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.

Interobserver and intraobserver variability in the cytologic diagnosis of normal and abnormal metaplastic squamous cells in pap smears.

OBJECTIVE: Interoberver variability has important implications for patient care, diagnostic error and medical litigation. In the management of any cervical epithelial abnormality, its biologic significance as well as diagnostic reproducibility is very important. Interobserver variability has not been measured adequately for metaplastic squamous lesions. We analyzed interobserver and intraobserver variability and diagnostic accuracy in the diagnosis of dysplastic metaplastic cells. STUDY DESIGN: Sixty Pap smears from patients with abnormalities of metaplastic squamous cells of varying severity were selected from the files of Lankenau Hospital, Wynnewood, Pennsylvania, U.S.A., diagnosed between 1990 and 1996. These were reviewed by four observers with different levels of cytology experience. Each of the observers blindly and independently reviewed all Pap smears. Tabulated results were analyzed to determine interobserver and intraobserver variability and diagnostic accuracy. RESULTS: Statistically significant interobserver reproducibility was found between both inexperienced observers as well as between observers 1 (experienced) and 3 (inexperienced) and between observers 2 (experienced) and 4 (inexperienced). The observed degree of agreement between both experienced observers (1 and 2) reflected random rating rather than reproducibility. There was no difference in interobserver reproducibility in low vs. high grade lesions. Intraobserver reproducibility had no significant correlation with experience of the observer. The sensitivity ranged from 0.69 to 0.97 (mean, 0.79), while the specificity ranged from 0.09 to 0.46 (mean, 0.30). Mean diagnostic accuracy was better in benign and low grade squamous intraepithelial lesions in comparison to high grade squamous intraepithelial lesions. CONCLUSION: There was good interobserver agreement in classifying squamous metaplastic lesions. The agreement did not correlate with grade of dysplasia or experience of the cytopathologists. These findings should be considered in making treatment, quality assurance and legal decisions. A larger study is indicated to study interobserver and intraobserver variability and define cytologic criteria for lesions of metaplastic squamous cells.

ASCUS, mature metaplastic type. Cytologic diagnosis and follow-up.

OBJECTIVE: To study the cytologic criteria for follow-up of mature metaplastic cells within the atypical squamous cells of undetermined significance (ASCUS) category. STUDY DESIGN: Squamous epithelial abnormalities between January 1994 and June 1997 at our institution totaled 2,632 and included squamous carcinoma (1), high grade squamous intraepithelial lesions (278), low grade squamous intraepithelial lesions (875) and ASCUS (1,478). From the ASCUS group, 134 (9.06%) were metaplastic; 89 were selected for review. Criteria for case selection were follow-up with tissue biopsy or at least two Pap smears and no previous epithelial abnormality. Patients ranged from 27 to 70 years of age. Parameters tabulated included number of abnormal cells per slide, their architecture, cell size, shape, cytoplasmic hue and texture, nuclear size and contour, chromatin pattern and nucleoli. Additionally, specimens were reviewed for hormonal status and inflammation. The findings were correlated with follow-up data. RESULTS: Cells generally appeared single or in loose, monolayered sheets of three to seven cells per group. The cells were well demarcated, polygonal or oval and ranged from 11 to 30 microns with cyanophilic or eosinophilic thickened cytoplasm. The round to oval nuclei with slight irregularity showed a minimally increased nuclear/cytoplasmic ratio with stippled chromatin. Upon review, 69 smears were confirmed as ASCUS-M. Follow-up revealed 42 with benign findings, 9 with persistent ASCUS/ASCUS-M and 18 with low grade squamous intraepithelial lesions. CONCLUSION: In mature metaplastic cells with minimal atypia in patients with no previous or concurrent dysplasia, the follow-up details were similar to those described for ASCUS-superficial/immediate squamous cells. These patients could be followed conservatively.

Optimization and performance of a rapid gas chromatography-mass spectrometry analysis for methylmalonic acid determination in serum and plasma.

We have developed a rapid and sensitive GC-MS assay for methylmalonic acid determination in serum and plasma utilizing an anion exchange solid-phase extraction and trimethylsilyl derivatization. Each step of the procedure was optimized by the experimental design methods to assure the assay reliable performance. The limit of detection and limit of quantitation were 0.025 and 0.1 micromol/l. The total coefficient of variation for the method was 9.8, 4.4, and 4.6% at the concentration of 0.2, 3.1, and 6.2 micromol/l methylmalonic acid concentration, respectively. The assay was linear up to 9.0 micromol/l, and showed good correlation with a reference method. The method has proven to be reliable in routine production, producing clean chromatography, unique ion fragments, and consistent ion mass ratio.

Comparison of representative ranges based on U.S. patient population and literature reference intervals for urinary trace elements.

Reference intervals for trace elements are very hard to obtain because of the difficulty of defining a nonexposed reference population. However, representative ranges for trace elements obtained from a general patient population can provide useful information in interpreting laboratory results. We have used urine specimens submitted for trace metal analysis from patients residing in the United States to calculate representative ranges for 25 urinary trace elements, and to compare them to reference values taken from the literature. All urine analytes were measured by inductively-coupled plasma-mass spectrometry except chromium, which was measured by graphite furnace atomic absorption spectroscopy. For representative range calculation two approaches were used. In the non-parametric calculation first, the top 10% of results were discarded assuming that those specimens came from individuals with unusually high trace element exposures. Next the central 95% of the remaining data was taken as the reference interval. In the parametric calculation the specimens from exposed or not healthy individuals were assumed to appear as outliers and were discarded. The mean and S.D. were calculated, and used to determine representative ranges. The two approaches yielded very similar results, and worked remarkably well for 14 analytes. There were minor discrepancies for 7 analytes, and major for 4 analytes. All analyses of urinary trace elements included a urine creatinine value, which was used to express urinary trace element concentrations in terms of creatinine ratio. This corrects for differences in urine concentration that affects the results for random specimens.

Delayed separation and the plasma amino acids arginine and ornithine.

When collecting blood for amino acid testing, leaving plasma in contact with cells at room temperature lowers the concentration of arginine and raises that of ornithine. This is presumably due to the arginase content of red blood cells. In contrast, the sum of arginine and ornithine is constant over the first hour, and defines a reference interval of 74-148 mumol/L (mean +/- 2 SD, n = 20) which is more insensitive to delayed separation. The ratio of arginine to the sum of arginine plus ornithine [arg/(arg + orn)] can be used to estimate the number of specimens not separated promptly. A ratio of 0.74-0.50 (mean +/- 2 SD, n = 20) is characteristic of specimens placed on ice and separated promptly, where delayed separation produces lower ratios. Of 91 adult specimens received for plasma amino acid analysis over five months, 35 (38 percent) showed a ratio < 0.50 suggestive of delayed processing.

Inadequate measurement of urinary chloride.

Urinary electrolytes are invaluable in the differential diagnosis and treatment of certain acid-base diseases. We have evaluated the accuracy and precision of three different automated chemistry analyzers and a chloridometer (Corning 925 Chloridometer, Hitachi 717 and 917 and Vitros 950) for chloride, sodium and potassium using standard solutions. Data indicate that the ISE modules on the Hitachi 717 and 917 analyzers measure sodium and potassium accurately and precisely throughout the studied concentration range. The Vitros 950 system had the poorest precision and accuracy performance at the low levels of sodium and potassium. The chloride ion-selective membranes on the Hitachi analyzers seriously overestimate the chloride concentration at all levels. The manual dilution method on the Vitros 950 analyzer for chloride measurements showed good precision and accuracy only at the higher chloride levels. For chloride determination the chloridometer displayed the best accuracy with good precision. We recommend that laboratories use chloridometers for the measurement of urinary chloride, and that the CAP include low chloride samples in their proficiency testing program for urine chloride.

Expression of DNA topoisomerase I, DNA topoisomerase II-alpha, and p53 in metastatic malignant melanoma.

New anticancer drugs that target DNA topoisomerase I (topo I) are showing activity against a wide variety of solid human neoplasms. These drugs work by a novel mechanism of action and cause topo I-mediated DNA breaks. These DNA breaks become lethal in cycling cells when they interact with the replication fork. Because of the challenges in treating metastatic malignant melanoma, we performed an immunohistochemical study of this group of neoplasms to search for the presence of molecular markers that might indicate tumor response to topo I active drugs. Using a new immunohistochemical stain for topo I, we found elevation of this protein in 10 of 24 cases (41.6%) of metastatic malignant melanoma. The metastatic tumors that showed increased expression of topo I (2+ or 3+) had statistically significant higher proliferation indices, measured by immunohistochemical staining for DNA topo II-alpha, than did metastatic lesions with no detectable topo I expression. The average topo II-alpha index of metastatic melanomas with 2+ topo I expression was 45.1 (SD = 17.9) and with 3+ topo I expression was 52.3 (SD = 32.5). These values were found to be statistically different (P = .05) than the average topo II-alpha index of 18.9 (SD = 17.7) found for metastatic melanomas without detectable topo I immunostaining. Immunohistochemical staining for p53 suggested abnormal p53 function in 6 of the 10 melanomas (60%), which showed elevations of topo I (2 to 3+ topo I immunostaining) but normal p53 function in all 14 metastatic lesions that showed normal topo I expression.

Nitrite adulteration of workplace urine drug-testing specimens. I. Sources and associated concentrations of nitrite in urine and distinction between natural sources and adulteration.

The active ingredient in the commercial workplace urine drug-testing adulterant, Klear, was previously determined to be nitrite ion. Nitrite adulteration compromises the confirmation of some drugs, notably the marijuana metabolite. A previously reported bisulfite step overcomes some nitrite adulteration, but it cannot do so in every case, which leaves the laboratory to report the specimen as not suitable for testing. Unlike many other adulterants, nitrite is found in normal urine at low concentrations. In order to defend a report of nitrite adulteration, it is necessary to provide evidence that the amount of nitrite in a workplace urine specimen could not arise by normal means. The objectives of this study were to identify all sources of nitrite in urine and the range of concentrations associated with these sources and to determine if nitrite adulteration can be supported based upon a quantitative result. The scientific literature was reviewed for internal and external sources of nitrite and their concentration ranges and are reported. The following specimens were obtained and nitrite concentrations measured by a spectrophotometric method: clinical specimens nitrite positive by test strip (< 15 micrograms/mL); specimens culture positive for nitrate-reducing microorganisms (< 36 micrograms/mL); specimens from patients on medications that may metabolize to nitrite (< 6 micrograms/mL); and drug-test specimens, both negative (< 130 micrograms/mL) and others that appeared to be adulterated with nitrite (range 1910-12,200 micrograms/mL, mean 5910). The literature and the nitrite measurements of this study indicate a substantial difference between concentrations from natural sources compared with adulteration. A quantitative measurement of nitrite by a well-structured assay can provide scientifically valid and forensically defensible proof of adulteration with a nitrite-containing substance.

Effect of storage on serum vitamin B12 and folate stability.

To facilitate transport from remote locations, the stability of vitamin B12 and folate was investigated in serum specimens. Serum vitamin B12 proved to be highly unstable, emphasizing that specimens should be frozen if not analyzed immediately. Light protection is necessary if the sample cannot be analyzed within 4 hours. In contrast, folate is a more robust analyte. In refrigerated serum specimens, folate was stable up to 7 days of storage. In situations where specimen stability is important, vitamin B12 status is better assessed with serum or urine methylmalonic acid measurements. Although folate status can be assessed in a similar fashion with homocysteine, specimen stability indicates that direct measurement of folate is a better strategy.

Serum succinate by capillary zone electrophoresis: marker candidate for hypoxia.

Serum succinate may offer an alternate analyte to lactate for the evaluation of hypoxia. To evaluate the potential uses of succinate, a relatively rapid capillary zone electrophoresis assay was developed for use in the clinical laboratory setting. Employing a simple indirect ultraviolet detection method with commercially available instrumentation, the limit of detection for serum succinate was determined to be 0.1 mumol/L, the upper limit of linearity 100 mumol/L, and the between-run coefficient of variation about 15 percent. Based on specimens from 202 apparently healthy adults, the non-parametric reference interval was 1.0 to 9.2 mumol/L. Preliminary studies in stored blood show succinate increased 2-fold while lactate increased 11-fold, suggesting that succinate may be a clinically useful marker for hypoxia in patients after blood transfusion. This assay provides a practical tool for the investigation of the clinical applications of succinate.

Anisotropy Changes of a Fluorescent Probe during the Micellar Growth and Clouding of a Nonionic Detergent.

The effects of temperature and Triton X-114 (TX-114) concentration on the fluorescence anisotropy of perylene were investigated before and after detergent clouding. The measured anisotropy values were used to estimate the microviscosity of the micellar interior. In the lower detergent concentration range, an anisotropy maximum was observed at the critical micelle concentration (CMC), while the values decreased in the range immediately above the CMC. This was ascribed to the micellar volume increase, which, in the case of TX-114, was not accompanied by a more ordered internal environment. A gradual decrease of anisotropy and microviscosity with increasing temperature below the cloud point was observed. At the cloud point, no abrupt changes were found to occur. Compared to detergents with more flexible hydrophobic moieties, TX-114 micelles have a relatively ordered micellar interior indicated by the microviscosity and calculated fusion energy values. In the separated micellar phase formed after clouding, the probe anisotropy increased as water was eliminated at higher temperatures.

Decontamination of oil-polluted soil by cloud point extraction.

An extraction procedure based on cloud point phase separation of nonionic surfactants was used to remove oil contamination from soils. The detergent employed was Triton X-114, and its clouding behavior was monitored by means of a fluorescence probe. Changes in the I (1)I (3) ratio of pyrene indicated gradual dehydration of the detergent micelles upon heating. The rate of phase separation, and the volume and water content of the micellar phase were determined. In the practical clean-up, 85-98% of the oil present in the soil was found to enter the micellar phase of the separated washing liquid. A 15-min washing time with 3-5% detergent was found to be sufficient for this degree of contaminant removal from soil containing 0.009-0.017% oil, using a liquid:solid ratio of 5:2. The extraction efficiency decreased with increasing carbon content of the soil. The process holds promise for large-scale treatment of oil-polluted soils.