Author Archives: د.حسام أبو فرسخ

This is one of the most important tests present nowadays for Cardiac functions, for management of patients with heart failure and for prognostic value in patients with cardiac ischemia, heart failure or vascular diseases. BNP is a neurohormone that affects body fluid homeostasis by natriuresis and diuresis, as well as vascular tone by decreasing angiotensin II and norepinephrine synthesis. BNP opposes regulatory hormones of the renin- angiotensin-aldosterone system and potentiates the effects of nitric oxide. It also increases parasympathetic tone. Consequently, it leads to decrease in vascular tone and decrease blood pressure. BNP is stored in heart muscle cells (myocytes) mainly of the left ventricle, and it is released upon dilatation of the heart (as may occur in dilated heart failure), or in ischemia (as seen in myocardial infarction). BNP blood level is found to correlate very well with patient�s status: the more is the value, the worse is the prognosis. Measurement of BNP is essential nowadays in all cases with heart failure and in patients with myocardial infarction. It is also essential to measure BNP is patient with �Shortness of Breath�. Many studies found that dyspneic patients who present to emergency room with high BNP blood levels have shorter survival time than patient with low levels. More studies have also shown that patients with pulmonary embolism with raised levels of BNP are more likely to die from cardiac complication within a year of their presentation compared with normal level patients

In summary: Measurement of BNP blood levels is now part of essential work up for any patients with heart disease (ischemia, cardiac dilatation, cardiac failure), in patients with Dyspnea, and in patients with pulmonary embolism. The higher the blood level value, the worse is the damage, and the worse is the prognosis

We in the first medical Lab are determined to bring the best of laboratory test to clinical practice in Jordan. Please do not hesitate to contact me for any further inquiries

.Dr. Hussam Abu- Farsakh, M.D

Consultant Pathologist and Cytopathologist

American boards of Anatomic, Clinical Pathology and Cytopathology

BAL is a powerful diagnostic tool if its triad are fulfilled: adequate specimen, prompt processing and a patholgist knowing what he is looking for. In normal BAL, fluid recovery of about 60% with total cell count 175^+/-30/mm³ is usually obtained. This count is increased in alveolitis (832^+/-221/mm³). While it is markedly reduced in bone marrow transplant, immunocompromised patients and in patient with diffuse alveolar damage (DAD). The normal differential for BAL is Free Alveolar Macrophages (FAM�s) 87%; neutrophils (PMN) 3% Lymphocytes 10% (reduced in smokers to less than 7%). Esoinophils are less than 0.5%. Lymphocytic alveolitis in BAL is seen in hypersensitivity pneumonitis, sarcoidosis, tuberculosis, carcinomatosis (in 45% of malignant cases), drug induced lung disease, collagen vascular disease and less commonly in asbestosis, AIDS, alveolar proteinosis and in inorganic dust exposure. Neutrophilic alveolitis is seen in active T.B, idiopathic pulmonary fibrosis, ARDS, collagen vascular disorders, diffuse pan bronchiolitis, pneumoconiosis and smokers. Esinophilic alveolitis with marked increase in eosinophils is seen in eosinophilic pneumonia, allergic bronchopulomnary aspergillosis, asthma bronchiale, Churg- Strauss syndrome, but it can be seen coupled with neutrophils in cryptogenic and secondary fibrosis and in idiopathic pulmonary fibrosis, scleroderma, and Wegner�s granuloma. Multinucleate giant cells can be seen in normal BAL and do not indicate a specific disease entity. Hemosiderosis, on the other hand, can be of important diagnostic pattern. It is increased in smokers, heart failure and more abundant in alveolar hemorrhage, and vasculitis of different patterns. CD4/CD8 ratio is of great diagnostic value in BAL. It is increased in sarcoidosis, asbestosis, and berylliosis. Decreased in hypersensitivity pneumonitis, silicosis, drug induced lung disease and in AIDS. It is normal in T.B and in carcinomatosis. In idiopathyic pulomary fibrosis or fibrosing alveolitis: increased eosinophils and neutrophils is seen in progressive cases. PMN of <6% indicate a remission. If >10% of PMN present, clinical deterioration seen in 50% of patients; stable disease in 37.5% , and improvement in 12.5%. Lymphocytosis indicates better response to therapy with clinical improvement seen in 40% of the cases, stable disease in 30% and deterioration in 30%. Treatment of conditions with PMN�s or eosinophils: may require cyclophosphomide in addition to steroids therapy. In bone marrow transplant with pulmonary symptoms, the presence of lymphocytosis in BAL indicates better outcome, especially if combined with free alveolar macrophages that are negative for hemosiderin deposition. Different diseases may have different BAL patterns. In sarcoidosis: lymphocytosis is seen in over 75% of cases with average percentage of lymphocytes 27%. CD4/CD8 ratio of 4 or above is almost diagnostic of sarcoidosis. In Rheumatoid lung diseaes: FAM�s are decreased to around 45%^+/-5%. In extrinsic allergic alveolitis: the pattern depends on time of BAL in relation to exposure: with tendency to have more lymphocytes and less PMN as exposure becomes older, accompanied by increase in immunoglobulin. In scleroderma: 58% of the cases show increased PMNs ^+/-esinophils. In pulmonary embolism: there is increase in total protein, albumin, decrease in FAM�s and increase in PMN

Much more information are present but it is too big to put all information in one page. Please contact me for any further inquiries

.Hussam Abu-Farsakh, M.D

American Board of Pathology and Cytopathology

c-erbB-2 (Her2-neu) is very important gene that is expressed in 30% of breast carcinoma. This test is performed now routinely in USA in all breast carcinoma cases. The significance of this gene in clinical practice is the following

Associated with high histologic grade-

(Associated with shortened disease free survival (early relapse–

The higher the level of c-erbB-2 , the worse is the prognosis–

CMF (cyclophosphomide/methotrexate/5-fluorouracil) has less effect on positive cases–

(Good Response to doxorubicin – containing regimens (CAF) (cyclophosphomide/ doxorubicin /5-fluorouracil–

(Taxol ( paclitaxel) can be influential in c-erbB-2 (Her2-neu–

Can be associated with positive or negative estrogen receptor studies–

More resistance to radiotherapy–

Herceptin ( a new drug : monoclonal anti- c-erbB-2) have a good effect on treatment of positive cases–

Now, this test can be performed in the First Medical Laboratories at a reduced cost. Results of the test will be available within few days of requesting the test

Our lab is determined to bring always what is new and clinically relevant to clinical practice in Jordan

Please call us for any further information

Dr. Hussam Abu-Farsakh

American boards of Anatomic, Clinical Pathology and Cytopathology

C-Kit is proto-oncogene; a tyrosine kinase receptor that is important for cell development and growth. It is located in chromosome 4. It is expressed in interstitial cells of Cajal which are the pacemaker cells in the intestine. Tumors that arise from these cells are called Gastrointestinal Stromal Tumors (GIST). These tumor are one of most common causes of sarcomas in the abdominal cavity. The identification of its expression is important for the management of these cases. A new oncology drug STI-571 (available commercially) is competitive inhibitors for KIT protein. Tumors expressing this protein responds by stopping growth and shrinkage

Gastrointestinal Stromal Tumors (used to be called leiomyomas/ leiomyosarcoma) are mesenchymal tumor that arise most commonly in the stomach , small intestinal, esophagus and colon, and mesentery (in this order). Tumors that express this protein tend to behave in a malignant fashion

Staining for these tumor for C-kit, can be performed by immunohistochemical staining on normally processed specimen submitted in formalin

The hope that these tumors can be cured now is giving advances to molecular pathology in selecting proper treatment for tumors

Now, this test can be performed in the First Medical lab, to be the first lab in Jordan to perform such a test

We, in the First Medical Laboratory, are dedicated to

bring the best of laboratory medicine to clinical practice to Jordan

Dr. Hussam Abu-Farsakh

American Board of Anatomic & Clinical Pathology, and Cytopathology

Diagnosing T.B could be difficult sometimes and requires more tests. Relying on finding Acid Fast Bacilli is usually not reliable in many cases. PCR for T.B also has a limitation and can not be performed on the blood. FDA approved 2 new tests for T.B. The first one is �anda-tb�. This test is relying on finding antibodies against A60 antigen complex. This antigen is found in the cytosol of typical and atypical mycobacteria. It could be IgM or IgG. The advantage of this test that healthy non-infected individuals are negative for this test even if they have positive intradermal reaction test. It is positive only in patients with active T.B infections. It can be used in blood and in CSF specimen for diagnosing T.B meningitis. It can be used for diagnosing pulmonary and extrapulmonary tuberculosis. It can be used for diagnosing typical and atypical myocobacteria. It disappears when the patient is cured, and re-appears again on relapses. The disadvantage of the test is that is can be positive in Nocardia infected individuals (since Nocardia species have A60 antigen complex in their cystosol). However, clinical examination and histologic findings are different. Also the antibodies to A60 antigen complex can be negative or weak in 5% of patient who are anergic with suppressed immunity (like in HIV infected individual). Several studies have posted the specificity of this test to be from 80-98% and sensitivity from 60-100%. (Charpin et al, Cominero et al, Wang et al). To increased sensitivity and specificity of anda-tb test, it is strongly recommended to ask for both IgG and IgM antibodies against A60 antigen complex anda-tb test

The second test is �patho-tb� test. The idea of this test is detecting mycobacteria bacilli. The specimens used in this test are sputum, pleural fluid, bronchioalveolar lavage, CSF, FNA aspirated material, lymph node fresh material, gastric and intestinal wash. The specimen is first decontaminated by specific method in the lab then filtered into a specially designed filter. When the specimen with T.B passes through the filter which is coated by anti TB antibodies, the reaction change the filter color and indicate the presence of mycobacterium or atypical mycobacterium in the specimen. The patho-tb test is about 100 times more sensitive than finding ordinary acid fast bacilli in one field

In summary, it is strongly recommended that �anda-tb� test to be requested in the blood when no tissue is available. The �patho-tb� test is recommended when tissue or fluid material (BAL, CSF, sputum, gastric or intestinal wash, or FNA aspirate) is present. Both tests carry very high sensitivity and specificity for diagnosing active T.B infection

We, in the First Medical Lab, are committed to bring the best of laboratory test to clinical practice in Jordan. Please do not hesitate to contact me for any further information

Dr Hussam Abu-Farsakh

First Medical Lab Director

Carnitine is a naturally occurring amino acid derivative. Serum Carnitine Deficiency (SCD) incidence is 1:37,000 newborns. Carnitine plays an essential role in the transfer of long-chain fatty acids into the mitochondria for beta-oxidation. Age at presentation of SCD is usually ranging from 1 month to 7 years, but cases can occur earlier or later (you have to keep it in your differential). Pathologic effects SCD include (1) the cardiac muscle, which is affected by progressive cardiomyopathy (by far, the most common form of presentation with possibility of sudden death), (2) the central nervous system, which is affected by encephalopathy caused by hypoketotic hypoglycemia, and (3) the skeletal muscle, which is affected by myopathy

:Clinical conditions which you should ask for measurement of serum blood Carnitine

Neonatolgy and pediatrics: Failure to thrive; Newborn receiving total parentral nutrition; Developmental delay, Recurrent infections, Hypotonic children

Hematology: Unexplained hypochromic microcytic anemia

Neurology: Encephalopathy (with non-ketotic hypoglycemia and hyperammonia), Unexplained peripheral neuropathy, Abnormal movement, Unexplained myopathy, Abnormal fatigability, epileptic patients taking Valproic acid

Hepatology: Unexplained hepatomegaly in children

Gastroenterology: Patient with gastrointestinal dysmotility

Opathalmology: Pigmented retintopathy

Lab studies: Check serum Carnitine when you have clinical abnormality (as listed above) plus abnormal lab results: e.g.: hypoglycemia without ketones in urine, hyperammonia, increased serum lactate, unexplained increased liver enzymes, increased CPK or unexplained high uric acid in young patients

Treatment: Carnitine supplement may prove to be life saving

Summary: Suspect serum Carnitine deficiency (SCD) in any cases with above clinical presentation. Treatment is life saving in these disorders

In our effort to bring the best of clinical tests to medical practice in Jordan, we would like to announce that this test is available now in Jordan in our lab only

Please contact us for any further inquiries

Dr. Hussam Abu-Farsakh

American Boards of Anatomic and Clinical pathology and Cytopathology

Introduction: Lymphocytosis in BAL specimen can be seen in variety of interstitial lung diseases, and can give indication of the causative of interstitial lung infiltrate. Further, indication of the cause of the disease can be sorted out by performing the CD4/CD8 ratio

:Clinical use

:Diseases this test is of clinical relevance

(Increased CD4/CD8 ratio: Sarcoidosis( a ratio of > 3.5, is specific for sarcoidosis in 93%

Decreased CD4/CD 8 ratio: Hypersensitivity pneumonitis (usually < 0.5) , collagen vascular disease and drug induced lung disease

Normal CD4/CD8 ratio : Tuberculosis, lymphangiosis carcinomatosis

This test now can be performed in our lab on the bronchial lavage specimen by immunohistochemistry

We, in the First Medical Laboratories, are dedicated to bring the best of laboratory medicine in clinical practice to Jordan

Please do not hesitate to contact us for further inquiries

Dr. Hussam Abu-Farsakh

American boards of Anatomic, Clinical Pathology and Cytopathology

Chromogranin A: belongs to a family of secretory proteins that are present in dense-core vesicles of neuroendocrine cells. Owing to its widespread distribution in neuroendocrine tissues, it can be used as an excellent serum marker of neuroendocrine activity because it is co-released with the peptide hormone content of the secretory granules. It has high specificity for detecting neuroendocrine tumors. It also has a high sensitivity to detect small tumor. The concentrationsof �Chromogranin A�, is elevated in 90% of patientswith neuroendocrine tumors. Serum �Chromogranin A� is mostfrequently increased in subjects with gastrinomas (100%), pheochromocytomas(89%), carcinoid tumors (80%), nonfunctioning tumors of theendocrine pancreas (69%), and medullary thyroid carcinomas (50%), small cell carcinomas of the lung (60%) and neuroblastoma in children (92%).The highest serum levels are

observed in subjects with carcinoidtumors. A significantpositive relationship was demonstrated between the tumor loadand serum �Chromogranin A� levels. Mild Elevated concentrationsof �Chromogranin A� has a specificity of 93%. Markedly elevated serum levelsof �Chromogranin A�, exceeding 300 �g/L, has a 98% specificity. If its concentration, in small cell carcinoma, is higher than 65 ng/ml, it is considered a bad independent prognostic marker. �Chromogranin A� is very helpful, not only in screening for neuroendocrine tumor mentioned above, but also is very helpful for detecting early recurrence

In Summary: �Chromogranin A� is the best general neuroendocrineserum marker available. It is very helpful in diagnosing and detecting the following tumors: Carcinoid tumors, pheochromocytoma, gastrinomas, islet cell tumors of the pancreas, medullary carcinoma of the thyroid, small cell carcinoma of the lung and neuroblastoma. It has the highest specificity for thedetection of neuroendocrine tumors compared to the other neuroendocrinemarkers (like NSE). The higher the tumor serum level is, the larger the tumor volume. Its level is important for detecting early recurrence of such tumors

In our effort to bring the best of clinical tests to medical practice in Jordan, we would like to announce that this test is available now in Jordan in our lab only

Please contact us for any further inquiries

Dr. Hussam Abu-Farsakh

American Boards of Anatomic and Clinical pathology and Cytopathology

Ref: Sch�rmann, G: Serum chromogranin A in the diagnosis and follow-up of neuroendocrine tumors of the gastroenteropancreatic tract. World Journal of Surgery 16 (4): pp 697-701

Introduction: Cytogenetics of leukemia is extremely important today for the best diagnosis, treatment and prognosis of leukemia patients

:Examples

:(Acute Lymphoblastic Leukemia (ALL

(Prognosis is best in Hyperdiploid, then t(12;21), then t(1;19-

Patients who have t(12,21) respond very well to chemotherapy-

Patients with t(1,19) have poor prognosis and require bone marrow transplant-

(Adult ALL : Never demonstrate t(12,21) or t(1;19) but many are t(9;22

:(In Acute Myeloid Leukemia (AML

t(8,21) frequent translocation in M2 in adults and carry good prognosis, respond to Ara-C-

Inv 16 (P13;q 22); t(16;16) (usually in M4Eo) responds to Ara-C-

Patients with t(15,17) (seen in M3) respond to regimen ATRA/DNA-

All these genetic markers now govern the treatment modalities of leukemia cases

All these test can now be performed efficiently now in our lab

We, in the First Medical Laboratory, are determined to bring the best of laboratory medicine in clinical practice to Jordan

Please do not hesitate to contact me for further inquires

Dr. Hussam Abu-Farsakh

American boards of Anatomic, Clinical Pathology and Cytopathology

Introduction : patient with degenerative brain disease may present with brain atrophy, mental retardation (usually progressive), seizures and musculoskeletal disorders

The causes of these problems are wide and should involve a wide battery of tests. The panel we suggested below should cover the most common disorders of degenerative brain disease

    (Mucopolysaccharide metabolite test (urine test-

    (Propionic aciduria test (urine test-

    (Isovaleric aciduria test (urine test-

    (Phenyl-ketonuria test (blood and urine test–

    (Glycine metabolite (blood and urine test–

    (Citrullinemia metabolites (blood and urine–

    (Dicarboxylic aciduria test (blood and urine–

    (Glutaric aciduria Miksi pelaisit Casino s4gambling.com/fi/ Eurossa? Koska pohjoismainen laatu seka miljoonien eurojen verottomat rahapelivoitot kiinnostavat sinua taatusti! Ei ole sattumaa, etta Kasino Euro on niin suosittu. test (urine test–

    Metachromatic leukodystrophy test-

    Gangliosidosis (GM1) test-

    Gangliosidosis (GM2) test-

    Mannosidosis test-

    (Carnitine total (blood and urine–

    (Carnitine free (blood and urine–

    (Lactate (blood test–

    (Ammonia (blood test–

We, in the First Medical Laboratory , are determined to bring the best of laboratory medicine in clinical practice to Jordan

Please call us for any further information

.Dr. Hussam Abu-Farsakh, M.D

American boards of Anatomic, clinical pathology & Cytopathology