Clinical Application of Overlapping Confidence Intervals for Monitoring Changes in Serial Clinical Chemistry Test Results

BACKGROUND: Interpretation of changes in serial laboratory results is necessary for both clinicians and laboratories; however, setting decision limits is not easy. Although the reference change value (RCV) has been widely used for auto-verification, it has limitations in clinical settings. We introduce the concept of overlapping confidence intervals (CIs) to determine whether the changes are statistically significant in clinical chemistry laboratory test results.METHODS: In total, 1,202,096 paired results for 33 analytes routinely tested in our clinical chemistry laboratory were analyzed. The distributions of delta% absolute values and cut-off values for certain percentiles were calculated. The CIs for each analyte were set based on biological variation, and data were analyzed at various confidence levels. Additionally, we analyzed the data using RCVs and compared their clinical utility.RESULTS: Most analytes had low indexes of individuality with large inter-individual variability. The 97.5th percentile cut-offs for each analyte were much larger than conventional RCVs. The percentages of results exceeding RCV(95%) and RCV(99%) corresponded to those with no overlap at the 83.4% and 93.2% confidence levels, respectively.CONCLUSIONS: The use of overlapping CIs in serial clinical chemistry test results can overcome the limitations of existing RCVs and replace them, especially for analytes with large intra-individual variation.

Venom complexity of Bothrops atrox (common lancehead) siblings

Variability in snake venoms is a well-studied phenomenon. However, sex-based variation of Bothrops atrox snake venom using siblings is poorly investigated. Bothrops atrox is responsible for the majority of snakebite accidents in the Brazilian Amazon region. Differences in the venom composition of Bothrops genus have been linked to several factors such as ontogeny, geographical distribution, prey preferences and sex. Thus, in the current study, venom samples of Bothrops atrox male and female siblings were analyzed in order to compare their biochemical and biological characteristics. Methods: Venoms were collected from five females and four males born from a snake captured from the wild in São Bento (Maranhão, Brazil), and kept in the Laboratory of Herpetology of Butantan Intitute. The venoms were analyzed individually and as a pool of each gender. The assays consisted in protein quantification, 1-DE, mass spectrometry, proteolytic, phospholipase A2, L-amino acid oxidase activities, minimum coagulant dose upon plasma, minimum hemorrhagic dose and lethal dose 50%. Results: Electrophoretic profiles of male's and female's venom pools were quite similar, with minor sex-based variation. Male venom showed higher LAAO, PLA2 and hemorrhagic activities, while female venom showed higher coagulant activity. On the other hand, the proteolytic activities did not show statistical differences between pools, although some individual variations were observed. Meanwhile, proteomic profile revealed 112 different protein compounds; of which 105 were common proteins of female's and male's venom pools and seven were unique to females. Despite individual variations, lethality of both pools showed similar values. Conclusion: Although differences between female and male venoms were observed, our results show that individual variations are significant even between siblings, highlighting that biological activities of venoms and its composition are influenced by other factors beyond gender.(AU)

Antivenomic approach of different Crotalus durissus collilineatus venoms

Our group has previously performed a proteomic study verifying that individual variations can occur among Crotalus durissus collilineatus venoms. These variations may lead to differences in venom toxicity and may result in lack of neutralization of some components by antivenom. In this way, this study aimed to evaluate the Brazilian anticrotalic serum capacity in recognizing twenty-two Crotalus durissus collilineatus venoms, as well as their fractions. Methods: The indirect enzyme-linked immunosorbent assay (ELISA) was chosen to evaluate the efficacy of heterologous anticrotalic serum produced by Instituto Butantan (Brazil) in recognizing the twenty-two Crotalus durissus collilineatus venoms and the pool of them. Moreover, the venom pool was fractionated using reversed-phase fast protein liquid chromatography (RP-FPLC) and the obtained fractions were analyzed concerning antivenom recognition. Results: Evaluation of venom variability by ELISA showed that all venom samples were recognized by the Brazilian anticrotalic antivenom. However, some particular venom fractions were poorly recognized. Conclusion: This study demonstrated that the Brazilian anticrotalic serum recognizes all the different twenty-two venoms of C. d. collilineatus and their fractions, although in a quantitatively different way, which may impact the effectiveness of the antivenom therapy. These results confirm the need to use a pool of venoms with the greatest possible variability in the preparation of antivenoms, in order to improve their effectiveness.(AU)

Progress in Genetic Polymorphism of Related Metabolic Enzymes Influencing Individualized Thiopurine Therapy / 中国药师

Thiopurines, one kind of immunosuppressants, represent an effective and widely prescribed therapy in clinic. Howev-er, the narrow therapeutic window and pharmacokinetic individual differences are always the problems in the clinical application of these drugs. Many factors can affect the metabolism and pharmacological effects of thiopurines, and the genetic polymorphisms of relat-ed metabolic enzymes involved in the metabolic process are considered to be the main factors. Recently, there is growing attention to the influence of the pharmacogenetics of related metabolic enzymes on the pharmacokinetics and pharmacodynamics of thiopurines. Therefore, based on the literature data, this review summarizes the correlation between the genetic polymorphisms of related metabolic enzymes ( TPMT, ITPA, GST, HPRT, XO, IMPDH and GMPS) and efficacy and side effects of thiopurines in order to provide guid-ance for the individualized thiopurine treatment in the clinical practice.

Associations of POR polymorphisms and warfarin stable maintenance dose in Han Chinese patients / 中国药理学通报

Aim To explore the effect of genetic poly-morphisms of POR on the stable warfarin maintenance doses in Han Chinese patients receiving mechanical heart valve replacement. Methods The association between POR gene polymorphisms and warfarin doses of 185 Han Chinese patients were investigated through ANOVA or t test. SNPs of POR and VKORC1 were de-tected by Sequenom? DNA MassArray genotyping method. CYP2C9*3 was genotyped by polymerase chain reaction-restriction fragment length polymorphism method ( PCR-RFLP ) . Patients ’ clinical characteris-tics, INR value and daily dose were obtained from their medical records. Statistical analysis was performed by SPSS 21. 0 software. Results No mutant carriers of POR rs17148944 , POR rs56256515 and rs72553971 were found in this study. The genotype frequencies of other SNPs were in accordance with Hardy-Weinberg e-quilibrium. In the group of patients with CYP2C9*1*1 , the mutant type carriers ( T carriers ) of POR rs17685 had a significantly higher dose than CC carri-ers(3. 50 ± 1. 07) mg·d-1 vs (3. 14 ± 0. 94) mg· d-1,P =0. 03. Also, in the group of patients with CYP2 C9*1*1 and VKORC1 rs9934438 G allele carri-ers, the mutant type carriers ( T carriers ) of POR rs17685 had a significantly higher dose than CC carri-ers(4. 76 ± 0. 90) mg·d-1 vs (4. 08 ± 1. 03) mg· d-1 ,P=0. 04. No significant difference was found in different genotypes of POR rs2868177 . Conclusion These results illustrate that POR rs17685 T carrier is closely associated with a higher warfarin maintenance dose, suggesting that this SNP is useful for clinical guidance of warfarin.

Nutritional intake of Korean population before and after adjusting for within-individual variations: 2001 Korean National Health and Nutrition Survey Data

Accurate assessment of nutrient adequacy of a population should be based on usual intake distribution of that population. This study was conducted to adjust usual nutrient intake distributions of a single 24-hour recall in 2001 Korean National Health and Nutrition Surveys (KNHNS) in order to determine the magnitude of limitations inherent to a single 24-hour recall in assessing nutrient intakes of a population. Of 9,960 individuals who provided one 24-hour recall in 2001 KNHNS, 3,976 subjects provided an additional one-day 24-hour recall in 2002 Korean National Nutrition Survey by Season (KNNSS). To adjust for usual intake distribution, we estimated within-individual variations derived from 2001 KNHNS and 2002 KNNSS using the Iowa State University method. Nutritionally at risk population was assessed in reference to the Dietary Reference Intakes for Koreans (KDRIs). The Korean Estimated Average Requirement (Korean EAR) cut-point was applied to estimate the prevalence of inadequate nutrient intakes except for iron intakes, which were assessed using the probability approach. The estimated proportions below Korean EAR for calcium, riboflavin, and iron were 73%, 41%, and 24% from usual intake distribution and 70%, 51%, and 39% from one-day intake distribution, respectively. The estimated proportion of sodium intakes over the Intake Goal of 2,000 mg/day was 100% of the population after adjustment. The energy proportion from protein was within Korean Acceptable Macronutrient Distribution Ranges (Korean AMDR), whereas that of carbohydrate was higher than the upper limit and that of fat was below the lower limit in the subjects aged 30 years or older. According to these results, the prevalence of nutritional inadequacy and excess intake is over-estimated in Korea unless usual intake distributions are adjusted for one-day intakes of most nutrients.

A radiological survey of femoral isometric point of anterior cruciate ligament / 中华创伤骨科杂志

Objective To investigate individual variations of the femoral isometric poiIit of anterrior cruciate ligament(ACL). Methods The femoral isometric points(i)were determined by measuring the knee joint lateral projections in 100 adults.The distances from the femoral isometric point i to the posterior border of intercondylar notch were measured and compared among 4 age groups(20 to 30 y,30 to 40 y,40 to 50 y and>50 y)by 2 × 2 factor analysis and Student-Newman-Keuls (SNK-q)Analysis to determine the effects of age and gender on the measurements. Results The average distance was(10.6±1.55)mm,ranging from 15.05 am to 7.50 mm.The 2×2 factor analysis showed the differences were signifcant between age groups(F=2.843,P=0.042)and between sexes(F=4.245,P=0.042).but the age and sex factors were not interacted (F=0.456,P=0.7 14). The SNK-q Analysis revealed the differences were significant between the 20 to 30 y group and the 40 to 50 y group as well as the>50 y group(P<0.05),but not significant between the 30 to 40 y group and the 20 to 30 y group(P>0.05).No signifieant difference was observed between any two of the 30 to 40 y group,40 to 50 y group and>50 y group(P>0.05). Conclusion Since the ACL femoral isometric points vary from person to person,it is valuable to check them twice radiologically before and during the operation.

Quantification of japanese quail eggshell colour by image analysis

The Japanese quail lays eggs with colourful and patterned shells which make the eggshell colour difficult to classify. In this study, the method of measuring colour of patchy eggs using image analyses and its power to discriminate among individual variation were established. Estimated repeatability for egg colour and proportion of patterned areas was high (>0.58), suggesting intermedíate or high heritability of eggshell colour characteristics. Three components have been identified as significant in discriminant function analysis. These three components explained 91.4 percent of the total variance in egg colour characteristics. In cluster analysis, 78.3 percent of the eggs that were collected from 15 females were correctly classified. This study indicates that eggshell colour characteristics can be reliably studied by image analyses and that this method can provide a unified character list for future examinations and interpretations of quail egg characteristics.

Within- and Between-Individual Variation in Nutrient Intakes with Day of the Week and Season in Korean Adults

This study was performed to examine component of variance in nutrient intakes and to estimate the level of accuracy with varying degree of precision in order to achieve estimates of usual nutrient intakes. Three-day dietary records including both weekdays and weekends were collected every 4 season over a 1-year period from 36 males and 93 females aged 40 - 65 y. For each nutrient, we partitioned total intake variance into weekly (weekday vs weekend), seasonal, within- and between- individual variation as components of variance, using analysis of variance. It was found that major components of variance were within- and between-individual variation. Particularly, within-individual variation(57.2 - 87.1%) was greater than between-individual variation (12.2 - 37.4%) for all nutrients. Weekly and seasonal variation contributed small components of variance for most nutrients. For protein, fat and carbohydrate, there were a little significant weekly variation (0.00 - 1.35%) in females but not in males. For some micronutrients, there were moderately significant seasonal variation (0.15 - 5.48%) in both sexes. Ratio of within- to between- individual variation ranged 1.4 (vitamin B2) - 4.5 (vitamin B1) in males and 1.6 (carbohydrate) - 2.9 (fat) in females. With total 12- day dietary records data, the maximum percentage deviation of observed intakes from usual (true) intakes ranged 12 - 37%. To estimate usual individual intakes within 20% of the true mean with 90% confidence level, 3 - 9 days of dietary survey were required for energy, protein, carbohydrate, phosphorus and iron, 13 - 19 days for fat and calcium, 25 - 29 days for vitamin A and vitamin C. Correlation coefficients between observed and true nutrient intakes were 0.71 - 0.91 for males, 0.81 - 0.91 for females. In conclusion, mean intakes of several nutrients can be reliably measured with the record method, using a limited number of days. Both nutrients of interest and the primary objectives should be taken account when planning method of assessment and number of replicates.

Daily urinary excretion of bisphenol A

<p><b>OBJECTIVES</b>Concerns over dietary exposure to bisphenol A (BPA), an endocrine disruptor, have been raised because BPA is contained in resins and plastics commonly used for the preservation of food and beverages. The purpose of the present study was to assess daily intake levels of BPA in a group of male subjects by measuring total urinary BPA (free BPA plus BPA released by treatment with β-glucuronidase), as well as determining intra-individual variation in BPA excretion.</p><p><b>METHODS</b>Twenty-four-hour urine was collected from 5 subjects for 5 consecutive days for the evaluation of between-day variation in urinary BPA excretion and from 36 male subjects for the estimation of the level of daily BPA intake. BPA in the urine samples was measured by GC/MS/MS following enzymatic hydrolysis of BPA glucuronate, solid phase extraction, and derivatization.</p><p><b>RESULTS</b>A large between-day variation was found over 5 days for the daily excretion of urinary BPA in the 5 subjects. The daily excretion of urinary BPA was distributed log-normally in the 36 male subjects, with the median value being 1.2 μg/day (range: <0.21-14 μg/day), which was far below the Tolerable Daily Intake (0.01 mg/kg bw) recommended by a scientific committee in the European Commission in 2002. However, the maximum estimated intake per body weight (0.2 μg/kg/day) was only one order of magnitude lower than the reported lowest level for reproductive/behavioral effects in pregnant mice (2 μg/kg/day).</p><p><b>CONCLUSIONS</b>Measuring urinary BPA in urine is a suitable approach for estimating short-term BPA intake levels in individuals and/or estimating the average exposure level of populations. Urine analyses will be increasingly important in the human health risk assessment of BPA.</p>

Daily Urinary Excretion of Bisphenol A

Objectives: Concerns over dietary exposure to bisphenol A (BPA), an endocrine disruptor, have been raised because BPA is contained in resins and plastics commonly used for the preservation of food and beverages. The purpose of the present study was to assess daily intake levels of BPA in a group of male subjects by measuring total urinary BPA (free BPA plus BPA released by treatment with β-glucuronidase), as well as determining intra-individual variation in BPA excretion. Methods: Twenty-four-hour urine was collected from 5 subjects for 5 consecutive days for the evaluation of between-day variation in urinary BPA excretion and from 36 male subjects for the estimation of the level of daily BPA intake. BPA in the urine samples was measured by GC/MS/MS following enzymatic hydrolysis of BPA glucuronate, solid phase extraction, and derivatization. Results: A large between-day variation was found over 5 days for the daily excretion of urinary BPA in the 5 subjects. The daily excretion of urinary BPA was distributed log-normally in the 36 male subjects, with the median value being 1.2 μg/day (range: <0.21-14 μg/day), which was far below the Tolerable Daily Intake (0.01 mg/kg bw) recommended by a scientific committee in the European Commission in 2002. However, the maximum estimated intake per body weight (0.2 μg/kg/day) was only one order of magnitude lower than the reported lowest level for reproductive/behavioral effects in pregnant mice (2 μg/kg/day). Conclusions: Measuring urinary BPA in urine is a suitable approach for estimating short-term BPA intake levels in individuals and/or estimating the average exposure level of populations. Urine analyses will be increasingly important in the human health risk assessment of BPA.

Reaction Times in Schizophrenia / 신경정신의학

The reaction time(RT) has been known to reflect attention that controls the flow of information processing. Extensive research has demonstrated cognitive impairment in schizophrenia subjects using RT tasks. However, little work has been done examining the relative contribution of DT(decision time) and MT(motor time) to slowed RT in schizophrenics. Also, recent investigators have observed that schizophrenic patients exhibit larger intra-individual variability in RT than do normal comparison subjects. The purpose of this study, using multi-stimulus convergent RT task, was to explore the speed of RT, relative contribution of decision time(DT) and motor time(MT) to slowed RT, overall sequential profile in 25 repeated-time measurements in 10 schizophrenic out-patients and 10 normal control subjects. Overall reaction time and decision time were slower in schizophrenic subjects than in normal controls. The motor time was not shown to be significantly different between the two groups with 0.05 significance level, although there was some trend indicating schizophrenic subjects were slower consistently in repreated measurements over time. These results suggested that the slower reaction time in schizophrenic subjects was mostly determined by cognitive component, decision time rather than motor time. Sequential profile of repeated measurements showed greater intraindividual and interindividual variations in schizophrenics than in normal controls. These results indicate that high variabilities are not merely measurement errors but characteristic of schizophrenic psychopathology.