Evaluation of a mobile diabetes care telemedicine clinic serving Aboriginal communities in northern British Columbia, Canada

INTRODUCTION

In British Columbia, Aboriginal diabetes prevalence, hospitalization and mortality rates are all more than twice as high as in the rest of the population. We describe and evaluate a program to improve access to diabetes care for Aboriginal people in northern communities.

STUDY DESIGN

Cost-effectiveness evaluation.

METHODS

A diabetes nurse educator and an ophthalmic technician travel to Aboriginal reserves, offering people with diabetes services recommended in current clinical practice guidelines: retinopathy screening by digital retinal fundus photography, glaucoma screening by tonometry, point-of-care urine and blood testing to detect microalbuminuria and dyslipidemia and to measure glycated hemoglobin, foot examinations and foot care advice, blood pressure and height and weight measurement and diabetes care advice. Via electronic communication, an ophthalmologist and an endocrinologist in Vancouver review the findings and supervise the mobile clinic staff.

RESULTS

During the first year, 25 clinics were held at 22 sites, examining 339 clients with diabetes. Exit surveys showed high levels of client satisfaction. Mean cost per client (Cdn dollars 1,231) was less than for the alternative, transporting clients to care in the nearest cities (Cdn dollars 1,437).

CONCLUSIONS

The mobile clinic is cost-effective and improves access to the recommended standard of diabetes care.

A study examining the bias of albumin and albumin/creatinine ratio measurements in urine

The objective of the study was to examine the bias of albumin and albumin/creatinine (ACR) measurements in urine.

Pools of normal human urine were augmented with purified human serum albumin to generate a series of 12 samples covering the clinical range of interest for the measurement of ACR. Albumin and creatinine concentrations in these samples were analyzed three times on each of 3 days by 24 accredited laboratories in Canada and the USA. Reference values (RV) for albumin measurements were assigned by a liquid chromatography-tandem mass spectrometry (LC-MS/MS) comparative method and gravimetrically. Ten random urine samples (check samples) were analyzed as singlets and albumin and ACR values reported according to the routine practices of each laboratory.

Augmented urine pools were shown to be commutable. Gravimetrically assigned target values were corrected for the presence of endogenous albumin using the LC-MS/MS comparative method. There was excellent agreement between the RVs as assigned by these two methods. All laboratory medians demonstrated a negative bias for the measurement of albumin in urine over the concentration range examined. The magnitude of this bias tended to decrease with increasing albumin concentrations. At baseline, only 10% of the patient ACR values met a performance limit of RV ±15%. This increased to 84% and 86% following post-analytical correction for albumin and creatinine calibration bias, respectively.

International organizations should take a leading role in the standardization of albumin measurements in urine. In the interim, accuracy based urine quality control samples may be used by clinical laboratories for monitoring the accuracy of their urinary albumin measurements.

Establishing reference intervals for clinical laboratory test results: is there a better way?

Reference intervals are essential for clinical laboratory test interpretation and patient care. Methods for estimating them are expensive, difficult to perform, often inaccurate, and nonreproducible. A computerized indirect Hoffmann method was studied for accuracy and reproducibility. The study used data collected retrospectively for 5 analytes without exclusions and filtering from a nationwide chain of clinical reference laboratories in the United States. The accuracy was assessed by the comparability of reference intervals as calculated by the new method with published peer-reviewed studies, and reproducibility was assessed by the comparability of 2 sets of reference intervals derived from 2 different data sets. There was no statistically significant difference between the calculated and published reference intervals or between the 2 sets of intervals that were derived from different data sets. A computerized Hoffmann method for indirect estimation of reference intervals using stored test results is proved to be accurate and reproducible.

Current issues in measurement and reporting of urinary albumin excretion

BACKGROUND

Urinary excretion of albumin indicates kidney damage and is recognized as a risk factor for progression of kidney disease and cardiovascular disease. The role of urinary albumin measurements has focused attention on the clinical need for accurate and clearly reported results. The National Kidney Disease Education Program and the IFCC convened a conference to assess the current state of preanalytical, analytical, and postanalytical issues affecting urine albumin measurements and to identify areas needing improvement.

CONTENT

The chemistry of albumin in urine is incompletely understood. Current guidelines recommend the use of the albumin/creatinine ratio (ACR) as a surrogate for the error-prone collection of timed urine samples. Although ACR results are affected by patient preparation and time of day of sample collection, neither is standardized. Considerable intermethod differences have been reported for both albumin and creatinine measurement, but trueness is unknown because there are no reference measurement procedures for albumin and no reference materials for either analyte in urine. The recommended reference intervals for the ACR do not take into account the large intergroup differences in creatinine excretion (e.g., related to differences in age, sex, and ethnicity) nor the continuous increase in risk related to albumin excretion.

DISCUSSION

Clinical needs have been identified for standardization of (a) urine collection methods, (b) urine albumin and creatinine measurements based on a complete reference system, (c) reporting of test results, and (d) reference intervals for the ACR.

Estimating pediatric glomerular filtration rates in the era of chronic kidney disease staging

With the use of information from a database of pediatric patients with concomitant nuclear GFR and serum creatinine (Cr), estimated GFR equations were derived on the basis of local laboratory methods and population. These formulas then were compared with those recommended by the National Kidney Foundation for estimating GFR in children. For this, their ability to estimate accurately an individual's true GFR and chronic kidney disease stage, identify patients whose true GFR was <60 ml/min per 1.73 m(2), and to identify correctly deterioration in an individual's GFR over time was compared. Next, two methods to estimate GFR in children without the use of height or weight were developed. The first was a height- and weight-independent formula; the second was a novel approach using the Schwartz formula and calculating a Cr cutoff based on age-based estimates of height and GFR level of interest, i.e., <60 ml/min per 1.73 m(2). Our results suggest that if local laboratory constants are derived and a height is known, then the Schwartz formula offers the most accuracy with least mathematical complexity to perform in the clinical setting. If height is not available but the local laboratory constants have been derived, then the British Columbia's Children's Hospital 2 formula is of value; however, in the setting of estimating pediatric renal function in the outpatient laboratory, where neither of these factors is commonly known, an approach whereby a Cr cutoff for a GFR of interest is developed is suggested. Provided are Cr levels that are based on a reference method of Cr measurement to facilitate this approach for the clinician.

Effect of cyclosporine A on the binding affinity and internalization of low-density lipoproteins in human skin fibroblasts

The aim of this study was to elucidate the possible causes of elevated low-density lipoprotein (LDL)-cholesterol levels in patients with transplants who were treated with the immunosuppressant drug cyclosporine A (CSA). The binding and internalization of (125)I-LDL in the presence or absence of CSA at varying concentrations (5-15 microg/mL) within human skin fibroblasts were determined. In addition, the effect of LDL-associated CSA on the binding of LDL to its receptor was determined. CSA decreases LDL internalization without altering the extent and affinity of its binding to the LDL receptor. CSA did not alter the number of available LDL binding sites. Furthermore, the association of CSA with LDL did not affect the binding affinity of LDL to its receptor, suggesting that this binding may not be a mechanism by which CSA affects the subsequent clearance of LDL from the bloodstream. These findings suggest that CSA may cause an increase in plasma LDL-cholesterol in patients with transplants, thereby inhibiting LDL particle internalization without altering LDL receptor binding.

Overexpression of acyl-coA binding protein and its effects on the flux of free fatty acids in McA-RH 7777 cells

Overexpression of acyl-CoA binding protein (ACBP) was induced in a rat hepatoma cell line (McA-RH 7777) by stable integration of rat ACBP cDNA. The transfected cells (ACBP-27) had 3.5-fold higher concentrations of ACBP than control cells (14 vs. 4 ng/microg DNA). Both ACBP-27 and control cells were cultured in the presence of various concentrations of radiolabeled palmitic acid; and the effects of ACBP on lipogenesis and beta-oxidation were studied. Incubation of the cells with 100 microM palmitic acid resulted in 42% greater incorporation of the fatty acid in ACBP-27 cells as compared to that in the control cells. This increased incorporation of the fatty acid was observed predominantly in the triglyceride fraction. Higher concentrations of palmitic acid (200 to 400 microM) were associated with a significant decrease in the production of 14CO2 in the ACBP-27 cell line than in the control cells, while lower concentrations had no effect. Our data suggest a role for ACBP in the partitioning of fatty acids between esterification reactions leading to the formation of neutral lipids and beta-oxidation. ACBP may play a regulatory role by influencing this important branch point in intermediary lipid metabolism.

A study to examine the accuracy of potassium measurements in clinical laboratories across Canada

OBJECTIVE

To assess the accuracy of potassium measurements in clinical laboratories across Canada.

DESIGN AND METHOD

The flame atomic emission spectrophotometry reference method for the determination of potassium was established at the Canadian Reference Laboratory by using National Institute of Science and Technology standard reference materials. The method was subsequently used to assign target values for potassium to Canadian Reference Laboratory's External Quality Assessment human-serum-based testing material. A total of 503 laboratories participated and 9,279 individual External Quality Assessment test results were included in the study. Bias was determined by using difference plots.

RESULTS

Clinically significant bias (>1.6%) was observed in 45.9% of the laboratories. Bias ranged from 0.34 mmol/L to -0.54 mmol/L. At low concentrations (<3.5 mmol/L) a positive bias was most frequently observed (14.7% of analytical systems). At high potassium concentrations (>5.1 mmol/L) a negative bias was most frequently observed (31.4% of analytical systems).

CONCLUSION

Inaccuracy in potassium results can contribute to test redundancy and mismanagement of patients, while prohibiting the merger of laboratory data from disparate testing sites for the purpose of trending and consolidation within a "universal health record." Inaccurate test results and the lack of standardization among laboratories adversely impact our ability to establish common reference intervals and critical limits. This inability has an adverse effect on medical decisions and patient care.

Laboratory standardization of a large international clinical trial: the DAIS experience. DAIS Project Group. Diabetes Atherosclerosis Intervention Study

OBJECTIVE

To implement a quality control program for the standardization and harmonization of lipid and lipoprotein analyses as performed at two core laboratories (St. Paul's Hospital, UBC [Vancouver], and NPHI [Helsinki]) for the Diabetes Atherosclerosis Intervention Study (DAIS).

DESIGN AND METHODS

A DAISSOFT computer program was designed to minimize the occurrence of data and sample management errors during the course of the study. Fresh human serum was used for the provision of an accuracy based external quality control program that monitored the analytical performance of lipid testing at these two laboratories. A separate program was designed for monitoring hemoglobin A1c (HbA1c). At the outset of the study, allowable total error goals were established for each analyte. Ongoing performance was monitored using bimonthly blinded challenges of fresh human serum. The two EQA programs routinely monitored the analysis of total cholesterol, calculated LDL-cholesterol, HDL-cholesterol, net triglycerides, apoprotein A-1, apoprotein B, and HbA1c.

RESULTS

The EQA precision and accuracy data for the measurement of total cholesterol at the two core laboratories over the last 5 years indicated both laboratories operated with good precision, approximately 1% CV over the time period. The accuracy at both laboratories was similar initially. Part way through the study, the accuracy of the cholesterol method at NHPI tended to drift upward with an operating positive bias (+3%) relative to the Abell Kendall reference method. Triglyceride measurements were the most problematic for the study. By EQA cycle 8, the accuracy of the method at UBC had stabilized and was meeting the accuracy goals of the study. NPHI's method was negatively biased relative to the accuracy base of the DAIS study. In spite of recalibrating their method, NPHI found it difficult to maintain consistent accuracy for the measurement of triglycerides during the study. Both laboratories operated their HDL methods with excellent precision. Accuracy at NHPI was well maintained over the course of the study whereas the accuracy of HDL measurements at UBC was more problematic. There was an inconsistent variation in the accuracy of apoprotein A-1 measurements at both laboratories. In most cases, the bias would be corrected by the time of the next EQA challenge. In the case of apo B, one laboratory was standardized to the CDC while the other laboratory was standardized to IFCC/WHO. The discrepancy between these two accuracy bases was >20%. Recalibration to a common accuracy base rectified the problem. Only minor problems were encountered with the precision and accuracy of the DIAMAT assay for hemoglobin A-1c. The two DAIS core laboratories consistently operated within the 9% total error goals of the study for HbA1c.

CONCLUSIONS

Through the use of this program, the two DAIS core laboratories were able to maintain their lipid analyses within the limits of allowable total error that had been established for the study.

Point: status of lipid and lipoprotein standardization

Cholesterol and triglyceride standardization procedures have been used extensively and continuously since the 1950s. Definitive and Reference Methods, as well as primary and secondary standards, have been developed and maintained as the basis for evaluating the accuracy of results by various methods in many laboratories. But, although standardization efforts for apolipoprotein A-I and B measurements have been reported in detail in the scientific literature, much less has been reported in the area of total and lipoprotein cholesterol and triglyceride standardization efforts. Standardized cholesterol and triglyceride concentrations, determined in multiple large epidemiological and clinical studies, have been instrumental to the National Cholesterol Education Program panels that have assessed the lipoprotein values associated with risk of coronary disease, and have determined the cutpoints that are now used extensively by physicians to guide diagnosis and treatment of individual patients.

Point Status of lipid and lipoprotein standardization

Cholesterol and triglyceride standardization procedures have been used extensively and continuously since the 1950s. Definitive and Reference Methods, as well as primary and secondary standards, have been developed and maintained as the basis for evaluating the accuracy of results by various methods in many laboratories. But, although standardization efforts for apolipoprotein A-I and B measurements have been reported in detail in the scientific literature, much less has been reported in the area of total and lipoprotein cholesterol and triglyceride standardization efforts. Standardized cholesterol and triglyceride concentrations, determined in multiple large epidemiological and clinical studies, have been instrumental to the National Cholesterol Education Program panels that have assessed the lipoprotein values associated with risk of coronary disease, and have determined the cutpoints that are now used extensively by physicians to guide diagnosis and treatment of individual patients.

The effects of 3-hydroxy-3-methylglutaryl-CoA reductase inhibition on tissue levels of carnitine and carnitine acyltransferase activity in the rabbit

Recently, a new class of lipid lowering agents [3-hydroxy-3-methylglutaryl (HMG)-CoA reductase inhibitors] was introduced into clinical practice. The use of these agents could lead to a secondary deficiency in carnitine, which may manifest clinically as a myalgia/myositis-a side effect that is occasionally seen with this class of drugs. In the present study, we examined the effect of an HMG-CoA reductase inhibitor (lovastatin) on serum and tissue levels of carnitine and carnitine acyltransferase activities in the rabbit. Rabbits (n = 6) were fed chow containing lovastatin (30 mg/d) for 16 wk. Blood was collected and tissues (liver, heart, and skeletal muscle) harvested at sacrifice. Free and total carnitine were measured in serum and tissues by a radioenzymatic method. Carnitine acetyltransferase and carnitine palmitoyltransferase (CPT) activities were determined and expressed relative to DNA. Serum free (24.0 +/- 2.6 vs. 29.4 +/- 3.1 microM) and total (35.1 +/- 4.7 vs. 52.8 +/- 8.8 microM) carnitine levels increased significantly with 16 wk of treatment. This increase in total carnitine was mainly due to an increase in the levels of serum acylcarnitine (12.7 +/- 3.1 vs 26.5 +/- 5.7 microM). Tissue levels of total carnitine were significantly decreased by the treatment. Carnitine acetyltransferase was unaffected by the treatment, whereas there was a significant increase in the activity of CPT in the liver and heart.

Effects of high-fat diet and fasting on levels of acyl-coenzyme A binding protein in liver, kidney, and heart of rat

Acyl-coenzyme A (CoA) binding protein (ACBP) is a 10-kd protein that binds acyl-CoA moieties and stimulates medium-chain fatty acid synthesis by goat mammary gland fatty acid synthetase. Its exact role in intermediary lipid metabolism has not been fully elucidated. It is hypothesized that ACBP is directly involved in the metabolism of lipid. In the present study, purified rat liver ACBP was used to generate a polyclonal antisera for radioimmunoassay of ACBP in tissue specimens isolated from fasted rats and rats fed normal rat chow and a high-fat diet. In addition, purified ACBP was used to examine its effect on the activity of mitochondrial outer membrane (OM) carnitine palmitoyltransferase (CPT0). Fasting for 24 hours significantly decreased tissue levels of ACBP in the liver (69.0 +/- 7.2 v 46.7 +/- 5.0 pg/ng DNA), whereas feeding of a high-fat diet for 48 hours caused ACBP levels to increase (69.0 +/- 7.2 v 103.9 +/- 18.0). Hepatic levels of this protein continued to increase and remained elevated with prolonged exposure to the high-fat diet (28 days). A similar pattern of change was observed in the kidney, but the magnitude of change was less. Heart ACBP did not respond acutely to the high-fat diet, but did increase after prolonged exposure (28 days). Fasting had no effect on ACBP levels in kidney and heart. Addition of ACBP to an in vitro assay system significantly increased the activity of CPT0 (from 5.2 +/- 0.8 to 72.1 +/- 5.3 nmol palmitoylcarnitine formed.min-1.mg-1 protein) when measured under inhibiting concentrations of palmitoyl-CoA (40 mumol/L).(ABSTRACT TRUNCATED AT 250 WORDS)

Electron transfer flavoprotein: ubiquinone oxidoreductase (ETF:QO) deficiency in an adult

A 19-year-old woman with mild myopathic symptoms from age 6 and fasting intolerance presented with a Reye-like syndrome and a myopathy. Investigations disclosed a lipid storage myopathy, type II glutaric acidemia, and carnitine deficiency in skeletal muscle. Riboflavin and carnitine treatment corrected the metabolic abnormalities and she improved clinically. She later died from pulmonary complications secondary to aspiration. Subsequent studies established electron transfer flavoprotein: ubiquinone oxidoreductase (ETF:QO) deficiency (fibroblast ETF:QO activity was 2.9 mU/mg, normal range is 14.1 +/- 3.8 mU/mg) as the cause of her illness. This is the first documented case of ETF:QO diagnosed in an adult.

The role of apoproteins in disorders of lipoprotein metabolism

Apolipoproteins are essential components of plasma lipoproteins. They facilitate the absorption and secretion of fat from the intestine, serve as activators of enzymes of lipoprotein metabolism and act as ligands for lipoprotein receptors on cell surfaces. Changes in the apoprotein quantity or composition affect plasma lipid concentrations. Specific examples of apolipoprotein alterations are known for apo A-I, apo B, and for C and E apolipoproteins. With the availability of both apolipoprotein protein and gene analytical techniques both quantitative and qualitative assays of apolipoproteins are becoming more important in the diagnosis of lipoprotein disorders. Assays of apo A-I, apo B and, less frequently, apo C-II and E apolipoproteins are useful diagnostic tools, if performed properly. Major problems with the standardization and quality control of these assays remain to be solved.

Digoxin-like immunoreactivity, displacement of ouabain and inhibition of Na+/K+ ATPase by four steroids known to be increased in essential hypertension

An endogenous digoxin-like immunoreactive substance(s) (DLIS, "endoxin") may be of significance in the etiology of essential hypertension (EH). Progesterone, dehydroepiandrosterone sulphate (DHEA-S), 11-deoxycortisol and 18-hydroxy-11-deoxycorticosterone (18-OH-DOC), four steroids known to be increased in essential hypertension, were found to have digoxin-like immunoreactivity at levels 1,000 times higher than physiological concentrations. Of these steroids, progesterone and 18-OH-DOC were the most efficient in displacing 3H-ouabain from canine kidney Na+/K+ ATPase whereas progesterone and 11-deoxycortisol were the most potent inhibitors of this enzyme's activity. Although 18-OH-DOC and DHEA-S cross-reacted with digoxin-specific antibodies, their ability to inhibit Na+/K+ ATPase activity was minimal. Although it is concluded that these steroids may contribute to DLIS as isolated from hypertensive patients, it is unlikely that they would be of physiological significance in the etiology of EH unless they were to accumulate and act synergistically within vascular wall smooth muscle tissues.

A study into the nature and organ source of digoxin-like immunoreactive substance(s) in the perinatal period

Digoxin-like immunoreactive substance(s) (DLIS) was isolated from sera and autopsy-derived tissue obtained from premature and full-term neonates. The highest tissue level of DLIS was in the small bowel followed by the adrenal, gallbladder and liver. Of the fluids examined, meconium had the highest level of DLIS. Preparative high performance liquid chromatography fractionation of cord blood generated at least six different fractions which not only contained DLIS material but also inhibited canine kidney Na+/K+-ATPase activity. Recovery/inhibition studies indicated that 72% of the canine kidney Na+/K+-ATPase inhibition within one fraction could be accounted for on the basis of progesterone content of the fraction.

L-carnitine treatment in the hyperlipidemic rabbit

A study was designed to examine the hypolipidemic effect of L-carnitine treatment (4 weeks, 170 mg/kg/d) in rabbits fed a high fat diet (5% corn oil/0.5% cholesterol, w/w). Eight weeks of exposure to the high fat diet significantly increased plasma total cholesterol and triglycerides. VLDL associated triglycerides, cholesterol, apo-B, and total protein were also significantly increased with the diet. There was no change in HDL-cholesterol levels. Plasma concentration of carnitine (free, acyl, and total) all increased significantly with the high fat diet. The content of free, short-chain, and total carnitine were decreased in the liver whereas the content of long-chain acylcarnitines was increased. The diet generated a significant steatosis within the livers of these animals. Four weeks of treatment of L-carnitine reduced the extent of the liver steatosis and significantly decreased plasma total cholesterol, triglycerides, VLDL associated triglycerides, cholesterol, and total protein. HDL-cholesterol levels were unaffected by the treatment. All plasma fractions of carnitine (free, acetyl, acyl, and total) were significantly increased above those levels seen after 8 weeks of the high fat diet alone. The content of liver carnitine and its esters was normalized following treatment. The high fat diet decreased liver HMG-CoA reductase activity and increased the activities of 7-alpha-hydroxylase and acylcholesterol acyltransferase (ACAT). L-Carnitine treatment blunted the magnitude of the diet induced increase in 7 alpha-hydroxylase activity, yet overall the activity still remained elevated relative to controls. ACAT activity increased (1.5 times) with the high fat diet and increased further (4.5 times) following carnitine treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Minimizing analytical interferences from digoxin-like immunoreactive substances (DLIS) in cases of digoxin toxicity

Recently, the value of therapeutic drug monitoring for digoxin has been called into question by the finding of endogenous digoxin-like immunoreactive substances (DLIS) in the serum of individuals, especially premature and full-term neonates, not being treated with digoxin. In some cases, values have been as high as 10 micrograms/L. Levels as high as 20 micrograms/L and 80 micrograms/g can be found in bile and meconium. Because of the magnitude of this interference, it is essential that methods be developed for measuring digoxin in the presence of DLIS. This is particularly important when such analyses are required in forensic science cases of suspected digoxin toxicity. This report outlines the high performance liquid chromatographic (HPLC) and radioimmunoassay (RIA) methods that we used in assessing the relative contribution made by digoxin, its metabolites, and DLIS to serum and tissue digoxin concentrations obtained by RIA in a forensic pediatric case of suspected digoxin toxicity.

L-carnitine treatment in glutaric aciduria type I

Patients with organic aciduria may have a higher than normal requirement for L-carnitine. In a patient with type I glutaric aciduria, serum total L-carnitine levels were 8.5 microM (normal, 54.4 +/- 14.2 [2 SD] microM). After treatment with L-carnitine for 1 month, serum levels of both free and total L-carnitine were normal with an acyl-to-total ratio of 0.18. The fractional clearance rates of free and acylcarnitine were increased fourfold by treatment. Acetylcarnitine accounted for a lower than normal percentage of acylcarnitine recovered in serum and urine. Data suggest that this patient may have been carnitine-deficient.

Effect of assay conditions on cross reactivity of digoxin-like immunoreactive substance(s) with radioimmunoassay kits

One or more digoxin-like immunoreactive substances (DLIS), most frequently present in serum of premature and full-term neonates. cross react to various extents with different digoxin immunoassay kit reagents. Mostly, this variation is attributed to the relative cross reactivity of DLIS with the antiserum in each kit. However, modification of standard assay procedures for digoxin can also greatly alter the relative cross reactivity of DLIS. Using sequential RIA kit methods for digoxin by 20 to 60% relative to the standard equilibrium RIA mode. Cross reactivity was decreased still more if the concentrations of antiserum (binding-site concentration) and tracer (125 l-labeled digoxin) were decreased, and conversely. Serum samples containing only digoxin, analyzed by the modified method, consistently yielded results well comparable with those obtained with the manufacturers' recommended procedures. We describe use of the different responses to digoxin and DLIS of standard and sequential radioimmunoassays and use of simultaneous equation to calculate the concentration of DLIS (in digoxin equivalents) in digoxin-containing samples.

Effect of assay conditions on cross reactivity of digoxin-like immunoreactive substance(s) with radioimmunoassay kits

One or more digoxin-like immunoreactive substances (DLIS), most frequently present in serum of premature and full-term neonates. cross react to various extents with different digoxin immunoassay kit reagents. Mostly, this variation is attributed to the relative cross reactivity of DLIS with the antiserum in each kit. However, modification of standard assay procedures for digoxin can also greatly alter the relative cross reactivity of DLIS. Using sequential RIA kit methods for digoxin by 20 to 60% relative to the standard equilibrium RIA mode. Cross reactivity was decreased still more if the concentrations of antiserum (binding-site concentration) and tracer (125 l-labeled digoxin) were decreased, and conversely. Serum samples containing only digoxin, analyzed by the modified method, consistently yielded results well comparable with those obtained with the manufacturers' recommended procedures. We describe use of the different responses to digoxin and DLIS of standard and sequential radioimmunoassays and use of simultaneous equation to calculate the concentration of DLIS (in digoxin equivalents) in digoxin-containing samples.

Perinatal changes in a digoxin-like immunoreactive substance

An endogenous digoxin-like immunoreactive substance(s) (DLIS) exists in the serum of premature and full term infants not receiving digoxin. We followed serum changes in DLIS concentration sequentially over the first 14 postnatal days in 24 premature neonates who did not receive digoxin in the intensive care nursery. All infants had measurable levels (greater than 0.6 ng/ml) of DLIS in their serum. There was a distinct peak in DLIS concentration in 19 of 24 infants occurring at 4 +/- 1.6 (SD) days after birth (range, 1-8 days). No peak was found in five infants. The peak serum level of DLIS obtained in the first 8 days of life was negatively correlated with gestational age and birth weight. DLIS levels in amniotic fluid remained constant from 16 to 33 weeks of gestation but rose from 33 wk to term. DLIS concentrations in umbilical artery, umbilical vein, and maternal serum at normal full term delivery suggested that DLIS was of fetal origin. DLIS and digoxin concentrations are additive when present in the same serum sample if measured by standard radioimmunoassay methods.

Seven different digoxin immunoassay kits compared with respect to interference by a digoxin-like immunoreactive substance in serum from premature and full-term infants

Seven different digoxin immunoassay kits showed cross reactivity with an endogenous digoxin-like immunoreactive substance consistently present in serum of neonates, whether premature or full-term. The degree of interference, in decreasing order was: NML greater than New England Nuclear greater than Bio-Rad greater than Clinical Assays greater than Becton Dickinson greater than Serono greater than Syva (EMIT). More recently purchased NML kits showed less sensitivity to the substance, evidently reflecting lot-to-lot differences in antibody. A single baseline determination of the substance before digoxin is administered inadequately compensates for this interference, because the interferent concentrations can differ from day to day, with evidence that it may be most concentrated on the fourth to sixth postnatal day. Its concentration in the serum of neonates is unrelated to the concentration of dehydroepiandrostenedione sulfate, an indicator of fetal adrenal-cortical activity.

Seven different digoxin immunoassay kits compared with respect to interference by a digoxin-like immunoreactive substance in serum from premature and full-term infants

Seven different digoxin immunoassay kits showed cross reactivity with an endogenous digoxin-like immunoreactive substance consistently present in serum of neonates, whether premature or full-term. The degree of interference, in decreasing order was: NML greater than New England Nuclear greater than Bio-Rad greater than Clinical Assays greater than Becton Dickinson greater than Serono greater than Syva (EMIT). More recently purchased NML kits showed less sensitivity to the substance, evidently reflecting lot-to-lot differences in antibody. A single baseline determination of the substance before digoxin is administered inadequately compensates for this interference, because the interferent concentrations can differ from day to day, with evidence that it may be most concentrated on the fourth to sixth postnatal day. Its concentration in the serum of neonates is unrelated to the concentration of dehydroepiandrostenedione sulfate, an indicator of fetal adrenal-cortical activity.

Carnitine acetyltransferase in developing mammals

Carnitine acetyltransferase (CAT) activity was determined in mitochondria and microsomes of liver and brown adipose tissue in fetal and postnatal rats, rabbits and guinea pigs. In rat liver and brown adipose tissue, mitochondrial CAT activity increased perinatally. Microsomal CAT activity also increased in brown adipose tissue. In liver, however, a rise was first noted after the 20th postnatal day. The ratio of mitochondrial to microsomal activity was higher in brown fat than liver throughout the period studied. Absolute values for both were always much higher in brown adipose tissue than in liver. Catalase activity (an enzyme localized in the peroxisomes) in rat liver increased after day 20 while in brown adipose tissue it attained a peak at 7 days after birth. At all times, hepatic activity exceeded activity in brown adipose tissue. The ratio on day 30 was 1 (brown adipose tissue) to 25 (liver). In both guinea pigs and rabbits, hepatic mitochondrial CAT activity was 10- to 20-fold higher than in the rat already prenatally. Microsomal activity, on the other hand, was approximately the same in all three species. It is concluded that probably only the mitochondrial CAT is directly related to fatty acid oxidation. The role of microsomal enzyme remains unclear.

Effect of fasting on free and esterified carnitine levels in human serum and urine: correlation with serum levels of free fatty acids and beta-hydroxybutyrate

Serum levels of free L-carnitine, acylcarnitines, creatinine, beta-hydroxybutyrate, free fatty acids, cholesterol, triglycerides, and glucose were determined in healthy volunteers during a 24-36-hr fast. The effect of oral administration of free L-carnitine (1 g/person) on these parameters was studied. Urinary excretion of carnitine and creatinine was monitored throughout. Serum and urine levels of free carnitine and its renal clearance decreased during the fast. However, the serum concentration and urinary excretion of acylcarnitines increased during the same interval. Following the ingestion of free L-carnitine, both serum and urinary levels of free L-carnitine rose. Within 6 hr of ingestion, 10% of the administered dose could be accounted for by urinary excretion. No significant effect on the other serum constituents under study was seen following the oral L-carnitine dose. A significant negative correlation was found between serum levels of free L-carnitine and beta-hydroxybutyrate and free fatty acids (r equal -0.567, p less than 0.001 and r equal -0.607, p less than 0.001, respectively) during the fast.

Fetal utilization of maternally derived ketone bodies for lipogenesis in the rat

When D-beta-[3-14C]hydroxybutyrate was injected via the femoral vein into pregnant Sprague-Dawley rats at 21 days of gestation, D-beta-[3-14C]hydroxybutyrate was enzymatically detected in fetal plasma within 5 min. The time course of the incorporation of DL-beta-[3-14C]hydroxybutyrate into fetal lipids was studied. Lipid extracts of brown adipose tissue exhibited the greatest relative incorporation followed by pancreas, liver and lung. Less radioactivity was incorporated into brain and placenta. The incorporation into fetal lipids was several-fold greater than into maternal lipids. The labelling of the individual phospholipids was similar in the different tissues with phosphatidylcholine accounting for more than 50%. 75% of the radioactivity in brown adipose tissue was in the triacylglycerol fraction. In brain, liver and placenta, approximately half of the neutral lipid radioactivity was in cholesterol. Experiments in which D-beta-[3-14C]hydroxybutyrate was directly injected into fetuses in utero confirmed that this substrate was directly used by the fetuses without maternal intervention. These studies demonstrate that the rat placenta is permeable to beta-hydroxybutyrate and suggest that this ketone body is rapidly used by the fetus for the synthesis of fatty acids and cholesterol.

Fructose-1,6-diphosphatase activity in brown adipose tissue of the developing rat

An enzyme activity capable of converting fructose-1,6-diphosphate to fructose-6-phosphate was demonstrated to present in crude tissue extracts from brown adipose tissue of the rat. Mg2+ was essential for the expression of activity. EDTA (0.5 mM) increased the activity by 30%. Fructose-1,6-diphosphate in concentrations of 1 and 10 mM inhibits activity by 30% and 60% respectively. A 65% inhibition was observed in the presence of 0.2 micrometer 5' AMP. The activity of the enzyme was measured in rat brown adipose tissue at different stages of development. It rises sharply between day 2 and day 6 and continues to increase reaching a maximum between 6 and 11 days. Thereafter the activity gradually declines to values observed prenatally. The normal developmental rise in activity could be prevented by chemical sympathectomy on day 2. This procedure had no effect when carried out on day 9. There was a significant increase in enzyme activity after cold adaptation. The possible physiological significance of this enzyme in brown adipose tissue is discussed.

Carnitine content of blood and amniotic fluid

Free carnitine levels were determined in amniotic fluids between the 10th and 40th week of gestation. They were found to decrease significantly with gestational age. Blood levels of carnitine were lower in pregnant than in nonpregnant women. Levels were found to be higher in cord blood than in maternal blood and usually were higher in the umbilical artery than vein. Intra-arterial injection of L-carnitine into a pregnant ewe did not cause a rise in the fetal blood level of carnitine, which, in contrast to human fetal blood, contained less than half the level of carnitine in maternal blood.

Automated method for L-carnitine determination

Because of renewed interest in a possible connection between carnitine, lipid disorders, and myopathy, an automated method of analysis is desirable. Deproteinization of serum by use of membrane filter cones and automated assay with a bichromatic analyzer (the ABA-100) substantially increases efficiency without sacrificing the specificity and accuracy of the original manual enzymatic method. The described procedure allows for analysis of 80 speciments a day and is thus suitable for screening of selected populations. Normal values found in blood sera of adults were in the range of 25.0-73.8 mu mol/liter and the method has sufficient sensitivity to accurately measure concentrations as small as 10 mu mol/liter.

Automated method for L-carnitine determination

Because of renewed interest in a possible connection between carnitine, lipid disorders, and myopathy, an automated method of analysis is desirable. Deproteinization of serum by use of membrane filter cones and automated assay with a bichromatic analyzer (the ABA-100) substantially increases efficiency without sacrificing the specificity and accuracy of the original manual enzymatic method. The described procedure allows for analysis of 80 speciments a day and is thus suitable for screening of selected populations. Normal values found in blood sera of adults were in the range of 25.0-73.8 mu mol/liter and the method has sufficient sensitivity to accurately measure concentrations as small as 10 mu mol/liter.