Benefits of using exchangeable copper and the ratio of exchangeable copper in a real-world cohort of patients with Wilson disease

Wilson disease (WD) is a complex disease in which diagnosis and long-term metabolic copper control remains challenging. The absence of accurate biomarkers requires the combination of different parameters to ensure copper homeostasis. Exchangeable copper and its ratio (REC) have been suggested to be useful biomarkers in this setting. We aimed at introducing these measurements and evaluate their performance and accuracy in our real-world cohort of WD patients. Exchangeable copper and REC were measured in 48 WD patients and 56 control individuals by inductively coupled plasma-mass-spectrometry. Demographic and clinical characteristics were collected. REC was shown to be significantly higher among WD patients compared to controls and useful for WD identification by using the previously established cutoffs: 71.4% of WD patients with a recent diagnosis had REC ≥18.5% and 95.1% of long-term treated WD had REC ≥14%; only four patients of the cohort presented discordant levels. Moreover, REC values were below 15% in all the control individuals. Exchangeable copper was significantly higher in WD patients compared to controls and tended to be reduced among WD patients who were compliant to medication. This real-life study confirmed that exchangeable copper and REC are useful serum biomarkers that can be used as complementary tests to ensure WD diagnosis (REC) and copper homeostasis whithin time (exchangeable copper). The desirable target levels for this last objective still needs to be validated in prospective cohorts.

Transcriptomic study in explanted liver from a patient with acute intermittent porphyria

Acute intermittent porphyria (AIP) is a rare disease caused by a deficiency of hydroxymethylbilane synthase (HMBS), the third enzyme of the heme-synthesis pathway. Decreased enzymatic activity in the liver induces an overproduction of heme-precursors and acute neurological attacks. We report a 36-years-old female with AIP with a long-term history of severe, disabling, recurrent attacks, who underwent curative liver transplantation. Tissue samples from the explant were obtained for transcriptome analysis. Whole RNA was extracted and 16 gene-transcripts were selected and investigated by quantitative polymerase chain reaction. These included nine genes encoding enzymes that consecutively catalyze heme-synthesis and catabolism in the liver (ALAS1; ALAD; HMBS; UROS; UROD; CPOX; PPOX; FECH; HMOX1). Additionally, we studied genes related to inflammation (IL6; TNF) insulin signaling (PGC-1α; IGF-1; FOXO-1) and tryptophan metabolism (TDO2; IDO). Transcripts of eight house-keeping genes were co-measured for normalization. All transcripts were also measured in five control samples from healthy living liver donors. The transcriptome of the controls showed important differences between the various genes, with the first two genes of the heme-synthesis pathway, ALAS1 and ALAD showing strikingly high mRNA levels compared to the consecutive HMBS gene. Transcripts of several genes significantly differed in the AIP liver compared to controls. Transcripts of HMOX1 and UROS were increased in the AIP liver whereas transcripts of UROD; CPOX, PPOX, and TDO2 were decreased. ALAS1 expression was not increased, possibly due to hemin administered to the patient before transplantation. These results highlight several transcriptomic changes related to heme homeostasis in AIP.

Dried Blood Spot (DBS) as a useful tool to improve clozapine, aripiprazole and paliperidone treatment: From adherence to efficiency

INTRODUCTION

Therapeutic Drug Monitoring (TDM) of antipsychotics in schizophrenia is a powerful tool that allows tailoring the treatment in an individualized approach. Our goals are to develop and validate a Dried Blood Spot (DBS) method for monitoring some commonly used antipsychotics (aripiprazole, clozapine, and paliperidone) and to evaluate its usefulness as a compliance biomarker, as well as in drug-dose adjustment to personalize the antipsychotic treatment to improve its efficacy and safety.

METHODS

31 first-psychotic episode (FEP) and schizophrenia patients were included; 5 refer to naïve FEP who started antipsychotic treatment; 26, to patients with more than one episode and under antipsychotic treatment: aripiprazole (7 cases), clozapine (17), paliperidone (11). For DBS sample collection, 25μl of capillary blood were placed in the spot of a FTA™DMPK-C-card. After completely dryness, antipsychotics were extracted and analyzed by a validated UHPLC-MS/MS-method. DBS antipsychotic results were compared with those obtained in venous blood/plasma.

RESULTS

Aripiprazole, paliperidone and clozapine showed from good to excellent correlations between concentrations in venous blood and DBS capillary blood (r², from 0.500 to 0.721). The correlation between conventional plasma and DBS concentrations for paliperidone, aripiprazole, clozapine, and their metabolites were moderate, suggesting that optimal drug target concentrations should be established for DBS.

CONCLUSIONS

In this study, for aripiprazole, dehydroaripiprazole, paliperidone, clozapine and desmethylclozapine, DBS has provided good analytical performance for TDM. Thus, DBS sampling can offer a great alternative over conventional sampling for plasma measurement. The assay provides good analytical performances for TDM and clinical research applicability, suggesting that DBS is a promising clinical application in TDM in psychiatry.

P-449 Storage of vitrified oocytes up to 8 years does not affect pregnancy and live birth rates: analysis of 5,362 cycles

Study question

Does long-term storage of vitrified oocytes affect laboratory and reproductive outcomes after ICSI?

Summary answer

The time spent by vitrified oocytes in liquid nitrogen banks does not affect oocyte survival, fertilization rate nor reproductive outcomes up to live birth.

What is known already

Vitrification is the most efficient approach to oocyte cryopreservation and is commonly applied in oocyte donation programs. The survival rate can be >90% and vitrified-warmed oocytes provide comparable reproductive results to fresh oocytes. However, even with modern cryobanking technology, there are potential temperature fluctuations caused by access to cryopreserved material, transportation, stocktaking events, and regular maintenance. While some studies indicate that a multiyear storage of vitrified oocytes does not affect pregnancy rates, others found decreased reproductive outcomes after as little as 6 months, and further investigations in large cohorts are needed to confirm the safety of long-term oocyte storage.

Study design, size, duration

Retrospective cohort study of 5,362 cycles with vitrified oocytes from oocyte donors carried out between 2013 and 2021. All cycles included fresh embryo transfer (ET). Oocyte vitrification and warming were carried using the Cryotop® protocol (Kitazato). We analyzed the effect of storage time of vitrified oocytes in liquid nitrogen vapors on laboratory outcomes (oocyte survival, fertilization rate (FR), percentage of viable embryos) and reproductive outcomes (pregnancy -biochemical and clinical- and live birth (LB) rates).

Participants/materials, setting, methods

Eight categories of storage time were established: 0-0.25 years (reference group, ≤3 months), 0.25-0.5, 0.5-1, 1-1.5, 1.5-2, 2-3, 3-4, and >4 years. The effect of oocyte storage time on laboratory and reproductive outcomes was analyzed by linear and logistic regression, respectively. These multivariate analyses were adjusted by multiple factors: sperm origin (partner vs donor), sperm parameters, number of oocytes inseminated, number of embryos transferred and day of ET (2-3 vs 5), among others.

Main results and the role of chance

Mean recipient age was 42.0±4.6, while oocyte donors age was 26.1±4.6. The mean number of thawed oocytes was 8.0±2.5, all surviving oocytes were inseminated by ICSI with partner (84.9%) or donor sperm (15.1%). The oocyte storage time ranged from 3 days to 8.2 years (mean: 0.7 ± 0.9 years). We did not find significant differences in oocyte storage time between positive and negative pregnancy and LB, nor between different survival rates (<100 vs = 100%), FR (<70 vs ≥ 70%) and percentages of viable embryos (<50 vs ≥ 50%) at univariate analysis (p > 0.05 in all cases). The mean oocyte survival rate was 90.2%±14.7% and, after adjusting for confounders, did not decrease with longer storage time (i.e. 88.9% for time >4 years, p = 0.963). Similarly, the linear regression model did not show a significant effect of storage time on FR, which was close to 70% in all categories (range: 67.6-70.6, p > 0.05), nor a decrease in the percentage of viable embryos. Finally, reproductive outcomes were similar across storage times (p > 0.05 for all categories when compared to the reference 0-0.25); specifically, long-term oocyte storage (>4 years) did not affect the chances of clinical pregnancy (OR: 0.657 [0.395-1.092], p = 0.194) and LB (OR: 0.666 [0.393-1.128], p = 0.231).

Limitations, reasons for caution

These results cannot be extended to cycles using the patient’s own oocytes or involving a severe male factor (testicular spermatozoa or criptozoospermia), which were excluded. Due to the retrospective nature of the study, some uncontrolled variables could affect the results.

Wider implications of the findings

This is the first study evaluating the effect of long-term oocyte storage on a large cohort of patients undergoing oocyte donation, thus partially discarding the effect of the female factor. Reassuringly, these results indicate that long-term storage of oocytes is a safe option for young patients and oocyte banks.

Trial registration number

Not applicable

Point-of-care test for rapid assessment of blood lithium levels in women with bipolar disorder during perinatal period

Introduction

Determination of lithium levels in serum has become a standard of care due to its narrow therapeutic rang, thus an immediate test for determination of blood lithium may contribute to minimize toxicit, to avoid relapse and to ensure treatment adherence. This is particularly relevant during pregnancy and early postpartum because pharmaokinetic changes in renal physiology.

Objectives

The aim of this study is verify Medimate point-of-care method performance and systematically compare it with the routine laboratory measurement of lithium.

Methods

This cross-sectional method comparison study was conductec in the Unit of Perinatal Mental Health in the Hospital Clinic of Barcelona. Pearson and Bland-Altman analyses were performed to assess the accuracy, precision and correlation between the capillary electrophoresis technology (Medimate MiniLab) and the ion selective electrode (ISE) potentiometry method (AVL 9180).

Results

Twenty-five women with bipolar disorder in treatment with lithium during perinatal period were enrolled, corresponding to 75 blood specimens for analyses. Correlation (r), mean difference (bias), and 95% limit of agreement (LOA) of the point-of-care method [r=0.917; bias 0.0021 (95% LOA; 0.440, 0.619) mEq/L], showed that difference between ISE method and capillary electrophoresis technology was not statistically significant.

Conclusions

Considering the practicality, the microchip capillary electrophoresis technology provides a simple and highly affordable way of measuring lithium levels in a single drop of blood outside the clinical laboratory. The Medimate point-of-care system (POC) appears well adapted for the rapid and specific detection of lithium as an alternative to the current ISE procedure.

Disclosure

No significant relationships.

Lithium placental passage at delivery: an observational study

Introduction

Lithium is used as a first-line treatment for bipolar disorder during perinatal period. Dosing of lithium can be challenging as a result of pharmacokinetic changes in renal physiology. Frequent monitoring of lithium blood levels during pregnancy is recommended in order remain within the therapeutic window (0.5 to 1.2 mEq/L). Lower neonatal lithium blood level (<0.64 mEq/L) at time of delivery reduces the risk of lithium side effects in the neonate.

Objectives

The aim of the present study was to quantify the rate of lithium placental passage in real word.

Methods

We included a total of 68 mother-infant pairs for which a lithium measurement was performed intrapartum. Lithium serum concentrations were determined by means of an AVL 9180 electrolyte analyzer. The limit of quantification (LoQ) was 0.20 mEq/L and detection limit was 0.10 mEq/L. Pearson analyse was performer to assess the correlation between mother and umbilical cord lithium serum concentrations.

Results

The mean of umbilical cord serum concentration at delivery was 0.57 mEq/L (SD=0.26, range 0,20-1,42). The mean infant-mother lithium ratio at delivery for the 68 pairs was 1.12 (SD=0.24) across a wide range of maternal concentrations (range 0.14-1,40 mEq/L). There was a strong positive correlation between maternal and umbilical cord lithium blood levels (Peearson correlation coefficient 0.948, p<0.001).

Conclusions

Lithium demostrates complete placental passage. This finding is consistent with the results of others studies (Newport 2005; Molenaar 2021).

Disclosure

No significant relationships.

Wrist flexion and extension strength in patients with work-related chronic elbow pain: the isokinetic effort factor and its implications

BACKGROUND

The validity of isokinetic strength findings relating to forearm muscles in patients with chronic elbow pain and/or epicondylitis is not well established. Furthermore, given the nature of this disorder, ensuring maximal effort in performing the tests is an essential prerequisite. The isokinetic-based DEC parameter (defined as the difference between high- and low-velocity eccentric-to-concentric ratios of a given muscle) has been shown to efficiently detect maximal effort. The purpose of this study was therefore to assess the validity of isokinetic strength tests in patients with chronic elbow pain and/or epicondylitis.

METHODS

A cohort consisting of 44 male patients with chronic elbow pain (average evolution time, 262 ± 193.04 days) was recruited. The wrist extensor and flexor concentric and eccentric isokinetic strength of the involved and uninvolved sides was measured. The involved-uninvolved and flexor-extensor (F/E) ratios, as well as the DEC (eccentric-concentric difference), were computed based on peak moment values. Work disability and relapse within the first year were registered. In maximal performers, associations between deficits, F/E ratios, work disability, and symptom relapse were explored applying multiple comparisons.

RESULTS

Of the patients, 68.2% met the maximal-effort criteria, with the involved-side muscles being significantly weaker than their uninvolved-side counterparts in most cases. Although the mean deficit in this group was not associated with either work disability or relapse, patients with a relapse of symptoms within the first year had a significantly higher F/E ratio than those without relapse.

CONCLUSION

In patients presenting with chronic elbow pain who perform at the maximal level of effort, high wrist F/E strength ratios may predict symptom relapse.

Neonatal Feeding Trajectories in Mothers With Bipolar Disorder Taking Lithium: Pharmacokinetic Data

Purpose: Women who take lithium during pregnancy and continue after delivery may choose to breastfeed, formula feed, or mix these options. The aim of the study was to evaluate the neonatal lithium serum concentrations based on these three feeding trajectories. Methods: We followed 24 women with bipolar disorder treated with lithium monotherapy during late pregnancy and postpartum (8 per trajectory). Lithium serum concentrations were determined by an AVL 9180 electrolyte analyser with a 0.10 mEq/L detection limit and a 0.20 mEq/L limit of quantification (LoQ). Results: There was complete lithium placental passage at delivery, with a mean ratio of lithium concentration in the umbilical cord to maternal serum of 1.12 ± 0.17. The median times to LoQ were 6-8, 7-8, and 53-60 days for formula, mixed, and exclusive breastfeeding respectively. The generalized log-rank testing indicated that the median times to LoQ differ according to feeding trajectory (p = 0.037). According to the multivariate analysis-adjusted lithium serum concentrations at birth, times to LoQ are, on average, longer under exclusive breastfeeding (formula, p = 0.015; mixed, p = 0.012). No lithium accumulation was observed in infants under either exclusive or mixed breastfeeding. During the lactation follow-up, there was no acute growth or developmental delays in any neonate or infant. Indeed, lithium concentrations in the three trajectories declined in all cases. However, the time needed to reach the LoQ was much longer for those breastfeeding exclusively. Conclusions: In breastfeed infant no sustained accumulation of lithium and no adverse effects on development or growth were observed.

Infant exposure to lithium through breast milk

Introduction

Women who take lithium during pregnancy and continue after delivery may opt to breastfeed, formula feed, or mix these options.

Objectives

To evaluate the neonatal lithium plasma concentrations and nursing infant outcomes based on these three feeding trajectories.

Methods

We followed 24 women with bipolar disorder on lithium monotherapy during late pregnancy and postpartum (8 per trajectory). Lithium serum concentrations were determined by an AVL 9180 electrolyte analyser with a 0.10 mEq/L detection limit and a 0.20 mEq/L limit of quantification (LoQ).

Results

The mean ratio of lithium concentration in the umbilical cord to maternal serum being 1.12 (0.17). We used the Turnbull estimator for interval-censored data to estimate the probability that the LoQ was reached as a function of time. The median times to LoQ was 6–8, 7–8, and 53–60 days for formula, mixed, and breastfeeding, respectively. Generalised log-rank testing indicated that the median times to LoQ differed by feeding trajectory (p = 0.037). Multivariate analysis confirmed that the differences remained after adjusting for serum lithium concentrations at birth (formula, p = 0.015; mixed, p = 0.012). We did not found any acute observable growth or developmental delays in any of the neonates/infants.

Conclusions

Lithium did not accumulate in the infant under either exclusive or mixed-breastfeeding. Lithium concentrations declined in all trayectories. The time needed to reach the LoQ was much longer for those breastfeeding exclusively. Lithium transfer via breastmilk is much less than via the placenta. We did not found any acute observable growth or developmental delays in any infant during follow-up.

Disclosure

No significant relationships.

P–013 Sperm freezing does not affect live birth rates: results from 6,594 cycles in normozoospermic patients

Study question

Does sperm cryopreservation influence the reproductive outcomes of normozoospermic patients undergoing elective ICSI?

Summary answer

After controlling for confounders, the use of cryopreserved semen from normozoospermic patients does not affect pregnancy and live birth rates after ICSI.

What is known already

Sperm cryopreservation with slow freezing is a common practice in ART. While frozen-thawed semen typically presents reduced motility and vitality, its use for ICSI is generally considered adequate in terms of reproductive outcomes. Nevertheless, most studies comparing reproductive outcomes between fresh versus cryopreserved sperm include patients with oligo- and/or asthenozoospermia, where the altered quality of the sample can partially mask the full effect of freezing/thawing. The objective of this study is to ascertain whether ICSI using fresh or cryopreserved semen from normozoospermic patients results in similar fertilization rates and reproductive outcomes.

Study design, size, duration

Retrospective cohort of 6,594 couples undergoing their first elective ICSI cycle between January 2011 and December 2019, using normozoospermic partner semen (fresh or cryopreserved). All cycles involved a fresh embryo transfer, either at cleavage or blastocyst stage. Cycles were divided in 4 groups: fresh semen with partner’s oocytes (FSPO, n = 1.878), cryopreserved semen with partner’s oocytes (CSPO, n = 142), fresh semen with donor oocytes (FSDO, n = 2.413), and cryopreserved semen with donor oocytes (CSDO, n = 2.161).

Participants/materials, setting, methods

A slow freezing protocol using GM501 SpermStore medium (Gynemed, Lensahn) was used for all sperm cryopreservation. Sperm washing, capacitation, and selection prior to ICSI were performed equally for fresh and frozen-thawed samples, using pellet swim-up in IVF® medium (Vitrolife, Göteborg). Fertilization rate (FR), pregnancy (biochemical, clinical, and ongoing) and live birth (LB) rates were compared among study groups using Pearson’s Chi square and Student’s t-test. A p-value &lt;0.05 was considered statistically significant.

Main results and the role of chance

Male and female age, sperm concentration and motility after ejaculation, and number of oocytes inseminated were similar between study groups compared (FSPO vs. CSPO, FSDO vs. CSDO). As expected, oocyte donation cycles resulted in higher LB rate than cycles in which partner’s oocytes were used (30.04% vs 18.17%, p &lt; 0.001). In cycles using partner’s oocytes, no significant differences were observed between fresh and cryopreserved sperm in FR, pregnancy and LB rates (p &gt; 0.05 for all outcomes). However, in oocyte donation, the mean FR after ICSI using cryopreserved semen (73.6 ± 19.6) was lower than the FR obtained with fresh semen (75.1 ± 19.2), p = 0.010. Similarly, in oocyte donation cycles, the biochemical pregnancy rate was significantly lower when using cryopreserved semen (48.5% in CSDO vs. 52.3% in FSDO, p = 0.009), while clinical, ongoing pregnancy and LB rates were similar between both semen status (p &gt; 0.05). In oocyte donation, a subgroup analysis including only the ICSI cycles with embryo transfer at blastocyst stage (n = 1.187 for FSDO, n = 337 for CSDO) confirmed that the LB rate was comparable between fresh and cryopreserved semen groups (34.7% vs 35.6% respectively, p = 0.76), without significant differences in pregnancy rates neither (p &gt; 0.05 for all outcomes).

Limitations, reasons for caution

Caution should be exerted when extrapolating these results to different protocols for sperm cryopreservation and selection, or to IVM and classical IVF cycles, which were excluded from analysis. Due to the retrospective nature of the study, some uncontrolled for variables may affect the results.

Wider implications of the findings: Sperm cryopreservation does not affect pregnancy and live birth rates in normozoospermic patients, although it may lower slightly fertilization rates. In line with previous studies including patients with an apparent male factor detected after routine semen analysis, sperm cryopreservation is a safe and convenient technique.

Trial registration number

Not applicable

Lithium placental passage at delivery and neonatal outcomes: A retrospective observational study

Introduction

Lithium is an effective mood stabilizer and is widely used as a first-line treatment for bipolar disorder in the perinatal period. Several guidelines have provided clinical advice on dosing strategy (dose reduction versus stop lithium) in the peripartum period to minimize the risk of neonatal complications. An association has been observed between high neonatal lithium concentrations (> 0.64 mEq/L) and lower 1-min Apgar scores, longer hospital stays, and central nervous system and neuromuscular complications.

Objectives

To quantify the rate of lithium placental passage at delivery. To assess any association between plasma concentration of lithium at delivery and neonatal outcome.

Methods

In this retrospective observational cohort study, we included women treated with llithium at least in late pregnancy. Maternal (MB) and umbilical cord (UC) lithium blood level measurement were collected at delivery. Lithium serum concentrations were determined by means of an AVL 9180 electrolyte analyzer. The limit of quantification (LoQ) was 0.20 mEq/L and detection limit was 0.10 mEq/L. From the medical records, we extracted information on neonatal outcomes (preterm birth, birth weight, Apgar scores, pH-values, and admision to NICU) and complications categoriced by organ system: respiratory, circulatory, hematological, gastro-intestinal, metabolic, neurological, and immune system (infections).

Results

Umbilical cord and maternal lithium blood levels were strongly correlated: mean (SD) range UC/MR ratio 1.15 (0.24). Umbilical cord lithium levels ranged between 0.20 to 1.42 mEq/L. We observed no associations between umbilical cord lithium blood levels at delivery and neonatal outcomes.

Conclusions

In our study, newborns tolerated well a wide range of lithemias, between 0.20 and 1.42 mEq/L.

Detection of effort maximality in adults performing isokinetic wrist flexion and extension

BACKGROUND: The difference between isokinetic eccentric to concentric strength ratios at high and low velocities (DEC) is a powerful tool for identifying submaximal effort in other muscle groups but its efficiency in terms of the wrist extensors (WE) and flexors (WF) isokinetic effort has hitherto not been studied. OBJECTIVE: The objective of the present study is to examine the usefulness of the DEC for identifying suboptimal wrist extensor and flexor isokinetic efforts. METHODS: Twenty healthy male volunteers aged 20–40 years (28.5 ± 3.2) were recruited. Participants were instructed to exert maximal and feigned efforts, using a range of motion of 20∘ in concentric (C) and eccentric (E) WE and WF modes at two velocities: 10 and 40∘/s. E/C ratios (E/CR) where then calculated and finally DEC by subtracting low velocity E/CR from high velocity ones. RESULTS: Feigned maximal effort DEC values were significantly higher than their maximal effort counterparts, both for WF and WE. For both actions, a DEC cutoff level to detect submaximal effort could be defined. The sensitivity of the DEC was 71.43% and 62.5% for WE ad WF respectively. The specificity was 100% in both cases. CONCLUSION: The DEC may be a valuable parameter for detecting feigned maximal WF and WE isokinetic effort in healthy adults.

Accelerated surgery versus standard care in hip fracture (HIP ATTACK): an international, randomised, controlled trial

BACKGROUND

Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications.

METHODS

HIP ATTACK was an international, randomised, controlled trial done at 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were aged 45 years or older were eligible. Research personnel randomly assigned patients (1:1) through a central computerised randomisation system using randomly varying block sizes to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. The coprimary outcomes were mortality and a composite of major complications (ie, mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Patients, health-care providers, and study staff were aware of treatment assignment, but outcome adjudicators were masked to treatment allocation. Patients were analysed according to the intention-to-treat principle. This study is registered at ClinicalTrials.gov (NCT02027896).

FINDINGS

Between March 14, 2014, and May 24, 2019, 27 701 patients were screened, of whom 7780 were eligible. 2970 of these were enrolled and randomly assigned to receive accelerated surgery (n=1487) or standard care (n=1483). The median time from hip fracture diagnosis to surgery was 6 h (IQR 4-9) in the accelerated-surgery group and 24 h (10-42) in the standard-care group (p<0·0001). 140 (9%) patients assigned to accelerated surgery and 154 (10%) assigned to standard care died, with a hazard ratio (HR) of 0·91 (95% CI 0·72 to 1·14) and absolute risk reduction (ARR) of 1% (-1 to 3; p=0·40). Major complications occurred in 321 (22%) patients assigned to accelerated surgery and 331 (22%) assigned to standard care, with an HR of 0·97 (0·83 to 1·13) and an ARR of 1% (-2 to 4; p=0·71).

INTERPRETATION

Among patients with a hip fracture, accelerated surgery did not significantly lower the risk of mortality or a composite of major complications compared with standard care.

FUNDING

Canadian Institutes of Health Research.

Clinical Lactation Studies of Lithium: A Systematic Review

Background: There is substantial evidence that postpartum prophylaxis with lithium lowers the rate of relapse in bipolar disorder. However, it is contraindicated during breastfeeding due to the high variability of the transfer into breast milk. Aims: We conducted a systematic review of the current evidence of studies assessing the transfer of lithium to lactating infants and short-term infant outcomes. Methods: An a priori protocol was designed based on PRISMA guidelines. Searches in PubMed and LactMed were conducted until September 2018. Studies assessing lithium pharmacokinetic parameters and short-term infant outcomes were included. Quality was assessed using a checklist based on international guidelines (i.e., FDA). Results: From 344 initial studies, 13 case reports/series with 39 mother-child dyads were included. Only 15% of studies complied with ≥50% of the items on the quality assessment checklist. Infants breastfeed a mean (SD) of 58.9 (83.3) days. Mean maternal lithium dose was 904 (293) mg/day, corresponding lithium plasma/serum concentration was 0.73(0.26) mEq/L, and breast milk concentration was 0.84(0.14) mEq/L. Mean infant lithium plasma/serum concentration was 0.23(0.26) mEq/L. Twenty-six (80%) infants had concentrations ≤0.30 mEq/L without adverse effects. Eight (20%) showed a transient adverse event (i.e., acute toxicity or thyroid alterations). All of them were also prenatally exposed to lithium monotherapy or polytherapy. Conclusion: The current evidence comes from studies with a degree of heterogeneity and of low-moderate quality. However, it identifies areas of improvement for future clinical lactation studies of lithium and provides support for some clinical recommendations.

Clozapine Use During Pregnancy and Lactation: A Case-Series Report

The current prescription of clozapine in psychotic women of reproductive age makes it crucial to understand its pharmacokinetics during pregnancy and lactation as well as its risk profile for neonatal outcome. The aim of this case series was to provide new evidence on the pharmacokinetic features of clozapine that determine its passage through the placenta and amniotic fluid, as well as the neonatal clozapine elimination half-life (t1/2). This case series demonstrates for the first time that clozapine might show partial placental passage similar to other atypical antipsychotics. Clozapine levels decreased during the first few days in nursing infants. The half-life of clozapine in neonates was slightly higher than previously estimated. Clozapine use in pregnancy may be associated with diabetes mellitus, especially if there is a family history of this disease. Although no acute toxicological effects were observed in the intrauterine exposed newborn, close follow-up of pregnancy is recommended. However, these results must be taken with caution being a case series with small sample size

A study on the bioequivalence of lithium and valproate salivary and blood levels in the treatment of bipolar disorder

Lithium (Li) and valproate (VPA) are used in the treatment of bipolar disorder (BD), with narrow therapeutic window requiring periodic control of serum levels. This prevents intoxication, lack of efficacy due to low serum concentrations, and allows monitoring adherence. We aimed at evaluating the bioequivalence of salivary and blood levels of LI or VPA in a sample of adult BD patients. Secondarily, lithium bioequivalence was evaluated across different patients' lifespans. BD patients treated with either Li or VPA underwent contemporary standard serum and salivary measurements. Blood levels of both drugs were taken according to standard procedures. Li salivary levels were performed by an adapted potentiometric method on the AVL9180 electrolyte analyzer. VPA salivary levels were taken with an immune-assay method with turbidimetric inhibition. A total of 50 patients (38 on Li, 12 on VPA) were enrolled. Blood-saliva bioequivalence for VPA was not found due to a high variability in salivary measures. Li measures resulted in a high correlation (r=0.767, p<0.001), showing no partial correlation with age (r=0.147, p=0.380). Li salivary test is a reliable method of measuring Li availability and is equivalent to serum levels. Potential advantages of Li salivary testing are its non-invasive nature and the possibility of doing the test during the usual appointment with the psychiatrist.

Antipsychotic response in delusional disorder and schizophrenia: a prospective cohort study

INTRODUCTION

Scientific evidence focused on the treatment response in delusional disorder (DD) patients is scarce, and the findings are controversial. Our goal was to compare the antipsychotic response at the 12-week followup between patients diagnosed with DD and patients diagnosed with schizophrenia and to identify potential response dimensions.

METHODS

A prospective, observational, cohort study with 12-week follow-up was conducted with DD and schizophrenia patients matched for sex, age and cumulative years of disease. The following scales were assessed: Positive and Negative Syndrome Scale (PANSS; 5-factors), Personal and Social Performance Scale (PSP), Clinical Global Impression Scale (CGI), and Columbia-Suicide Severity Rating Scale (C-SSRS). Treatment response was defined as a &#8805;30% reduction in the total PANSS score. Linear and logistic regression models were used to investigate the potential predictive value of psychopathological variables for the antipsychotic response.

RESULTS

Response percentages in DD and schizophrenia were 61.5% and 69.2%, respectively. The duration of untreated psychosis, antipsychotic dosage, and diagnosis did not predict antipsychotic response. In the whole sample, improvement in positive symptoms was significantly associated with the clinical global improvement (p=0.006), explaining almost 20% of the variance in the model. Within the DD group, improvement in cognitive symptoms explained 30% of the variance in clinical global improvement.

CONCLUSIONS

Both response percentages and required antipsychotic doses were similar between DD and schizophrenia. Changes in positive symptoms were associated with clinical global improvement in the entire sample, and improvement in cognitive symptoms was correlated with global improvement exclusively in DD.

[Outbreak of lead poisoning associated with Ayurvedic medicine]

BACKGROUND AND OBJECTIVE

Lead poisoning is normally caused by repeated occupational inhalation of lead. However, lead may also be absorbed through the digestive route. Some alternative medical treatments, such as Ayurvedic medicine, can also contain lead and may result in poisoning.

PATIENTS AND METHOD

We collected cases of lead poisoning related to Ayurvedic treatments attended at the Hospital Clinic of Barcelona.

RESULTS

Two female patients, aged 45 and 57 years, respectively, who initiated Ayurvedic treatments which involved the ingestion of various medicaments, were included. The first patient presented with anemia and abdominal pain. The lead level was 74μg/dL and free erythrocyte protoporphyrin was 163μg/dL. She was treated with intravenous calcium disodium ethylenediaminetetraacetic acid (CaNa2EDTA) and later with oral dimercaptosuccinic acid (DMSA) with a good evolution. The second patient presented with abdominal pain and a Burton's line. The lead level was 52μg/dL and free erythrocyte protoporphyrin was 262μg/dL. She was treated with oral DMSA and evolved favorably. Lead concentrations in some of the tablets supplied to the patients reached 2,003 and 19,650μg/g of tablet.

CONCLUSIONS

Lead poisoning may result from treatments based on Ayurvedic medicine and may reach epidemic proportions. Health control of alternative medicines is necessary.

Association between symptomatic profile and remission following antidepressant treatment in unipolar major depression

BACKGROUND

To evaluate, in patients affected by an acute major depressive episode, what predictive value certain baseline psychopathological characteristics have with regard to expected therapeutic remission following biological antidepressant treatment (pharmacological/electroconvulsive; non-psychological).

METHODS

Six predefined psychopathological characteristics in acute major depressive episode were evaluated using a logistic regression model through a protocolised antidepressant treatment to assess their predictive value with regard to expected remission rate.

RESULTS

The final study sample consisted of 129 subjects affected by an acute major depressive episode. From the baseline evaluation of the anguish/restlessness, reduced emotional reactivity, reduced attention, reduced motor response, feeling of worthlessness, and mood characteristics items, it was possible to correctly classify 88.1% of the sample as remitter/non-remitter with sensitivity of 0.77 and specificity of 0.96. Addition of the 17-item HRSD baseline variable to the regression model increased the capacity for correct classification of the baseline sample by only 0.09%.

LIMITATIONS

Protocolised antidepressant treatment was used. The results of this study may not be generalisable to pharmacological treatments not included in this protocol.

CONCLUSIONS

The results of this study suggest that certain baseline psychopathological characteristics (and perhaps other clinical variables too) of the acute major depressive episode may be of great use in establishing patient subgroups according to expected clinical remission to the administration of biological antidepressant treatment. This could have considerable consequences for individualised therapeutic decision-making and for future researches (clinical trials included).

Prolonged bisphosphonate release after treatment in women with osteoporosis. Relationship with bone turnover

Bisphosphonates (BP), especially alendronate and risedronate, are the drugs most commonly used for osteoporosis treatment, being incorporated into the skeleton where they inhibit bone resorption and are thereafter slowly released during bone turnover. However, there are few data on the release of BP in patients who have received treatment with these drugs for osteoporosis. This information is essential for evaluating the possibility of BP cyclic therapy in these patients and for controlling their long-term presence in bone tissue. This study evaluated the urinary excretion of alendronate and risedronate in patients treated with these drugs for osteoporosis and analysed its relationship with bone turnover, time of previous drug exposure and time of treatment discontinuation. We included 43 women (aged 65±9.4 years) previously treated with alendronate (36) or risedronate (7) during a mean of 51±3 and 53±3 months, respectively, who had not been treated with other antiosteoporotic treatment and with a median time of discontinuation of 13.5 and 14 months, respectively. Both BP were detected in 24-hour urine by HPLC. In addition, bone formation (PINP) and resorption (NTx) markers were analysed. Both BP were also determined in a control group of women during treatment. Alendronate was detected in 41% of women previously treated with this drug whereas no patient previously treated with risedronate showed detectable urinary values. All control patients showed detectable values of both BP. In patients with detectable alendronate levels, the time of drug cessation was shorter than in patients with undetectable values (12 [6-19] versus 31 [7-72] months, p<0.001). Alendronate was not detected in any patient 19 months after treatment cessation. Alendronate levels were inversely related to time of treatment discontinuation (r=-0.403, p=0.01) and the latter was directly related to NTx (r=0.394, p=0.02). No relationship was observed with age, length of drug exposure, renal function or weight. In conclusion, contrary to risedronate, which was not detected in patients after cessation of treatment, alendronate was frequently detected in women previously treated with this agent up to 19 months after discontinuation of therapy. The relationship between alendronate levels and both bone resorption and time of treatment cessation further indicates a residual effect of this drug in bone, despite treatment discontinuation.

The PFA-100® detects sub-optimal antiplatelet responses in patients on aspirin

Although it is suspected that some patients with acute coronary syndromes (ACS) could have a sub-optimal response to aspirin (SASAR), currently a fixed dose of ASA is long-term used in all individuals. This study was designed to determine SASAR and whether a SASAR is a predictor for recurrence of ischemic events in patients on low-dose ASA with a previous ACS. One hundred patients taking ASA 100 mg/day were assessed at 1 and 6 months after a first ACS. SASAR was initially defined as a failure of the ASA treatment to significantly prolong the closure time in the Platelet Function Analyzer (PFA-100). SASAR in these samples was reconfirmed by conventional aggregometry. TXB2 levels were determined in plasma. At one month 49 patients showed SASAR in the PFA-100; only 25 of them showed SASAR by conventional aggregometry. At six months, 39 of 81 patients showed SASAR by PFA-100, but conventional aggregometry detected SASAR in only 12 of the 39 patients. TXB2 levels were significantly higher in patients with SASAR. Five patients with SASAR, by both tests, died during follow-up (p = 0.013). The PFA-100 detected a high rate of SASAR in patients with ACS. This instrument could be used to screen for suboptimal response to the antiplatelet action of ASA. Whether persistence of SASAR could relate to a higher risk of recurrence and how adjusting the dose of ASA could reduce the rate of SASAR are issues that deserve further investigations.

Single-blind comparison of venlafaxine and nortriptyline in elderly major depression

The objective of this single-blind study was to compare the efficacy and safety of venlafaxine extended-release and nortriptyline in elderly patients with moderate to severe major depression. In- and out-patients (N=68) with unipolar major depression were randomized to receive 6-month treatment with either nortriptyline or venlafaxine. Outcomes of the two groups were compared using measures including the Hamilton Depression Rating Scale (HDRS) and the Newcastle Scale. Side effects were assessed with the UKU side-effect rating scale. Of the 34 venlafaxine-treated patients, 22 were remitters, 7 were nonremitters, and 5 dropped out. The intent-to-treat remission rate was 71% (22 of 31). Of the 34 who received nortriptyline, 21 were remitters, 7 were nonremitters, and 6 dropped out. The intent-to-treat remission rate was 70% (21 of 30). These results suggest that the remission rate with a therapeutic plasma level of nortriptyline is similar to the remission rate with a standard dose of venlafaxine in this group of elderly major depressed patients. No significant differences were observed between dropout rates in the two groups, but autonomic side-effects were significantly more frequent for nortriptyline than for venlafaxine. These results confirm the efficacy and safety of venlafaxine extended-release for treating elderly major depression.

[Ponderal evolution in the Girona population, 1989-1999]

BACKGROUND AND OBJECTIVE

Despite the number of plans leading to lose weight among individuals in the developed countries, the prevalence of obesity has increased since 1980. The knowledge of ponderal evolution in a given population is very important because the adverse effects of obesity vary greatly among individuals and populations. The objective of the present paper was to determine the modifications in the different degrees of body adiposity in a population in Catalunya.

PATIENTS AND METHODS

A measurement was made of weight and height of 24554 users aged over 14 years (10595 males and 13959 females) attended at four basic health areas (BHA): Girona 1, Girona 4, Salt and Camprodon, and a Primary Health Center (PHC) in the Girona province, for a five-year period, 1995-1999. The prevalence of the different degrees of obesity was compared with that obtained in a previous study with 6373 individuals during the 1986-1989 period (4,579 males and 1794 females).

RESULTS

The prevalence of women with overweight (defined as a body mass index [BMI] > 25 kg/m2) increased from 7.3% (1986-1989, study 0) to 17.6% (1995-1999, study 1) for women aged 15 to 24 years ( p < 0.001), from 17.9 % to 28.1% for women aged 25 to 34 years (p < 0.001), and from 37.5% to 44.7 % for women aged 35 to 44 years (p < 0.001). In the latter age group, the proportion of women with obesity (BMI > 30 kg/m2) increased from 6.9% to 12.9%. Similar trends were observed among men, and the change in the 35-44 year age group (from 10.5 % of obese men to 16% [p < 0.001]), and 55 to 65 years (from 16.6% of obese men to 22.7% [p < 0.001] was particularly significant. And lastly, it is also noteworthy the proportion of individuals with low weight (BMI < 18.5 kg/m2) which increased from 7.3% to 11.6% for women aged 15 to 24 years, and from 0.3% to 2.2% for women aged 35 to 44 years. This trend was also observed for men aged 15 to 24 years (11% to 17.2%).

CONCLUSIONS

The relative increase in the prevalence of overweight and obesity runs in parallel to that found in other surrounding countries. Also, it is worth mentioning that among women aged 15 to 24 years the increase in the prevalence of low weight and obesity is almost identical, which invalidates the mean and median values as a means to assess the ponderal evolution in this population. The current compartmentalization between the extreme BMIs, particularly among the youngest portion of population should be addressed from a multidisciplinary perspective.

Biological monitoring of environmental exposure to manganese in blood samples from residents of the city of Barcelona, Spain

Serum manganese levels were determined in 250 healthy subjects (122 men and 128 women) living in Barcelona in northeastern Spain. The study was designed to assess the reference levels for serum manganese and to investigate its relationship to age and sex. The age distribution ranged from 15 to 90 years. The assays were performed by means of a graphite furnace atomic absorption spectrometry. The geometric mean of serum manganese concentration was 1.1 microg/l, ranging from 0.3 microg/l to 2.5 microg/l. In almost every case, the 95th upper percentiles of this element were < 1.8 microg/l. No correlation between the concentration of manganese and sex could be established, but in the younger population the manganese levels were nearly three times higher than the results obtained in the older population.

[Prevalence of obesity in the population assisted at primary health care services in Girona, 1995-1999]

OBJECTIVES

To estimate the prevalence of obesity and overweight in the population of Girona (Spain) between 1995 and 1999 and to divide the prevalences in geographical areas according to age and sex.

METHODS

Height and weight were directly measures in 24,554 health care consumers older than 14 years (10,595 men and 13,959 women) treated in four primary health care areas: Girona 1, Girona 4, Salt and Camprodon and in one primary health care center in the province of Girona. Body mas index (BMI) was calcuted by dividing weight in kilograms bye height in meters squared. Obesity was defined as grades II and III of Garrow's index (BMI >= 30 kg/m2) and overweight as degree I (25 kg/m2 >= BMI < 30 kg/m2). Because the sample was not randomized, the prevalences were adequately weighted. The comparison between prevalences in two different primary health care areas for each sex (in the same Garrow's index and age group) was carried out using a parametric test of differences in proportions (Student's t-test). A hierarchical logistic regression was used to compare prevalences in the same grade Garrow's index, controlling for age and sex.

RESULTS

The prevalence of obesity was estimated as 15.6% in men aged from 20-74 years (from 14.0% in Girona 1 to 22.4% in Camprodon) and 17.5% for women (15.6% in Girona 1, 22.7% in Camprodon). The weighted mean was 16.7%. The prevalence of overweight was 44% in men and 33% in women and the weighted mean was 37.8%. The prevalence of obesity was graduated with statistically significant differences between Girona 1, Salt, Girona 4, Camprodon and Sils.

CONCLUSIONS

The estimates of the prevalences of obesity and overweight obtained in this study were closer to those of other studies in similar populations than previously believed. Indeed, the prevalences may be similar to those of the European Union and, in some age groups, to those of the United States.

Dietary micronutrients/antioxidants and their relationship with bronchial asthma severity

BACKGROUND

Because little is known about micronutrient/antioxidant intake and asthma severity, we investigated dietary intake and plasma/serum levels of micronutrients/antioxidants in a group of asthma patients with various degrees of severity, and compared the results with healthy subjects.

METHODS

A case control study was carried out on 118 asthma patients and 121 healthy subjects. The severity of the disease was classified by division of patients into four groups. Normal dietary micronutrient/antioxidant intake was estimated from a food frequency questionnaire. Plasma/serum levels of vitamins C, E, and A, selenium, magnesium, zinc, and platelet glutathione peroxidase (GSH-Px) activity were also determined.

RESULTS

No differences in daily micronutrient/antioxidant intake were seen between patients and healthy subjects. The severity of the disease showed no significant relationship with micronutrient/antioxidant intake. There were no differences in plasma/serum levels in any of the micronutrients/antioxidants between healthy subjects and asthmatics. Nor were any differences found between asthma groups in severity in the biochemical measures, except in platelet GSH-Px activity, which was significantly lower in the most severe groups.

CONCLUSIONS

In this study, we found no evidence of any association between micronutrient/antioxidant intake or plasma/serum levels of micronutrients/antioxidants and asthma. Reduction of platelet GSH-Px activity in the most severe patients suggests that these patients have a diminished capacity to restore part of the antioxidant defences.

Optimized procedure for lamotrigine analysis in serum by high-performance liquid chromatography without interferences from other frequently coadministered anticonvulsants

The authors have developed a simple isocratic high-pressure liquid chromatographic (HPLC) assay for the simultaneous determination of lamotrigine and other frequently coadministered antiepileptic drugs in serum samples. Lamotrigine extraction was performed on a reversed-phase Oasis HBL preparation column. The eluates containing butalbital as internal standard were separated with a 7-microm Chromsystems C18 250 x 4.0 mm I.D. reversed-phase column at a temperature of 40 degrees C using a mobile phase consisting of pH 3.8 phosphate-acetonitrile buffer (55:45, v/v), at a flow rate of 0.8 mL/min. Ultraviolet detection was carried out at 210 nm. Measurement of the peak:height ratio allowed quantitative determination of the samples. The method was linear over a concentration range of 0.2 to 20 microg/mL for lamotrigine. Recovery was >90%. Within-day and between-day coefficients of variation ranged from 1.8% to 6.7%. The mean lamotrigine concentration was 8.01 +/- 5.63 microg/mL. After studying sera from 130 patients treated with lamotrigine the authors confirmed that associated antiepileptic therapy affected the serum lamotrigine levels, which were significantly higher in patients under valproic acid treatment.

Alpha-1-acid glycoprotein in major depressive disorder. Relationships to severity, response to treatment and imipramine plasma levels

BACKGROUND

Increased plasma levels of alpha-1-acid glycoprotein (AGP) were reported in major depressive disorder. However, the relationship between AGP levels, severity of depression, treatment response and antidepressant levels are still unclear.

METHODS

Plasma AGP levels were measured in 36 subjects with major depressive disorder before and after a 6-week treatment with imipramine and in 30 controls. Free imipramine plasma levels of depressed patients were measured at 6 weeks. Comparative analysis between depressed patients and controls, between non-responders (N = 12) and responders (N = 24), and between severely depressed patients (N = 14) and moderately depressed patients (N = 22) were made.

RESULTS

Depressed patients had significantly higher mean values of AGP than control subjects. Imipramine non-responders and specially severely depressed patients had significantly greater increases of AGP levels during treatment than other depressed subgroups. There was no correlation between baseline AGP levels and severity of depression or free imipramine levels.

LIMITATIONS

The most significant limitations of this study are the small sample size and the fact that all the subjects were out-patients. Results should not be generalized to in-patient populations.

CONCLUSIONS

Depressed patients showed high baseline concentrations of AGP. AGP levels did not predict either free imipramine plasma levels or differential response after 6 weeks of treatment with imipramine. A greater increase of AGP during treatment was associated with severity of depression and treatment non-response.

CLINICAL IMPLICATIONS

The relationship between high plasma levels of AGP, severity of depression and lack of treatment response is clarified. The influence of imipramine levels is minimized.

Cyclical etidronate versus sodium fluoride in established postmenopausal osteoporosis: a randomized 3 year trial

To compare the effects of sodium fluoride and etidronate in severe postmenopausal osteoporosis, we conducted a 3 year, prospective, trial in 118 postmenopausal osteoporotic women with at least one vertebral fracture, who were randomly assigned to receive sodium fluoride (25 mg twice daily, as enteric-coated tablets) plus calcium (1000 mg/day) or intermittent etidronate (400 mg/day for 14 days) followed by calcium (1000 mg/day for 76 days). Lateral spine X-ray films and dual-energy X-ray absorptiometry (DXA) measurements of the lumbar spine and proximal femur were performed at enrollment and yearly. Nonvertebral fractures were recorded every 6 months. Thirty-one women in the fluoride group and 47 in the etidronate group completed the trial. At 36 months, the mean change from baseline of the lumbar bone density in the fluoride group was 8.5 +/- 2.04% (p = 0.001) and in the etidronate group was of 3.6 +/- 0. 84% (p < 0.001). The changes in the fluoride group were significantly higher than in the etidronate group (p = 0.01). Both groups showed nonsignificant changes in femoral neck bone density. There was no significant difference between groups in the cumulative proportion of women with new vertebral fractures, with an incidence in the fluoride group of 16% vs. 17% in the etidronate group. However, the number of new vertebral fractures was significantly lower in the fluoride group (6 fractures) than in the etidronate group (19 fractures) (p = 0.05). The number of patients with nonvertebral fractures was similar in both groups. A high incidence of side effects, mainly gastrointestinal symptoms and lower extremity pain syndrome, was observed in the fluoride group. Etidronate was well tolerated. We conclude that, in women with severe osteoporosis, although sodium fluoride is more favorable than cyclical etidronate for increasing lumbar bone mass, no differences were observed in the incidence of fractures.

Blood chromium determination in assessing reference values in an unexposed Mediterranean population

Plasma chromium levels were determined in 243 healthy subjects. The study group consisted of 134 men and 109 women, ages 19-71 yr, all residing in Barcelona in northeastern Spain. The study was designed to assess the reference levels for plasma chromium and to investigate its relationships to age and sex. The assays were performed by means of a graphite-furnace atomic absorption spectrometer. The mean plasma chromium concentration was 3.01 +/- 1.45 nmol/L, ranging from 0.6 to 6 nmol/L. The upper reference values in the 0.95 percentile for this population was 5 nmol/L. No significant differences were observed with respect to the subjects' sex.

Serum and urine fluoride concentration: relationships to age, sex and renal function in a non-fluoridated population

Serum and urine fluoride levels were determined in 250 healthy subjects (15-90 years, 122 men and 128 women) residing in Catalonia, Spain, and in 150 patients (20-81 years, 84 men and 66 women) with chronic renal failure undergoing regular dialysis treatment, living in the same geographical area, to determine normal range and to investigate its relationships to age, sex and renal function. Serum and urine fluoride were determined by a fluoride ion specific electrode system. Mean (+/- S.D.) serum fluoride concentration was 17.5 +/- 9.5 micrograms/l, ranging from 1 to 47 micrograms/l, in the control group and 58 +/- 31 micrograms/l, ranging from 28 to 185 micrograms/l, in renal patients. Urine fluoride concentration in the healthy group was 671 +/- 373 micrograms/24 h, ranging from 156 to 1900 micrograms/24 h. Fluoride status in the patient group was significantly greater than the control group. There was significant correlation between serum fluoride and age. No sex related difference was found.

Serum and urine ionic fluoride: normal range in a nonexposed population

The present study was undertaken to evaluate the fluoride status in the general healthy population of Barcelona. Serum and urine fluoride ionic concentration was determined in a random sample of 250 subjects (age range 15-90 yr) by the Orion fluoride electrode system to determine the normal range of fluoride in this population. The results obtained show that in the general population of Barcelona, fluoride ionic serum concentration ranges between 1 and 47 microg/L (x = 17.5 +/- 9.7 microg/L) and fluoride ionic urine concentration ranges between 156 and 1990 microg/24 h (x = 671 +/- 373 microg/24 h). The mean serum fluoride concentration of the younger population was shown to be significantly greater (p < 0.05) than that of the older group. No sex-related difference was found.

Etidronate versus fluoride for treatment of osteopenia in primary biliary cirrhosis: preliminary results after 2 years

BACKGROUND & AIMS

Because osteopenia increases morbidity of primary biliary cirrhosis (PBC), the effects of cyclical etidronate vs. sodium fluoride on bone mass were compared in patients with PBC.

METHODS

Thirty-two women with PBC were randomly assigned to receive etidronate (400 mg/day during 14 days every 3 months) or fluoride (50 mg/day, enteric-coated tablets). Bone mineral density of the lumbar spine and proximal femur were measured initially and every 6 months. Bone fractures were also evaluated.

RESULTS

Sixteen patients were allocated into each group, which were comparable with respect to the severity of PBC and osteopenia. Thirteen patients with etidronate and 10 patients with fluoride completed 2 years in the study. In the etidronate group, bone mineral density increased in the lumbar spine (P = 0.02) and did not change in the proximal femur. In the fluoride group, lumbar bone mineral density did not change but femoral bone mass decreased, particularly in the Ward's triangle. Two patients in the fluoride and none in the etidronate group developed new vertebral fractures, and the number of new nonvertebral fractures was similar in both groups. Neither treatment impaired liver function or cholestasis.

CONCLUSIONS

Cyclical etidronate is more effective and better tolerated than sodium fluoride in preventing bone loss in PBC.

Serum selenium concentration of a healthy northwest Spanish population

Selenium (Se) is an essential element, cofactor for glutathione peroxidase (GSHPx) activity, whose deficiency may induce modifications in the cellular antioxidative status and induce the appearance of different diseases. Current views suggest that a serum Se concentration inferior to 45 micrograms/L may correlate with an increased risk of coronary hearth diseases, coronary atherosclerosis and cancer. Since the Se concentration in human blood varies between geographical areas, we initiated a study to evaluate the Se status in the general healthy population of Barcelona. Serum Se concentration was investigated in a random sample of 150 subjects (age range 18-70 yr) by graphite furnace atomic spectrometry (FLAAS). L'vov platform, Zeeman background correction, and other specifications of stabilized temperature platform furnace (STPF) concept were followed. The results show that in the general population of Barcelona, Se serum concentration ranges between 60 and 106 micrograms/L (X = 80.7 +/- 10 micrograms/L). These values can be considered within the safe limits, since no subject was found with a concentration lower than the threshold of 45 micrograms/L.

[Exposure to lead among the population of Barcelona: chronologic trends from 1984 to 1995]

BACKGROUND

This study was designed to determine current lead exposure in the Barcelona population and to evaluate the changes occurred during the last 10 years. Blood lead concentration was investigated in a random sample of 694 healthy subjects (age range: 0-65 years).

PATIENTS AND METHODS

Adults were random selected from a group of blood donors. Samples of children analysed were selected from subjects with a preoperatory analyses without any disease that could modify blood lead levels. Lead levels were determined by atomic absorption spectrometry.

RESULTS

Blood lead concentration was 4.06 +/- 1.4 micrograms/dl in umbilical cord, 8.9 +/- 2.9 micrograms/dl in the paediatric population and 7.8 +/- 4.2 micrograms/dl in the total of adults analyzed. There was statistical differences between the younger subjects and the older population. In 1984 the results found were 18.6 +/- 6.6 micrograms/dl.

CONCLUSIONS

The results obtained show that in the last 10 years a reduction on the blood lead levels was occurred. This reduction is parallel with a diminish in the lead petrol concentration in the ambient air.

Comparative analysis of tacrolimus (FK506) in whole blood liver transplant recipients by PRO-TRAC enzyme-linked immunosorbent assay and microparticle enzyme immunoassay IMX methods

The macrolide tacrolimus (FK506) is a powerful immunosuppressive drug that acts early in the T-cell activation process and inhibits cytokine gene transcription. Data from several trials in liver transplantation have shown the efficacy of tacrolimus in the prevention of allograft rejection and its potent hepatotrophic effect, which could explain its great success in liver transplantation. However, tacrolimus is not devoid of adverse effects (mainly nephrotoxicity and neurotoxicity) requiring careful blood level monitoring, which is an essential aid in the adjustment of drug dosing. Several methods of analysis are available to measure tacrolimus in whole blood. A new assay based on the enzyme-linked immunosorbent assay (ELISA) technology has been developed. The INCSTAR PRO-TRAC FK506 is a sensitive immunoassay (range, 0.5 to 60 ng/ml), which uses a mouse monoclonal antibody to FK506. Samples are extracted into methanol and dried under nitrogen. The reconstituted extracts are analyzed by ELISA by using 2-h incubation. The aim of this study was to evaluate the ELISA method in routine monitoring of liver transplant patients and to compare the whole blood results with those obtained by Abbott microparticle enzyme immunoassay (MEIA) IMx. Precision studies with 20 samples from 4.37 and 17.1 ng/ml gave within-run total coefficients of variance of 14.4 and 17.4%, respectively. A total of 63 blood samples was analyzed. The mean +/- SD were 9.68 +/- 5.92 and 10.52 +/- 7.54 ng/ml by ELISA and MEIA assays, respectively. There was an acceptable correlation between the methods: ELISA = 1.419 + 0.785 MEIA; Sy x x = 2.639; r = 0.804. Serial tacrolimus measurements (n = 13) in two patients with bilirubin levels > 20 mg/dl yielded mean +/- SD (range) of 11.64 +/- 7.59 ng/ml (2.60-25.40 ng/ml) and 15.55 +/- 10.78 ng/ml (3.60-34.4 ng/mL) by ELISA and MEIA assays, respectively. These discrepancies in concentrations can result from variation in matrix or different cross-reactivities or both in the two tests. We concluded that the INCSTAR PRO-TRAC FK506 is suitable for routine whole blood tacrolimus monitoring.