

Determination of specific IgE against particular allergens helps to identify the triggers of an allergic reaction. Specific IgE can be measured by in vitro assays based on whole extracts of the allergen source or individual proteins thereof. Extract-based assays provide a screening for IgE antibodies against the respective substance. However, cross reactions may occur due to structural similarities between the proteins present in different sources. For example, cross reactions can occur between different pollens, between pollens and foods, or between different insect venoms. 

Assays based on purified partial allergens identify the precise allergy-causing proteins, enabling discrimination of primary sensitisations from cross reactions. Moreover, they allow differentiation of reactions to high-and low-risk components, aiding assessment of the patient’s risk of severe allergic reactions. These allergen component-resolved diagnostics are essential for decision-making on specific immunotherapy and the necessity of equipping patients with an emergency set.

Multiparameter IgE Detection by Immunoblot
Immunoblots are highly suited to detection of specific IgE, as they enable many different allergens to be investigated simultaneously. For example, the EUROLINE system provides immunoblots with up to 54 allergens on one test strip. The use of individual membrane chips means that allergens with different properties can be combined on one test strip and profiles complied according to the exact application.

The EUROLINE tests are simple to perform, with a choice of incubation protocols for different requirements. For example, the time-optimised protocol yield results in less than three hours, while the volume-optimised protocol requires only small serum volumes, e.g. 100 µl, making it ideal for use in paediatrics. An indicator band on each strip verifies correct performance of the test. Results are evaluated and archived automatically using the EUROLineScan software and issued in standardised EAST classes.

Cross-reactive Carbohydrate Determinants (CCDs)
Many allergens are glycoproteins, containing oligosaccharide side chains attached to the protein framework. Some patients develop specific IgE antibodies against these carbohydrate structures, known as cross reactive carbohydrate determinants (CCDs). These reactions generally have no clinical relevance but can complicate the interpretation of results in in vitro diagnostics. For this reason, it is helpful to investigate IgE antibodies against CCDs as part of allergy diagnostics to provide additional information on the patient’s sensitisation profile. All EUROLINE profiles are equipped with a band of CCD to aid interpretation of positive results. If anti-CCD IgE antibodies are present in patient serum, they can be removed using a special anti-CCD absorbent and the analysis repeated. Anti-CCD antibody reactions are, however, only possible in diagnostics based on particular allergen extracts and native components; they do not occur with recombinantly produced components, as these proteins do not undergo posttranslational glycosylation.

Comprehensive and Targeted Profiles
Whole allergen extracts are available for an enormous range of allergen sources and enable fast and comprehensive screening in allergy diagnostics. The EUROLINE range includes many indication-oriented profiles (e.g. food, inhalation, atopy, insect venoms or paediatrics ), as well as region-specific profiles, which consider local allergen exposure. For example, various profiles focus on food or inhalation allergens in the Middle East region, the Gulf states, the Mahgreb, Iran, Lebanon, the Mediterranean region, Turkey, India, China or South East Asia. 
The EUROLINE range also includes assays for defined partial allergen diagnostics (DPA-Dx). These combine species-specific marker molecules with cross-reactive panallergens for highly differentiated diagnostics. Comprehensive profiles are available for peanut, insect venoms, paediatric food allergies, pollens, and Mediterranean-specific inhalation allergens. 
In particular applications, extracts and defined partial allergens are combined in one profile. This enables parallel investigation of sensitisations to different whole allergens and precise characterisation of important allergic reactions in one test.

Example: Paediatric Food Allergies  
The component-resolved profile EUROLINE DPA-Dx Paediatrics 1 provides detailed diagnostics of the most common food allergies in childhood, by combining key partial allergens from milk, egg and peanut in one multiplex test (Figure 1).

Reactions to the heat-stable protein 
Bos d 8 (casein) from cow’s milk indicate a persistent sensitisation encompassing raw and cooked milk, milk products as well as casein-containing products such as chocolates and potato chips. Patients with reactions to the heat-sensitive milk proteins Bos d, Bos d 4, Bos d 5 and Bos d 6, on the other hand, may tolerate cooked milk, as well as yogurt, cheese and bakery products.

Similarly, high levels of IgE antibodies against the heat-stable protein Gal d 1 from egg are associated with a persistent sensitisation, and patients should avoid both raw and cooked eggs. Patients with reactions against the heat-sensitive egg proteins Gal d 2, Gal d 3 and Gal d 4 may tolerate cooked eggs. 

In peanut allergy, reactions against the seed storage proteins Ara h 1, Ara h 2, and Ara h 3 and the lipid transfer protein Ara h 9 carry a high risk of a severe reaction. The severity of the reaction is, moreover greater when multiple high-risk components are involved. Patients at high risk must strictly avoid peanuts, even in trace amounts, and always carry an emergency kit. A reaction with the birch pollen component Bet v 1, which is homologous to the peanut component Ara h 8, indicates that the peanut-allergy symptoms are due to a pollen-associated cross reaction. In this case, the risk of anaphylaxis is extremely low, and a strict peanut-free diet is not absolutely necessary. If specific immunotherapy against the pollen allergy is undertaken, this would most likely additionally alleviate the peanut symptoms.

Example: Food Allergies in the Middle East Region
The region-specific profile EUROLINE Food Lebanon 3 focuses on foods which commonly cause allergies in this region (Figure 2). The profile contains extracts from 34 different foods, encompassing fish, shellfish, egg, cow’s milk, flour, yeast, fruits, vegetables, nuts and meats. In addition, five components from cow’s milk are also included, namely Bos d, Bos d 4, Bos d 5, Bos d 6 and Bos d 8. The profile thus enables a comprehensive analysis of sensitisations to an extremely diverse range of foods, and, at the same time, an in-depth characterisation of allergic reactions to cow’s milk. 

Perspectives
The burden of allergic diseases worldwide is anticipated to increase significantly in the future, from one billion people today to four billion by the 2050s. In vitro tests for specific IgE are non-invasive and risk-free for the patient and provide important support in the diagnosis of allergies. These simple blood tests are especially useful in countries with limited healthcare resources for more labour-intensive and skilled tests such as the double-blind placebo-controlled food challenge. The advent of component-resolved diagnostics has ushered in a new era of allergy diagnostics, enabling targeted risk assessment, therapy decision-making and patient monitoring. The identification of proteins targeted by specific IgE is, moreover, an ongoing process. Thus, these state-of-the-art allergy diagnostics will continue to play an increasingly prominent role in the future, as more allergies become characterised at the molecular level.

EUROLINE DPA-Dx Pediatrics profile

EUROLINE Food Lebanon 3 profile

Cardiovascular disease (CVD) is the leading cause of death globally with no geographic, gender or socio-economic boundaries. More people die annually from CVDs than from any other cause. An estimated 17.7 million people died from CVDs in 2015, representing 31 per cent of all global deaths. Of these deaths, an estimated 7.4 million were due to coronary heart disease and 6.7 million were due to stroke.

Coronary heart disease is caused by atherosclerotic plaque build-up in the arteries causing ischemia and heart attacks. Ischemic heart disease accounts for almost half of the increase in the number of cardiovascular deaths. Population aging contributed to an estimated 55 per cent increase in cardiovascular disease deaths globally, and population growth contributed to a 25 per cent increase. Acute coronary syndrome (ACS) refers to a spectrum of clinical presentations ranging from unstable angina to non–ST-segment elevation myocardial infarction (NSTEMI) to ST-segment elevation myocardial infarction (STEMI). It is almost always associated with rupture of an atherosclerotic plaque and partial or complete thrombosis of the infarct-related artery. ACS requires prompt diagnosis and timely initialisation of revascularisation to reduce complications and recurrence. 

While the earliest criteria included ECGs and history, biomarkers were also used quite early on. An ideal biomarker should have sufficient concentration in the myocardium with minimal or no presence in the serum and non-myocardial tissue and be rapidly released into the blood during ischemia. The assay should have analytical precision, with sufficient sensitivity and specificity to distinguish diseased and non-diseased states. In 2001, National Institute of Health (NIH) working group standardised the definition of a biomarker as “a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention.”

History of Biomarkers
The use of biomarkers in the diagnosis of acute myocardial infarction (AMI) began in 1954 when Karmen et al., first reported the elevation of aspartate aminotransferase (AST) in the serum of patients with AMI in 1954. AST (Aspartate aminotransferase) also called as serum glutamic oxalaacetic transaminase (SGOT) increases in blood three to four hours after AMI and reaches maximum value in 15-28 hours and returns to normal around five days. AST however is non-specific as it can be raised in a variety of conditions.

Subsequently, LDH was first published as a marker of MI by Wróblewski and LaDue who observed an increase in LDH activity in serum of patients with AMI, which was subsequently confirmed by Ulmer et al. Since LDH is present in nearly all human tissues, LDH isoenzymes, either as an alpha-hydroxybutyrate dehydrogenase (HBD) or lactate dehydrogenase isoenzyme 1 (LDH-1), were described as possible biomarkers of AMI. A direct enzymatic assay for α-hydroxybutyrate dehydrogenase activity was developed to increase cardiac specificity. LDH and its isoenzyme LDH-1 increases in blood five to 10 hours after AMI, reaches maximum value in blood in 60 –144 hours and returns to normal values in 12 days.

The 1960s marked the beginning of creatine kinase (CK) as a better biomarker as it was demonstrated to be more cardiac-specific and clinically useful due to its kinetics after AMI. Subsequently an effective enzymatic assay for the quantification of creatine kinase (CK) activity was developed by Rosalki and was established as a marker for AMI diagnosis for the next 20 years. While the sensitivity of CK is high (98 per cent within 72 hours) specificity is low. Total CK activity is related to the extent of the myocardial infarction and therefore, prognosis. CK appears in blood three to nine hours after an AMI reaches the maximum value in blood in 10–20 hours and returns to normal in approximately 72 hours.

Myoglobin is a globular, oxygen-carrying heme protein found in skeletal and cardiac with a low molecular weight (17.8 kDa), found in the cytoplasm, which accounts for its early release profile. Myoglobin appears in serum in one to three hours after onset of infarction, peaks at four to seven hours, and returns to normal within 24-36 hours. However, it is cleared rapidly from serum and is not cardio-specific with levels rising in muscular dystrophy, trauma and inflammation or even after strenuous exercise or after intra-muscular injections. The initial RIA assay was followed rapidly by latex-enhanced immunoassays and automated nonisotopic immunoassay.

In the 1970s, radioimmunoassays were developed and revolutionised laboratory medicine including AMI diagnosis. Roe et al in 1972 developed a zone electrophoresis for identification and quantification of the CKMB, an isoenzyme of CK with highest concentration in heart muscle (25-30 per cent vs 1-2 per cent in skeletal muscle). CKMB was shown to help with specific diagnosis in the first few hours after ischemia. 

In 1976, Roberts et al developed a radioimmunoassay for CK isoenzymes and in 1979, the World Health Organization (WHO) recognised the role of CKMB and other enzymes in AMI, and a rise and fall in cardiac enzymes was included in the diagnostic criteria. CK-MB first appears four to six hours after symptom onset, peaks at 24 hours, and returns to normal in 48-72 hours. Its value in the early and late (>72 h) diagnosis of acute MI is limited. 

Subsequently immunoassays were substantially improved by using monoclonal antibodies, and rapid immunoassays for measuring the so-called CKMB “mass” replaced CKMB activity measurements as the criterion standard for AMI diagnosis.

Present Scenario
Towards the end of the 1980s, cardiac troponins emerged with more sensitivity and specificity and AMI diagnosis moved on from a clinical-electrocardiographic-biochemical centred approach to a biomarker-centred definition of AMI where cardiac troponins played a central role. Troponins are cardiac proteins important for actin and myosin interaction, modulating sarcomeric contractile function in response to cytosolic calcium and protein phosphorylation. The troponin complex is composed of three regulatory proteins: cTnC, cTnI, and cTnT though only cardiac tropnions T and I have unique isoforms and are currently the gold standard for detection of myocardial injury and also play a key role in risk stratification and management strategy.

Lately, high sensitive troponins have emerged, which permits detection of very low levels of cTnT. Using the hs-cTn assay improves the overall diagnostic accuracy in patients with suspected AMI, while a negative result also has a high negative predictive value. These assays are extremely sensitive, allowing for earlier and faster recognition of MI patients, quicker diagnosis and ability to treat patients appropriately. The new assays are precise, having small CV levels even at the 99 per cent in reference populations CRP – C-reactive protein is an acute-phase inflammatory reactant marker that has been extensively studied as indicative of a higher cardiovascular risk among patients with established atherosclerosis. CRP is commonly elevated in ACS. (hsCRP) detects lower levels of CRP and can stratify patients into low, intermediate and high-risk category of future cardiovascular risk. Statins have been shown to be capable of reducing CRP.

Emerging Biomarkers
Myeloperoxidase (MPO) is a member of the heme peroxidase family- a leukocyte enzyme that generates reactant oxidant species, which are released in inflammatory conditions. Myocardial injury involves leukocyte accumulation and activation in the atherosclerotic plaque. These leukocytes undergo degranulation in the coronary circulation in patients with ACS, which leads to the release of MPO and thus accounts for the elevated levels of MPO seen in ACS. MPO is capable of inducing low density lipid (LDL) and ApoA-I oxidation, is involved in plaque formation, plaque instability (mismatch between pro and anti-oxidants) and vasoconstriction from nitrous oxide depletion. Elevated MPO was first linked with coronary artery disease in 2001 and is also an independent predictor of major adverse cardiac events (MACE). Esporcatte et al., who reported a diagnostic sensitivity of 92 per cent and specificity of 40 per cent for identifying AMI patients with acute chest pain.
Ischemia modified albumin (IMA) is a novel marker of ischemia that is produced when circulating serum albumin contacts ischemic heart tissues. IMA can be measured by the albumin cobalt binding assay that is based on IMA’s inability to bind to cobalt. IMA levels rise within minutes of transient ischemia, peak within six hours, and can remain elevated for as long as 12 hours. While sensitivity varies from 71-98 per cent and specificity between 45-65 per cent use of multimarker panels can improve sensitivity to 97 per cent for myocardial ischemia.

Copeptin a glycosylated 39-amino-acid peptide, is a C-terminal part of the precursor pre-provasopressin (pre-proAVP) and is released in the same amount as AVP. Copeptin is stable and has a half-life of days in plasma, as compared to five to 20 min for AVP. Keller et al showed that addition of copeptin to troponin(cTnT) improved sensitivity and negative predictive value to 92.4 per cent whereas the CHOPIN trial improved the negative predictive value to 99 per cent.

Matrixmetalloproteinases (MMPs) are a family of endopeptidases expressed by macrophages, vascular smooth muscle cells, and endothelial cells in response to inflammatory stimuli and oxidative stress and are extracellular matrix degrading enzymes. MMPs are consistently implicated in atherogenesis and plaque destabilisation, responsible for thinning and rupturing of atherosclerotic fibrous cap. MMP-2, MMP-8, and MMP-9 have been recognised as proteases that contribute to atherosclerotic plaque rupture and clinical events by degenerating structural components of the plaque matrix. MMP-2 is elevated post-MI, elevated MMP-2 activity in plaques is associated with higher rate of ischemic cerebrovascular events and is an independent predictor of all-cause mortality in post-ACS. MMP-9 progressively increases with severity of clinical presentation and there is strong association between serum levels of MMP-9 and subsequent cardiovascular complications. This maybe related to increased activity of circulating monocytes related to more extensive myocardial necrosis. Elevated MMP-8 levels in the carotid plaque have been associated with unstable plaque phenotype. 

GDF 15 or Growth differentiation Factor is a member of the transforming growth factor -B cytokine superfamily expressed by activated macrophages associated with cellular oxidative stress and is inducible in the myocardium after ischemia. GDF 15 has been used to identify those pts with ACS who would benefit from an invasive strategy.

Micro-RNAs or MiRNAs are endogenous, small, noncoding RNA molecules, which regulate the expression of approximately 30 per cent of genes in the human genome and are highly stable in the circulation. Several MiRNA’s are found in blood early after MI and are correlated with risk of cardiovascular death. MiRNA-145 is expressed in smooth muscle cells of the blood vessel and is implicated in atherosclerosis along with miR-126 and miR 155. Wang et al., have reported that elevated levels of cardiac specific miR-208a in plasma may represent a new biomarker for early detection of myocardial damage.

PAPP-A or Pregnancy-associated plasma protein A (PAPP-A), a zinc-binding matrix metalloproteinase, was originally identified in pregnant women, produced in the placenta, and has been found to be a useful biomarker for predicting the rupture of unstable atherosclerotic plaques and risk of future cardiac events in patients with CAD. Wu et al., also showed that higher PAPP-A levels are associated with higher 3 vessel thin cap-fibroatheroma burden and instability.

H-FABP or heart-type Fatty acid binding protein is a low molecular weight protein with 132 aminoacids, involved in myocardial fatty acid metabolism. It is released into the cytosol in early AMI and serves as a highly specific marker for ACS and can detect myocardial ischemia and minor myocardial injury even in the absence of myocardial necrosis.

MR-PAMP or mid regional proadrenomedullin is a peptide that is used to indirectly quantify ADM. ADM or Adrenomedullin a potent vasodilator synthesised in the adrenal medulla, endothelial cells and the heart. It is more stable than ADM. It is elevated in patients with early atherosclerotic plaque and subclinical CAD and also has prognostic value as predictor of cardiovascular mortality.

ST2 is a member of the interleukin family and is involved in activation of T helper type2 cells and its cytokines. ST2 helps to predict mortality in low risk patients and can also be used for risk stratification in STEMI patients and in heart failure (ENTIRE-TIMI 23, CLARITY). A highly sensitive ELISA for sST2 has been developed (Presage ST2), which has low imprecision (coefficient of variation <5 per cent) even at very low analyte concentrations.
Neuregulin-1β (NRG-1β) is a member of the neuregulin family of signalling proteins, a myocardial stress activated growth and survival factor released from endocardial and endothelial cells. It acts through ErbB receptors on NRG-responsive cells. NRG-1β exerts paracrine effects on local myocytes and blood vessels. Geisberg et al, found that that NRG-1β levels inversely correlates with CAD severity in stable patients and plasma NRG-1β levels are statistically higher in patients with stress-induced ischemia.

Galectin-3 (Gal-3) belongs to a family of soluble β-galactoside binding lectins and plays an important role in atherogenesis through some of its actions such as monocytes chemoattraction, enhancement of phagocytosis, and induction of vascular smooth muscle cells proliferation. Gal3 has been shown to independently predict CAD occurrence and also cardiovascular mortality in pts at high cardiac risk.

Endothelin -1(ET-1) is a 21 aminopeptide secreted by the vascular endothelial cells with potent vasoconstrictor effects and is considered a surrogate marker of atherosclerosis. Elevated plasma levels of endothelin have been associated with coronary artery disease, essential hypertension and heart failure. Both in stable CAD and AMI patients, CT-proET-1 has been shown to be associated with cardiovascular death and HF independent of clinical variables.

Lipoprotein – associated phospholipase A1 (Lp-PLA2) is a member of the phospholipase A2 superfamily mainly produced by monocytes and macrophages. Lp-PLA2 is an enzyme that hydrolyzes oxidized phospholipids on oxidized LDL particles within the arterial. The localisation of Lp-PLA2 in atherosclerotic lesions and its association with plaque instability support a potential causal role for Lp-PLA2 in cardiovascular disease. Several studies have shown Lp-LPA2 activity to be independently predictive of cardiovascular events.

Future Prospects
Fibrinogen is a 340-kDa acute phase glycoprotein synthesised in the liver and is involved in platelet aggregation, endothelial injury, plasma viscosity, and mediates thrombus formation. Elevated fibrinogen levels are associated with an increased risk of CAD, stroke and mortality.

Uric acid is the end product of purine metabolism in humans. Elevated serum UA has been hypothesised to contribute to CVD development since the 1950s. Uric acid has been found to impair nitric oxide synthesis, resulting in vascular endothelial dysfunction lower flow-mediated vasodilatation, increasing oxidative stress and enhancing inflammation. Here is an independent positive association between UA and cardiovascular mortality. The National Health and Nutrition Examination Survey I Follow-Up Study, in which 5,926 subjects with 16.4 years of follow up were enrolled, demonstrated that increased serum uric acid levels were associated significantly with a higher risk of cardiovascular mortality. Other studies have showed similar results.

In summary, since those early days of non-specific and poorly sensitive biomarkers, we have come a long way with current biomarkers having the ability to diagnose cardiac injury earlier and at very low levels. Further, many of these current markers have the ability to risk stratify and help to apply the appropriate strategy as well for better outcomes. Newer biomarkers continue to emerge opening up new vistas from predicting vulnerable plaques to vascular endothelial activity and will continue to play a central role in cardiac therapy in times to come.