A simple blood test is never so simple. Every time you go under the needle for a blood test, have you ever wondered how your blood gets tested? We see anxious patients lined up to give their samples and see a relief when the process is done. But do you know what happens to that sample? How can you be assured that the sample has been tested using the right SOPs and that the lab is adhering to global standards. Welcome to the sample journey to understand how an accurate report is produced.

BLOOD COLLECTION

The true mark of a laboratory that cares is the one that adopts global practices during sample collection, giving the customer a hassle free experience. Sample collection needs to be efficient and effortless and can only be perfected with practice. Most of our phlebotomists have over 10 years of experience. Our Phlebotomists are well skilled and trained in collecting samples from babies, kids, patients who are hospitalised and frail or elderly patients.

Some steps in phlebotomy that are followed only by specialists

Before sample collection, the puncture site is cleaned with a disinfectant and is allowed to dry completely before needle is entered. Puncture site should not be touched after disinfection. Failing to let alcohol or disinfectant dry before sample collection can affect a test result. The vein should be visible without the application of a tourniquet and tourniquet should always be applied 4-5 finger widths above the puncture site. Tourniquet should be released before needle is withdrawn. Prolonged application of a tourniquet during blood collection can result in a blood sample with a falsely elevated total protein. After sample collection the needle is withdrawn gently and gentle pressure applied to the site with a clean gauze or dry cotton-wool ball. Patient is advised to hold the gauze with their arms extended. Bending the arm could cause a hematoma (clot)

Contaminated Tourniquets are a potential source of methicillin-resistant Staphylococcus aureus (MRSA). To avoid this, at Metropolis we apply a fresh piece of sanitised tissue on the patients skin before applying a tourniquet.

STORAGE & TRANSPORTATION

At times,a sample needs to be taken to the central laboratory for processing and testing. This is seen in case of specialised and super specialised tests. Different samples have different requirements for transportation and at Metropolis, through years of experience, we have a built a SOP that has been adapted for the Indian conditions.
The most labile analytes like Ammonia, Semen and Bicarbonate are collected only at the main processing laboratory. Any other collected sample is not accepted. Other labile analytes like PTH, ACTH and HIV-RNA are transported in dry ice. All the regular samples are transported in cool gel packs in a temperature controlled thermocol box. In addition to temperature control, some analytes require protection from light to ensure specimen integrity. Tests like Bilirubin, Vitamin A and Vitamin E require samples to be transported in a light controlled environment.

SAMPLE REGISTRATION

Accurate demographics for accurate results
About 10% of laboratory errors could be attributed to incorrect entry of patient details like gender, age, name, SID, PID etc. At Metropolis, we employ a dedicated and trained data entry team to perform accessioning and ensure error free sample demographics.

SAMPLE LABELLING

Assurance of barcoding

As soon as accessioning is done, specific bar code for the patient’s sample is generated, which carries SID (Sample identification number) information. The software generates appropriate number of bar codes for each patient depending on the variety of containers required. The bar code label also contains patient’s name, date and time of collection, name of tests and type of container. The system ensures zero chance of wrong labelling.

SAMPLE PROCESSING

Sample treatment for highest standards
Processing a specimen may include mixing the specimen to ensure that all the components are evenly distributed throughout the sample or spinning the specimen in a centrifuge to separate the serum/plasma layer from the red cells. Serum or plasma in contact with RBC over a prolong period of time may result in haemolysis. Additionally at room temperature, serum/plasma is separated within 30 minutes and should not exceed two hours. Critical or labile samples like semen or ESR and sent for analysis immediately.

SAMPLE TESTING

The best of Manual Testing and Automation

Many tests need to be performed manually with the help of right devices and chemicals. At Metropolis, best of our scientific team work on these manual tests as they are time consuming, intricate and demands the attention of experienced hands and eyes. Some of the tests are automated and we use US FDA approved technology and machines. In addition, all reagents that we use for testing are imported to ensure best quality and pinpoint precision.

SAMPLE RECHECKING

Reflex Testing for pinpoint accuracy

Metropolis offers reflex testing, in which additional testing will be performed on specimens depending on the results of the initial test. The additional tests are performed based on the Pathologist’s recommendation and the customer is not billed for any extra testing. There are two types of reflex panels: standard reflex test panels and compulsory reflex test panels. A standard reflex test panel allows the physician the option of ordering either the reflex test group or a single test. A compulsory reflex test panel automatically generates a request for additional testing if the result of the initial test meets or falls outside certain ranges. In many cases and especially in infectious diseases compulsory reflex test panels have been predetermined based on specific medical criteria accepted as standard-of-care by the medical community. Through our 30 year experience, we have also built a Unique Reference Range for the Indian audience for various tests. This is a practice that is only followed at Metropolis.

REPORTING

100% Accurate Results and Globally accepted reports

A separate Report Section team is responsible for report generation.Automatic “All reports mode” ensures that reports have undergone three levels of authorization before they are printed. The physical copies carry patient’s demographics in detail, reference details, test information, results of analysis and digital signature of the pathologist who has finally authorized the report. For all emergency reports, your doctor is notified immediately through an SMS. An email copy of the report is sent to the patient and the patient’s doctor that eliminates the need to carry physical copies.

Conclusion

At Metropolis, every sample undergoes a rigorous 149 steps before the report is produced. Through a 3 decade experience, we have built SOPs that account for each possibility of error. Automation in various sections of the lab has helped us eliminate a margin of error. Our processes give us the confidence of providing our customers with Error Free Diagnosis thereby enabling them to reveal their inner health. We are Metropolis. The Pathology Specialists.

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Prolonged stress leads to multiple inner health problems

By Dr SonaliKolte
General Manager, MedicoMarketing
Metropolis Healthcare

Stress – just the word may be enough to set your nerves on edge.Everyone is stressed in some form or other. Some people handlestress effectively or recover from stressful situations quicker than others. Stress is good if it is a short term phenomenon and pushes you to achieve your goals or targets, but it is harmful, if it prolongs or becomes routine.

Stress can be defined as a physical, mental, or emotional factor that causes bodily or mental tension. We usually tend to think that stress can lead to negativity, but that isn’t the case always. However, anything that puts high demands and forces you to adjust accordingly can be stressful. Stress may have adverse effect on your health, but one may not realize it. Chronic unrelenting stress has become so common in modern life; provoking feelings of hopelessness; what is usually termed as a defeat response.

Stress and emotions related to stress trigger chemical reactions in the body and leads to increased fat storage, abdominal obesity, tissue breakdown, suppression of the immune system, increased risk for heart disease etc.

The human body is wired to react to stress in a particular manner which helps you prepare for a situation. Imagine a close encounter with a speeding car; this is when you encounter a perceived threat. The hypothalamus, which is a small portion of the brain, sets off your body in to an alarm mode. A combination of nerve and hormonal responses signals the adrenal gland to release hormones that includes Adrenaline and Cortisol.

When stressors are always present and the subsequent exposure to these hormones, especially cortisol for a prolonged period leads to a lowered BMI, increased fat storage and increases risk for hypertension, heart disease and stroke. Furthermore, stress also wrecks the immune system. During stress, cortisol suppresses the inflammation process and over a period of time the body develops resistance to cortisol. Additionally, cortisol and corticosteroids suppresses lymphocytes and puts the body at an increased risk of infection such as influenza and other diseases.

There are multiple ways to cope up with stress; which begins with identifying the sources of stress and dealing with it. Since stress has a direct impact on health, it is important to regularly monitor health parameters to make sure your vital organs are performing well. A typical health package to monitor stress and its effects would include tests to measure blood sugar, cholesterol, lipids, cortisol etc. This tells you if you are at risk for heart disease, stroke and gives an overall indication of your inner health.

To conclude: “It’s not stress that kills us, it is our reaction to it”, Says Hans Selye, author of The Stress of Life. What is your reaction to stress?

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4
Moving towards personalised medicine & targeted therapy in Cancer Diagnosis: A New Horizon

Over one million new cancer cases are being diagnosed in India each year; says the latest study by The Lancet. This has been possible largely due to improved awareness and more patients getting diagnosed. Moreover, today we have better diagnostic technology and facility compared to a decade back. Cancer Diagnosis attains significance as it is an extremely specialised area of diagnosis and needs to be validated by oncologists. Cancer testing is of different types and a combination of technologies is applied to arrive at conclusive diagnosis.

Histopathology

Surgical pathology involves the gross and microscopic examination of surgical specimens, as well as biopsies submitted by surgeons and non-surgeons such as general internists, medical subspecialists, dermatologists, and interventional radiologists. Surgical pathology allows for definitive diagnosis of disease (or lack thereof) in any case where tissue is surgically removed from a patient. This is usually performed by a combination of gross (i.e., macroscopic) and histologic (i.e., microscopic) examination of the tissue, and may involve evaluations of molecular properties of the tissue by immunohistochemistry or other laboratory tests

Cytogenetics

The Cytogenetics Lab offers karyotype analysis and SNP-microarray analysis to detect balanced, unbalanced, and copy number neutral chromosome abnormalities at the whole genome level. The lab also performs fluorescence in-situ hybridization (FISH) analysis to detect targeted chromosome abnormalities. The results from these studies play important roles in cytogenetic diagnosis, prognosis, and guide treatment of specific types of hematologic malignancies and solid tumors.

Molecular Pathology

The Molecular Diagnostic Lab offers DNA or RNA based assays. DNA and RNA are extracted from a variety of specimen types, including peripheral blood, bone marrow, fresh tissue and formalin-fixed paraffin-embedded tissue. Our tests range from simple, routine PCR amplifications to complex tests translated from cutting-edge research findings to clinical utility.

Moving towards a new era in Cancer Testing

Cancer treatment has shifted in recent years to the use of biologic therapeutics that target genomic alterations in cancers, creating demand for more advanced and sensitive genomic testing to identify these alterations. It is important to provide diagnostically more significant information and correctly identify mutations present in smaller samples.

Today diagnosis is more widely used for identifying the right course of treatment. One size fits all is no more the approach and below is an example of one such extensive study conducted by us.

Example for personalised treatment:

Surgery , Radiotherapy , Chemotherapy and Hormone therapy are the 4 modalities of treatment of Breast Cancer.Every patient of breast cancer needs to be treated individually and pathology reports play a significant part. One of the areas where data based analysis has been minimal is in the arena of Hormone Therapy.We carried out a retrospective analysis of 3500 breast cancer patients for ER, PR, CerbB2 receptor expression for the last 3 years i.e. 2012, 2013 and till September 2014. Our study proved that with accurate diagnosis, more breast cancer patients in India can opt for Hormone therapy rather than chemotherapy as a choice of treatment. Hormone therapy in these patients has better prognosis and is less painful with a lesser degree of recurrence when compared to chemotherapy.

Conclusion:

What is most important to address in case of cancer is “can I have a report that is conclusive and one that will help me design my treatment?”

Single point, effective, cost effective and conclusive diagnosis is a void in India and Metropolis is at the forefront in bringing about this change. Through our Oncomet division, weprovide conclusive and cost effective cancer testing by correlating all techniques and technology with Morphology which refers to the histological classification of the cancer tissue.

Metropolis’s Oncology Directory of Services is accredited by the College of American Pathologists (CAP) and adheres to American Society of Clinical Oncology (ASCO) WHO Grading & AJCC/TNM Staging for Standardized Oncology reporting.

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The Metropolis Difference

Every sample has to undergo several steps before a reliable and an accurate report is produced. When you walk in to an accredited lab that adopts global practices, you will see that technology is intervened in every step; right from collecting the patient data to registering the sample and then the reports being auto-emailed through a meticulously built system. There are several things that could go wrong even before a sample is tested and hence it is important to adopt global practices to ensure that every report has the mark of a specialist and provide error free diagnosis.

Our Central Laboratory is spread over 10,000 sqft area. All samples across the city are routed to the central laboratory for processing through a seamlessly working logistics team. Some samples also arrive from all over the country in case of specialised or super-specialised tests. A lab of International standards such as Metropolis will have a wide test menu. We have about 4500 tests and test combinations. We do many of the tests that are not available anywhere else in India or are generally outsourced.

Samples are first categorised according to the department. For effective functioning, our central laboratory services has been segmented in to 7 core functions; Clinical Chemistry, Clinical Microbiology, Cytogenetics, Haematology, Molecular Diagnostics, Surgical Pathology and Research & Development.

A rapid sample handling Pneumatic System designed on Lean Concept ensures that samples are sent to respective departments with no manual intervention. This significantly reduces the margin of error and ensures a superior TAT. Today technology is helping us perform better and faster thereby helping us make a difference to our customer’s health. For Ex: the Genexpert test that is based on DNA PCR accurately determines the presence of tuberculosis and also tells us if it is resistant to rifampicin. This is possible within 24 hours which used to take up to a week previously.

Some of the technology that is in everyday use at such a laboratory are: ELISA, HPLC, Graphite Furnace Atomic Absorption Spectrometry, Fourier transform infrared spectroscopy, G Banding & Hi-resolution Banding, Karyotyping, Fluorescent in-situ hybridisation, Flow Cytometry, DNA sequencing, Real time PCR, Line Probe Assay, Liquid Based Cytology, Chromogenic In-situ hybridisation etc.

Data mining technology has also helped us build a unique Indian Reference Range system for some tests. This results from our 3 decade experience in pathology. Such kind of innovations is possible only in a lab that adopts global practices and adheres to gold standards. Our CAP (College of American Pathologists) and NABL (National Accreditation Board for Calibration and testing) accreditations are proof to the work we do and the quality protocol that we rigorously adopt.

Advancements in technology are taking diagnostics to newer heights. Today it is possible to personalise treatment based on diagnostic reports. At Metropolis, Innovations and investments in newer technologies and infrastructure is a given. As pathology specialists, we are well positioned to deliver the absolute best in the only thing we do: Revealing Inner Health.

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ovarian cancer

Mumbai May 7, 2015: Ovarian cancer has emerged as one of the most common cancer affecting women in India. An analysis of samples collected over the past two years (2013-2014) by Metropolis Healthcare Ltd reveals that a total of 7945 tested positive for high CA125 levelsout of the 36,515samples processed at Metropolis Healthcare in Mumbai.

According to Indian Journal of Cancer, 1 out of 5 women are prone to ovarian cancer. The majority of ovarian cancers arise from the epithelium (outer lining) of the ovary. 9 out of 10 ovarian cancers are epithelial ovarian cancers.A host of factors affects female ovaries such as family history, age, obesity, fertility drugs, personal history and hormone replacement therapy (HRT). Ovarian cancer is a highly aggressive cancer and is one of the leading causes of women’s death. It is an important cause of morbidity and mortality, especially in the middle aged women. Development of cancer cells in ovary accounts for about 4% per cent of all cancers in women.Certain inherited gene changes (mutations) can increase the risk of ovarian cancer. These include changes in the BRCA1 and BRCA2 genes. If you have inherited a mutation of one of these genes from either parent, your chances of getting breast and/or ovarian cancer increases.

Ovarian cancer is difficult to pick up as symptoms like abdominal pain, persistent bloating and difficulty while eating are extremely common conditions in the disease.Accurate ways to detect ovarian cancer early could have a great impact on the cure rate. If a woman has these symptoms more than 12 times a month, she should see her doctor, preferably a gynecologist.

Cancer Antigen – 125 test or popularly known as CA-125, assesses the concentration of this protein in the blood.Doctors may suggest a CA-125 test if they suspect ovarian cancer, endometrial, peritoneal or fallopian tube cancer. CA – 125 is a screening and monitoring test marker. However CA-125 has a low specificity & positive predictive value as it can be elevated in other cancers involving pancreas, breast, bladder, lung, and liver & in benign conditions like diverticulitis, endometriosis, pelvic tuberculosis, pleural effusion. Combining other detection methods like transvaginalsonography and rectovaginal pelvic examination increases the accuracy of detecting ovarian cancer. A CA-125 test result of greater than 35 U/ml is generally accepted as being elevated.CA125 test is one of the first tests doctor orders if he suspects early symptoms of Ovarian Cancer.

In an analysis of data of over 2 years (2013-14), Metropolis Healthcare has analyzed the risk of ovarian cancer in Mumbai

Of all the 7945 samples that tested abnormal, the following is the pattern of abnormality within age groups

Commenting on the study, Dr.DeepakSanghavi, Deputy Chief of Lab Services, Metropolis Healthcare said “In ovarian cancer, cells in the ovary start to change and grow abnormally. If the cancer isn’t identified at an early stage, it can spread to the abdomen and pelvis, including other parts of the female reproductive system. Women who have their first full-term pregnancy after age 35 or who never carried a pregnancy to term have a higher risk of ovarian cancer.Breastfeeding may lower the risk even further. Fertility drugs with no outcome or hormone therapy after menopause is also linked to the disease. Mutations in BRCA1 and BRCA2 are also responsible for most inherited ovarian cancers.”

Several advances in biomarker discovery and development have now led to additional tools that may be useful in the clinical management of women with adnexal masses, with recent FDA approval of Risk of Ovarian Malignancy Algorithm index popularly known as ROMA index gives a fair indication for the risk of ovarian cancer in pre- and post-menopausal women with a pelvic mass.The ROMA test is intended for use in women who meet the following criteria such as over 18 years of age, have an ovarian mass, surgery is planned or not yet referred to an oncologist

(Source: Indian Journal of Cancer, American Cancer Society)

*CA-125 (Reference range: All values between 0-35 U/ml is considered normal and values above 35 are out of the normal range. Clinical correlation is suggested

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*Keeping pace with newer biomarkers in Autoimmunity- new antibody test launched for renal disease*

11th March 2015: One of the major kidney diseases, Nephrotic Syndrome is defined by massive continued loss of urinary proteins and edema (water retention).

One of the major causes of Nephrotic Syndrome is Membranous Nephropathy or Membranous Glomerulonephritis which is a chronic inflammatory disease of the glomeruli (the network of capillaries in kidneys that perform the first step in filtering blood). In Membranous Nephropathy, an antibody-antigen complex otherwise called as the immune complex is formed in the glomerulus. This eventually leads to loss in kidney function and kidney failure.

Membranous Nephropathy can be primary (where cause of the disease is not known; idiopathic) or could be secondary (as a result of an underlying condition like prolonged infection, tumor, cancer and even certain medications etc).

It is important to differentiate primary and secondary since the treatment and disease management varies. In Primary Membranous Nephropathy, an individual undergoes an immunosuppressive therapy or kidney transplant), whereas in secondary, the underlying disease is treated.

PLA2R Antibody Test is used to correctly differentiate the two kinds of disease, evaluate the intensity of the disease, monitor therapy and risk assessment after kidney transplant.

Advantages of the test

  • Serum based test and requires only a blood sample
  • Easy to perform
  • Presents a non-invasive alternative to the common biopsy.
  • Anti-PLA2R autoantibodies are a highly specific and sensitive marker for primary MN.

Additionally to its usage in differentiation of primary and secondary MN, the anti-PLA2R titer reveals a high predictive value for:

Disease evaluation

Anti-PLA2R autoantibody results correlate with disease activity (proteinuria). High titers are directly proportional with a severe course of primary MN.

Therapy monitoring

The anti-PLA2R autoantibody titer decreases in patients undergoing successful immunosuppressive therapy. A relapse of disease is associated with a recurrence of the antibodies. Furthermore, a high anti-PLA2R titer was identified as a considerable risk factor for primary MN patients to not achieve a remission of proteinuria.

 Risk assessment

Up to 40 % of patients with primary MN experience a relapse after kidney transplantation. This risk is particularly high if anti-PLA2R autoantibodies are persistently found during the six months after organ transplantation. Therefore, the titer can be useful to assess the necessity and intensity of an immunosuppressive therapy after transplantation to avoid relapses.

Commenting on the test, Dr Deepak Sanghavi who heads the Immunochemistry section at Metropolis Healthcare said “It is an important test that will help improve outcomes and disease management in such a chronic kidney disease. We have tied up with few hospitals and Institute of Kidney Diseases and offer this test at INR 4,500. Out of the suspected samples that we receive, almost 4 out of 10 returns positive”

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Lead poisoning serious threat to GenNext: Metropolis Study

Mumbai June 2015:Lead poisoning remains one of the most important environmental health concerns globally. It is a cumulative toxicant that affects multiple body systems and is particularly harmful to young children. An analysis of 733 blood samples collected over the past one year by Metropolis Healthcare Ltd reveals that 23.47% of the total samples tested positive with Lead poisoning. At Metropolis, Lead Poisoning is tested using high sensitivity technology called ICPMS (Inductively Coupled Plasma Mass Spectrometry) and Graphite Furnace Atomic absorption spectrometry. Blood, Serum and Urine samples can be tested for Lead.

According to a WHO study, lead exposure is estimated to account for 1,43,000 deaths per year with the highest burden in developing regions. Young children are particularly vulnerable to the toxic effects of lead and can suffer profound and permanent adverse health effects, particularly affecting the development of the brain and nervous system. Lead exposure is estimated to contribute to 6,00,000 new cases of children with intellectual disabilities every year. In growing children, lead poisoning causes low IQ, hyperactivity, attention deficit, learning disabilities and anemia.

Lead-based paint and lead-contaminated dust in older buildings are the most common sources of lead poisoning in children. Other sources include contaminated air, water and soil. Lead also causes long-term harm in adults, including increased risk of high blood pressure and kidney damage. Adults who work with batteries, do home renovations or work in auto repair shops also may be exposed to lead. It can induce brain, kidney, stomach, heart, hearing, muscle and fertility damage. Exposure of pregnant women to high levels of lead can cause miscarriage, stillbirth, premature birth and low birth weight, as well as minor malformations. Women with high blood lead levels develop early osteoporosis, lower backache, joint pain and persistent anemia.

Lead Profile

(Reference range : Normal – 0 – 9 μg/dL , Positive – Above 9 μg/dL)

*Children under the age of 6 are especially vulnerable to lead poisoning, which can severely affect mental and physical development. While the American Center for Disease Control and Prevention suggests that a value below 9 ug/dl is safe in children and adults, the healthcare practitioner takes disease management decision based on the symptoms in the patient.

Please note: The data represents patient sample testing in clinically suspected individuals and hence the % of positivity seen cannot be extrapolated to general population. However, possibility of lead toxicity exists across all age groups & should be considered in appropriate clinical settings.

Commenting on the study Dr.SandeepWarghade, Consulting Pathologist Metropolis HealthcareLtd said, “Lead poisoning can be hard to detect even people who seem healthy can have high blood levels of lead. At high levels of exposure, lead damages the brain and central nervous system and can lead to coma, convulsions and even death, signs and symptoms of lead poisoning usually don’t appear until dangerous amounts have accumulated. Lead poisoning can be treated if detected at an early stage; taking some simple precautions can help protect yourself and your family”.

Major sources of blood lead include leaded contaminated soil, drinking water, petrol emissions, household dust, battery recycling, silver refining, paints (especially yellow), pigments, printing presses, ceramic pottery glazes, cosmetics, colours (including kumkum, sindoor, spices and Holi colours), children’s toys (crayons and painted pencils), plant foods and traditional medicines.

Lead poisoning cases in young children are high because of licking or eating lead-containing paint when it is peeling off the walls or toys. Lead from a mother’s blood can pass to the fetus during pregnancy, possibly giving rise to genetic disorders.

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DNA Sequencing: A Powerful Tool In Genomics

What is sequencing?

A DNA molecule carries information in the form of four chemical groups or bases ie. adenine, cytosine, guanine, and thymidine, represented by the letters A, C, G and T. Nucleic acid sequencing is a method for determining the order of the nucleotide bases in a molecule of DNA. Sanger sequencing (the chain-termination method), developed in 1975 by Edward Sanger, was considered the gold standard for nucleic acid sequencing for the subsequent two and a half decades. Life Technologies has been providing automated capillary electrophoresis platforms for sanger sequencing for almost two decades now.

Importance

Knowledge of DNA sequences has become indispensable for basic biological research, other research branches utilizing DNA sequencing, and in numerous applied fields such as:

  • Diagnostic
  • Biotechnology
  • Forensic Biology
  • Biological Systematics.

The advent of DNA sequencing has significantly accelerated biological research and discovery.

The sequencing of the human genome along with related organisms represents has been one of the largest scientific endeavors in the history of mankind. The information garnered from sequencing has provided the raw data for the exploding field of bioinformatics, where computer science and biology live in symbiotic harmony.

Figure 1: 3500Dx is an automated DNA Sequencer/ Genetic Analyzer from Applied Biosystems. It is an In Vitro Diagnostic Medical Device, specifically suited for clinical market for detection of genetic changes that may indicate disease presence or susceptibility..

Figure 2: Electropherogram – is the computer generated output of automated sequencing. The peaks represent the intensity of the fluorescent ddNTPs. The sequence is printed across the top of the peaks. The DNA nucleotides G, A, T, C are represented by black, green, red and blue peaks respectively.

Role of Human Genome Project

Due to immense potential of DNA sequencing, The Human Genome Project, an international research effort to determine the sequence of the human genome was drafted to identify the genes that it contains. The ultimate goal of the Human Genome Project was to decode, letter by letter, the exact sequence of all 3.2 billion nucleotide bases that make up the human genome. This means constructing detailed genetic and physical maps of the human genome. The Project was coordinated by the National Institutes of Health and the U.S. Department of Energy. Additional contributors included universities across the globe. The Human Genome Project formally began in 1990 and was completed in 2003, 2 years ahead of its original schedule.

Impact of Next Generation sequencing in Genomics

The requirement for electrophoretic separation of DNA fragments for reading DNA sequence content in Sanger-based sequencing was the primary bottleneck for throughput with this method, increasing time and limiting the number of reactions that can be run in parallel. Next generation” or “deep” sequencing (NGS) refers to a new, versatile technology of DNA sequencing that permits high-throughput, highly adaptable whole genome-scale assays at reasonable cost and high accuracy.

NGS Platforms for Genomic Research and Diagnostics

The NGS platforms market is dominated by Illumina, which occupies the largest market share. Other companies with commercial platforms include Life Technologies (Thermo Fisher Scientific) (U.S.), 454 Roche (U.S.), and Pacific Biosciences (U.S.). The recently introduced platforms such as HiSeq X Ten and NextSeq 500 from Illumina will drive the market. Based on steps in the NGS workflow, the overall next generation sequencing market has three major segments, namely, pre-sequencing, NGS platforms and services, and NGS data analysis, storage and management. With NGS based assays there is a shift towards data analysis rather than the technical component.

Applications

NGS technology finds applications in research as well as diagnostic fields. Whole genome sequencing, investigation of genome diversity, metagenomics, epigenetics, discovery of non-coding RNAs and protein-binding sites, and gene-expression profiling by RNA sequencing are some of the reseach based applications. Discovery of new microorganisms and viruses by using metagenomic approaches, analysis of viral genome variability within the host (i.e., quasispecies), detection of low-abundance antiviral drug-resistance mutations in patients with human immunodeficiency virus (HIV) infection or viral hepatitis are all possible with NGS.

The major clinical diagnostic/ IVD applications of NGS are detection of germline variants in cancer as well as other genetically inherited disorders, BRCA1/2 mutation detection in familial breast and ovarian cancers, non-invasive prenatal testing (NIPT), pharmacogenomics and personalized medicine, HLA typing and preimplantation genetic diagnosis/ screening (PGD/PGS). At metropolis, we are offering a variety of sequencing based assays in the areas of Predictive Diagnostics (e.g. BRCA1/2), Drug Resistance Detection (e.g. HIV Drug Resistance), Genetic Disorders (e.g. Beta Thalassemia), Pharmacogenetics (AbacavirHypersentitivty in HIV-1), Companion Diagnostics (EGFR, Kras Mutation) etc.

Additional Requisites

Besides NGS instrument and technical expertise, NGS workflow demands strong bioinformatic pipeline, bioinformaticians, experienced geneticist for medical remarks and reporting and genetic counseling services for analyzing and interpretation of sequencing data.

At Metropolis, we are offering a variety of sequencing based assays in the areas of Predictive Diagnostics (e.g. BRCA1/2), Drug Resistance Detection (e.g. HIV Drug Resistance), Genetic Disorders (e.g. Beta Thalassemia), Pharmacogenetics (AbacavirHypersentitivty in HIV-1), Companion Diagnostics (EGFR, Kras Mutation) etc.

The Cytogenetic department in Metropolis is certified by CAP (College of American Pathologist) and NABL (National Accreditation Laboratory Testing and Calibration). We adhere to global quality standards.

A wide range of cytogenetic tests are offered under single roof i.e. ranging from blood, bone marrow, POC (product of conception), prenatal and solid tumors. We also offer genetic counseling. Our expertise lies in offering genetic counseling to number of genetic disorders for different conditions and different age group.

  • Pre – conceptional, prenatal genetic counseling
  • Post natal (pediatric, pubertal, adults) genetic counseling
  • Pre-marital genetic counseling
  • Counseling in cancer genetics

Research & Development – Our R&D is currently working on the following

  • Prenatal: Karyotyping and FISH from Amniotic fluid
  • Postnatal: Karyotyping and FISH from blood in various pediatric cases, Infertility, BOH, Products of conception
  • Cancer genetics: Karyotyping and FISH in various blood cancers ,solid tumors like breast cancers
  • Sperm FISH: In males with abnormal semen analysis report and repeated pregnancy losses with foetal aneuploidies.

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Low Vitamin D levels – Significance beyond Bone Health: Metropolis Healthcare

Despite ample sunlight in India throughout the year, almost 80% of Indians are deficient in Vitamin D. Prolonged Vitamin D deficiency leads to a host of health issues. Recent studies link Vitamin D Deficiency with Diabetes, metabolic syndrome, blood pressure, heart disease, stroke and may even trigger symptoms of depression in a healthy population.

There are various studies that directly correlate Vitamin D deficiency to PTH levels in the blood which is studied further in detail here.

Vitamin D Deficiency& Parathyroid Hormone (PTH)

Vitamin D deficiency, simply put is having low levels of Vitamin D in body, which causes the bones to become thin, porous and brittle.Vitamin D helps the intestines absorb calcium. Once activated, Vitamin D acts to greatly increase the amount of calcium that the intestines can absorb from food. For patients with vitamin D deficiency, it is difficult for the body to obtain calcium from the diet. This often leads to a rise in the PTH level, since the parathyroid glands must increase the PTH production, in order to increase calcium levels they absorb it from bones. Therefore, people with a normal blood calcium levels and a high PTH level may have secondary hyperparathyroidism, which means that the high PTH level is a normal response of healthy parathyroid glands to another problem (like vitamin D deficiency or kidney failure).The sole purpose of the parathyroid glands is to control calcium within the blood in a very tight range between 9.0 and 10.1. In doing so, parathyroid glands also control how much calcium is in the bones, and therefore, how strong and dense the bones are.

Primary hyperparathyroidism

Primary hyperparathyroidism most of the times results due to a non-cancerous tumor of the parathyroid, called an adenoma. Because of the adenoma, the parathyroid can make too much PTH, which can cause calcium to be too high in the blood, and overtime, lead to poor bone health. Sometimes doctors decide to treat primary hyperparathyroidism surgically, by removing the adenoma. If you have primary hyperparathyroidism, you need to work with your doctor to see if you can take vitamin D. Since you may have high blood calcium, it’s important to make sure you’re under a doctor’s supervision if considering taking vitamin D.

Secondary hyperparathyroidism

Secondary hyperparathyroidism is caused by either long term vitamin D deficiency or kidney failure. With long term vitamin D deficiency, the body may not get enough vitamin D to absorb adequate calcium. This can be corrected by treating vitamin D deficiency. It is important to note that accurate diagnosis is important to get to the core of the disorder and decide course and dosage of treatment accordingly.

How does the Human body ensure that there is adequate amount of calcium in the blood?

The human body can produce Vitamin D3 from direct exposure to sunlight. 7-dehydrocholestrerol is converted to Vitamin D3 with the help of UV Rays. However a large population of India does not face the sun as over 80% of the population is deficient in Vitamin D

  • Poor/inefficient exposure to sunlight
  • Sunscreen, full sleeved clothes acts as an impediment
  • Dark colored skin requires longer exposure to sunlight
  • Poor dietary /supplementary intake

When you get enough vitamin D from good sun exposure and supplementation habits and enough calcium from your diet, this allows you to maintain a healthy calcium level in your blood and keep good amounts of calcium in your bones. Healthy vitamin D and calcium habits also help keep your PTH levels in check.

Prolonged Vitamin D Insufficiency or Deficiency leads to reflex increase in PTH levels in the blood. This is called secondary Hyperparathyroidism, in which PTH mobilizes bone calcium which leads to increased bone fragility and risk of fractures or increased level of calcium in blood. Secondary Hyperparathyroidism is commonly the result of compensatory over secretion of PTH in response to Vitamin D deficiency.

In a recent study done by the R&D team at Metropolis Healthcare, the following are the study results.

According to R&D team in Metropolis Healthcare, when the calcium level in the blood drops, due to Vitamin D deficiency, high levels of Parathyroid Hormone (PTH) are secreted by the parathyroid gland, which absorbs calcium from bones, leading it to become brittle and porous.

How it affects the people?

Many people with Vitamin D deficiency can have increased levels of Parathyroid Hormone (PTH) in the body. The main function of PTH is to maintain calcium levels in the blood stream. With the decrease in Vitamin D levels, there will be drop in the calcium levels, in order to balance the calcium level in the blood, parathyroid gland starts secreting high levels of parathyroid hormone. PTH starts to absorb calcium from bone replenishing the calcium level in the blood, which in turns leads to weakening of bones, making it more fragile or prone to fractures.

The Study

In an analysis of over 7,542 patients who underwent both Vitamin D and PTH tests, the following trends emerged.

An increasing trend can be witnessed from 30 to 40 age group and above, indicating an increasing level of susceptibility with progression in age

Observations:

Elevated PTH levels were found in the age group of 20 – 50 years contributing to 24.11%. Such patients are at a high risk of developing High BP, Diabetes, Heart diseases.

Of these deficient samples 28.98% were of women.Vitamin D deficiency with PTH elevation can have several ill effects on bone and increased risk of high BP, Diabetes & Heart disease.

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How Hormone Therapy could change the lives of Breast Cancer patients in India?

Breast cancer is the second most common cancer in Indian women. The incidence is more in urban than rural women. According to a GLOBOCAN report for the year 2012, the incidence of Breast Cancer in women in India was 144,937. Over 70, 218 women died of breast cancer in India in 2012.

For every 2 women newly diagnosed with breast cancer, one lady is dying of it.

Breast Cancer, like many other cancers is curable if detected early. While there are several risk factors, breast cancer can happen to anyone. There are multiple reasons why Breast Cancer is diagnosed in India in the later stages: Fear, Social Stigma, Shyness on part of the women and an overall lack of awareness of the disease.

There is no one way to prevent breast cancer but we can detect it early and treat adequately. One of the bigger challenges in India is lack of data and research that can contribute effectively to prognosis and treatment decisions.

Surgery, Radiotherapy, Chemotherapy and Hormone therapy are the 4 modalities of treatment of Breast Cancer.Every patient of breast cancer needs to be treated individually and pathology reports play a significant part.

One of the areas where data based analysis has been minimal is in the arena of Hormone Therapy.

One major way of defining a type of breast cancer is whether or not it is:

  • ER positive (Estrogen Receptor)
  • PgR Positive (Progesterone Positive)
  • HER2 neu positive (Receptive to Protein Her 2 Neu, which is produced by cancer cells)
  • Triple negative, that is not positive to receptors for estrogen, progesterone, or HER2

If a patient’s breast cancer’s cells have a significant number of receptors for either estrogen or progesterone, the cancer is considered hormone-receptor positive and likely to respond to hormone/endocrine therapies.

Endocrine therapies for breast cancer are treatments usually taken after surgery, chemotherapy, and/or radiation are finished. They are designed to help prevent recurrence of the disease.

Study Overview

There are several literatures in the west that show higher positivity for ER Pgr and Her 2 neu. However Indian investigations show much lesser percentage ranging from 32% to 58%. Also studies in India have been limited to minimal sample size. Another important factor that greatly affects the results is adherence or non-adherence to stringent quality protocols. Right from fixation of the sample to the choice of fixative and various other guidelines need to be followed meticulously to arrive at a high quality study and a reliable report.

Metropolis Healthcare Study

We carried out a retrospective analysis of 3500 breast cancer patients for ER, PR, CerbB2 receptor expression for the last 3 years i.e. 2012, 2013 and till September 2014. SOPs were circulated amongst all surgeons & laboratories for ideal fixation especially with special respect to 1. Cold Ischemic time 2. Total fixation time 3. Choice of fixative. The IHC was carried out using manual & automated staining with standard clones after grading on H & E. The ASCO/CAP guidelines for reporting ER, PgR& Her 2 neu were applied & complimented with a Quick score.

Result: Of the 3500 cases – 68% were ER positive, 61% PgR positive & 27% positive for Her 2 neu. Triple negative cases were 16%. These figures are in concordance with the quality stringent labs in the world & the US CAP recommendations. Although there have been a few reports of closely similar data from India, most of the Indian data shows a lower positivity percentage and has been analyzed on a smaller patient cohort. This is probably the largest cohort of its type.

Why is this study important?

This study is evidence that more breast cancer patients in India are amenable to hormonal & targeted therapy. However due to lack of research, evidence and awareness, this path has not been approached in a big way

How is Hormone Therapy useful to Breast cancer patients?

  • Hormone therapy can reduce the risk of early-stage hormone-receptor-positive breast cancers coming back (recurring) after surgery.
  • Hormonal therapy medicines can also be used to help shrink or slow the growth of advanced-stage or metastatic hormone-receptor-positive breast cancers.
  • It is also a less painful alternative to chemotherapy
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