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Lever M, George PM, Slow S, Bellamy D, Young JM, Ho M, McEntyre CJ, Elmslie JL, Atkinson W, Molyneux SL, Troughton RW, Frampton CM, Richards AM, Chambers ST. Betaine and Trimethylamine-N-Oxide as Predictors of Cardiovascular Outcomes Show Different Patterns in Diabetes Mellitus: An Observational Study. PLoS One 2014; 9:e114969. [PMID: 25493436 PMCID: PMC4262445 DOI: 10.1371/journal.pone.0114969] [Citation(s) in RCA: 171] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Accepted: 11/15/2014] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Betaine is a major osmolyte, also important in methyl group metabolism. Concentrations of betaine, its metabolite dimethylglycine and analog trimethylamine-N-oxide (TMAO) in blood are cardiovascular risk markers. Diabetes disturbs betaine: does diabetes alter associations between betaine-related measures and cardiovascular risk? METHODS Plasma samples were collected from 475 subjects four months after discharge following an acute coronary admission. Death (n = 81), secondary acute MI (n = 87), admission for heart failure (n = 85), unstable angina (n = 72) and all cardiovascular events (n = 283) were recorded (median follow-up: 1804 days). RESULTS High and low metabolite concentrations were defined as top or bottom quintile of the total cohort. In subjects with diabetes (n = 79), high plasma betaine was associated with increased frequencies of events; significantly for heart failure, hazard ratio 3.1 (1.2-8.2) and all cardiovascular events, HR 2.8 (1.4-5.5). In subjects without diabetes (n = 396), low plasma betaine was associated with events; significantly for secondary myocardial infarction, HR 2.1 (1.2-3.6), unstable angina, HR 2.3 (1.3-4.0), and all cardiovascular events, HR 1.4 (1.0-1.9). In diabetes, high TMAO was a marker of all outcomes, HR 2.7 (1.1-7.1) for death, 4.0 (1.6-9.8) for myocardial infarction, 4.6 (2.0-10.7) for heart failure, 9.1 (2.8-29.7) for unstable angina and 2.0 (1.1-3.6) for all cardiovascular events. In subjects without diabetes TMAO was only significant for death, HR 2.7 (1.6-4.8) and heart failure, HR 1.9 (1.1-3.4). Adding the estimated glomerular filtration rate to Cox regression models tended to increase the apparent risks associated with low betaine. CONCLUSIONS Elevated plasma betaine concentration is a marker of cardiovascular risk in diabetes; conversely low plasma betaine concentrations indicate increased risk in the absence of diabetes. We speculate that the difference reflects control of osmolyte retention in tissues. Elevated plasma TMAO is a strong risk marker in diabetes.
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Affiliation(s)
- Michael Lever
- Clinical Biochemistry Unit, Canterbury Health Laboratories, Christchurch, New Zealand
- Department of Pathology, University of Otago Christchurch, Christchurch, New Zealand
- * E-mail:
| | - Peter M. George
- Clinical Biochemistry Unit, Canterbury Health Laboratories, Christchurch, New Zealand
- Department of Pathology, University of Otago Christchurch, Christchurch, New Zealand
| | - Sandy Slow
- Clinical Biochemistry Unit, Canterbury Health Laboratories, Christchurch, New Zealand
- Department of Pathology, University of Otago Christchurch, Christchurch, New Zealand
| | - David Bellamy
- Clinical Biochemistry Unit, Canterbury Health Laboratories, Christchurch, New Zealand
| | - Joanna M. Young
- The Christchurch Heart Institute, Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Markus Ho
- Clinical Biochemistry Unit, Canterbury Health Laboratories, Christchurch, New Zealand
| | | | - Jane L. Elmslie
- Clinical Biochemistry Unit, Canterbury Health Laboratories, Christchurch, New Zealand
| | - Wendy Atkinson
- Clinical Biochemistry Unit, Canterbury Health Laboratories, Christchurch, New Zealand
| | - Sarah L. Molyneux
- Clinical Biochemistry Unit, Canterbury Health Laboratories, Christchurch, New Zealand
| | - Richard W. Troughton
- The Christchurch Heart Institute, Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Christopher M. Frampton
- The Christchurch Heart Institute, Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - A. Mark Richards
- The Christchurch Heart Institute, Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Stephen T. Chambers
- Department of Pathology, University of Otago Christchurch, Christchurch, New Zealand
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Assessment of urinary betaine as a marker of diabetes mellitus in cardiovascular patients. PLoS One 2013; 8:e69454. [PMID: 23936331 PMCID: PMC3735559 DOI: 10.1371/journal.pone.0069454] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 06/09/2013] [Indexed: 01/18/2023] Open
Abstract
Abnormal urinary excretion of betaine has been demonstrated in patients with diabetes or metabolic syndrome. We aimed to identify the main predictors of excretion in cardiovascular patients and to make initial assessment of its feasibility as a risk marker of future diabetes development. We used data from 2396 patients participating in the Western Norway B-vitamin Intervention Trial, who delivered urine and blood samples at baseline, and in the majority at two visits during follow-up of median 39 months. Betaine in urine and plasma were measured by liquid-chromatography-tandem mass spectrometry. The strongest determinants of urinary betaine excretion by multiple regression were diabetes mellitus, age and estimated glomerular filtration rate; all p<0.001. Patients with diabetes mellitus (n = 264) had a median excretion more than three times higher than those without. We found a distinct non-linear association between urinary betaine excretion and glycated hemoglobin, with a break-point at 6.5%, and glycated hemoglobin was the strongest determinant of betaine excretion in patients with diabetes mellitus. The discriminatory power for diabetes mellitus corresponded to an area under the curve by receiver-operating characteristics of 0.82, and betaine excretion had a coefficient of reliability of 0.73. We also found a significant, independent log-linear relation between baseline betaine excretion and the risk of developing new diabetes during follow-up. The good discriminatory power for diabetes, high test-retest stability and independent association with future risk of new diabetes should motivate further investigation on the role of betaine excretion in risk assessment and long-term follow-up of diabetes mellitus.
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Variability of plasma and urine betaine in diabetes mellitus and its relationship to methionine load test responses: an observational study. Cardiovasc Diabetol 2012; 11:34. [PMID: 22510294 PMCID: PMC3395555 DOI: 10.1186/1475-2840-11-34] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Accepted: 04/17/2012] [Indexed: 11/23/2022] Open
Abstract
Background Since betaine is an osmolyte and methyl donor, and abnormal betaine loss is common in diabetes mellitus (>20% patients), we investigated the relationship between betaine and the post-methionine load rise in homocysteine, in diabetes and control subjects. The post-methionine load test is reported to be both an independent vascular risk factor and a measure of betaine sufficiency. Methods Patients with type 2 diabetes (n = 34) and control subjects (n = 17) were recruited. We measured baseline fasting plasma and 4-hour post-methionine load (L-methionine, 0.1 mg/kg body weight) concentrations of homocysteine, betaine, and the betaine metabolite N,N-dimethylglycine. Baseline urine excretions of betaine, dimethylglycine and glucose were measured on morning urine samples as the ratio to urine creatinine. Statistical determinants of the post-methionine load increase in homocysteine were identified in multiple linear regression models. Results Plasma betaine concentrations and urinary betaine excretions were significantly (p < 0.001) more variable in the subjects with diabetes compared with the controls. Dimethylglycine excretion (p = 0.00014) and plasma dimethylglycine concentrations (p = 0.039) were also more variable. In diabetes, plasma betaine was a significant negative determinant (p < 0.001) of the post-methionine load increase in homocysteine. However, it was not conclusive that this was different from the relationship in the controls. In the patients with diabetes, a strong relationship was found between urinary betaine excretion and urinary glucose excretion (but not with plasma glucose). Conclusions Both high and low plasma betaine concentrations, and high and low urinary betaine excretions, are more prevalent in diabetes. The availability of betaine affects the response in the methionine load test. The benefits of increasing betaine intake should be investigated.
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Lever M, George PM, Elmslie JL, Atkinson W, Slow S, Molyneux SL, Troughton RW, Richards AM, Frampton CM, Chambers ST. Betaine and secondary events in an acute coronary syndrome cohort. PLoS One 2012; 7:e37883. [PMID: 22649561 PMCID: PMC3359285 DOI: 10.1371/journal.pone.0037883] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 04/26/2012] [Indexed: 12/31/2022] Open
Abstract
Background Betaine insufficiency is associated with unfavourable vascular risk profiles in metabolic syndrome patients. We investigated associations between betaine insufficiency and secondary events in acute coronary syndrome patients. Methods Plasma (531) and urine (415) samples were collected four months after discharge following an acute coronary event. Death (34), secondary acute myocardial infarction (MI) (70) and hospital admission for heart failure (45) events were recorded over a median follow-up of 832 days. Principal Findings The highest and lowest quintiles of urinary betaine excretion associated with risk of heart failure (p = 0.0046, p = 0.013 compared with middle 60%) but not with subsequent acute MI. The lowest quintile of plasma betaine was associated with subsequent acute MI (p = 0.014), and the top quintile plasma betaine with heart failure (p = 0.043), especially in patients with diabetes (p<0.001). Top quintile plasma concentrations of dimethylglycine (betaine metabolite) and top quintile plasma homocysteine both associated with all three outcomes, acute MI (p = 0.004, <0.001), heart failure (p = 0.027, p<0.001) and survival (p<0.001, p<0.001). High homocysteine was associated with high or low betaine excretion in >60% of these subjects (p = 0.017). Median NT-proBNP concentrations were lowest in the middle quintile of plasma betaine concentration (p = 0.002). Conclusions Betaine insufficiency indicates increased risk of secondary heart failure and acute MI. Its association with elevated homocysteine may partly explain the disappointing results of folate supplementation. In some patients, especially with diabetes, elevated plasma betaine also indicates increased risk.
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Affiliation(s)
- Michael Lever
- Clinical Biochemistry Unit, Canterbury Health Laboratories, Christchurch, New Zealand.
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Lever M, George PM, Atkinson W, Elmslie JL, Slow S, Molyneux SL, Troughton RW, Richards AM, Frampton CM, Chambers ST. The contrasting relationships between betaine and homocysteine in two clinical cohorts are associated with plasma lipids and drug treatments. PLoS One 2012; 7:e32460. [PMID: 22396767 PMCID: PMC3292573 DOI: 10.1371/journal.pone.0032460] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2011] [Accepted: 01/26/2012] [Indexed: 12/31/2022] Open
Abstract
Background Urinary betaine excretion positively correlated with plasma homocysteine in outpatients attending a lipid disorders clinic (lipid clinic study). We aimed to confirm this in subjects with established vascular disease. Methods The correlation between betaine excretion and homocysteine was compared in samples collected from subjects 4 months after hospitalization for an acute coronary episode (ACS study, 415 urine samples) and from 158 sequential patients visiting a lipid disorders clinic. Principal findings In contrast to the lipid clinic study, betaine excretion and plasma homocysteine did not correlate in the total ACS cohort. Differences between the patient groups included age, non-HDL cholesterol and medication. In ACS subjects with below median betaine excretion, excretion correlated (using log transformed data) negatively with plasma homocysteine (r = −0.17, p = 0.019, n = 199), with no correlation in the corresponding subset of the lipid clinic subjects. In ACS subjects with above median betaine excretion a positive trend (r = +0.10) between betaine excretion and homocysteine was not significant; the corresponding correlation in lipid clinic subjects was r = +0.42 (p = 0.0001). In ACS subjects, correlations were stronger when plasma non-HDL cholesterol and betaine excretion were above the median, r = +0.20 (p = 0.045); in subjects above median non-HDL cholesterol and below median betaine excretion, r = −0.26 (p = 0.012). ACS subjects taking diuretics or proton pump inhibitors had stronger correlations, negative with lower betaine excretion and positive with higher betaine excretion. Conclusions Betaine excretion correlates with homocysteine in subjects with elevated blood lipids.
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Affiliation(s)
- Michael Lever
- Canterbury Health Laboratories, Clinical Biochemistry Unit, Christchurch, New Zealand.
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Lever M, Slow S. The clinical significance of betaine, an osmolyte with a key role in methyl group metabolism. Clin Biochem 2010; 43:732-44. [DOI: 10.1016/j.clinbiochem.2010.03.009] [Citation(s) in RCA: 273] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2010] [Revised: 03/16/2010] [Accepted: 03/17/2010] [Indexed: 01/29/2023]
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Craig SS, Craig SA, Ganio MS, Maresh CM, Horrace G, da Costa KA, Zeisel SH. The betaine content of sweat from adolescent females. J Int Soc Sports Nutr 2010; 7:3. [PMID: 20205750 PMCID: PMC2822829 DOI: 10.1186/1550-2783-7-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2009] [Accepted: 01/22/2010] [Indexed: 11/25/2022] Open
Abstract
Background This study was developed to establish whether betaine was present in the sweat of females and to determine any correlations with other sweat components. Methods Sweat patches were placed on eight trained adolescent Highland dancers (age = 13.6 ± 2.3 yr), who then participated in a dance class for 2 hours. Patches were removed, and the sweat recovered via centrifugation. The sweat was subsequently analyzed for betaine, choline, sodium, potassium, chloride, lactate, glucose, urea and ammonia. Results Betaine was present in the sweat of all subjects (232 ± 84 μmol·L-1), which is higher than typically found in plasma. The concentration of several sweat components were correlated, in particular betaine with most other measured components. Conclusion Betaine, an osmoprotectant and methyl donor, is a component of sweat that may be lost from the body in significant amounts.
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Lever M, Atkinson W, Slow S, Chambers ST, George PM. Plasma and urine betaine and dimethylglycine variation in healthy young male subjects. Clin Biochem 2009; 42:706-12. [PMID: 19217890 DOI: 10.1016/j.clinbiochem.2009.02.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2008] [Revised: 02/03/2009] [Accepted: 02/03/2009] [Indexed: 10/21/2022]
Abstract
OBJECTIVES We aimed to compare the individuality (within subject consistency) of plasma and urine betaine and N,N-dimethylglycine. DESIGN AND METHODS In two separate groups of 8 males (ages 19 to 40), plasma (10) and urine (6) samples were collected either over a single day or over an 8 week period. The individuality of the betaine and N,N-dimethylglycine plasma concentrations and excretions were estimated by one-way repeated measures analysis of variance. The reliability coefficients and indices of individuality were calculated. The between-subject variation in the study population was compared with that in a normal population (n=192 for plasma, 205 for urine). RESULTS Plasma betaine concentrations were significantly different between subjects over 24 h and 8 weeks (p<0.00001). Plasma dimethylglycine concentrations were different over 24 h. Urine betaine and dimethylglycine excretions were different in both (p<0.0001). Betaine was more individual than dimethylglycine in both plasma and urine. Compared with a normal healthy population, the between-subject variation in plasma betaine was less (p<0.001) in the study group, but similar for dimethylglycine and for urine betaine. CONCLUSIONS Plasma betaine and urinary betaine excretions are more individual than dimethylglycine. Plasma and urine betaine are highly individual in the general population.
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Affiliation(s)
- Michael Lever
- Biochemistry Unit, Canterbury Health Laboratories, Christchurch, New Zealand.
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Atkinson W, Elmslie J, Lever M, Chambers ST, George PM. Dietary and supplementary betaine: acute effects on plasma betaine and homocysteine concentrations under standard and postmethionine load conditions in healthy male subjects. Am J Clin Nutr 2008; 87:577-85. [PMID: 18326594 DOI: 10.1093/ajcn/87.3.577] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Betaine comes from the diet and from choline, and it is associated with vascular disease in some patient groups. Betaine supplementation lowers plasma total homocysteine. OBJECTIVE We compared the acute effects of dietary and supplementary betaine and choline on plasma betaine and homocysteine under standard conditions and after a methionine load. DESIGN In a randomized crossover study, 8 healthy men (19-40 y) consumed a betaine supplement (approximately 500 mg), high-betaine meal (approximately 517 mg), choline supplement (500 mg), high-choline meal (approximately 564 mg), high-betaine and -choline meal (approximately 517 mg betaine, approximately 622 mg choline), or a low-betaine and -choline control meal under standard conditions or postmethionine load. Plasma betaine, dimethylglycine, and homocysteine concentrations were measured hourly for 8 h and at 24 h after treatment. RESULTS Dietary and supplementary betaine raised plasma betaine concentrations relative to control (P < 0.001) under standard conditions. This was not associated with raised plasma dimethylglycine concentration, and no significant betaine appeared in the urine. A small increase in dimethylglycine excretion was observed when either betaine or choline was supplied (P = 0.011 and < 0.001). Small decreases in plasma homocysteine 6 h after ingestion under standard conditions (P < or = 0.05) were detected after a high-betaine meal and after a high-betaine and high-choline meal. Dietary betaine and choline and betaine supplementation attenuated the increase in plasma homocysteine at both 4 and 6 h after a methionine load (P < or = 0.001). CONCLUSIONS Dietary betaine and supplementary betaine acutely increase plasma betaine, and they and choline attenuate the postmethionine load rise in homocysteine concentrations.
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Affiliation(s)
- Wendy Atkinson
- Clinical Biochemistry Unit, Canterbury Health Laboratories, Christchurch, New Zealand
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Yantasee W, Hongsirikarn K, Warner CL, Choi D, Sangvanich T, Toloczko MB, Warner MG, Fryxell GE, Addleman RS, Timchalk C. Direct detection of Pb in urine and Cd, Pb, Cu, and Ag in natural waters using electrochemical sensors immobilized with DMSA functionalized magnetic nanoparticles. Analyst 2008; 133:348-55. [DOI: 10.1039/b711199a] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Lever M, Atkinson W, George PM, Chambers ST. Sex differences in the control of plasma concentrations and urinary excretion of glycine betaine in patients attending a lipid disorders clinic. Clin Biochem 2007; 40:1225-31. [PMID: 17706956 DOI: 10.1016/j.clinbiochem.2007.05.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2007] [Revised: 05/22/2007] [Accepted: 05/23/2007] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To find whether the control of betaine metabolism differs between male and female patients and identify the effects of insulin and other hormones. DESIGN AND METHODS Data from non-diabetic lipid clinic patients (82 female symbol and 76 male symbol) were re-analyzed by sex. Data on insulin, thyroid hormones and leptin were included in models to identify factors affecting the circulation and excretion of betaine and its metabolites. RESULTS Different factors influenced plasma concentrations and urinary excretion of betaine, dimethylglycine and homocysteine in males and females. In males, apolipoprotein B (negative), thyroid stimulating hormone (positive) and insulin (negative) predicted circulating betaine, consistent with betaine-homocysteine methyltransferase mediated control. In females, insulin positively predicted plasma dimethylglycine. Urinary betaine excretion positively predicted circulating homocysteine in males (p<0.001), whereas dimethylglycine excretion (also indicating betaine loss) was a stronger positive predictor (p<0.001) in females. Carnitine affected betaine homeostasis. CONCLUSIONS Betaine metabolism is under endocrine control, and studies should use sex stratified groups.
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Affiliation(s)
- Michael Lever
- Clinical Biochemistry Unit, Canterbury Health Laboratories, Christchurch, New Zealand.
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Lever M, Atkinson W, George PM, Chambers ST. An abnormal urinary excretion of glycine betaine may persist for years. Clin Biochem 2007; 40:798-801. [PMID: 17490630 DOI: 10.1016/j.clinbiochem.2007.03.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2007] [Accepted: 03/14/2007] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Does abnormal betaine excretion persist? DESIGN AND METHODS Patients (10) with abnormal excretion in 1998 were recalled in 2005. Subsequent urine samples were collected on 4 days from persistently abnormal subjects. RESULTS Half the 1998 abnormal patients were abnormal in 2005. Only 1/20 controls was abnormal (p=0.015). All patients with abnormal excretion in 1998 and 2005 had abnormal excretion on successive days while no controls did. CONCLUSIONS High betaine excretion may be chronic and a health risk.
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Affiliation(s)
- Michael Lever
- Clinical Biochemistry Unit, Canterbury Health Laboratories, Christchurch School of Medicine and Health Sciences, Christchurch, New Zealand.
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