Mammalian cardenolides as biomarkers in congestive heart failure.

Congestive heart failure (CHF) afflicts over 5 million individuals in the United States, and most die within 5 yr of diagnosis. Because of the high morbidity and mortality associated with CHF, the search for biomarkers to predict, diagnose, and manage this disease has intensified. Calcium homeostasis and alterations in intracellular concentrations of this cation have been implicated in both hypertrophy as well as the adaptive mechanisms observed in CHF. In this article, we discuss the roles of the sodium pump and the endogenous mammalian cardenolides and their involvement in the pathophysiology of this disease in view of the regulation of intracellular calcium. Understanding the mechanisms for the release of mammalian cardenolides in plasma, the alterations in sodium pump isoforms and function, and the modulation of pathways involving calcium in hypertrophy and CHF may assist in the development of new biological markers capable of predicting the disease before significant progression and irreversible heart failure.

The role of the clinical laboratory in managing chemical or biological terrorism.

BACKGROUND: Domestic and international acts of terrorism using chemicals and pathogens as weapons have recently attracted much attention because of several hoaxes and real incidents. Clinical laboratories, especially those affiliated with major trauma centers, should be prepared to respond rapidly by providing diagnostic tests for the detection and identification of specific agents, so that specific therapy and victim management can be initiated in a timely manner. As first-line responders, clinical laboratory personnel should become familiar with the various chemical or biological agents and be active participants in their local defense programs. APPROACH: We review the selected agents previously considered or used in chemical and biological warfare, outline their poisonous and pathogenic effects, describe techniques used in their identification, address some of the logistical and technical difficulties in maintaining such tests in clinical laboratories, and comment on some of the analytical issues, such as specimen handling and personal protective equipment. CONTENT: The chemical agents discussed include nerve, blistering, and pulmonary agents and cyanides. Biological agents, including anthrax and smallpox, are also discussed as examples for organisms with potential use in bioterrorism. Available therapies for each agent are outlined to assist clinical laboratory personnel in making intelligent decisions regarding implementation of diagnostic tests as a part of a comprehensive defense program. SUMMARY: As the civilian medical community prepares for biological and chemical terrorist attacks, improvement in the capabilities of clinical laboratories is essential in supporting counterterrorism programs designed to respond to such attacks. Accurate assessment of resources in clinical laboratories is important because it will provide local authorities with an alternative resource for immediate diagnostic analysis. It is, therefore, recommended that clinical laboratories identify their current resources and the extent of support they can provide, and inform the authorities of their state of readiness.

Standardizing utilization of biomarkers in diagnosis and management of acute cardiac syndromes.

Publications on the development and use of myocardial markers have exploded in the decade of the 1990s. According to subscriptions to proficiency testing surveys, enzymatic measurement of creatine kinase and lactate dehydrogenase isoenzymes have largely been replaced by CK-MB mass immunoassays. Laboratories reporting use of myoglobin and cardiac troponin have increased tremendously over the past few years. In this field of medicine where there have been dramatic changes, development of consensus guidelines can be helpful to provide assistance to clinicians and laboratorians as to how they can make the best use of new cardiac markers for clinical practice.

Validity of unbound digoxin measurements by immunoassays in presence of antidote (Digibind).

Measurement of unbound digoxin in presence of Fab fragments may be useful in management of overdoses. The analysis can be performed on serum directly or on ultrafiltrate of serum. The architecture of the immunoassay may influence the validity of results obtained using these two approaches. We tested this hypothesis by preparing serum mixtures containing various concentrations of digoxin and Digibind and analyzed them by the immunoassays before and after ultrafiltration. Four samples collected from Digibind-treated patients were also analyzed before and after ultrafiltration. The slopes and the y-intercepts of the measured versus the expected values for serum and its ultrafiltrate overlapped for the MEIA digoxin assay. For other three immunoassays tested (ACS:180, Stratus, and On-Line), either the slope or the intercept for measured versus the expected results for serum were significantly different (P < 0.05) than those for ultrafiltrate. Following addition of digoxin and Digibind, differences in results for serum analyzed directly or after ultrafiltration were < 0.50 ng/ml. Comparable samples from digoxin-overdosed patients treated with Digibind had differences of > 1.0 ng/ml. Previous claims reporting direct analysis of digoxin in presence of antidote but not having used patient samples for validation should be revisited. To date, analysis of serum ultrafiltrate by an immunoassay proven not to have matrix bias remains the most accurate approach in measuring unbound digoxin in presence of antidote.

Simultaneous rapid measurement of whole blood myoglobin, creatine kinase MB, and cardiac troponin I by the triage cardiac panel for detection of myocardial infarction.

This multicenter study evaluated the Biosite Triage(R) Cardiac Panel as a quantitative, multimarker, whole blood system for the detection of acute myocardial infarction (MI). Optimum cutoffs for the discrimination of acute MI (n = 192 patients, 59 with MI) as determined by ROC curve analyses were as follows: 0.4 microgram/L for cardiac troponin I (cTnI); 4.3 microgram/L for the creatine kinase MB isoenzyme (CK-MB); and 107 microgram/L for myoglobin. The Triage Panel showed the following concordances for detection or rule-out of MI compared with established devices: cTnI >89%; CK-MB >81%; myoglobin >69%. No significant differences were present between methods for the same marker. Diagnostic efficiencies demonstrated comparable sensitivities and specificities for the diagnosis of MI in patients presenting with symptoms compared with the Dade, Beckman, and Behring CK-MB, cTnI, and myoglobin assays; the ratio of sensitivity to specificity for each marker was as follows: cTnI, 98%:100%; CK-MB, 95%:91%; myoglobin, 81%:92%. The areas under the ROC curves for the Biosite myoglobin, CK-MB, and cTnI were 0.818, 0.905, and 0.970, respectively; the areas were significantly different, P <0.05. In patients with skeletal muscle injury and renal disease, the Triage cTnI showed 94% and 100% specificity, respectively. The Triage panel offers clinicians a whole blood, point-of-care analysis of multiple cardiac markers that provides excellent clinical sensitivity and specificity for the detection of acute MI.

Standards of laboratory practice: cardiac drug monitoring. National Academy of Clinical Biochemistry.

In this Standard of Laboratory Practice we recommend guidelines for therapeutic monitoring of cardiac drugs. Cardiac drugs are primarily used for treatment of angina, arrhythmias, and congestive heart failure. Digoxin, used in congestive heart failure, is widely prescribed and therapeutically monitored. Monitoring and use of antiarrhythmics such as disopyramide and lidocaine have been steadily declining. Immunoassay techniques are currently the most popular methods for measuring cardiac drugs. Several reasons make measurement of cardiac drugs in serum important: their narrow therapeutic index, similarity in clinical complications and presentation of under- and overmedicated patients, need for dosage adjustments, and confirmation of patient compliance. Monitoring may also be necessary in other circumstances, such as assessment of acetylator phenotypes. We present recommendations for measuring digoxin, quinidine, procainamide (and N-acetylprocainamide), lidocaine, and flecainide. We discuss guidelines for measuring unbound digoxin in the presence of an antidote (Fab fragments), for characterizing the impact of digoxin-like immunoreactive factor (DLIF) and other cross-reactants on immunoassays, and for moni-toring the unbound (free fraction) of drugs that bind to alpha1-acid glycoprotein. We also discuss logistic, clinical, hospital, and laboratory practice guidelines needed for implementation of a successful therapeutic drug monitoring service for cardiac drugs.

Implementation of a successful on-call system in clinical chemistry.

Successful practice of clinical pathology depends on a wide variety of laboratory, clinical, and managerial decisions. The skills needed to make these decisions can most effectively be learned by residents and fellows in pathology using a service-oriented on-call approach. We report our experience implementing an on-call system in the clinical chemistry laboratory at the University of Louisville Hospital (Ky). We detail the guidelines used to establish this system and the elements required for its successful implementation. The system emphasizes a laboratory-initiated approach to linking laboratory results to patient care. From inception of the program during late 1990 through 1995, the number of beeper calls (including clinician contacts) steadily increased and is currently 8 to 20 per week. The on-call system is active 24 hours per day, 7 days per week, thus representing activity on all three laboratory shifts. Types of responses were separated into administrative (12%), analytical (42%), clinical (63%), quality control or quality assurance (12%), and consultation (13%) categories. We also present 6 case reports as examples demonstrating multiple elements in these categories. In 23% of the calls, clinician contact was required and achieved by the fellow or resident on call for the laboratory. The on-call reports are documented and presented informally at weekly on-call report sessions. Emphasis is placed on learning and refinement of investigative skills needed to function as an effective laboratory director. Educational emphasis for the medical staff is in establishing awareness of the presence of the laboratory as an important interactive component of patient care. In addition, we found this program to be beneficial to the hospital and to the department of pathology in fulfilling its clinical service and teaching missions. Our experience may be helpful to other institutions establishing such a program.

Digoxin and its related endogenous factors.

The digitalis drugs are plant-derived cardenolide compounds used medicinally for several hundred years. These drugs elicit inotropic and chronotropic effects on the heart, but they also affect many other tissues. The mechanism of action involves inhibition of the ion-transport activity of a membrane-associated protein called Na, K-ATPase (sodium pump). Present theory holds that the sodium pump is the principal molecular receptor for the digitalis drugs. Recent evidence indicates the presence of naturally occurring digitalis-like compounds in mammals. It is believed these compounds, collectively known as either digitalis-like (DLF) or ouabain-like (OLF) factors, may be endogenous hormones regulating the biological activity of the sodium pump and its isoforms. The presence of deglycosylated and other congeners of one specific DLF, the digoxin-like immunoreactive factor (DLIF), has very recently been described in humans. Digoxin as a drug is the most widely prescribed digitalis in the U.S., and its measurement in serum has established a model for present-day therapeutic drug monitoring (TDM). Historically, the accurate measurement of digoxin in blood has been difficult. This article focuses on the present understanding of the clinical use of digoxin, factors that affect the accuracy of measuring digoxin, the principle of measuring metabolically active species of digoxin, and the effects of DLIF and other interfering substances in digoxin immunoassay.

A case of nondigitalis cardiac glycoside toxicity.

A case is presented of cardiac glycoside poisoning in a 1-year-old patient from the plant Nerium oleander (common oleander). The patient had bradycardia, vomiting, altered level of consciousness, and no history of ingestion. Antibody-based digoxin assays may cross-react with other cardiac glycosides nonquantitatively. Chromatographic techniques can be used in the specific diagnosis.

Inhibition of Na,K-ATPase by oleandrin and oleandrigenin, and their detection by digoxin immunoassays.

Ingestion of oleander plant, containing the cardiac glycoside oleandrin, has been reported to induce fatal poisonings. Derivatives of oleandrin are structurally similar to digoxin. We investigated the cross-reactivities of oleandrin and its aglycone metabolite, oleandrigenin, in several commercially available digoxin immunoassays; assessed their ability to inhibit Na,K-ATPase catalytic activity; and measured their binding to proteins in serum. As assayed with ACS:180, Stratus, RIA, On-Line, and TDx digoxin assays, oleandrin at 100 micromol/L in digoxin-free serum gave apparent digoxin values of 0, 0.83, 2.24, 2.37, and 5.34 nmol/L, respectively, whereas oleandrigenin at that concentration gave results of 0, 0.52, 0.77, 4.94, and 1.40 nmol/L. Study of Na,K-ATPase inhibition showed IC50 values (micromol/L) of 0.22 for ouabain, 0.62 for oleandrin, 1.23 for oleandrigenin, and 2.69 for digoxin. At 25 degrees C, 96% of oleandrin and 48% of oleandrigenin were bound to serum proteins. Because detection of oleandrin and oleandrigenin by digoxin immunoassays is variable between assays as well as between congeners, assessment of cross-reactivity is warranted for each assay. The inhibition of Na,K-ATPase by oleandrin and oleandrigenin confirms that they likely exert their toxic effects through inhibition of sodium pump activity. In cases of digitalis-like poisoning with suspicion of oleander ingestion, a combination of digoxin immunoassays may be useful to effectively rule out the presence of oleander.

Evidence for presence of a reduced form of digoxin-like immunoreactive factor (dihydro-DLIF) in mammalian tissues.

Digoxin-like immunoreactive factor (DLIF) from adrenal glands is an endogenous ligand structurally related to the plant-derived cardiac glycoside digoxin. Cardiac glycosides regulate the activity of the sodium pump and thus play key roles in disease processes involving regulation of ion transport. We now report the discovery of an endogenous dihydro-DLIF analogous to dihydrodigoxin. We used HPLC, ultraviolet spectrophotometry, and cross-reactivity with two antibodies, one specific for digoxin and one for dihydrodigoxin, to support the hypothesis that dihydro-DLIF contains a chemically reduced lactone ring. The spectral absorbance maximum for dihydro-DLIF is at 196 nm, identical to dihydrodigoxin. DLIF and dihydro-DLIF are 975- and 2588-fold less immunoreactive than digoxin and dihydrodigoxin for their respective antibodies. The molar ratio of dihydro-DLIF to DLIF is approximately 5.3 in bovine adrenocortical tissue and approximately 0.38 in human serum. Dihydrodigoxin (reduced lactone ring) added to microsomes isolated from bovine adrenal cortex produced a 4.5-fold increase in digoxin-like immunoreactivity (oxidized lactone ring) after 3 h of incubation. The biotransformation is likely mediated by a cytochrome P-450 NADPH-dependent process. Our findings demonstrate the presence of a dihydro-DLIF in mammals and suggest a metabolic route for synthesis of endogenous DLIF in mammalian tissue.

Discriminative stimulus effects of esteratic local anesthetics in squirrel monkeys.

A number of esteratic local anesthetics serve as positive reinforcers and produce cocaine-like discriminative stimulus effects in animals. It has been suggested that the affinity of these compounds for a site on the dopamine transporter, and not their local anesthetic actions, is responsible for these abuse-related behavioral effects. In the present study, three local anesthetics previously shown to be self-administered in animals were examined in squirrel monkeys trained to discriminate cocaine (0.3 mg/kg) from saline in a two-lever, food-reinforced procedure. Dimethocaine (0.1-3.0 mg/kg) fully and dose-dependently substituted for cocaine. Doses of dimethocaine (1.7 mg/kg) and cocaine (0.3 mg/kg) which produced full (> 80%) substitution for cocaine were administered in combination with the dopamine D1 receptor antagonist SCH 39166 ((-)-trans-6,7,7a,8,9,13b-hexahydro-3-chloro-2-hydroxy-N-methyl-5H -benzo [d]naphtho-(2,1-b)azepine) and the dopamine D2 receptor antagonist raclopride (both at 0.003-0.03 mg/kg). SCH 39166 fully blocked the cocaine-like discriminative stimulus effects of dimethocaine and cocaine, but raclopride produced only partial antagonism of cocaine-lever selection. In addition, there was some evidence that raclopride blocked cocaine-lever responding produced by a lower dose of dimethocaine. In substitution studies, neither procaine (1-10 mg/kg) nor chloroprocaine (1-30 mg/kg) produced cocaine-like effects. These results support a role for dopamine in the behavioral effects of some local anesthetics.

Direct determination of benzoylecgonine in serum by EMIT d.a.u. cocaine metabolite immunoassay.

An EMIT d.a.u. immunoassay for urine testing was applied on the Syva ETS Plus analyzer for the detection of the cocaine metabolite, benzoylecgonine (BE), in human serum. Serum was analyzed without prior extraction, concentration, or matrix modification. Calibrators and serum controls were prepared from EMIT d.a.u. calibrators that were reconstituted and diluted with EMIT Tox serum calibrator. The assay cutoff concentration for BE was 50 ng/mL. The within-run and between-run precisions of the assay were both less than 5%. Analysis of 162 patient serums yielded 43 BE positive results. All EMIT positive serum BE results were confirmed by gas chromatography-mass spectrometry. All patients with positive BE serums also had BE positive urine samples. Serum bilirubin and triglycerides as high as 38 mg/dL and 319 mg/dL, respectively, did not interfere with the assay. Modification of the EMIT urine assay allowed for a simple, rapid, and reliable method for the detection of BE in serum.

Thioridazine enantiomers in human tissues.

Enantiomers of thioridazine (TRZ) were determined in postmortem tissues obtained from a patient on chronic TRZ therapy by sequential achiral and chiral high pressure liquid chromatography. Tissue concentrations of (+)-TRZ found in liver, brain, bile and blood were: 6.46, 0.40, 0.48 and 0.07 mg/l or mg/kg, respectively. Concentrations of (-)-TRZ in liver, brain, bile and blood were: 12.2, 0.81, 1.07 and 0.20 mg/l or mg/kg, respectively. These data demonstrate the stereoselective disposition of TRZ in human tissues.

Determination of thioridazine enantiomers in human serum by sequential achiral and chiral high-performance liquid chromatography.

Quantitation of thioridazine (TRZ) enantiomers, (+)-TRZ and (-)-TRZ, in patient serums was performed by a sequential achiral and chiral HPLC method. The lower limit of quantitation was 50 ng/mL for each enantiomer, and the method was linear up to 1000 ng/mL. The within-run and between-run precision at 125 and 500 ng/mL of each enantiomer yielded coefficients of variation (CV) of less than 10% and less than 12%, respectively. Absolute recovery of 250 ng/mL racemic TRZ added to serum (n = 9) yielded mean recoveries of 77.2% and 77.8% for (+)-TRZ and (-)-TRZ, respectively. Absolute recovery of 1000 ng/mL racemic TRZ added to serum (n = 9) yielded mean recoveries of 74.0% and 74.7% for (+)-TRZ and (-)-TRZ, respectively. Significantly different TRZ enantiomer concentrations were present in patient serums. The mean serum concentration was 110 ng/mL for (+)-TRZ (n = 18), and 317 ng/mL for (-)-TRZ (n = 21). The ratios of (-)-TRZ to (+)-TRZ ranged from 2.2 to 5.3, with a mean of 3.3. Variations in the concentration of TRZ enantiomers may contribute to the lack of correlation between serum TRZ values and therapeutic effect.

Response of the Emit II amphetamine/methamphetamine assay to specimens collected following use of Vicks inhalers.

The possible cross-reactivity of l-methamphetamine (desoxyephedrine) to the Syva Emit II amphetamine/methamphetamine assay was evaluated in urine specimens collected from seven subjects using Vicks Inhalers. The subjects were six males and one female ranging from 24 to 47 years of age. Four subjects used the inhaler every two waking hours for five consecutive days, while three subjects inhaled hourly for three consecutive days. All urine voids were collected, totaling 150 specimens. All specimens were analyzed by the Emit II assay on a Hitachi 717 automatic analyzer with a 1000-ng/mL d-methamphetamine cutoff calibrator. None of the inhaler specimens produced an Emit II response equal to or greater than the cutoff calibrator; all were negative. Specimens producing the highest rates were further analyzed by chiral GC/MS. The highest concentrations of l-methamphetamine were observed in urines from two subjects inhaling hourly: 1390, 1290, and 740 ng/mL. These specimens were collected the evenings of the second and third day. When used as directed or even with double the daily dose, Vicks Inhalers did not cause false-positive results in urine tested with the Emit II Amphetamine/Methamphetamine assay.

Evaluation of the ADx REA assay for determination of ethanol in serum and urine.

The Abbott ADx REA assay (ADx) for the determination of ethanol in human serum and urine was evaluated. The within-run precision of a urine sample containing 3.00 g/L ethanol resulted in a coefficient of variance (CV) of 2.1% (n = 20). The within-run precision of a serum sample containing 1.47 g/L ethanol resulted in a CV of 2.3% (n = 20). The between-run precision of the TDx REA ethanol assay controls yielded 0.50 +/- 0.02 g/L ethanol (target value, 0.50 g/L) with a CV of 3.0% (n = 6); 1.03 +/- 0.03 g/L ethanol (target value, 1.00 g/L) with a CV of 2.7% (n = 6); and 2.56 +/- 0.07 g/L ethanol (target value, 2.50 g/L) with a CV of 2.8% (n = 6). Results of an intermethod comparison study of clinical serum and urine ethanol determinations by gas chromatography (x) and ADx (y) yielded by regression analysis y = 0.993x - 0.04 g/L (r = 0.985; n = 92) for serums and y = 0.974x - 0.02 g/L, (r = 0.991; n = 75) for urines. No significant interference was seen with low molecular weight alcohols or ketones.

Evaluation of the Syva ETS Plus urine drug and serum ethanol analyzer.

The Syva ETS is an automated system designed for analysis of drugs of abuse in urine. Recently, the Syva Company has upgraded this system to the ETS Plus, which is capable of analyzing ethanol in urine, serum, or plasma. We evaluated the new ETS Plus for urine screening of barbiturates, benzodiazepines, cocaine metabolite, opiates, and phencyclidine. Results of 505 patient sample assays obtained by ETS Plus were compared with those of ETS. There were only four discrepant results which had absorbance rates close to the low calibrator cutoff values. The within-run precision of the ETS Plus Ethyl Alcohol Assay yielded a CV of 2.6% at a target value of 1.00 g/L (1.06 +/- 0.03 g/L, n = 32) and a CV of 3.2% at a target value of 0.40 g/L (0.42 +/- 0.01 g/L, n = 30). The linear regression analysis of 30 patient serum ethanol results by the ETS Plus and by gas chromatography yielded y = 0.939 x + 0.03 g/L. The software modifications in the new ETS Plus allow the accurate quantitation of ethanol in serum and reliable detection of drugs of abuse within the same batch.