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Civil R, Dolan E, Swinton PA, Santos L, Varley I, Atherton PJ, Elliott-Sale KJ, Sale C. P1NP and β-CTX-1 Responses to a Prolonged, Continuous Running Bout in Young Healthy Adult Males: A Systematic Review with Individual Participant Data Meta-analysis. SPORTS MEDICINE - OPEN 2023; 9:85. [PMID: 37725246 PMCID: PMC10509102 DOI: 10.1186/s40798-023-00628-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 08/12/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Circulating biomarkers of bone formation and resorption are widely used in exercise metabolism research, but their responses to exercise are not clear. This study aimed to quantify group responses and inter-individual variability of P1NP and β-CTX-1 after prolonged, continuous running (60-120 min at 65-75% V̇O2max) in young healthy adult males using individual participant data (IPD) meta-analysis. METHODS The protocol was designed following PRISMA-IPD guidelines and was pre-registered on the Open Science Framework prior to implementation ( https://osf.io/y69nd ). Changes in P1NP and β-CTX-1 relative to baseline were measured during, immediately after, and in the hours and days following exercise. Typical hourly and daily variations were estimated from P1NP and β-CTX-1 changes relative to baseline in non-exercise (control) conditions. Group responses and inter-individual variability were quantified with estimates of the mean and standard deviation of the difference, and the proportion of participants exhibiting an increased response. Models were conducted within a Bayesian framework with random intercepts to account for systematic variation across studies. RESULTS P1NP levels increased during and immediately after running, when the proportion of response was close to 100% (75% CrI: 99 to 100%). P1NP levels returned to baseline levels within 1 h and over the next 4 days, showing comparable mean and standard deviation of the difference with typical hourly (0.1 ± 7.6 ng·mL-1) and daily (- 0.4 ± 5.7 ng·mL-1) variation values. β-CTX-1 levels decreased during and up to 4 h after running with distributions comparable to typical hourly variation (- 0.13 ± 0.11 ng·mL-1). There was no evidence of changes in β-CTX-1 levels during the 4 days after the running bout, when distributions were also similar between the running data and typical daily variation (- 0.03 ± 0.10 ng·mL-1). CONCLUSION Transient increases in P1NP were likely biological artefacts (e.g., connective tissue leakage) and not reflective of bone formation. Comparable small decreases in β-CTX-1 identified in both control and running data, suggested that these changes were due to the markers' circadian rhythm and not the running intervention. Hence, prolonged continuous treadmill running did not elicit bone responses, as determined by P1NP and β-CTX-1, in this population.
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Affiliation(s)
- Rita Civil
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom.
- Musculoskeletal Physiology Research Group, Sport, Health and Performance Enhancement (SHAPE) Research Centre, School of Science and Technology, Nottingham Trent University, Nottingham, United Kingdom.
| | - Eimear Dolan
- Applied Physiology and Nutrition Research Group, School of Physical Education and Sport, Rheumatology Division; Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, Brazil
| | - Paul A Swinton
- School of Health Sciences, Robert Gordon University, Aberdeen, UK
| | - Lívia Santos
- Musculoskeletal Physiology Research Group, Sport, Health and Performance Enhancement (SHAPE) Research Centre, School of Science and Technology, Nottingham Trent University, Nottingham, United Kingdom
| | - Ian Varley
- Musculoskeletal Physiology Research Group, Sport, Health and Performance Enhancement (SHAPE) Research Centre, School of Science and Technology, Nottingham Trent University, Nottingham, United Kingdom
| | - Philip J Atherton
- Centre of Metabolism, Ageing and Physiology (CMAP), MRC-Versus Arthritis Centre of Excellence for Musculoskeletal Ageing Research, Nottingham NIHR Biomedical Research Centre, School of Medicine, University of Nottingham, Derby, United Kingdom
| | - Kirsty J Elliott-Sale
- Musculoskeletal Physiology Research Group, Sport, Health and Performance Enhancement (SHAPE) Research Centre, School of Science and Technology, Nottingham Trent University, Nottingham, United Kingdom
- Department of Sport and Exercise Sciences, Institute of Sport, Manchester Metropolitan University, Manchester, United Kingdom
| | - Craig Sale
- Musculoskeletal Physiology Research Group, Sport, Health and Performance Enhancement (SHAPE) Research Centre, School of Science and Technology, Nottingham Trent University, Nottingham, United Kingdom
- Department of Sport and Exercise Sciences, Institute of Sport, Manchester Metropolitan University, Manchester, United Kingdom
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Lan YS, Feng YJ. The volume of brisk walking is the key determinant of BMD improvement in premenopausal women. PLoS One 2022; 17:e0265250. [PMID: 35294490 PMCID: PMC8926180 DOI: 10.1371/journal.pone.0265250] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 02/25/2022] [Indexed: 11/18/2022] Open
Abstract
SUMMARY Osteoporosis is an increasing health problem in postmenopausal women. Our findings indicated that long-term brisk walking with a volume greater than 16 per week is effective for improving BMD in premenopausal women. PURPOSE To examine the effects of brisk walking on bone mineral density (BMD) in premenopausal women, and further determine the effective frequency, intensity, time and volume (frequency x duration) of brisk walking for training strategy prescription. METHODS 222 healthy premenopausal women were recruited for BMD measurement. According to the survey of their physical activity level, 84 subjects (age: 46±1.8) whose physical activity index ≥40 were categorized into the brisk walking group, and 138 subjects (age: 47±2.2) whose physical activity index <40 were assigned to the sedentary group. The BMD of these two groups were statistically compared with an independent t test. Next, 35 subjects from the original sedentary group were recruited for BMD measurement after 2-year moderate brisk walking. According to the volume of physical activity per week, they were divided into the control group (n = 10, aged 49±0.9), volume 8 group (n = 4, aged 48±1.2), volume 12 group (n = 7, aged 49±1.4), volume 16 group (n = 8, aged 49±1.3), and volume 20 group (n = 6, aged 49±1.5). ANOVA was used to analyze BMD before and after brisk walking among the five groups. RESULTS The BMD in the brisk walking group (1.00±0.008 g/cm2) was significantly higher than that in the sedentary group (0.89±0.008 g/cm2) (P<0.001). Stepwise regression analysis revealed that the volume of brisk walking was significantly correlated with BMD (P<0.001). In particular, brisk walking with a volume greater than 16 (a score of duration up to 4 and a score of frequency up to 4 or 5) per week is effective for improving BMD in premenopausal women (P = 0.03, P = 0.002, respectively). CONCLUSIONS Long-term brisk walking is an efficient way to improve BMD. Taking brisk walks for 30 minutes per day 3 or more times per week (volume>16) is recommended to prevent bone loss in premenopausal women.
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Affiliation(s)
- Yong-Sheng Lan
- School of Physical Education, Changchun Normal University, Changchun, Jilin, China
- * E-mail:
| | - Yu-Juan Feng
- Shandong University of Art and Design, Jinan, Shandong, China
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Gombos GC, Bajsz V, Pék E, Schmidt B, Sió E, Molics B, Betlehem J. Direct effects of physical training on markers of bone metabolism and serum sclerostin concentrations in older adults with low bone mass. BMC Musculoskelet Disord 2016; 17:254. [PMID: 27278385 PMCID: PMC4899888 DOI: 10.1186/s12891-016-1109-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 06/01/2016] [Indexed: 02/07/2023] Open
Abstract
Background Both gravitational loading and the forces generated by muscle contraction have direct effects on serum markers of bone metabolism. The object of this study was to examine the direct effects of a single session of resistance exercise or walking on biochemical markers of bone metabolism in participants with low bone mass. Methods A total of 150 otherwise healthy female subjects (mean age = 59.1 ± 7.1 years) diagnosed with osteoporosis or osteopenia were randomly allocated to either a resistance exercise group (RG; n = 50), walking group (WG; n = 50), or control group (CG; n = 50). Changes in bone-specific alkaline phosphatase (BALP), carboxy-terminal cross-linked telopeptide of type I collagen (CTX), and serum sclerostin concentrations were measured before and immediately after a single exercise intervention. Results There was no significant change in BALP values in any of the groups. Sclerostin levels increased in the RG and WG, and there was significant difference between the WG and CG after the exercise intervention (P < 0.01). In contrast, the changes in CTX concentrations from baseline were significant in the RG (P < 0.01) but not in the WG (P = 0.11), and there was a significant difference between resistance exercise and walking (P < 0.01). Conclusions In participants with low bone mass, resistance exercise influenced the serum concentrations of CTX, a marker of bone resorption, but walking did not. Trial registration Current Controlled Trials ISRCTN16329455; retrospectively registered on 05/05/2016.
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Affiliation(s)
| | - Viktória Bajsz
- University of Pécs, Faculty of Health Sciences, 33 Landorhegyi Road, Zalaegerszeg, 8900, Hungary
| | - Emese Pék
- University of Pécs, Faculty of Health Sciences, 33 Landorhegyi Road, Zalaegerszeg, 8900, Hungary
| | - Béla Schmidt
- University of Pécs, Faculty of Health Sciences, 33 Landorhegyi Road, Zalaegerszeg, 8900, Hungary
| | - Eszter Sió
- University of Pécs, Faculty of Health Sciences, 33 Landorhegyi Road, Zalaegerszeg, 8900, Hungary
| | - Bálint Molics
- University of Pécs, Faculty of Health Sciences, 33 Landorhegyi Road, Zalaegerszeg, 8900, Hungary
| | - József Betlehem
- University of Pécs, Faculty of Health Sciences, 33 Landorhegyi Road, Zalaegerszeg, 8900, Hungary
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Centi AJ, Booth SL, Gundberg CM, Saltzman E, Nicklas B, Shea MK. Osteocalcin carboxylation is not associated with body weight or percent fat changes during weight loss in post-menopausal women. Endocrine 2015; 50:627-32. [PMID: 25963022 PMCID: PMC4643414 DOI: 10.1007/s12020-015-0618-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Accepted: 04/27/2015] [Indexed: 12/28/2022]
Abstract
Osteocalcin (OC) is a vitamin K-dependent bone protein used as a marker of bone formation. Mouse models have demonstrated a role for the uncarboxylated form of OC (ucOC) in energy metabolism, including energy expenditure and adiposity, but human data are equivocal. The purpose of this study was to determine the associations between changes in measures of OC and changes in body weight and percent body fat in obese, but otherwise healthy post-menopausal women undergoing a 20-week weight loss program. All participants received supplemental vitamins K and D and calcium. Body weight and body fat percentage (%BF) were assessed before and after the intervention. Serum OC [(total (tOC), ucOC, percent uncarboxylated (%ucOC)], and procollagen type 1N-terminal propeptide (P1NP; a measure of bone formation) were measured. Women lost an average of 10.9 ± 3.9 kg and 4 %BF. Serum concentrations of tOC, ucOC, %ucOC, and P1NP did not significantly change over the twenty-week intervention, nor were these measures associated with changes in weight (all p > 0.27) or %BF (all p > 0.54). Our data do not support an association between any serum measure of OC and weight or %BF loss in post-menopausal women supplemented with nutrients implicated in bone health.
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Affiliation(s)
- Amanda J Centi
- Human Nutrition Research Center on Aging, Tufts University, 711 Washington Street, Boston, MA, 02111, USA
| | - Sarah L Booth
- Human Nutrition Research Center on Aging, Tufts University, 711 Washington Street, Boston, MA, 02111, USA.
| | | | - Edward Saltzman
- Human Nutrition Research Center on Aging, Tufts University, 711 Washington Street, Boston, MA, 02111, USA
| | - Barbara Nicklas
- Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - M Kyla Shea
- Human Nutrition Research Center on Aging, Tufts University, 711 Washington Street, Boston, MA, 02111, USA
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Assessment of lumbar vertebrae morphology by magnetic resonance imaging in osteoporosis. Skeletal Radiol 2012; 41:1583-90. [PMID: 22592591 DOI: 10.1007/s00256-012-1435-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Revised: 04/20/2012] [Accepted: 04/24/2012] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To investigate the lumbar spinal morphology in patients with and without osteoporosis by comparing the endplate changes, intervertebral disc changes, and vertebral heights. DESIGN This is a retrospective study. Medical records of the 3,530 patients admitted to the Physical Medicine and Rehabilitation outpatient clinics with low back pain between August 2010 and August 2011 were retrospectively reviewed. A total of 64 patients of whom 57 were females (89.1 %) and seven were males (10.9 %) were included in the study. Participants were divided into an osteoporosis group, an osteopenia group, and a nonosteoporotic control group, according to bone mineral densities. RESULTS In this study, mid heights of L3, L4, and L5 vertebrae were found to be higher in the normal group than in both the osteopenic and osteoporotic groups. Mid part heights of L1-2, L2-3, and L5-S1 intervertebral discs were significantly lower in the normal group when compared to the osteopenic and osteoporotic groups. End-plate marrow abnormality was detected in L1 lower end plate in 75 % of normal subjects, 40.6 % of osteopenics, and 25 % of osteoporotics. Statistically significant difference in the presence of Schmorl nodes in L5 vertebra lower end plates was present between groups; 58.3 % of normals, 34.4 % of osteopenics and 15 % of osteoporotics had Schmorl nodes in L5 vertebra lower end plates. There was a significant difference regarding disc degeneration and intradiscal gas presence in L5-S1 intervertebral discs between groups; 66.7 % of normals, 28.1 % of osteopenics, and 25 % of osteoporotics had severe disc degeneration and intradiscal gas was present in L5-S1 intervertebral discs. CONCLUSIONS Significant changes in morphology of the lumbar spine and intervertebral discs were found. It was revealed that the effects of osteoporosis are not limited to the bone but also present in the intervertebral discs. Mid heights of intervertebral discs were higher in the osteoporotic and osteopenic groups when compared to normal subjects along with the lowered mid heights of lumbar vertebrae. It was also observed that stronger vertebral bones were associated with more disc and vertebral degeneration.
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Scott JPR, Sale C, Greeves JP, Casey A, Dutton J, Fraser WD. Effect of fasting versus feeding on the bone metabolic response to running. Bone 2012; 51:990-9. [PMID: 22960044 DOI: 10.1016/j.bone.2012.08.128] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Revised: 07/30/2012] [Accepted: 08/22/2012] [Indexed: 11/16/2022]
Abstract
Individuals often perform exercise in the fasted state, but the effects on bone metabolism are not currently known. We compared the effect of an overnight fast with feeding a mixed meal on the bone metabolic response to treadmill running. Ten, physically-active males aged 28 ± 4y (mean ±SD) completed two, counterbalanced, 8d trials. After 3d on a standardised diet, participants performed 60 min of treadmill running at 65% VO(2max) on Day 4 following an overnight fast (FAST) or a standardised breakfast (FED). Blood samples were collected at baseline, before and during exercise, for 3h after exercise, and on four consecutive follow-up days (FU1-FU4). Plasma/serum were analysed for the c-terminal telopeptide region of collagen type 1 (β-CTX), n-terminal propeptides of procollagen type 1 (P1NP), osteocalcin (OC), bone alkaline phosphatase (bone ALP), parathyroid hormone (PTH), albumin-adjusted calcium, phosphate, osteoprotegerin (OPG), cortisol, leptin and ghrelin. Only the β-CTX response was significantly affected by feeding. Pre-exercise concentrations decreased more in FED compared with FAST (47% vs 26%, P<0.001) but increased during exercise in both groups and were not significantly different from baseline at 1h post-exercise. At 3h post-exercise, concentrations were decreased (33%, P<0.001) from baseline in FAST and significantly lower (P<0.001) than in FED. P1NP and PTH increased, and OC decreased during exercise. Bone markers were not significantly different from baseline on FU1-FU4. Fasting had only a minor effect on the bone metabolic response to subsequent acute, endurance exercise, reducing the duration of the increase in β-CTX during early recovery, but having no effect on changes in bone formation markers. The reduced duration of the β-CTX response with fasting was not fully explained by changes in PTH, OPG, leptin or ghrelin.
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Moghadasi M, Siavashpour S. The effect of 12 weeks of resistance training on hormones of bone formation in young sedentary women. Eur J Appl Physiol 2012; 113:25-32. [PMID: 22562545 DOI: 10.1007/s00421-012-2410-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2011] [Accepted: 04/18/2012] [Indexed: 10/28/2022]
Abstract
Physical activity has been proposed as one strategy to enhance bone mineral acquisition; however, the basic mechanisms of this effect are not fully understood. The purpose of this study was to investigate the effect of 12 weeks of resistance training on hormones of bone formation in young sedentary women. Twenty sedentary females (aged 25.3 ± 3.2 years; ±SD) volunteered to participate in this study. The subjects were randomly assigned to a training group (n = 10) or control group (n = 10). Subjects executed eight resistance exercises selected to stress the major muscle groups in the following order: chest press, leg extension, shoulder press, leg curls, latissimus pull down, leg press, arm curls, and triceps extension. Resistance training consisted of 50-60 min of circuit weight training per day, 3 days a week, for 12 weeks. This training was circularly performed in eight stations and included two to four sets with 8-12 maximal repetitions at 65-80 % of one-repetition maximum in each station. After 12 weeks, the training group had a significant increase (P < 0.05) in the growth hormone, estrogen, parathyroid hormone and testosterone compared to the control group. The results showed that insulin-like growth factor I levels did not change significantly in response to resistance training. In conclusion, the results suggest that resistance training with specific intensity and duration utilized in this study increases the hormones of bone formation in young sedentary women.
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Affiliation(s)
- Mehrzad Moghadasi
- Department of Exercise Physiology, Shiraz Branch, Islamic Azad University, Shiraz, Iran.
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Acute effects of plyometric jumping and intermittent running on serum bone markers in young males. Eur J Appl Physiol 2011; 112:1475-84. [PMID: 21837450 DOI: 10.1007/s00421-011-2108-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Accepted: 07/28/2011] [Indexed: 10/17/2022]
Abstract
The purpose of this study was to investigate whether different modes of single-bout exercise would cause different responses in short-term bone metabolism. 24 untrained male college students (19.1 ± 0.1 years old) were recruited and randomly assigned to three groups: (1) a single-bout plyometric exercise group (the PL group, n = 8), (2) a 200-meter × 10 intermittent running group (the IR group, n = 8) and (3) a sedentary control group, which followed the same time schedule of experimentation without performing any exercise (the CON group, n = 8). Serial blood samples were collected before (baseline) and 5 min, 15 min, 1 h, 3 h, 6 h, 24 h, 48 h, and 72 h after exercise trials. Within 15 min of exercise, the PL and IR groups showed significantly higher serum phosphorus than did the control group (P < 0.05). Osteocalcin levels were significantly higher in the PL group at 5 min and 1 h after exercise (P < 0.05), while serum tartrate-resistant acid phosphatase (TRAP) showed no differences among groups. Exercises with different mechanical impact levels responded differently in serum bone formation markers as shown by osteocalcin. Because the increase in osteocalcin in the PL group was revealed shortly after the exercise bout, the changes might due to an exercise-induced mechanical impact rather than bone cellular activities.
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Levinger I, Zebaze R, Jerums G, Hare DL, Selig S, Seeman E. The effect of acute exercise on undercarboxylated osteocalcin in obese men. Osteoporos Int 2011; 22:1621-6. [PMID: 20734028 DOI: 10.1007/s00198-010-1370-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2010] [Accepted: 08/03/2010] [Indexed: 12/21/2022]
Abstract
SUMMARY The purpose of this study was to examine if the reduction in glucose post-exercise is mediated by undercarboxylated osteocalcin (unOC). Obese men were randomly assigned to do aerobic or power exercises. The change in unOC levels was correlated with the change in glucose levels post-exercise. The reduction in glucose post-acute exercise may be partly related to increased unOC. INTRODUCTION Osteocalcin (OC) in its undercarboxylated (unOC) form may contribute to the regulation of glucose homeostasis. As exercise reduces serum glucose and improves insulin sensitivity in obese individuals and individuals with type 2 diabetes (T2DM), we hypothesised that this benefit was partly mediated by unOC. METHODS Twenty-eight middle-aged (52.4 ± 1.2 years, mean ± SEM), obese (BMI = 32.1 ± 0.9 kg m(-2)) men were randomly assigned to do either 45 min of aerobic (cycling at 75% of VO(2peak)) or power (leg press at 75% of one repetition maximum plus jumping sequence) exercises. Blood samples were taken at baseline and up to 2 h post-exercise. RESULTS At baseline, unOC was negatively correlated with glucose levels (r = -0.53, p = 0.003) and glycosylated haemoglobin (HbA1c) (r = -0.37, p = 0.035). Both aerobic and power exercises reduced serum glucose (from 7.4 ± 1.2 to 5.1 ± 0.5 mmol L(-1), p = 0.01 and 8.5 ± 1.2 to 6.0 ± 0.6 mmol L(-1), p = 0.01, respectively). Aerobic exercise significantly increased OC, unOC and high-molecular-weight adiponectin, while power exercise had a limited effect on OC and unOC. Overall, those with higher baseline glucose and HbA1c had greater reductions in glucose levels after exercise (r = -0.46, p = 0.013 and r = -0.43, p = 0.019, respectively). In a sub-group of obese people with T2DM, the percentage change in unOC levels was correlated with the percentage change in glucose levels post-exercise (r = -0.51, p = 0.038). CONCLUSIONS This study reports that the reduction in serum glucose post-acute exercise (especially aerobic exercise) may be partly related to increased unOC.
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Affiliation(s)
- I Levinger
- Institute for Sport, Exercise and Active Living, School of Sport and Exercise Science, Victoria University, Melbourne, Australia.
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Herrmann M, Müller M, Scharhag J, Sand-Hill M, Kindermann W, Herrmann W. The effect of endurance exercise-induced lactacidosis on biochemical markers of bone turnover. ACTA ACUST UNITED AC 2007; 45:1381-9. [PMID: 17727311 DOI: 10.1515/cclm.2007.282] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
AbstractClin Chem Lab Med 2007;45:1381–9.
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Affiliation(s)
- Markus Herrmann
- Department of Clinical Chemistry and Laboratory Medicine, University Hospital of Saarland, Homburg/Saar, Germany.
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