Effects of age and gender on the cytochrome P450 2D6 activity in a Korean population.

WHAT IS KNOWN AND OBJECTIVE: Age and gender have been reported to play a crucial role in modulating the disposition of pharmacological agents, and to influence the activities of cytochrome P450 (CYP) 2D6, a drug-metabolizing enzyme involved in the disposition of clinically used drugs. In the present study, the effects of age and gender on the CYP2D6 activity were evaluated using dextromethorphan as a probe drug in humans. METHODS: Healthy young (20 < age < 30 years, n = 60) and old age (age >60 years, n = 60) subjects were enrolled and were given 15 mg dextromethorphan orally. Blood samples were collected before and 3 h after medication. Dextromethorphan and its metabolite dextrorphan were measured using HPLC-fluorescence, and dextromethorphan metabolic ratio (MR, log [dextromethorphan/dextrorphan]) was used to evaluate the CYP2D6 activity. RESULTS AND DISCUSSION: Mean (±SD) dextromethorphan MR was -2.42 ± 0.46 for the young male group, -2.28 ± 0.56 for the young female group, -2.46 ± 0.55 for the older male group and -2.34 ± 0.65 for the old female group. Based on our findings, the effects of age and gender on CYP2D6 activity were not statistically significant. WHAT IS NEW AND CONCLUSION: The results of the present study indicate that age and gender play a minor role in the modulation of CYP2D6 activity in the Korean population.

Performance of Copeptin for Early Diagnosis of Acute Myocardial Infarction in an Emergency Department Setting.

BACKGROUND: Rapid and accurate diagnosis of acute myocardial infarction (AMI) is critical for initiating effective treatment and achieving better prognosis. We investigated the performance of copeptin for early diagnosis of AMI, in comparison with creatine kinase myocardial band (CK-MB) and troponin I (TnI). METHODS: We prospectively enrolled 271 patients presenting with chest pain (within six hours of onset), suggestive of acute coronary syndrome, at an emergency department (ED). Serum CK-MB, TnI, and copeptin levels were measured. The diagnostic performance of CK-MB, TnI, and copeptin, alone and in combination, for AMI was assessed by ROC curve analysis by comparing the area under the curve (AUC). Sensitivity, specificity, negative predictive value, and positive predictive value of each marker were obtained, and the characteristics of each marker were analyzed. RESULTS: The patients were diagnosed as having ST elevation myocardial infarction (STEMI; N=43), non-ST elevation myocardial infarction (NSTEMI; N=25), unstable angina (N=78), or other diseases (N=125). AUC comparisons showed copeptin had significantly better diagnostic performance than TnI in patients with chest pain within two hours of onset (AMI: P=0.022, ≤1 hour; STEMI: P=0.017, ≤1 hour and P=0.010, ≤2 hours). In addition, TnI and copeptin in combination exhibited significantly better diagnostic performance than CK-MB plus TnI in AMI and STEMI patients. CONCLUSIONS: The combination of TnI and copeptin improves AMI diagnostic performance in patients with early-onset chest pain in an ED setting.

Evaluation of global laboratory methods and establishing on-therapy ranges for monitoring apixaban and rivaroxaban: Experience at a single institution.

BACKGROUND: Apixaban and rivaroxaban are approved for the prevention and treatment of deep vein thrombosis (DVT), pulmonary embolism (PE), and embolic stroke in atrial fibrillation (AF) patients. The aim of this study was to find appropriate methods of monitoring the anticoagulant effects of are direct oral anticoagulants (DOACs) and establish on-therapy ranges using conventional tests. METHODS: A total of 184 samples were collected from 91 patients receiving DOACs. Concentrations of apixaban and rivaroxaban in plasma were accessed by an anti-factor Xa chromogenic assay. PT, APTT, antithrombin, D-dimer, dRVVT screen/confirm, FDP, and fibrinogen levels were measured. On-therapy ranges were calculated by substituting previously reported trough plasma concentrations of DOACs. RESULTS: Anti-factor Xa chromogenic assay-based DOACs levels were 26.0-279.5 (115.9 ± 56.5) ng/mL for apixaban at 2.5 mg BID, 19.9-565.1 (205.3 ± 162.4) ng/mL for apixaban at 5 mg BID, 2.3-395.3 (205.3 ± 162.4) ng/mL for rivaroxaban at 15 mg OD, 3.6-494.8 (119.6 ± 95.1) ng/mL for rivaroxaban at 20 mg OD, and 9.6-431.4 (140.8 ± 113.6) ng/mL for rivaroxaban at 15 mg BID. PT (%), antithrombin, and dRVVT confirm tests showed good correlation with plasma apixaban levels. Plasma rivaroxaban concentrations were correlated well with PT (sec), PT (%),and dRVVT confirm results. On-therapy ranges established for dRVVT confirm test by linear regression were as follows: 1.32-1.52 for apixaban 2.5 mg BID, 1.12-1.75 for apixaban 5 mg BID, 1.11-1.78 for rivaroxaban 15 mg OD, 1.09-1.64 for rivaroxaban 20 mg OD, and 1.22-1.81 for rivaroxaban 20 mg BID. CONCLUSIONS: Apixaban concentrations were well correlated with PT (%), antithrombin, and dRVVT confirm test. Rivaroxaban concentrations showed good correlation with PT (sec), PT (%), and dRVVT confirm test.

How useful is bone marrow study as an initial investigative tool without lymph node biopsy in malignant lymphoma?: Eleven years of experience at a single institution.

BACKGROUND: Bone marrow (BM) study plays an important role as initial investigation specimen of lymphoma as well as staging lymphoma. This study aimed to investigate the utility of BM studies for classification of lymphoma and evaluate features of BM involvement by lymphoma over a period of 11 years. METHODS: A total of 1162 cases of BM studies for lymphoma evaluation were reviewed for the incidence of lymphoma subtypes, the percentage of marrow involvement, the pattern of involvement and discordance with histopathologic diagnoses of lymph nodes and other tissues. RESULTS: A total of 255 of 1162 cases underwent BM study without pathologic information, and 108 cases show lymphoma involvement. Lymph node biopsy underwent in 66 cases, and 10 cases show discordant result between BM and lymph node biopsy. Seven discordant cases were due to insufficient further studies. Lymphoma was diagnosed only by BM study in 38 cases. Abnormal lymphocytes were found in BM aspiration in 34 cases. Also, abnormal clonal lymphocytes were detected by flow cytometry in 26 cases. Four cases showed disease-related chromosomal abnormalities. FISH analysis detected abnormal findings in two cases, however, discordant with other additional studies. CONCLUSIONS: Discrepancies between the BM study and lymph node biopsy were due to insufficient further study and discordance of immunohistochemical stain result. BM study can be utilized as initial diagnosis of lymphoma by the combination of morphological feature, involvement pattern, and additional tests such as flow cytometry, chromosomal analysis, and FISH analysis. Thus, BM study with further analysis is an essential choice when lymph node biopsies are unavailable.

Detection and genomic analysis of genital group B streptococcus in pregnant Korean women.

AIM: Group B streptococcus (GBS) is a leading cause of life-threatening bacterial infections among newborns, and neonates born to heavily colonized women may be subject to vertical transmission. We sought to determine an appropriate detection method for genital GBS in pregnant women by comparing culture-based methods and real-time polymerase chain reaction (PCR). In addition, we performed molecular serotyping and multilocus sequence typing (MLST) on isolates. METHODS: A total of 150 pregnant women were enrolled and underwent vaginal-rectal swabbing at 16-40 weeks of gestation. GBS was identified by conventional culture and real-time PCR with or without enrichment. Molecular serotyping and MLST were performed on isolates. RESULTS: Overall genital GBS positive rate among the 150 study subjects was 17.3%. Direct culture identified 18 (12.0%) positive specimens, enrichment culture 22 (14.6%), direct PCR 24 (16.0%) and enrichment PCR 25 (16.6%). The sensitivity and specificity by direct and enrichment PCR were as follows: for direct PCR, 90.9% and 96.9%, respectively; and for enrichment PCR, 95.5% and 96.9%, respectively. Resistance rates to clindamycin and erythromycin were 33.3% and 19.1%, respectively. Serotype III-1 was the most common (26.3%), followed by serotype Ib (21.1%), III-3 (15.8%), V (15.8%), II (10.5%), IV (5.3%) and VI (5.3%). Most common sequence types (ST) were ST-1, ST-19 and ST-862 (15.8%), followed by ST-2 and ST-654 (10.5%). CONCLUSION: Direct real-time PCR using vaginal-rectal specimen could be used for detecting GBS in emergent conditions. Molecular serotypes III, Ib and V were most common. MLST analysis frequently presented ST-1, ST-19 and ST-862.

Mean platelet volume as a marker for differentiating disease flare from infection in Behçet's disease.

AIM: The aim of this study was to investigate the association between mean platelet volume (MPV) and clinical manifestations, disease activity or infection in patients with Behçet's disease (BD). METHODS: In total, 193 patients diagnosed with BD according to the international criteria for BD were enrolled. Demographic data, clinical manifestations and laboratory results were collected by medical interviews and reviewing medical records. RESULTS: The female : male ratio was 2 : 1 and the age of symptom onset was 32.2 ± 11.1 years. The age at diagnosis of BD was 44.7 ± 11.1 years and the follow-up duration was 4.7 ± 3.8 years. MPV at diagnosis were significantly lower than of age and sex-matched controls (8.2 ± 1.2 vs. 8.6 ± 1.2 fL, P < 0.0001). Lower MPV was not related to organ involvement except skin diseases. During follow-up, MPV was lower in BD flare than in stable BD (8.2 ± 1.4 vs. 9.1 ± 1.4 fL, P < 0.0001) in the same patients. MPVs were significantly higher in cases of accompanying infections than in those with both BD flare and stable BD (9.3 ± 1.4 vs. 8.1 ± 1.3 fL, P = 0.018 and 9.7 ± 1.4 vs. 8.8 ± 1.0 fL, P = 0.001, respectively). CONCLUSIONS: MPV was significantly lower in patients with BD than controls. MPV declined in BD flare and increased in cases of infection in same patients. MPV may be useful as a marker of BD activity and its monitoring can be helpful for differentiating BD flare from infection in BD patients.

Body and liver fat content and adipokines in schizophrenia: a magnetic resonance imaging and spectroscopy study.

RATIONALE: Although antipsychotic treatment often causes weight gain and lipid abnormalities, quantitative analyses of tissue-specific body fat content and its distribution along with adipokines have not been reported for antipsychotic-treated patients. OBJECTIVES: The purposes of the present study were to quantitatively assess abdominal and liver fat in patients with schizophrenia on antipsychotic treatment and age- and body mass index (BMI)-matched healthy controls and to evaluate their associations with plasma leptin and adiponectin levels. METHODS: In 13 schizophrenia patients on antipsychotic treatment and 11 age- and BMI-matched controls, we simultaneously quantified visceral and subcutaneous fat content using T1-weighted magnetic resonance imaging and liver fat content by 1H magnetic resonance spectroscopy. Associations of tissue-specific fat content with plasma levels of leptin and adiponectin were evaluated. RESULTS: Plasma adiponectin level (µg/mL) was not statistically different between groups (7.02 ± 2.67 vs. 7.59 ± 2.92), whereas plasma leptin level (ng/mL) trended to be higher in patients than in controls (11.82 ± 7.89 vs. 7.93 ± 5.25). The values of liver fat (%), visceral fat (L), and subcutaneous fat (L) were 9.64 ± 8.03 vs. 7.07 ± 7.35, 4.41 ± 1.64 vs. 3.31 ± 1.97, and 8.37 ± 3.34 vs. 7.16 ± 2.99 in patients vs. controls, respectively. Liver fat content was inversely correlated with adiponectin in controls (r = - 0.87, p < 0.001) but not in patients (r = - 0.26, p = 0.39). In both groups, visceral fat was inversely associated with adiponectin (controls : r = - 0.66, p = 0.03; patients : r = - 0.65, p = 0.02), while subcutaneous fat was positively correlated with leptin (controls : r = 0.90, p < 0.001; patients : r = 0.67, p = 0.01). CONCLUSIONS: These findings suggest that antipsychotic treatment may disrupt the physiological relationship between liver fat content and adiponectin but does not essentially affect the associations of adiponectin and leptin with visceral and subcutaneous compartments.

Laboratory diagnosis of Clostridium difficile infection: Comparison of Techlab C. diff Quik Chek Complete, Xpert C. difficile, and multistep algorithmic approach.

BACKGROUND: Clostridium difficile is a major pathogen responsible for nosocomial infectious diarrhea. We explored optimal laboratory strategies for diagnosis of C. difficile infection (CDI) in our clinical settings, a 1400-bed tertiary care hospital. METHODS: Using 191 fresh stool samples from adult patients, we evaluated the performance of Xpert C. difficile (Xpert CD), C. diff Quik Chek Complete (which simultaneously detects glutamate dehydrogenase [GDH] and C. difficile toxins [CDT]), toxigenic culture, and a two-step algorithm composed of GDH/CDT as a screening test and Xpert CD as a confirmatory test. RESULTS: Clostridium difficile was detected in 35 samples (18.3%), and all isolates were toxigenic strains. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value of each assay for detecting CDI were as follows: Quik Chek Complete CDT (45.7%, 100%, 100%, 89.1%), Quik Chek Complete GDH (97.1%, 99.4%, 97.1%, 99.4%), Xpert CD (94.3%, 100%, 100%, 98.7%), and toxigenic culture (91.4%, 100%, 100%, 98.1%). A two-step algorithm performed identically with Xpert CD assay. CONCLUSION: Our data showed that most C. difficile isolates from adult patients were toxigenic. We demonstrated that a two-step algorithm based on GDH/CDT assay followed by Xpert CD assay as a confirmatory test was rapid, reliable, and cost effective for diagnosis of CDI in an adult patient setting with high prevalence of toxigenic C. difficile.

Prognostic significance of PCR-based molecular staging in patients with diffuse large B-cell lymphoma treated with R-CHOP immunochemotherapy.

The prognostic role of detecting clonal immunoglobulin gene rearrangement (IgR) from bone marrow (BM) aspirates was evaluated by BIOMED-2 PCR in 97 patients with diffuse large B-cell lymphoma (DLBCL) treated with rituximab-CHOP immunochemotherapy. Sixteen (16.5%) patients had BM involvement (BMI) defined by BM biopsy (MOR+) and 39 (40.2%) had positive IgR (PCR+). Patients with MOR + BMI showed inferior event-free survival (EFS) compared to those with MOR-/PCR- (p < 0.001) or those with MOR-/PCR + BMI (p = 0.002), while no significant difference in EFS was observed between patients with MOR-/PCR + and those with MOR-/PCR - BMI (p = 0.497). Use of the BIOMED-2 for PCR resulted in significant increase in detection of BMI. However, the increased sensitivity by PCR did not translate into improved prediction of prognosis, emphasizing the essential role of histopathological review of trephine biopsy for the detection of BMI.

Performance evaluation of Mindray CAL 8000(BC-6800 and SC-120) hematology analyzer and slidemaker/stainer.

INTRODUCTION: The Mindray CAL 8000 is a cellular analysis line that consists of the BC-6800, an automated hematology analyzer, and the SC-120, an automated slidemaker/stainer. We evaluated the performances of the BC-6800 and the SC-120. METHODS: Four hundred and eight normal and abnormal samples were analyzed. The performance of the BC-6800 and Sysmex XE-2100 were compared, and blood films by the SC-120 and manual method were compared according to the CLSI guideline H26-A2 and H20-A2. RESULTS: Most parameters measured by the BC-6800 matched well with the XE-2100 and manual differential. The flag efficiency of the BC-6800 for blasts (95.3%) and atypical lymphocytes (92.6%) were higher while immature granulocytes (89.7%) and NRBCs (94.1%) were lower than that of the XE-2100. Additionally, the BC-6800 detected four of five samples infected with plasmodium parasites. The SC-120 showed no carry-over and expected repeatability. There was good agreement on the five-part differential including abnormal cells between blood films by the SC-120 and manually prepared blood films. The shape of the RBC was also comparable between blood films. CONCLUSION: The CAL-8000 analysis line is beneficial for precise, fast hematology work, and even more useful in malaria endemic areas.

Ahcyl2 upregulates NBCe1-B via multiple serine residues of the PEST domain-mediated association.

Inositol-1,4,5-triphosphate [IP3] receptors binding protein released with IP3 (IRBIT) was previously reported as an activator of NBCe1-B. Recent studies have characterized IRBIT homologue S-Adenosylhomocysteine hydrolase-like 2 (AHCYL2). AHCYL2 is highly homologous to IRBIT (88%) and heteromerizes with IRBIT. The two important domains in the N-terminus of AHCYL2 are a PEST domain and a coiled-coil domain which are highly comparable to those in IRBIT. Therefore, in this study, we tried to identify the role of those domains in mouse AHCYL2 (Ahcyl2), and we succeeded in identifying PEST domain of Ahcyl2 as a regulation region for NBCe1-B activity. Site directed mutagenesis and coimmunoprecipitation assay showed that NBCe1-B binds to the N-terminal Ahcyl2-PEST domain, and its binding is determined by the phosphorylation of 4 critical serine residues (Ser151, Ser154, Ser157, and Ser160) in Ahcyl2 PEST domain. Also we revealed that 4 critical serine residues in Ahcyl2 PEST domain are indispensable for the activation of NBCe1-B using measurement of intracellular pH experiment. Thus, these results suggested that the NBCe1-B is interacted with 4 critical serine residues in Ahcyl2 PEST domain, which play an important role in intracellular pH regulation through NBCe1-B.

The Prognostic Value of Serum Levels of Heart-Type Fatty Acid Binding Protein and High Sensitivity C-Reactive Protein in Patients With Increased Levels of Amino-Terminal Pro-B Type Natriuretic Peptide.

BACKGROUND: Amino-terminal pro-B type natriuretic peptide (NT-proBNP) is a well-established prognostic factor in heart failure (HF). However, numerous causes may lead to elevations in NT-proBNP, and thus, an increased NT-proBNP level alone is not sufficient to predict outcome. The aim of this study was to evaluate the utility of two acute response markers, high sensitivity C-reactive protein (hsCRP) and heart-type fatty acid binding protein (H-FABP), in patients with an increased NT-proBNP level. METHODS: The 278 patients were classified into three groups by etiology: 1) acute coronary syndrome (ACS) (n=62), 2) non-ACS cardiac disease (n=156), and 3) infectious disease (n=60). Survival was determined on day 1, 7, 14, 21, 28, 60, 90, 120, and 150 after enrollment. RESULTS: H-FABP (P<0.001), NT-proBNP (P=0.006), hsCRP (P<0.001) levels, and survival (P<0.001) were significantly different in the three disease groups. Patients were divided into three classes by using receiver operating characteristic curves for NT-proBNP, H-FABP, and hsCRP. Patients with elevated NT-proBNP (≥3,856 pg/mL) and H-FABP (≥8.8 ng/mL) levels were associated with higher hazard ratio for mortality (5.15 in NT-proBNP and 3.25 in H-FABP). Area under the receiver operating characteristic curve analysis showed H-FABP was a better predictor of 60-day mortality than NT-proBNP. CONCLUSIONS: The combined measurement of H-FABP with NT-proBNP provides a highly reliable means of short-term mortality prediction for patients hospitalized for ACS, non-ACS cardiac disease, or infectious disease.

Screening PCR Versus Sanger Sequencing: Detection of CALR Mutations in Patients With Thrombocytosis.

BACKGROUND: Mutations in calreticulin (CALR) have been reported to be key markers in the molecular diagnosis of myeloid proliferative neoplasms. In most previous reports, CALR mutations were analyzed by using Sanger sequencing. Here, we report a new, rapid, and convenient system for screening CALR mutations without sequencing. METHODS: Eighty-three bone marrow samples were obtained from 81 patients with thrombocytosis. PCR primers were designed to detect wild-type CALR (product: 357 bp) and CALR with type 1 (product: 302 bp) and type 2 mutations (product: 272 bp) in one reaction. The results were confirmed by Sanger sequencing and compared with results from fragment analysis. RESULTS: The minimum detection limit of the screening PCR was 10 ng for type 1, 1 ng for type 2, and 0.1 ng for cases with both mutations. CALR type 1 and type 2 mutants were detected with screening PCR with a maximal analytical sensitivity of 3.2% and <0.8%, respectively. The screening PCR detected 94.1% (16/17) of mutation cases and showed concordant results with sequencing in the cases of type 1 and type 2 mutations. Sanger sequencing identified one novel mutation (c.1123_1132delinsTGC). Compared with sequencing, the screening PCR showed 94.1% sensitivity, 100.0% specificity, 100.0% positive predictive value, and 98.5% negative predictive value. Compared with fragment analysis, the screening PCR presented 88.9% sensitivity and 100.0% specificity. CONCLUSIONS: This screening PCR is a rapid, sensitive, and cost-effective method for the detection of major CALR mutations.

A t(11;14)(p13;q11.2) in myelofibrosis following polycythemia vera.

Chromosomal abnormalities at 14q11, which encodes the T-cell receptor α and δ chain genes, are generally specific for T-cell malignancies, and are rarely reported in other malignancies. We report a novel t(11;14)(p13;q11.2) in a patient with myelofibrosis (MF) following polycythemia vera (PV). This 55-year-old male developed post-PV MF 12 years after the initial diagnosis of PV. He had a normal karyotype at polycythemic disease stage, t(11;14)(p13;q11.2) was newly detected at the time of fibrotic transformation. Therefore, it is likely that this clonal chromosomal abnormality was associated with progression of disease.

Prognostic impact of concordant and discordant bone marrow involvement and cell-of-origin in Korean patients with diffuse large B-cell lymphoma treated with R-CHOP.

AIMS: Previous studies have suggested many prognostic factors in diffuse large B-cell lymphoma (DLBCL), but the prognostic importance of cell-of-origin and discordant bone marrow involvement remains unclear. The aim of this study was to evaluate the prognostic impact of bone marrow involvement histological subtype, cell-of-origin subtype and international prognostic index (IPI) scores in patients with DLBCL. METHODS: Patients who were newly diagnosed with DLBCL and treated with rituximab plus cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP) were analysed. Clinical information was reviewed retrospectively. Patients were classified into negative, concordant and discordant bone marrow involvement by histological review. The cell-of-origin types were defined using immunohistochemical analysis. RESULTS: Both concordant and discordant bone marrow involvement had a negative prognostic impact on progression-free survival, independent of the standard and National Comprehensive Cancer Network (NCCN) IPI scores and cell-of-origin. Patients with non-germinal centre B-cell type showed significantly shorter progression-free survival than those with germinal centre B-cell type. However, non-germinal centre B-cell type did not have a prognostic impact on progression-free survival or overall survival after controlling for the standard and NCCN-IPI and bone marrow involvement. CONCLUSIONS: Both concordant and discordant bone marrow involvement had an adverse prognostic impact on progression-free survival and overall survival; this was independent of the standard and NCCN-IPI and cell-of-origin (non-germinal centre B-cell type). The NCCN-IPI had more powerful prognostic value than the standard IPI (sIPI). The non-germinal centre B-cell type lost significant prognostic impact on progression-free survival after adjustment for standard and NCCN-IPI and bone marrow involvement.