Exceptional Response of BRAFV600E-Mutated Acinar Cell CUP to BRAF/MEK Inhibition.

Complete remission of BRAF V600E-driven ACC CUP by BRAF/MEK inhibition underscores importance of precision oncology.

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.

Effects of dexamethasone on mitogen-activated protein kinases in mouse macrophages: implications for the regulation of 85 kDa cytosolic phospholipase A(2).

In mouse macrophages, arachidonate mobilisation in response to several stimuli is severely inhibited by prolonged (16-20 hr) treatment with nanomolar dexamethasone (dex). It was shown earlier that this inhibition was accompanied by a dual effect on cPLA(2); down-regulation of the enzyme protein and inhibition of its activation. We now report that cycloheximide, a protein synthesis inhibitor, caused an almost complete reversion of the inhibitory effects of dex on cPLA(2) activation. These results indicate that the effects depend on new protein synthesis. This is consistent with other data, obtained with a glucocorticoid receptor antagonist, indicating that the effects are mediated via the glucocorticoid receptor. Northern blot results showed pronounced down-regulation of cPLA(2) at the level of its mRNA. The possibility that dex also targeted the level or activation of one or more of the three mitogen-activated protein kinases (MAP kinases), extracellular signal-regulated kinase (ERK), p38, or c-Jun N-terminal kinase (JNK) was also addressed. While the level of these MAP kinases and their phorbol myristate acetate (PMA)-induced activation were unaffected by dex, there was a partial inhibition of their zymosan-induced activation. However, this inhibition was not as pronounced as the dex-mediated inhibition of cPLA(2) activation. These data were confirmed by Western blot using antibodies against the phosphorylated forms of ERK, p38, and JNK. The results suggest that dex-mediated inhibition of PMA-induced cPLA(2) activation is exerted downstream of the MAP kinases, while the partial inhibition of the zymosan-induced activation may be explained by effects exerted more upstream. Thus, the MAP kinases investigated here do not appear to be main targets for the inhibitory effects of dex on cPLA(2) activation.

Phosphatidylinositol 3-kinase in zymosan- and bacteria-induced signalling to mobilisation of arachidonic acid in macrophages.

Stimulation of mouse peritoneal macrophages with zymosan or bacteria results in activation of 85-kDa cytosolic phospholipase A(2) (cPLA(2)) and release of arachidonate. We have investigated the role of phosphatidylinositol 3-kinase (PtdIns 3-kinase) in the signalling leading to activation of cPLA(2) and release of arachidonate in response to zymosan and the bacterium Prevotella intermedia. The specific PtdIns 3-kinase inhibitor wortmannin completely inhibited zymosan- and bacteria-induced release of arachidonate with an IC(50) value of 10-20 nM. Wortmannin also completely inhibited the zymosan-induced activation of cPLA(2), while the cPLA(2) activation by bacteria was partially inhibited by about 50%. Further experiments showed that zymosan-induced activation of extracellular signal-regulated kinase was inhibited, and bacteria-induced activation of the kinase strongly reduced, in the presence of wortmannin. Also zymosan-induced activation of p38 mitogen-activated protein kinase was inhibited by wortmannin, while p38 activation induced by bacteria was not. The zymosan- and bacteria-induced activation of phospholipase C, as determined by the generation of inositol phosphates, was also inhibited by wortmannin. Moreover, zymosan caused activation of PtdIns 3-kinase, which was totally inhibited by wortmannin. In contrast to zymosan and bacteria, arachidonate release induced by calcium ionophore alone, or further amplified by phorbol ester, was not sensitive to wortmannin. These results suggest that PtdIns 3-kinase constitutes a critical component in the zymosan- and bacteria-induced signalling leading to release of arachidonate and that PtdIns 3-kinase is positioned upstream of phospholipase C in this pathway.

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.

Input/output balance of estrogenic active compounds in a major municipal sewage plant in Germany.

24 h samples of untreated and treated wastewater were taken in parallel from a modern municipal sewage plant in southern Germany in March and June 1998. After solid phase extraction, total estrogenic activity was quantitatively measured with a miniaturized E-screen assay and the levels of nine estrogenic phenolic chemicals analyzed by HRGC/LRMS. 17Beta-estradiol equivalent concentrations (EEQ) were 58 and 70 ng/l in the influent and 6 ng/l in the effluent, indicating that the load of estrogenic activity of the wastewater was reduced by about 90% in the sewage plant. Less than 3% of the estrogenic activity was found in the sludge. 4-t-octylphenol, 4-nonylphenol, bisphenol A, 2-hydroxybiphenyl, and 4-chloro-3-methylphenol were detected in the untreated wastewater at levels from 0.13 to 3.6 microg/l. 4-t-octylphenol, 4-nonylphenol, and bisphenol A were present in the effluent at concentrations from 0.16 to 0.36 microg/l, 2-hydroxybiphenyl and 4-chloro-3-methylphenol were not detectable. The contribution of the quantified levels of phenolic xenoestrogens to total estrogenic activity in the sewage was 0.7-4.3%.

Linking the physical examination and electrocardiography.

This article will help critical care nurse managers raise staff awareness of the crucial link between electrocardiography and the physical examination.

Activation of arachidonate release and cytosolic phospholipase A2 via extracellular signal-regulated kinase and p38 mitogen-activated protein kinase in macrophages stimulated by bacteria or zymosan.

The mitogen-activated protein kinases (MAP kinases), extracellular signal-regulated kinase (ERK) and p38, can both contribute to the activation of cytosolic phospholipase A2 (cPLA2). We have investigated the hypothesis that ERK and p38 together or independent of one another play roles in the regulation of cPLA2 in macrophages responding to the oral bacterium Prevotella intermedia or zymosan. Stimulation with bacteria or zymosan beads caused arachidonate release and enhanced in vitro cPLA2 activity of cell lysate by 1.5- and 1.7-fold, respectively, as well as activation of ERK and p38. The specific inhibitor of MAP kinase kinase, PD 98059, and the inhibitor of p38, SB 203580, both partially inhibited cPLA2 activation and arachidonate release induced by bacteria and zymosan. Together, the two inhibitors had additive effects and completely blocked cPLA2 activation and arachidonate release. The present results demonstrate that ERK and p38 both have important roles in the regulation of cPLA2 and together account for its activation in P. intermedia and zymosan-stimulated mouse macrophages.

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.