Interference in immunoassay measurements of total and free phenytoin in uremic patients: a reappraisal

Accumulation of phenytoin metabolites in uremia has been shown to interfere with some immunoassay methods for phenytoin measurement. We evaluated the effects of uremia (serum creatinine > 13 mg/L) on free and total phenytoin concentrations measured by the Abbott TDx fluorescence polarization immunoassay, and the DuPont aca and Syva EMIT homogeneous enzyme-multiplied immunoassay methods, using HPLC as the comparison method. In uremic patients, the TDx assay showed both fixed and proportional bias in comparison with the HPLC for both total phenytoin concentration (TDx = 1.24 x HPLC + 1.9 mg/L) and free phenytoin concentration (TDx = 1.52 x HPLC + 0.24 mg/L). The total bias was as great as 100% for both total and free phenytoin. Cross-reactive substances other than 5-(p-hydroxyphenyl)-5-phenylhydantoin (HPPH) and HPPH-glucuronide appeared to be responsible. In contrast, there was minimal interference with aca and EMIT assays.

Performance characteristics of a point of care C-reactive protein assay

BACKGROUND

C-reactive protein (CRP) is a non-specific marker of inflammation that can be used for atherosclerotic risk assessment. This application requires increased precision at low CRP concentrations compared to traditional assays.

METHODS

The Micros CRP analyzer (ABX Diagnostics) is a small bench top device. Its limit of detection, limit of quantitation, linearity and imprecision were assessed. Method comparison studies were performed using samples both inside and outside the reference interval. Anticoagulant effects and the prozone effect were also evaluated.

RESULTS

The limit of detection was 0.1 mg/l. The method was linear from 2 to 60 and 0.3 to 60 mg/l using systematic error limits of 10% and 20%, respectively. The total imprecision was <8% for CRP concentrations from 0.7 to 9.1 mg/l. A prozone effect was seen at CRP concentrations >500 mg/l. Using samples from 120 apparently healthy adults, the Micros CRP method demonstrated excellent concordance with the BN II high sensitivity CRP (hs-CRP) method. The Micros CRP method compared well with a nephelometric method using samples with elevated CRP concentrations.

CONCLUSIONS

The Micros CRP method is adequate for atherosclerotic risk prediction in clinical practice but does not have adequate accuracy at CRP concentrations <2 mg/l for epidemiological studies.

Analysis of dicarboxylic acids by tandem mass spectrometry. High-throughput quantitative measurement of methylmalonic acid in serum, plasma, and urine

BACKGROUND

Methylmalonic acid (MMA) is a dicarboxylic acid whose concentration can be increased in blood and urine in patients with an inborn error of metabolism or vitamin B(12) deficiency. We developed a method for the selective analysis of dicarboxylic acids that exploits the high specificity of tandem mass spectrometry (MS/MS) and the substantial difference in fragmentation patterns of the isomers methylmalonic (MMA) and succinic acid (SA).

METHODS

Dicarboxylic acids were extracted from samples with methyl-tert-butyl ether and derivatized with butanolic HCl to form dibutyl esters. The derivative was injected into the liquid chromatography (LC)-MS/MS system using TurboIonSpray (nebulizer-assisted electrospray) ionization and quantified by the multiple reaction monitoring mode of MS/MS.

RESULTS

The assay for MMA was linear up to 150 micromol/L. The total imprecision was < or =7.5% at both low and high concentrations. The limits of quantification and detection were 0.1 and 0.05 micromol/L, respectively. The degree of interference from SA could be predicted from the branching ratios of the major product ions.

CONCLUSIONS

The method is specific for dicarboxylic acids. The LC-MS/MS analysis for MMA requires minimal chromatographic separation and takes <60 s per sample. The entire analysis, including sample preparation, for a batch of 100 specimens can be performed in <4 h.

Glucuronidation of prodrug reactive site: isolation and characterization of oxymethylglucuronide metabolite of fosphenytoin

BACKGROUND

This investigation was undertaken to identify the structure of a novel immunoreactive metabolite derived from fosphenytoin that has been hypothesized previously as present in sera from renally impaired patients receiving this prodrug.

METHODS

The metabolite was isolated from uremic sera using solid-phase extraction and HPLC. Structural analysis was performed using HPLC-tandem mass spectrometry, nuclear magnetic resonance (NMR), deuterium exchange, and chemical derivatization. Immunoreactivity was evaluated using a fluorescence polarization immunoassay.

RESULTS

The metabolite had a parent ion at m/z 457 in the negative-ion mode and fragmented to yield the m/z 251 of phenytoin, as well as other mass fragments of phenytoin. Mass fragments associated with glucuronic acid were also present. The chromatographic peak corresponding to this metabolite demonstrated immunoreactivity sufficient to lead to falsely increased reported values for phenytoin immunoassays. The observed immunoreactivity was also proportional to the relative concentration of the metabolite in collected fractions. Analysis by NMR indicated the presence of phenyl groups with chemical shifts identical to those of phenytoin, as well as the presence of a methylene bridge, which was consistent with the same methylene bridge present on the phosphate ester of fosphenytoin. Comparative analysis of serum samples from renally impaired patients receiving phenytoin vs fosphenytoin using multiple reaction monitoring quantification demonstrated that this metabolite was associated with fosphenytoin administration.

CONCLUSIONS

A unique immunoreactive oxymethylglucuronide metabolite derived from fosphenytoin has been isolated from sera from uremic patients receiving this prodrug.

Performance characteristics of four free phenytoin immunoassays

The measurement of the unbound or free phenytoin concentration is indicated in several situations, including uremia. In patients with uremia, metabolites of phenytoin and other substances accumulate and can displace phenytoin from its protein binding sites, with a consequent increase in the free fraction of drug. Some of the phenytoin metabolites that accumulate in uremia can cross-react with phenytoin immunoassays. In this study the authors evaluated four free phenytoin immunoassays compared with a high-performance liquid chromatography (HPLC) method: the Roche COBAS Integra, the Syva EMIT 2000, the Opus INNOFLUOR, and the Abbott TDx. All four methods demonstrated good precision, with interday coefficients of variation of < or = 5% and comparable recoveries using quality control material. Two of the methods, the EMIT 2000 and COBAS Integra, showed excellent agreement with the HPLC method using samples from patients both with normal renal function and with renal insufficiency. The other two methods, the INNOFLUOR and TDx, showed average positive biases for the therapeutic range of 3-7% and 21-22%, respectively, compared with the HPLC method for samples from patients with normal renal function, and average positive biases of 24-32% and 75-81%, respectively, with samples from patients with uremia.

Evaluation of nine automated high-sensitivity C-reactive protein methods: implications for clinical and epidemiological applications. Part 2

BACKGROUND

C-Reactive protein (CRP) can provide prognostic information about risk of future coronary events in apparently healthy subjects. This application requires higher sensitivity assays than have traditionally been available in the clinical laboratory.

METHODS

Nine high-sensitivity CRP (hs-CRP) methods from Dade Behring, Daiichi, Denka Seiken, Diagnostic Products Corporation, Iatron, Kamiya, Olympus, Roche, and Wako were evaluated for limit of detection, linearity, precision, prozone effect, and comparability with samples from 388 apparently healthy individuals.

RESULTS

All methods had limits of detection that were lower than the manufacturers' claimed limit of quantification except for the Kamiya, Roche, and Wako methods. All methods were linear at 0.3-10 mg/L. The Diagnostic Products Corporation, Kamiya, Olympus, and Wako methods had imprecision (CVs) >10% at 0.15 mg/L. The Iatron, Olympus, and Wako methods demonstrated prozone effects at hs-CRP concentrations of 12, 206, and 117 mg/L, respectively. hs-CRP concentrations demarcating each quartile in a healthy population were method-dependent. Ninety-two to 95% of subjects were classified into the same quartile of hs-CRP established by the Dade Behring method by the Denka Seiken, Diagnostic Products Corporation, Iatron, and Wako methods. In contrast, 68-77% of subjects were classified into the same quartile by the Daiichi, Kamiya, Olympus, and Roche methods. No subject varied by more than one quartile by any method.

CONCLUSIONS

Four of the nine examined hs-CRP methods classified apparently healthy subjects into quartiles of hs-CRP similar to the classifications assigned by the comparison method. Additional standardization efforts are required because an individual patient's results will be interpreted using population-based cutpoints.

Two distinct proteins are associated with tetrameric acetylcholinesterase on the cell surface

In mammalian brain, acetylcholinesterase (AChE) exists mostly as a tetramer of 70-kDa catalytic subunits that are linked through disulfide bonds to a hydrophobic subunit P of approximately 20 kDa. To characterize P, we reduced the disulfide bonds in purified bovine brain AChE and sequenced tryptic fragments from bands in the 20-kDa region. We obtained sequences belonging to at least two distinct proteins: the P protein and another protein that was not disulfide-linked to catalytic subunits. Both proteins were recognized in Western blots by antisera raised against specific peptides. We cloned cDNA encoding the second protein in a cDNA library from bovine substantia nigra and obtained rat and human homologs. We call this protein mCutA because of its homology to a bacterial protein (CutA). We could not demonstrate a direct interaction between mCutA and AChE in vitro in transfected cells. However, in a mouse neuroblastoma cell line that produced membrane-bound AChE as an amphiphilic tetramer, the expression of mCutA antisense mRNA eliminated cell surface AChE and decreased the level of amphiphilic tetramer in cell extracts. mCutA therefore appears necessary for the localization of AChE at the cell surface; it may be part of a multicomponent complex that anchors AChE in membranes, together with the hydrophobic P protein.

Evaluation of four automated high-sensitivity C-reactive protein methods: implications for clinical and epidemiological applications

BACKGROUND

C-reactive protein (CRP) can provide prognostic information about the risk of developing atherosclerotic complications in apparently healthy patients. This new clinical application requires quantification of CRP concentrations below those traditionally measured in the clinical laboratory.

METHODS

The Dade Behring BN II, the Abbott IMx, the Diagnostic Products Corporation IMMULITE, and the Beckman Coulter IMMAGE are four automated analyzers with high-sensitivity CRP (hs-CRP) methods. We evaluated these assays for precision, linearity, and comparability with samples from 322 apparently healthy blood donors.

RESULTS

The imprecision (CV) of the BN II, IMx, IMMULITE, and IMMAGE methods was < or = 7.6%, < or = 12%, < or = 9.8%, and < or = 9.7% at 3.5 mg/L, respectively. The BN II, IMx, IMMULITE, and IMMAGE methods were linear down to < or = 0.30, < or = 0.32, < or = 0.85, and 2.26 mg/L, respectively. CRP concentrations demarcating each quartile in a healthy population were method dependent. The IMx method gave results comparable to the BN II method for values in the reference interval. The IMMULITE method had a positive intercept compared with the BN II method. The IMMAGE method demonstrated more scatter and a positive intercept compared with the BN II method, which may reflect the fact that it is a less sensitive assay.

CONCLUSIONS

The four hs-CRP methods exhibited differences in results for a healthy population. Additional standardization efforts are required to ensure that hs-CRP results can be related to large-scale epidemiologic studies.

Overestimation of hemoglobin in a patient with an IgA-kappa monoclonal gammopathy

A patient with multiple myeloma had an automated blood count performed on a Coulter STK-S counter that repeatedly failed internal limits for both mean corpuscular hemoglobin and mean corpuscular hemoglobin concentration. The calculated hematocrit agreed with a spun hematocrit, suggesting that the hemoglobin concentration was being overestimated by the automated counter. Measurement of the plasma hemoglobin concentration of the sample, which showed no visible hemolysis, gave a hemoglobin concentration of 32 g/L on the STK-S analyzer. Correction of the whole blood hemoglobin using the plasma hemoglobin gave a value consistent with the hematocrit. The corrected mean corpuscular hemoglobin and mean corpuscular hemoglobin concentration values were within standard limits. This patient's paraprotein was characterized as IgA-kappa and was present at a concentration of 61 g/L. The hemoglobin concentration measured on whole blood by Sysmex NE 8000 and Technicon H*1E autoanalyzers agreed reasonably well with the corrected result from the STK-S.

Performance characteristics of three serum iron and total iron-binding capacity methods in acute iron overdose

Accurate serum iron and total iron binding capacity (TIBC) measurements may be useful in acute iron overdoses. Two alumina column TIBC methods were found to measure increased TIBC when free iron was present. A homogeneous TIBC method gave consistent results until iron concentrations exceeded 500 micrograms/dL (90 mumol/L), when it began to underestimate the TIBC. Serious iron overdoses require chelation therapy with deferoxamine. Iron recovery was reduced by up to 50% for all 3 methods with clinically achievable concentrations of deferoxamine 8,400 micrograms/dL (150 mumol/L). TIBC measurements by both alumina column methods were reduced by deferoxamine in the presence of free iron and unaffected when the iron concentration was less than the TIBC. The homogeneous TIBC method yielded falsely elevated results in the presence of free deferoxamine. Procedures that measure TIBC by addition of excess ferric iron followed by alumina adsorption are not suitable for monitoring TIBC in acute iron overdose. The homogeneous TIBC assay can be used in acute iron overdose but underestimates TIBC when iron concentrations exceed 500 micrograms/dL (90 mumol/L). None of the methods examined are useful for measuring iron or TIBC in the presence of deferoxamine.

Falsely increased immunoassay measurements of total and unbound phenytoin in critically ill uremic patients receiving fosphenytoin

BACKGROUND

Fosphenytoin, a phosphate ester prodrug of phenytoin, is metabolized to phenytoin in vivo. Phenytoin metabolites accumulate in renal insufficiency and cross-react in some phenytoin immunoassays. Our aim was to determine the accuracy of phenytoin immunoassays in renal patients treated with fosphenytoin.

METHODS

We measured phenytoin with HPLC and with the aca, ACS:180, TDx phenytoin II, Vitros, and AxSYM methods. Specimens were collected 2-120 h after fosphenytoin administration from 17 patients with renal insufficiency.

RESULTS

The AxSYM, TDx phenytoin II, ACS:180, and Vitros assays displayed falsely increased phenytoin results up to 20 times higher than the HPLC results. The aca Star results for these specimens were comparable to the HPLC results. Although fosphenytoin can cross-react with phenytoin immunoassays, no fosphenytoin was detected by a sensitive HPLC method in any sample that was tested for its presence.

CONCLUSION

These results are consistent with the formation of one or more novel metabolites or adducts of fosphenytoin that accumulate in some critically ill patients with renal insufficiency and that display significant cross-reactivity with some, but not all, phenytoin immunoassay methods.

Suppression of NF-kappaB-dependent proinflammatory gene expression in human RPE cells by a proteasome inhibitor

PURPOSE

To determine whether nuclear transcription factor-kappaB (NF-kappaB) is activated in human retinal pigment epithelial (hRPE) cells in response to interleukin-1beta (IL-1beta), tumor necrosis factor-alpha (TNF-alpha), or interferon-gamma (IFN-gamma) alone or in combination and if so, whether expression of proinflammatory genes induced by these agents can be blocked by a proteasome inhibitor, MG-132, which inhibits the degradation of I kappaB, an NF-kappaB inhibitor, thereby preventing nuclear translocation of NF-kappaB.

METHODS

Cultured hRPE were pretreated for 60 minutes with medium alone or medium containing the proteasome inhibitor MG-132 (20 microM) and then exposed to TNF-alpha (1.1 x 10(3) U/ml), IL-1beta (5 U/ml), or IFN-gamma (7.5 x 10(3) U/ml) alone or in combination (TII). Nuclear translocation of NF-kappaB was determined by fluorescence staining of the NF-kappaB Rel A (p65) subunit. Cytoplasmic I kappaB protein was measured by western blot analysis. Nuclear extract binding to kappaB DNA motifs was measured by electrophoretic mobility shift assay and antibody supershift assay. Steady state mRNA expression of the chemokines melanoma growth stimulating activity (MGSA)/gro-alpha, regulated on activation normal T-cell expression and secreted (RANTES), and monocyte chemoattractant protein (MCP-1), the cytokines IL-1beta and macrophage colony stimulating factor (M-CSF) and intercellular adhesion molecule-1 (ICAM-1) was evaluated by semiquantitative reverse transcription-polymerase chain reaction. Chemokine and cytokine protein secretion was measured by enzyme-linked immunosorbent assay. Cell-surface ICAM-1 expression was determined by flow cytometry.

RESULTS

TNF-alpha, IL-1beta, and TII but not IFN-gamma alone caused degradation of I kappaB, Rel A nuclear translocation, and increased NF-kappaB DNA binding activity, effects that were blocked by pretreatment with MG-132. MG-132 suppressed MGSA/gro-alpha, RANTES, MCP-1, IL-1beta, M-CSF, and ICAM-1 mRNA expression and secreted RANTES, MCP-1, and M-CSF protein, and cell-surface ICAM-1 that were induced by IL-1beta, TNF-alpha, and TII.

CONCLUSIONS

TNF-alpha, IL-1beta, and TII induce expression of proinflammatory cytokines and ICAM-1 in hRPE cells through an NF-kappaB-dependent signal transduction pathway. This effect is blocked by MG-132, a proteasome inhibitor that prevents I kappaB degradation. Inhibition of NF-kappaB may be a useful strategy to treat proliferative vitreoretinopathy and uveitis, ocular diseases initiated and perpetuated by cytokine activation.

Analytic performance of two automated nonpretreatment digoxin immunoassays

The analytic performance of two automated nonpretreatment digoxin methods, AxSYM Digoxin II and Vitros digoxin immunoassays, was assessed. Both assays had analytic sensitivities of less than 0.2 microg/L, were linear from digoxin concentrations of 0.5 to 4.0 microg/L, and showed acceptable precision, with a maximum total coefficient of variation (CV) of 8.9% and 6.4% for the AxSYM and Vitros, respectively. Comparison of the two methods using samples from patients receiving digoxin gave the following relationship: Vitros = 0.91 x AxSYM + 0.23 (r = 0.97, Sy,x = 0.12). Digoxinlike immunoreactive factor (DLIF) crossreactivity was examined in specimens from patients who had hepatic disease, renal insufficiency, had undergone cardiac surgery, and in neonatal cord blood samples. Minimal crossreactivity was observed for most samples and the average crossreactivity for each group of samples was comparable for the two methods. The recovery of digoxin added to samples from each group of DLIF was similar, except for that from cord blood samples, for which recovery was significantly lower with the AxSYM method. Titration of a digoxin-spiked serum pool with digoxin-immune Fab showed a similar decrease in the measured digoxin concentration for both methods. Overall, the analytic performance characteristics of these two methods were comparable.

Wide variation in serum anion gap measurements by chemistry analyzers

The traditional anion gap [AG = Na-Cl-(total CO2)] mean value of 12 mEq/L was established during the 1970s with analyzer methods that are no longer used widely. No studies have systematically compared mean AG values from analyzers in current use. We used data from healthy subjects obtained from 27 clinical laboratories, 5 manufacturers, and 8 publications to compute mean AG values from 1970s analyzers and 8 current analyzers. We also compared mean AG values by evaluating Na, Cl, and total CO2 data from the College of American Pathologists Chemistry Surveys (1990-1996). Data from healthy subjects showed that overall mean AG values of the 9 analyzers ranged from 5.9 to 12.4 mEq/L. The pooled (i.e., average) AG SD was 2.3 mEq/L. We then used the data of the Surveys and the mean value from 1 analyzer to compute predicted mean values for the other 7 current analyzers. Almost all mean AG values predicted from the Surveys agreed (within 1.5 mEq/L) with mean values from healthy subjects. These results show that mean values of analyzers vary widely, indicating that analytic bias strongly influences the AG. The results should be a useful guide for the AG measurements that can be expected from different analyzers.

Incidence of passive exposure to crack/cocaine and clinical findings in infants seen in an outpatient service

OBJECTIVES

Passive exposure to crack/cocaine and the associated clinical symptoms may present a significant health risk to very young infants and children. This study was designed to determine the incidence of cocaine exposure, presumed to be passive, in ill infants younger than 1 year of age, using a threshold of detection for cocaine and/or its major metabolite, benzoylecognine (BE), that is lower than the current National Institute on Drug Abuse standard. The study also investigates the morbidity associated with passive cocaine exposure in this population.

METHODS

We prospectively obtained 124 samples of urine from 122 children younger than 1 year of age for routine clinical indications from the emergency department at Yale-New Haven Hospital. Samples were analyzed by radioimmunoassay (RIA) for cocaine, with cross-reactivity for BE. The presence of BE in a portion of the RIA-positive samples also was detected in additional analyses by enzyme-multiplied immunoassay technique or by gas chromatography-mass spectrometry. A chart review was conducted on all 122 patients by reviewers blind to the urine toxicology results. Presenting complaints, symptoms, vital signs, and diagnosis were obtained for all visits before the first birthday. Birth history, including maternal drug history and birth weight, demographics, and number of medical visits in the first year, were recorded as well.

RESULTS

Of the 124 samples, 45 (36.3%) were positive (>/=50 ng/mL of BE equivalents) for cocaine and/or cocaine metabolite by RIA testing. The positive results, determined by RIA, were highly correlated with patients who had lower and upper respiratory symptoms and sought medical care more often.

CONCLUSIONS

The incidence of unsuspected, passive cocaine exposure in ill infants seeking medical care primarily through an emergency service may be as high as 1 in 3 to 6 infants from our predominantly inner city population. Current immunoassay methods, specific for BE, and their routine threshold of detection (200 to 300 ng/mL) may not be sensitive enough to detect cocaine and BE in the urine samples of children younger than 1 year of age who are exposed passively. The development of upper and lower respiratory symptoms is correlated significantly with positive urine results in this study. The increased use of health care resources correlated with passive cocaine exposure in this sample may serve as an indirect marker for the increased medical needs of these infants.

Effects of sickle cell trait and hemoglobin C trait on determinations of HbA1c by an immunoassay method

OBJECTIVE

A number of studies, including the Diabetes Control and Complications Trial (DCCT), have shown that good glycemic control, as assessed by GHb measurements, can reduce the chronic complications of diabetes. The National Glycohemoglobin Standardization Program (NGSP) was established to insure that GHb measurements by different methods were comparable and could be related to the candidate reference method used in the DCCT. The measurement of HbA1c in patients with Hb variants is one area not directly addressed by the NGSP. Therefore, we assessed the comparability of two DCCT-traceable methods in samples with Hb variants.

RESEARCH DESIGN AND METHODS

Samples containing HbAA, HbAC, and HbAS were collected from diabetic and nondiabetic patients. HbA1c concentrations were measured by a high-performance liquid chromatography method (Bio-Rad Diamat) and an immunoassay that is suitable for use in a physician's office (Bayer DCA 2000).

RESULTS

The two methods compared well for samples with HbAA and HbAS. However, for samples containing HbAC the immunoassay method showed relative positive biases of 8.4 and 10.4% at HbA1c levels of 7 and 9%, respectively, such that the two methods would not be judged comparable according to NGSP guidelines.

CONCLUSIONS

The DCA 2000 HbA1c immunoassay method showed significant positive bias in patients with HbC trait. One possible clinical implication of this overestimation is overly rigorous glycemic control with a concomitant increase in hypoglycemia. This may be especially important in certain ethnic populations, such as African-Americans, who have a relatively high prevalence of HbC trait.

Comparison of four commercial urinary albumin (microalbumin) methods: implications for detecting diabetic nephropathy using random urine specimens

The results of four urinary albumin methods used to identify patients with early diabetic renal disease were compared using random urine samples from healthy and diabetic patients. These methods were the Beckman Array and Behring BNAI immunonephelometric methods, the Dade aca particle-enhanced turbidimetric inhibition immunoassay method, and the INCSTAR SPQ immunoturbidimetric method. The albumin/creatinine ratio reference interval was found to be 2-20 mg albumin/g creatinine (mg/g) for the Array and 3.5-27.5 mg/g for the aca method. All four methods were compared using urines from a group of diabetic and nondiabetic patients. The BNAI, SPQ and Array methods compared well with one another while the aca demonstrated a positive bias of almost 60% at the 30 mg/g and 300 mg/g levels with certain lots of reagent and calibrator. Calibrator cross-over experiments demonstrated that some of the positive bias of the aca method could be accounted for by calibrator differences.

Characterization of the antimonial antileishmanial agent meglumine antimonate (glucantime)

Meglumine antimonate (Glucantime), a drug of choice for the treatment of leishmaniasis, is produced by the reaction of pentavalent antimony with N-methyl-D-glucamine, a carbohydrate derivative. We investigated the structure and composition of meglumine antimonate, which remain poorly understood, despite 50 years of use. Measurement of the antimony content of meglumine antimonate powder indicated a 1:1.37 molar ratio of antimony to N-methyl-D-glucamine. Osmolality measurements performed with meglumine antimonate solutions demonstrated an average of 1.43 antimony atoms per molecule of meglumine antimonate. The osmolality of a 1:10 dilution of stock meglumine antimonate increased by 45% over 8 days, suggesting hydrolysis to less complex species. A comparison of the proton nuclear magnetic resonance spectra of N-methyl-D-glucamine and meglumine antimonate revealed an increase in complexity in the latter but with all of the resonances of the former still being evident, consistent with the presence of coordination complexes between antimony and each of the N-methyl-D-glucamine hydroxyls. Fast atom bombardment and electrospray ionization mass spectrometry coupled with several derivatization procedures provided evidence that up to four N-methyl-D-glucamine hydroxyls are coordinated with each antimony. A series of oligomers were observed. The major moiety has a molecular mass of 507 atomic mass units and consists of NMG-Sb-NMG, where Sb represents antimony and NMG represents N-methyl-D-glucamine. Additional species containing up to four antimony atoms and five N-methyl-D-glucamine moieties and corresponding to the general form (NMG-Sb)n-NMG are also present. These results suggest that this agent is a complex mixture that exists in equilibrium in aqueous solution.

Expression of CD44 and variant isoforms in cultured human retinal pigment epithelial cells

PURPOSE

CD44 is a major hyaluronic acid receptor that exists as a number of isoforms, generated by alternative splicing of 9 "variant" exons in humans (v2 to v10) and 10 exons in rodents. Little is known about the expression and function of CD44 in human retinal pigment epithelium (RPE) cells. Therefore, the authors determined whether human RPE cells express CD44, and whether the expression differs depending on the proliferative status of the cells.

METHODS

Human RPE cells were harvested from normal donor eyes and propagated in culture. Total RNA was extracted from cultured cells. mRNA expression of CD44 was determined by reverse transcription-polymerase chain reaction (RT-PCR), followed by cloning and sequencing of the PCR products, and by Southern hybridization. CD44 cell surface expression was measured by flow cytometry. Western hybridization and immunohistochemistry were used to determine the CD44 immunoreactivity of cultured human RPE cells and normal human RPE cells in situ.

RESULTS

The standard form of CD44 mRNA and variant isoforms containing exon v6 or v10 were expressed in cultured human RPE cells. CD44 mRNA and protein levels were increased in proliferating human RPE cells compared with density-arrested counterparts. Addition of 1 microM retinoic acid enhanced the cell density-induced downregulation of CD44 mRNA, but did not significantly affect the CD44 cell surface protein expression. As previously reported, CD44 immunoreactivity was not detected in normal human RPE cells in situ.

CONCLUSIONS

Cultured human RPE cells express CD44 standard form and variant isoforms containing exon v6 or v10, which are preferentially expressed by proliferating human RPE cells.

The serum anion gap. Has the reference interval really fallen?

OBJECTIVE

To compare the anion gap (calculated as the sodium concentration minus the sum of the chloride and total carbon dioxide concentrations) reference interval for three automated chemistry analyzers.

DESIGN

We measured serum sodium, chloride, and total carbon dioxide on aliquoted specimens using three commercial instruments. Quality control and proficiency survey materials were run to ensure that the analyzers were functioning optimally.

SETTING

Three separate clinical laboratories affiliated with one university medical center participated in the study.

PARTICIPANTS

Healthy volunteers from 20 to 60 years of age were recruited from within a clinical laboratory.

MAIN OUTCOME MEASURES

The mean and standard deviations of the anion gaps measured by each method were calculated.

RESULTS

The parametric reference intervals (+/-2 SD from the mean) were 5 to 10 mmol/L for the Beckman Synchron CX3 analyzer, 9 to 14 mmol/L for the Boehringer Mannheim Hitachi 717 analyzer, and 8 to 13 mmol/L for the Johnson & Johnson Vitros 950 analyzer.

CONCLUSIONS

Our results suggest that while it may be appropriate to lower the anion gap reference interval to 5 to 10 mmol/L for some analyzers, as suggested by earlier reports, 9 to 14 mmol/L may be a more appropriate reference interval for other analyzers. For the anion gap to be an effective tool for diagnosing acid-base disorders, clinical laboratorians need to establish (or at least verify) the anion gap reference interval for the instrumentation used in their laboratory, inform clinicians of this reference interval, and perform quality control studies to ensure that the reference interval for this calculated result remains valid.

Temperature measurement by degenerate four-wave mixing with strong absorption of the excitation beams

We have made simultaneous temperature measurements by degenerate four-wave mixing (DFWM) and absorption spectroscopy of OH in a CH(4)-air, lifted-diffusion flame. After we corrected the DFWM data for laser beam absorption of as much as 60%, the DFWM-based temperatures were in good agreement with temperatures derived strictly from the absorption data, as well as a one-dimensional reacting flow simulation.

Pentavalent antimony-mannan conjugate therapy of experimental visceral leishmaniasis

Pentavalent antimony-mannan (Sb[V]-mannan) was 10-fold more potent than sodium stibogluconate in a murine model of visceral leishmaniasis. Liver antimony concentrations were six-fold higher after Sb[V]-mannan therapy compared with a dose of sodium stibogluconate that was equipotent in reducing liver parasite burdens. Murine toxicity of Sb[V]-mannan was variable, with a 50% lethal dose (LD50) for one preparation that was well above the concentration that killed 90% of the parasites, and for another preparation was only modestly higher than the concentration that killed 90% of the parasites.

Metabolite and matrix interference in phenytoin immunoassays

The major phenytoin metabolite, 5-(p-hydroxyphenyl)-5-phenylhydantoin glucuronide (HPPG), was primarily responsible for the positive bias noted when uremic specimens were assayed with the Abbott TDx Free Phenytoin fluorescence polarization immunoassay. The amount of bias depended on both HPPG and phenytoin concentration, increasing with increases in either concentration. The new Abbott TDx II assays for phenytoin and free phenytoin exhibited no significant cross-reactivity with HPPG and no bias in clinical specimens from uremic patients. Both assays correlated well with Emit-based assays (r >0.98), had CVs of <3.5%, and had minimum detection limits of <0.1 mg/L. Calibration curves were stable for at least 6 weeks. All of the TDx assays cross-reacted with another metabolite, 5-(p-hydroxyphenyl)-5-phenylhydantoin (HPPH), but expected HPPH concentrations are too low to cause a clinically significant bias. The Emit-based phenytoin assay exhibited a significant matrix effect when calibrators were prepared in defibrinated plasma processed to resemble serum.

Metabolite and matrix interference in phenytoin immunoassays

The major phenytoin metabolite, 5-(p-hydroxyphenyl)-5-phenylhydantoin glucuronide (HPPG), was primarily responsible for the positive bias noted when uremic specimens were assayed with the Abbott TDx Free Phenytoin fluorescence polarization immunoassay. The amount of bias depended on both HPPG and phenytoin concentration, increasing with increases in either concentration. The new Abbott TDx II assays for phenytoin and free phenytoin exhibited no significant cross-reactivity with HPPG and no bias in clinical specimens from uremic patients. Both assays correlated well with Emit-based assays (r &gt;0.98), had CVs of &lt;3.5%, and had minimum detection limits of &lt;0.1 mg/L. Calibration curves were stable for at least 6 weeks. All of the TDx assays cross-reacted with another metabolite, 5-(p-hydroxyphenyl)-5-phenylhydantoin (HPPH), but expected HPPH concentrations are too low to cause a clinically significant bias. The Emit-based phenytoin assay exhibited a significant matrix effect when calibrators were prepared in defibrinated plasma processed to resemble serum.

Pyrimethamine analysis by enzyme inhibition and HPLC assays

Pyrimethamine is an antiparasitic agent currently used for therapy of central nervous system toxoplasmosis, a disease seen with increasing frequency in association with the AIDS epidemic. Monitoring of pyrimethamine levels may be particularly important because patients may be treated with high doses of the drug for extended periods of time. The authors have developed and validated both a new enzyme inhibition assay that can be run on an automated analyzer and an improved high performance liquid chromatography (HPLC) method. The calibration range of both methods is 100 to 3,000 micrograms/L. Both demonstrate good linearity, specificity, and precision, and correlate well with one another (r = 0.99). The CVs of the enzyme inhibition assay were < or = 8.6% and those of the HPLC method were < or = 5.4%. No interference was noted for a variety of drugs likely to be used concomitantly with or in lieu of pyrimethamine with the exception of a minor interference from trimethoprim in the enzyme inhibition assay. The major advantage of the enzyme inhibition assay is its ease of automation. The major advantages of the HPLC assay are its precision and relative simplicity. These methods should facilitate therapeutic monitoring of pyrimethamine.

In vitro antileishmanial properties of tri- and pentavalent antimonial preparations

To better understand the antileishmanial effects of antimonial agents we synthesized complexes of tri- and pentavalent antimony with mannan. The 50% inhibitory concentrations (IC50s) of these agents, along with those of potassium antimony tartrate [Sb(III)] and sodium stibogluconate [Sb(V)], were determined for promastigotes and intramacrophage amastigotes. The trivalent antimonial agents were more potent than the pentavalent agents. Although the IC50s were 60- to more-than-600-fold higher for promastigotes than for amastigotes, similar intracellular antimony concentrations in both life forms were measured after incubation with all four drugs at their respective IC50s. Macrophages accumulated antimony during a 4-h exposure that was retained intracellularly for at least 3 days. Amastigotes inside macrophages had a higher antimony content 6 days after a single 4-h treatment than they did immediately after treatment, suggesting that macrophages serve as a reservoir for antimonial agents and prolong parasite exposure. Macrophages concentrated antimony from the medium with potassium antimony tartrate, trivalent antimony-mannan, and pentavalent antimony-mannan treatments. N-Acetylcysteine antagonized the antileishmanial effects of these three drugs against intracellular amastigotes; in contrast, it had minimal effects on the action of sodium stibogluconate.

Monocyte-induced cytokine expression in cultured human retinal pigment epithelial cells

Monocytes and retinal pigment epithelial cells are intimately associated in membranes of eyes with proliferative vitreoretinopathy and in certain types of uveitis. The goal of this study was to determine whether monocytes modulate cytokine expression in retinal pigment epithelial cells, and if so, to identify the monocyte products responsible for this effect. Cultured human retinal pigment epithelial cells were exposed to varying concentrations of monocyte-conditioned medium from unstimulated human monocytes for 1-48 hr, or from monocytes prestimulated with lipopolysaccharide. mRNA expression of interleukin-1 beta, interleukin-6, interleukin-8, melanoma growth stimulating activity/gro alpha and gamma, macrophage colony stimulating factor, transforming growth factor-beta 2, basic fibroblast growth factor and activin beta A chain was determined by reverse transcription polymerase chain reaction. Protein secretion of selected cytokines, interleukin-1 beta, interleukin-6, interleukin-8, macrophage colony stimulating factor and transforming growth factor-beta 2 was measured in RPE-conditioned medium by ELISA. Retinal pigment epithelial cells constitutively expressed mRNA for interleukin-6, macrophage colony stimulating factor, transforming growth factor-beta 2, basic fibroblast growth factor and activin beta A chain. Interleukin-1 beta, melanoma growth stimulating activity/gro alpha and gamma and interleukin-8 were not expressed under basal conditions. Stimulated monocyte-conditioned medium markedly induced mRNA of all cytokines except basic fibroblast growth factor and transforming growth factor-beta 2 in a dose- and time-dependent manner. Unstimulated monocyte-conditioned medium was a less potent inducing agent, but still enhanced mRNA expression of interleukin-6, interleukin-8 and melanoma growth stimulating activity/gro alpha. Stimulated monocyte-conditioned medium also induced a time-dependent increase in interleukin-6, Interleukin-8, macrophage colony stimulation factor and transforming growth factor-beta 2, but not interleukin-1 beta protein secretion (p < 0.05 for all time points). Neutralizing antibodies to interleukin-1 beta, or tumour necrosis factor alpha, but not interleukin-1 alpha, significantly reduced cytokine mRNA expression induced by stimulated monocyte-conditioned medium. The combination of all three neutralizing antibodies almost entirely eliminated monocyte-induced mRNA expression and protein production of all cytokines studied. Activated monocytes secrete a heterogeneous mixture of products that together strongly induce expression of multiple cytokines in human retinal pigment epithelial cells. Most if not all of the inducing effect can be accounted for by interleukin-1 beta and tumour necrosis factor alpha. Because cytokines have been implicated in proliferative vitreoretinopathy and uveitis, monocyte-mediated cytokine expression by RPE cells may serve to initiate and perpetuate these diseases.

Activin expression by cultured human retinal pigment epithelial cells

PURPOSE

To determine whether human retinal pigment epithelial (hRPE) cells produce activin, a growth factor in the transforming growth factor beta family, and to characterize growth regulatory effects of activin on retinal pigment epithelium.

METHODS

mRNA expression was examined using polymerase chain reaction with primers specific for the beta A and beta B chains of activin and by slot blot analysis with a probe specific for the beta A chain. Protein localization was determined immunocytochemically using antibodies specific for the beta A chain of activin and intact activin A. The effect of activin A on DNA synthesis was studied by measuring (3H) thymidine incorporation after cells were exposed to recombinant human activin A (rhA). Growth regulatory effects of rhA on hRPE cells were examined with cell growth assays.

RESULTS

beta A mRNA was expressed constitutively in 8/8 cells lines tested. beta B mRNA was not expressed in any of the six cell lines tested but was expressed in human ovarian granulosa cell controls. Positive immunostaining was observed for both the beta A chain and intact activin A. (3H) thymidine incorporation was inhibited 44% (P < 0.025), 45% (P < 0.025), and 44% (P < 0.015) when RPE cells were exposed to 100 ng/ml rhA and grown in serum-free medium, medium with 0.5% serum, and 1% serum, respectively. Cell growth was inhibited 33.2% (P = 0.0001) after RPE cells were exposed to 100 ng/ml rhA for 8 days.

CONCLUSIONS

These results suggest that activin A can act as an autocrine-paracrine growth regulator in RPE cells and may help control cellular growth in ocular development and proliferative eye disease.

Solid-phase extraction combined with radioimmunoassay for measurement of zalcitabine (2',3'-dideoxycytidine) in plasma and serum

Of the antiviral agents that are currently in clinical use in the US for therapy for human immunodeficiency virus infections, zalcitabine (ddC) is the most potent and is effective at the lowest plasma concentrations. The two reported procedures for measuring these low concentrations involve a chromatographic technique coupled with mass spectrometry. We have developed a procedure combining solid-phase extraction with a strong cation-exchange resin and commercially available RIA reagents for the quantification of ddC in plasma or serum. The method demonstrates good linearity, specificity, and precision, with overall CVs of &lt; 10% from 2-20 micrograms/L and 17% at 0.8 microgram/L (the lower limit of quantitation). No significant cross-reactivity with nucleoside analogs other than ddC analogs was noted. The major advantages of this assay are its efficiency and relative simplicity, which should facilitate its performance in many laboratories.

Solid-phase extraction combined with radioimmunoassay for measurement of zalcitabine (2',3'-dideoxycytidine) in plasma and serum

Of the antiviral agents that are currently in clinical use in the US for therapy for human immunodeficiency virus infections, zalcitabine (ddC) is the most potent and is effective at the lowest plasma concentrations. The two reported procedures for measuring these low concentrations involve a chromatographic technique coupled with mass spectrometry. We have developed a procedure combining solid-phase extraction with a strong cation-exchange resin and commercially available RIA reagents for the quantification of ddC in plasma or serum. The method demonstrates good linearity, specificity, and precision, with overall CVs of < 10% from 2-20 micrograms/L and 17% at 0.8 microgram/L (the lower limit of quantitation). No significant cross-reactivity with nucleoside analogs other than ddC analogs was noted. The major advantages of this assay are its efficiency and relative simplicity, which should facilitate its performance in many laboratories.

Interference in immunoassay measurements of total and free phenytoin in uremic patients: a reappraisal

Accumulation of phenytoin metabolites in uremia has been shown to interfere with some immunoassay methods for phenytoin measurement. We evaluated the effects of uremia (serum creatinine > 13 mg/L) on free and total phenytoin concentrations measured by the Abbott TDx fluorescence polarization immunoassay, and the DuPont aca and Syva EMIT homogeneous enzyme-multiplied immunoassay methods, using HPLC as the comparison method. In uremic patients, the TDx assay showed both fixed and proportional bias in comparison with the HPLC for both total phenytoin concentration (TDx = 1.24 x HPLC + 1.9 mg/L) and free phenytoin concentration (TDx = 1.52 x HPLC + 0.24 mg/L). The total bias was as great as 100% for both total and free phenytoin. Cross-reactive substances other than 5-(p-hydroxyphenyl)-5-phenylhydantoin (HPPH) and HPPH-glucuronide appeared to be responsible. In contrast, there was minimal interference with aca and EMIT assays.

Antileishmanial activity of sodium stibogluconate fractions

Sodium stibogluconate, a pentavalent antimony derivative produced by the reaction of stibonic and gluconic acids, is the drug of choice for the treatment of leishmaniasis. It has been reported to be a complex mixture rather than a single compound. We separated sodium stibogluconate into 12 fractions by anion-exchange chromatography. One fraction accounted for virtually all the leishmanicidal activity of the fractionated material against Leishmania panamensis promastigotes, with a 50% inhibitory concentration (IC50) of 12 micrograms of Sb per ml; that of unfractionated sodium stibogluconate was 154 micrograms of Sb per ml. Further analysis of this active fraction revealed that a major component was m-chlorocresol, which had been included in the sodium stibogluconate formulation as a preservative. The IC50 of pure m-chlorocresol was 1.6 micrograms/ml, a concentration equivalent to that present in unfractionated sodium stibogluconate at a concentration of 160 micrograms of Sb per ml. After ether extraction to remove m-chlorocresol, the IC50 of sodium stibogluconate was > 4,000 micrograms of Sb per ml. In contrast, when L. panamensis amastigotes were grown in macrophages, the IC50 of ether-extracted sodium stibogluconate was 10.3 micrograms of Sb per ml. The 12 fractions of ether-extracted sodium stibogluconate obtained by anion-exchange chromatography had IC50s of 10.1 to 15.4 micrograms of Sb per ml. We conclude that preservative-free sodium stibogluconate has little activity against L. panamensis promastigotes but is highly active against L. panamensis amastigotes in macrophages. This activity is associated with multiple chemical species.

Antimony quantification in Leishmania by electrothermal atomic absorption spectroscopy

Tri- and pentavalent antimony were quantified in Leishmania mexicana pifanoi amastigotes and promastigotes by atomic absorption spectroscopy with electrothermal atomization. Leishmania grown in axenic culture were treated with either potassium antimony tartrate [Sb(III)] or sodium stibogluconate [Sb(V)]. The parasites were collected, digested with nitric acid, and subjected to atomic absorption spectroscopy. The method was linear from 0 to 7 ng of antimony. The interassay coefficients of variation were 9.6 and 5.7% (N = 5) for 0.52 and 3.7-ng samples of leishmanial antimony, respectively. The limit of detection was 95 pg of antimony. The assay was used to characterize Sb(III) and Sb(V) influx and efflux kinetics. Influx rates were determined at antimony concentrations that produced a 50% inhibition of growth (IC50). The influx rates of Sb(V) into amastigotes and promastigotes were 4.8 and 12 pg/million cells/h, respectively, at 200 micrograms antimony/ml. The influx rate of Sb(III) into amastigotes was 41 pg/million cells/h at 20 micrograms antimony/ml. Influx of Sb(III) into promastigotes at 1 microgram antimony/ml was rapid and reached a plateau of 175 pg/million cells in 2 h. Efflux of Sb(III) and Sb(V) from amastigotes and promastigotes exhibited biphasic kinetics. The initial (alpha) half-life of Sb(V) efflux was less than 4 min and that of Sb(III) was 1-2 h. The apparent terminal (beta) half-lives ranged from 7 to 14 h.