Cardiac markers of acute coronary syndromes: is there a case for point-of-care testing?

Aptamer-based surface-enhanced resonance Raman scattering assay on a paper fluidic platform for detection of cardiac troponin I

SIGNIFICANCE

Cardiac troponin I (cTnI) is a primary biomarker for diagnosis of myocardial infarction (MI). In contrast to central laboratory tests for cTnI, point-of-care (POC) testing has the advantage of providing results when the patient is first encountered, which helps high-risk patients to be treated more rapidly and low-risk patients to be released in a timely fashion. A paper fluidic platform is good for POC testing because the paper is abundant, low cost, and disposable. However, current cTnI assays on paper platforms use antibodies as the recognition element, which has limitations due to the high cost of production and antibody stability issues at the POC.

AIM

To develop an aptamer-based assay on a paper strip using surface-enhanced resonance Raman spectroscopy (SERRS) for detection of cTnI in the clinically relevant range at the POC.

APPROACH

Gold nanoparticles (AuNPs) were functionalized with a Raman reporter molecule, malachite green isothiocyanate. The functionalized AuNPs were encapsulated in a silica shell and provided a SERRS signal using a handheld Raman system with a 638-nm excitation wavelength. A primary aptamer and a secondary aptamer of cTnI were used in a sandwich assay format to bind the cTnI on a test line of a paper fluidic platform. By measuring the SERRS signal from the test line, the concentration of cTnI was quantitatively determined.

RESULTS

The aptamer-based SERRS assay on a paper strip had a detection range of 0.016 to 0.1  ng  /  ml for cTnI, had good selectivity for cTnI compared to three other markers, had good stability over 10 days, and had good performance in the more complex serum sample matrix.

CONCLUSIONS

The aptamer-based SERRS assay on a paper strip has the potential to provide a sensitive, selective, stable, repeatable, and cost-effective platform for the detection of cTnI toward eventual use in diagnosis of MI at the POC.

Bedside evaluation of cardiac markers

Accurate and rapid diagnostic tests can help identify high-risk patients with ACS among those presenting to the emergency department with chest pain. Such tests can also differentiate low-risk patients with chest pain who are suitable for early emergency department discharge. In this article, Drs Amsterdam and Deedwania elucidate the varieties of ACS, their pathophysiology, and the methods used for diagnosis. The authors also explore the potential of point-of-care testing for cardiac injury markers in the timely and accurate identification of ACS.

Cardiac troponin assays: a review of quantitative point-of-care devices and their efficacy in the diagnosis of myocardial infarction

Cardiac troponin (cTn) I and T are released from myocardial cells following necrosis, i.e., cell death. An accurate measure of cTn concentrations in a patient’s blood following ischemia/chest pain can enable providers to determine whether or not a myocardial infarction (MI) has occurred. Point-of-care (POC) devices that measure blood cTn concentrations in under 30 min may help to significantly reduce hospital costs by managing and triaging patients out of the emergency department as quickly as possible. The use of POC devices that measure cTnI and cTnT with a coefficient of variation (CV) ≤20% at the 99th percentile upper reference limit (URL) limits both false positive and negative results and provides clinically acceptable findings to assist in appropriate diagnoses. This article reviews nine POC devices that measure cTn in terms of their clinical sensitivity and specificity, analytical imprecision, sample type and preparation, and each assay’s principle of analysis.

Cardiovascular disease detection using bio-sensing techniques

Universally, cardiovascular disease (CVD) is recognised as the prime cause of death with estimates exceeding 20 million by 2015 due to heart disease and stroke. Facts regarding the disease, its classification and diagnosis are still lacking. Hence, understanding the issues involved in its initiation, its symptoms and early detection will reduce the high risk of sudden death associated with it. Biosensors developed to be used as rapid screening tools to detect disease biomarkers at the earliest stage and able to classify the condition are revolutionising CVD diagnosis and prognosis. Advances in interdisciplinary research areas have made biosensors faster, highly accurate, portable and environmentally friendly diagnostic devices. The recent advances in microfluidics and the advent of nanotechnology have resulted in the development of improved diagnostics through reduction of analysis time and integration of several clinical assays into a single, portable device as lab-on-a-chip (LOC). The development of such affinity based systems is a major drive of the rapidly growing nanotechnology industry which involves a multidisciplinary research effort encompassing nanofluidics, microelectronics and analytical chemistry. This review summarised the classification of CVD, the biomarkers used for its diagnosis, biosensors and their application including the latest developments in the field of heart-disease detection.

Potential environmental implications of nano-enabled medical applications: critical review

The application of nanotechnology and nanoscience for medical purposes is anticipated to make significant contributions to enhance human health in the coming decades. However, the possible future mass production and use of these medical innovations exhibiting novel and multifunctional properties will very likely lead to discharges into the environment giving rise to potentially new environmental hazards and risks. To date, the sources, the release form and environmental fate and exposure of nano-enabled medical products have not been investigated and little or no data exists, although there are a small number of currently approved medical applications and a number in clinical trials. This paper discusses the current technological and regulatory landscape and potential hazards and risks to the environment of nano-enabled medical products, data gaps and gives tentative suggestions relating to possible environmental hotspots.

Evaluation of a modified lateral flow immunoassay for detection of high-sensitivity cardiac troponin I and myoglobin

We prospectively evaluated the use of lateral flow immunoassay (LFIA) test modified with nanoparticles for combined detection of high-sensitivity cardiac troponin I (hs-cTnI) and myoglobin with the aim of excluding acute myocardial infarction (AMI). Specimens from 173 patients with symptoms suggestive of AMI were collected to measure hs-cTnI and myoglobin using an electrochemiluminescence immunoassay (ECLI) and the LFIA test modified with nanoparticles, and a comparison was performed between the modified method and a commercial LFIA test for detection of the two proteins. The accuracy of the modified LFIA test was also evaluated. Consistent agreement was observed in the quantitative comparison of 173 clinical samples using the modified LFIA and ECLI, and the modified method was more sensitive than the commercial LFIA test. The accuracy of the modified LFIA was <12% for both hs-cTnI and myoglobin. Thus, the new approach has great potential to improve LFIAs test, demonstrating its usefulness for simple screening applications and for sensitivity and quantitative immunoassays for diagnosis ofAMI.

Decreased expression of cardiac troponin C is associated with cardiac lesions in Amorimia exotropica poisoned cattle

The plants which cause sudden death of cattle in Brazil occupy a leading position for losses in the cattle industry. Amorimia exotropica is one of the plants pertaining to this group. Diagnostic findings in these cases may be inconclusive; further knowledge is necessary. This paper identifies cardiac lesions through anti-cardiac troponin C (cTnC) immunehistochemistry performed in tissues from cattle poisoned after consumption of A.exotropica in southern Brazil. Heart fragments from nine A. exotropica-poisoned cattle were studied immunohistochemically using anti-human cTnC as the primary antibody. In the hearts from all of the poisoned cattle, there was a sharp decrease in the cTnC expression level in the cytoplasm of groups of cardiomyocytes. A significant decrease in anti-cTnC immunoreactivity occurred particularly in degenerated or necrotic cardiomyocytes. Occasional groups of cells showed complete loss of immunolabeling. In the remaining intact cardiomyocytes from poisoned cattle and in cardiomyocytes from six cattle that died from other causes there was intense cytoplasmic staining.

Multiplex detection of B-type natriuretic peptide, cardiac troponin I and C-reactive protein with photonic suspension array

A novel photonic suspension array has been developed for multiplex immunoassay. The carriers of this array were silica colloidal crystal beads (SCCBs). The codes of these carriers have characteristic reflection peaks originating from their structural periodicity; therefore they do not suffer from fading, bleaching, quenching or chemical instability. In addition, the fluorescence background of SCCBs is negligible because no fluorescence materials or dyes are involved. With a sandwich method, the proposed suspension array was used for simultaneous multiplex detection of heart failure (HF) and coronary heart disease (CAD) biomarkers in one test tube. The results showed that the three biomarkers: cardiac troponin I (cTnI), C-reactive protein (CRP) and B-type natriuretic peptide (BNP) could be assayed in the ranges of 0.1-500 ng/ml, 1-500 mg/L and 0.02-50 ng/ml with detection limits of 0.01 ng/ml, 0.36 mg/L and 0.004 ng/ml at 3σ, respectively. There were no significant differences between the photonic suspension array and traditional parallel single-analyte test. This novel method demonstrated acceptable accuracy, high detection sensitivity and reproducibility and excellent storage stability. This technique provides a new strategy for low cost, automated, and simultaneous multiplex immunoassays of bio-markers.

Cardiac biomarkers in acute myocardial infarction

Each year, a large number of patients are seen in the Emergency Department with presentations necessitating investigation for possible acute myocardial infarction. Patients can be stratified by symptoms, risk factors and electrocardiogram results but cardiac biomarkers also have a prime role both diagnostically and prognostically. This review summarizes both the history of cardiac biomarkers as well as currently available (established and novel) assays. Cardiac troponin, our current "gold standard" biomarker criterion for the diagnosis of myocardial infarction has high sensitivity and specificity for this diagnosis and therapies instituted in patients with elevated troponin have been shown to influence outcomes. Other markers of myocardial necrosis, inflammation and neurohormonal activity have also been shown to have either diagnostic or prognostic utility, but none have been shown to be superior to troponin. The measurement of multiple biomarkers and the use of point of care markers may accelerate current diagnostic protocols for the assessment of such patients.

Assessing Performance of i-STAT at the Point of Care in the Emergency Room

Context:

Point-of-care testing (POCT) for blood gas and chemistries is widely adopted in the emergency department (ED) for fast turnaround and critical medical decisions.

Objective:

To assess performance of ED physicians compared to laboratory technologists carrying out i-STAT analysis. Impact of user skill on POCT performance was also studied.

Design:

Over a 3-month period, ED physicians performed tests with their i-STAT unit with parallel blood specimens (n=60) sent to the central laboratory to be tested on another i-STAT unit and laboratory analysers (blood gas and chemistries). Comparisons to laboratory results (obtained with ABL 520 and Beckman-Coulter LX20PRO) were carried out. Two operators from ED and central laboratory performed side by side, repeated tests on the i-STAT units. Their overall within-run imprecision were compared. The analytical performance of i-STAT was further assessed by another laboratory technologist to verify its capability to deliver good results.

Results:

Platform comparisons showed that ED physicians performed poorer compared to laboratory technologists, particularly with chloride and pO2 (Spearman coefficient of correlation — 0.49 and 0.54 respectively indicate wide scatter). This is also mirrored in the higher overall within-run imprecision for chemistries (sodium, chloride, potassium, glucose, urea and creatinine) by an ED physician (5.4%) compared to a laboratory technologist (3.7%). Including blood gas results showed an even wider gap in their testing skills. Except at a low creatinine of 67 μmol/L, the i-STAT analyser delivered precise measurements for the chemistries and blood gas parameters.

Conclusions:

Performances by medical staff with the i-STAT analyser did not adequately approach the same skill level as laboratory technologists.

Directed immobilization of reduced antibody fragments onto a novel SAM on gold for myoglobin impedance immunosensing

The successful construction of an immunosensor depends on having an effective procedure for immobilising the bio-recognition element to the transducer surface. In the present study, an amino-terminated 4-aminothiophenol (ATP) self-assembled monolayer (SAM) was modified with heterobifunctional crosslinker sulfosuccinimidyl 4-[N-maleimidomethyl] cyclohexane-1-carboxylate to couple reduced anti-myoglobin half-antibody fragments. The disulphide groups present in the hinge region of IgG molecules were selectively cleaved by 2-mercaptoethylamine to produce reduced half-antibody fragments with free sulphydryl groups. The maleimide terminated 4-ATP SAM modified surface was coupled to these reduced antibody fragments to produce highly oriented immobilization of the half-antibody via its Fc domain and to allow free access to the Fv bindings sites. This represents an improvement by comparison with biotin/avidin mediated IgG attachment which is essentially randomly oriented. Functional immunosensors were able to detect myoglobin in both phosphate buffered saline and whole serum over the range of concentrations from 10(-13)M to 10(-6)M, and order of magnitude better than avidin/biotin linked immunosensors. In addition, atomic force microscopy (AFM) was carried out to elucidate the nanotopology of the immunosensor surface at different stages of fabrication; the images demonstrate that half antibodies bind as described and show structural changes on subsequent antigen binding.

Surface plasmon resonance aided electrochemical immunosensor for CK-MB determination in undiluted serum samples

This article presents a simple chronoamperometric immunosensor for the quantitative assessment of creatine kinase MB (CK-MB) in 50 microL undiluted serum samples. The immunosensor consists of gold working and counter electrodes patterned onto a glass chip by thin-film photolithography and an external Ag|AgCl reference electrode. The detection limit (DL) of the chronoamperometric method is 13 ng mL(-1) (DL = 2xRMSD/S, where RMSD is the residual mean standard deviation of the measured points around a calibration curve with a slope of S). In spiked serum samples, the response was linear up to 300 ng mL(-1) of CK-MB. A surface plasmon resonance (SPR) system with simultaneous electrochemical detection (EC-SPR) aided the development of the sandwich immunoassay. Real-time monitoring of the SPR signal was used to optimize the capture antibody immobilization, CK-MB and detection antibody binding, as well as to minimize the nonspecific adsorption of serum proteins to the sensor surface. The detection antibody has been labeled with alkaline phosphatase (ALP) enzyme for sensitive electrochemical detection. ALP catalyzes the hydrolysis of ascorbic acid phosphate and generates ascorbic acid, which is measured chronoamperometrically. The electrochemical immunoassay for CK-MB was less sensitive to nonspecific adsorption related interferences, had a better detection limit, and required a lower volume of sample than the SPR method.

Cardiac markers: a clear cause for point-of-care testing

Point-of-care testing (POCT) in patients with ischemic heart disease is driven by the time-critical need for fast, specific, and accurate results to initiate therapy instantly. According to current guidelines, the results of the cardiac marker testing should be available to the physician within 30 min ("vein-to-brain" time) to initiate therapy within 60-90 min ("door-to-needle" time) after the patient has arrived at the emergency room or intensive care unit. This article reviews the current efforts to meet this goal (1) by implementing POCT of established biochemical markers such as cardiac troponins, creatine kinase MB, and myoglobin, in accelerated diagnosis and management workflow schemes, (2) by improving current POCT methods to obtain more accurate, more specific, and even faster tests through the integration of optical and electrochemical sensor technology, and (3) by identifying new markers for the very early and sensitive detection of myocardial ischemia and necrosis. Furthermore, the specific requirements for cardiac POCT in regard to analytical performance, comparability, and diagnostic sensitivity/specificity are discussed. For the future, the integration of new immunooptical and electrochemical chip technology might speed up diagnosis even further. However, every new development will have to meet the stringent method validation criteria set for corresponding central laboratory testing.

Decreasing lab turnaround time improves emergency department throughput and decreases emergency medical services diversion: a simulation model

BACKGROUND

The effect of decreasing lab turnaround times on emergency department (ED) efficiency can be estimated through system-level simulation models and help identify important outcome measures to study prospectively. Furthermore, such models may suggest the advantage of bedside or point-of-care testing and how they might affect efficiency measures.

OBJECTIVES

The authors used a sophisticated simulation model in place at an adult urban ED with an annual census of 55,000 patient visits. The effect of decreasing turnaround times on emergency medical services (EMS) diversion, ED patient throughput, and total ED length of stay (LOS) was determined.

METHODS

Data were generated by using system dynamics analytic modeling and simulation approach on 90 separate days from December 2, 2007, through February 29, 2008. The model was a continuous simulation of ED flow, driven by real-time actual patient data, and had intrinsic error checking to assume reasonable goodness-of-fit. A return of complete laboratory results incrementally at 120, 100, 80, 60, 40, 20, and 10 minutes was compared. Diversion calculation assumed EMS closure when more than 10 patients were in the waiting room and 100% ED bed occupancy had been reached for longer than 30 minutes, as per local practice. LOS was generated from data insertion into the patient flow stream and calculation of time to specific predefined gates. The average accuracy of four separate measurement channels (waiting room volume, ED census, inpatient admit stream, and ED discharge stream), all across 24 hours, was measured by comparing the area under the simulated curve against the area under the measured curve. Each channel's accuracy was summed and averaged for an overall accuracy rating.

RESULTS

As lab turnaround time decreased from 120 to 10 minutes, the total number of diversion days (maximum 57 at 120 minutes, minimum 29 at 10 minutes), average diversion hours per day (10.8 hours vs. 6.0 hours), percentage of days with diversion (63% vs. 32%), and average ED LOS (2.77 hours vs. 2.17 hours) incrementally decreased, while average daily throughput (104 patients vs. 120 patients) increased. All runs were at least 85% accurate.

CONCLUSIONS

This simulation model suggests compelling improvement in ED efficiency with decreasing lab turnaround time. Outcomes such as time on EMS diversion, ED LOS, and ED throughput represent important but understudied areas that should be evaluated prospectively. EDs should consider processes that will improve turnaround time, such as point-of-care testing, to obtain these goals.

Present and Future Biochemical Markers for Detection of Acute Coronary Syndrome

The use of biochemical markers in the diagnosis and management of patients with acute coronary syndrome has increased continually in recent decades. The development of highly sensitive and cardiac-specific troponin assays has changed the view on diagnosis of myocardial infarction and also extended the role of biochemical markers of necrosis into risk stratification and guidance for treatment. The consensus definition of myocardial infarction places increased emphasis on cardiac marker testing, with cardiac troponin replacing creatine kinase MB as the "gold standard" for diagnosis of myocardial infarction. Along with advances in the use of more cardiac-specific markers of myocardial necrosis, biochemical markers that are involved in the progression of atherosclerotic plaques to the vulnerable state or that signal the presence of vulnerable plaques have recently been identified. These markers have variable abilities to predict the risk of an individual for acute coronary syndrome. The aim of this review is to provide an overview of the well-established markers of myocardial necrosis, with a special focus on cardiac troponin I, together with a summary of some of the potential future markers of inflammation, plaque instability, and ischemia.

Integration of optical fiber light guide, fluorescence detection system, and multichannel disposable microfluidic chip

A combination of fluorescence detection and microfluidic technology provides promising applications in life sciences. A prototype of an integrated fluorescence detection system and optical fiber light guide on a laminate-based multichannel microfluidic chip has been developed and tested. A blue LED, plastic optical fiber, photodiode, Mylar and PMMA, and fluorescein and BSA-FITC were used as an excitation source, light coupler and guide, detector, microfluidic substrate and sample, respectively. The results show that the system is capable of detecting weak fluorescence emission from a fluorescein solution at concentration down to 0.01 ng/ml, and gives linear response. The results were also reproducible, and no cross-talk between adjacent channels was observed. The test using BSA as a model analyte demonstrates its feasibility for on-chip immunosensor applications. The performance and applications can be developed further. This prototype can be used as a platform to develop a simple and compact bio-fluorescence detection system integrated with an inexpensive and disposable multichannel microfluidic chip for biomedical devices.

Cardiac markers and their point-of-care testing for diagnosis of acute myocardial infarction

Acute myocardial infarction (AMI) is the world's leading cause of mortality and morbidity. Therefore, quick and reliable diagnostics of AMI is extremely critical. Compared to the traditionally used central laboratory tests (CLT), which can be time-consuming and expensive, point-of-care testing (POCT) for AMI-indicative cardiac markers provides a convenient means for rapid diagnostic assays to be performed at the site of patient care delivery. In this article, the etiology and diagnosis of AMI are introduced, and some typical cardiac markers and their clinical applications are reviewed. Furthermore, the various POC cardiac marker devices that are currently available, the benefits of using cardiac marker POC assays, and challenges that cardiac marker POCT are facing are also discussed.

Point-of-Care Testing and Cardiac Biomarkers: The Standard of Care and Vision for Chest Pain Centers

Point-of-care testing (POCT) is defined as testing at or near the site of patient care. POCTdecreases therapeutic turnaround time (TTAT), increases clinical efficiency, and improves medical and economic outcomes. TTAT represents the time from test ordering to patient treatment. POC technologies have become ubiquitous in the United States, and, therefore,so has the potential for speed, convenience, and satisfaction, strong advantages for physicians, nurses, and patients in chest pain centers. POCT is applied most beneficially through the collaborative teamwork of clinicians and laboratorians who use integrative strategies, performance maps, clinical algorithms, and care paths (critical pathways). For example, clinical investigators have shown that on-site integration of testing for cardiac injury markers (myoglobin, creatinine kinase myocardial band [CKMB],and cardiac troponin I [cTnI]) in accelerated diagnostic algorithms produces effective screening, less hospitalization, and substantial savings. Chest pain centers, which now total over 150 accredited in the United States, incorporate similar types of protocol-driven performance enhancements. This optimization allows chest pain centers to improve patient evaluation, treatment, survival, and discharge. This article focuses on cardiac biomarker POCT for chest pain centers and emergency medicine.

Advances in cardiac biomarkers

The diagnostic and prognostic roles of new and established cardiac biomarkers are continually changing. This update article discusses clinical diagnosis as a framework for directing biomarker testing. Markers are reviewed in the settings of acute coronary syndromes, decompensated heart failure, and noncardiac clinical scenarios.

Fatty acid-binding proteins as plasma markers of tissue injury

BACKGROUND

One of the novel and promising plasma markers for detection of tissue injury is the family of 15 kDa cytoplasmic fatty acid-binding proteins of which various tissue-specific types occur.

AIMS AND OBJECTIVES

The present status of heart-type fatty acid-binding protein (H-FABP) as a diagnostic and prognostic marker for acute and chronic cardiac injury, as well as the preliminary diagnostic use of other types of FABP for detecting injury in other organs, is reviewed.

METHODS

This review is based on an overview of the literature on clinical diagnostics of various forms of organ injury, and uses additional literature on physiological aspects relevant for the interpretation of plasma marker concentrations.

RESULTS

H-FABP not only proves to be an excellent early marker for cardiac injury in acute coronary syndromes, but also allows detection of minor myocardial injury in heart failure and unstable angina. Preliminary results indicate that sensitivity, rule-out power and prognostic value of H-FABP in cardiac injury surpass the performance of the standard early marker myoglobin. The liver only contains liver-type FABP (L-FABP), but co-expression of H-FABP and L-FABP occurs in the kidney. Similarly, intestinal-type FABP (I-FABP) and L-FABP are found in intestines, and brain-type FABP (B-FABP) and H-FABP occur in the brain. Preliminary but promising applications of these proteins have been demonstrated for liver rejection, viability selection of kidneys from non-heart-beating donors (NHBD), inflammatory and ischemic bowel disease, traumatic brain injury and in the prevention of muscle injury in trained athletes.

CONCLUSIONS

Further study of the diagnostic and prognostic use of various FABP types is warranted, but their clinical application will require further commercialization of automated and rapid assays.

The significance of troponin T and CK-MB release in coronary artery bypass surgery

Measurement of cardiac markers is an index of care standard in the assessment and diagnosis of cardiovascualr disease. Two of the major cardiac markers are Creatine Kinase isoenzyme CK-MB and Troponin T, which are extensively used in the diagnosis of heart disease. The release of Troponin T and creatine kinase isoenzyme (CK-MB) was investigated in 50 coronary artery bypass surgery patients. Measurement of plasma samples was carried out at five different time points, namely before surgery, 1,6,12,24 hours after surgery. The results indicated that CK-MB level were increased by a factor more than four times compared with the upper limit of baseline (befor surgery). Troponin T concentration showed more than six fold over the upper limit of baseline (before surgert) at 1,6,12,24 hours after surgery. In order to assess the significance of the length of the surgical procedure on the release of Troponin T and CK-MB, the surgery patient were divided into two groups according to the length of the surgical procedure: group I was selected on the basis that the surgical procedure they underwent lasted above 90 minutes and group II with a surgical procedure below 90 minutes. Both Troponin T and CK-MB showed a significant increase in-group I compared to group II. To investigate the likelihood that this effect is party due to myocardial infarction during surgery, the patients were divided into two groups: Group A with some sings of myocardial infarction on Q wave of ECG and group B without any change. The results showed approximately a two-fold increase of these markers in-group A compared to group B. Since these markers reach into blood following damage to myocardial their increase in patients with time course surgery of more than 90 minutes and those with a probability of MI during operation, indicating that these patient fall into a high risk group of repeat (MI) after surgery.

Processing of serum proteins underlies the mass spectral fingerprinting of myocardial infarction

The MALDI-TOF spectra of peptides from the sera of normal and myocardial infarction patients produced patterns that provided an accurate diagnostic of MI. In myocardial infarction, the spectral pattern originated from the cleavage of complement C3 alpha chain to release the C3f peptide and cleavage of fibrinogen to release peptide A. The fibrinogen peptide A and complement C3f peptide were in turn progressively truncated by aminopeptidases to produce two families of fragments that formed the characteristic spectral pattern of MI. Time course and inhibitor studies demonstrated that the peptide patterns in the serum reflect the balance of disease-specific-protease and aminopeptidase activity ex vivo.