Not T too! False elevations in high-sensitivity cardiac troponin T (hs-TnT) following specimen transport.

Though false elevations attributed to preanalytical specimen handling have been widely reported for Troponin I (TnI), Troponin T (TnT) has appeared more robust to falsely elevated Tn. We describe reproducible false elevations in high sensitivity TnT (hs-TnT) in specimens after courier transport in plasma separator tubes (PST) off-site for testing. Hs-TnT was measured under 5 different conditions: 1) at collection location (N = 24); 2) after transport upright in racks (N = 66); 3) after transport with no control over tube agitation (N = 69); 4) on transported aliquots (N = 84); or 5) immediately after transport with no control over tube agitation (N = 16), followed by keeping the specimen upright and re-measuring at 1hr, 2hr, 4hr, and 20-24hrs (N = 6). To assess the degree of discrepancy, plasma from the original PST was aliquotted, re-centrifuged, potential debris removed, and hs-TnT re-measured. 43% of PST specimens collected offsite and transported with no control over tube agitation had clinically significant false elevations of hs-TnT which subsequently decreased following aliquotting and re-centrifugation (median decrease = 9.9 ng/L). Onsite testing or transported aliquots demonstrated no discrepancy. After being kept upright, discrepant specimens were not different from re-centrifuged aliquots by 4hrs (p = 0.6141, repeated measures ANOVA with Dunn's multiple comparisons). Clinically significant false elevations of hs-TnT occurred in approximately 40% of separated PSTs that were transported in containers where specimens are transported with no control over tube agitation. This interference does not occur if plasma is aliquoted or if hs-TnT is tested at the collection site. In order to prevent these false elevations, and their potential patient impact on the diagnosis of acute myocardial infarction, specimens for hs-TnT measurement should be aliquoted at the collection location prior to transport.

Low partial pressure of oxygen causes significant and unrecognized under-recovery of glucose on blood gas analyzers.

BACKGROUND: Blood gas analyzers employing glucose-oxidase biosensors under-recover glucose when pO2 is low. The manufacturer of the GEM®Premier™ series of analyzers introduced an algorithm to detect specimens at risk of low pO2 interference. We investigated the reliability of this algorithm. METHODS: Whole blood specimens were tested by GEM®Premier™ 4000 (GEM 4000) and 5000 (GEM 5000). Specimens with an incalculable ("incalc") error code for glucose result or that had a glucose ≥ 20 mmol/L were retested on a second analyzer of the same type within 5 min over the course of 30 months in 5 hospitals in Calgary, Alberta. Discordant retests were defined as either: 1) paired numeric results with a difference >10 %, or 2) an "incalc" code that yielded a numeric result upon retesting. Glucose recovery in relation to pO2 level was assessed by comparing specimens experimentally depleted of pO2 between GEM 5000 and a laboratory analyzer (Siemens Vista®). RESULTS: Of 1,776 glucose tests repeated on the GEM 5000 or 1,544 on GEM 4000, 10% were discordant. GEM 5000 produced twice as many discordant numeric retests versus the GEM 4000 [5.9% (98/1,651) vs 2.7% (38/1,391)]. The majority of "incalc" error codes repeated with a numeric glucose result on both GEM analyzers [(79.7% (122/153) vs 75.2% (94/125)]. Among specimens experimentally depleted of pO2, the GEM 5000 under-recovered glucose by up to 30% compared to the Siemens Vista and were not flagged by an "incalc" code. CONCLUSIONS: The algorithm in the GEM®PremierTM series of analyzers that flags specimens at risk for glucose under-recovery due to low pO2 does not reliably detect specimens at risk for glucose under-recovery.

Filling in the GAPS: validation of anion gap (AGAP) measurement uncertainty estimates for use in clinical decision making.

OBJECTIVES: We compare measurement uncertainty (MU) calculations to real patient result variation observed by physicians using as our model anion gap (AGAP) sequentially measured on two different instrument types. An approach for discretely quantifying the pre-analytical contributions and validating AGAP MU estimates for interpretation of patient results is proposed. METHODS: AGAP was calculated from sodium, chloride, and bicarbonate reported from chemistry or blood gas analyzers which employ different methodologies and specimen types. AGAP MU was calculated using a top-down approach both assuming no correlation between measurands and alternatively, including consideration of measurand correlation. MU-derived reference change values (RCV) were calculated between chemistry and blood gas analyzers results. Observational paired AGAP data (n=39,626 subjects) was obtained from retrospectively analyzed specimens from five urban tertiary care hospitals in Calgary, Alberta, Canada. RESULTS: The MU derived AGAP RCV for paired specimen data by the two platforms was 5.2-6.1 mmol/L assuming no correlation and 2.6-3.1 mmol/L assuming correlation. From the paired chemistry and blood gas data, total observed variation on a reported AGAP has a 95% confidence interval of ±6.0 mmol/L. When the MU-derived RCV assuming correlation is directly compared against the observed distribution of patient results, we obtained a pre-analytical variation contribution of 2.9-3.5 mmol/L to the AGAP observed variation. In contrast, assuming no correlation leads to a negligible pre-analytical contribution (<1.0 mmol/L). CONCLUSIONS: MU estimates assuming no correlation are more representative of the total variation seen in real patient data. We present a pragmatic approach for validating an MU calculation to inform clinical decisions and determine the pre-analytical contribution to MU in this system.

A high-throughput test for diabetes care: An evaluation of the next generation Roche Cobas c 513 hemoglobin A1C assay.

OBJECTIVES: The level of glycated hemoglobin A (HbA1C) in blood is the preferred marker for diabetes monitoring and treatment. Here, we evaluate the analytical performance of the Roche Diagnostics Cobas c 513, a stand-alone HbA1C immunoassay analyzer. DESIGN AND METHODS: Performance was assessed with regards to imprecision, accuracy, linearity, method comparison against the Roche Cobas Integra 800 CTS, specimen stability, interference from common hemoglobin variants and hemoglobin F, and throughput. RESULTS: Within-run and between-run precisions were 0.5-0.7 and 0.8-1.3%CV, respectively. An average bias of -1.6% to proficiency survey samples was observed. The c 513 correlated well with the Integra (slope = 0.94, y-intercept = 0.50, and correlation coefficient = 0.998). The effect of hemoglobin variants on this assay was negligible while specimens containing ≥10% HbF demonstrated a negative bias. The c 513 instrument can process up to 340 samples per hour. CONCLUSIONS: The c 513 is a precise, accurate, automated high throughput analyzer for measuring HbA1C in large laboratories.

Strategies for mitigating risk posed by biotin interference on clinical immunoassays.

Recently, biotin use as an oral supplement has increased significantly among the general population. Biotin is a water soluble B-vitamin and is marketed to improve the cosmetic appearance of hair, skin, and nails. In addition, high-dose biotin (>5 mg/day) is prescribed to treat inborn errors of metabolism and multiple sclerosis. Many commercial immunoassays employ the high affinity interaction between biotin and streptavidin, a protein purified from bacteria, as part of the analyte capture mechanism. As such, these immunoassays are subject to this interference. The list of affected immunoassays is vendor specific but includes tests for troponin, serum and urine Beta hCG, thyroid function, and tumor markers. The interference can be positive or negative in nature depending on the immunoassay. To address this issue, patients are recommended to abstain from taking biotin supplements for 48 h, and laboratorians and clinicians must be familiar with the potential for biotin interference in performed lab tests. Here we describe strategies to treat high biotin specimens and make them suitable for testing; and detail a number of approaches used successfully by our laboratory to educate patients, doctors, and other healthcare professionals about this interference and to mitigate the posed patient safety risk.

Stabilizing specimens for routine ammonia testing in the clinical laboratory.

BACKGROUND: In vitro deamination generates ammonia in freshly collected blood specimens. To prevent this, samples for ammonia testing are usually collected on ice and run rapidly (e.g., within 1h). We developed a method to stabilize specimens for ammonia analysis. METHODS: Following plasma separation, 500µmol/l cycloserine or a combination of 2mmol/l sodium borate with 5mmol/l l-serine were added to sample pools with normal or increased concentrations of ALT and/or GGT to inhibit deamination; and/or residual platelets were removed via centrifugation. Sample pools were then incubated at room temperature or 4°C. Untreated sample pools were also incubated at -80°C. Ammonia was measured at 0, 1, 2, 4, 8, 16, and 24h. RESULTS: When incubated at 4°C without treatment, sample pools with enzymes within their reference limit had an increase of 0.5µmol/l/h, whereas sample pools with ALT and/or GGT activity above their upper reference limit had an increase of 3.6µmol/l/h (p<0.001). When sample pools were incubated at 4°C with sodium borate/l-serine, the rate of ammonia increase was significantly reduced in samples with normal (0.3µmol/l/h, p<0.001 vs. untreated controls) or high enzyme activity (0.1µmol/l/h, p<0.001 vs. untreated controls). Independent of the ALT and/or GGT concentrations, storing the sample at -80°C also preserved the specimens for ammonia analysis (0.2µmol/l/h, p<0.001 vs. untreated controls). CONCLUSIONS: By combining sodium borate/l-serine with refrigeration, plasma ammonia specimens can be stabilized for >12h.

Erroneous HbA1c results in a patient with elevated HbC and HbF.

BACKGROUND: HbA1c is used in the diagnosis and monitoring of diabetes mellitus (DM). Interference from hemoglobin variants is a well-described phenomenon, particularly with HPLC-based methods. While immunoassays may generate more reliable HbA1c results in the presence of some variants, these methods are susceptible to negative interference from high concentrations of HbF. We report a case where an accurate HbA1c result could not be obtained by any available method due to the presence of a compound hemoglobinopathy. METHODS: HbA1c was measured by HPLC, immunoassay, and capillary electrophoresis. Hemoglobinopathy investigation consisted of a CBC, hemoglobin fractionation by HPLC and electrophoresis, and molecular analysis. RESULTS: HbA1c analysis by HPLC and capillary electrophoresis gave no result. Analysis by immunoassay yielded HbA1c results of 5.9% (Siemens DCA 2000+) and 5.1% (Roche Integra), which were inconsistent with other markers of glycemic control. Hemoglobinopathy investigation showed HbC with the hereditary persistence of fetal hemoglobin-2 Ghana deletion. CONCLUSION: Reliable HbA1c results may be unobtainable in the presence of some hemoglobinopathies. HPLC and capillary electrophoresis alerted the laboratory to the presence of an unusual hemoglobinopathy. Immunoassays generated falsely low results without warning, which could lead to missed diagnoses and under treatment of patients with DM.

Comparing the calcium binding abilities of two soybean calmodulins: towards understanding the divergent nature of plant calmodulins.

The discovery that plants contain multiple calmodulin (CaM) isoforms of variable sequence identity to animal CaM suggested an additional level of sophistication in the intracellular role of calcium regulation in plants. Past research has focused on the ability of conserved or divergent plant CaM isoforms to activate both mammalian and plant protein targets. At present, however, not much is known about how these isoforms respond to the signal of an increased cytosolic calcium concentration. Here, using isothermal titration calorimetry and NMR spectroscopy, we investigated the calcium binding properties of a conserved (CaM1) and a divergent (CaM4) CaM isoform from soybean (Glycine max). Both isoforms bind calcium with a semisequential pathway that favors the calcium binding EF-hands of the C-terminal lobe over those of the N-terminal lobe. From the measured dissociation constants, CaM4 binds calcium with a threefold greater affinity than CaM1 (K(d,Ca,mean) of 5.0 versus 14.9 µM) but has a significantly reduced selectivity against the chemically similar magnesium cation that binds preferentially to EF-hand I of both isoforms. The implications of a potential magnesium/calcium competition on the activation of CaM1 and CaM4 are discussed in context with their ability to respond to stimulus-specific calcium signatures and their known physiological roles.

Structural analysis of a calmodulin variant from rice: the C-terminal extension of OsCaM61 regulates its calcium binding and enzyme activation properties.

OsCaM61 is one of five calmodulins known to be present in Oryza sativa that relays the increase of cytosolic [Ca(2+)] to downstream targets. OsCaM61 bears a unique C-terminal extension with a prenylation site. Using nuclear magnetic resonance (NMR) spectroscopy we studied the behavior of the calmodulin (CaM) domain and the C-terminal extension of OsCaM61 in the absence and presence of Ca(2+). NMR dynamics data for OsCaM61 indicate that the two lobes of the CaM domain act together unlike the independent behavior of the lobes seen in mammalian CaM and soybean CaM4. Also, data demonstrate that the positively charged nuclear localization signal region in the tail in apo-OsCaM61 is helical, whereas it becomes flexible in the Ca(2+)-saturated protein. The extra helix in apo-OsCaM61 provides additional interactions in the C-lobe and increases the structural stability of the closed apo conformation. This leads to a decrease in the Ca(2+) binding affinity of EF-hands III and IV in OsCaM61. In Ca(2+)-OsCaM61, the basic nuclear localization signal cluster adopts an extended conformation, exposing the C-terminal extension for prenylation or enabling OsCaM61 to be transferred to the nucleus. Moreover, Ser(172) and Ala(173), residues in the tail, interact with different regions of the protein. These interactions affect the ability of OsCaM61 to activate different target proteins. Altogether, our data show that the tail is not simply a linker between the prenyl group and the protein but that it also provides a new regulatory mechanism that some plants have developed to fine-tune Ca(2+) signaling events.

Altered mechanical properties of titin immunoglobulin domain 27 in the presence of calcium.

Titin (connectin) based passive force regulation has been an important physiological mechanism to adjust to varying muscle stretch conditions. Upon stretch, titin behaves as a spring capable of modulating its elastic response in accordance with changes in muscle biochemistry. One such mechanism has been the calcium-dependent stiffening of titin domains that renders the spring inherently more resistant to stretch. This transient titin-calcium interaction may serve a protective function in muscle, which could preclude costly unfolding of select domains when muscles elongate to great lengths. To test this idea, fluorescence spectroscopy was performed revealing a change in the microenvironment of the investigated immunoglobulin domain 27 (I27) of titin with calcium. Additionally, an atomic force microscope was used to evaluate the calcium-dependent regulation of passive force by stretching eight linked titin I27 domains until they unfolded. When stretching in the presence of calcium, the I27 homopolymer chain became stabilized, displaying three novel properties: (1) higher stretching forces were needed to unfold the domains, (2) the stiffness, measured as a persistence length (PL), increased and (3) the peak-to-peak distance between adjacent I27 domains increased. Furthermore, a peak order dependence became apparent for both force and PL, reflecting the importance of characterizing the dynamic unfolding history of a polymer with this approach. Together, this novel titin Ig-calcium interaction may serve to stabilize the I27 domain permitting titin to tune passive force within stretched muscle in a calcium-dependent manner.

Structural characterization of the interaction of human lactoferrin with calmodulin.

Lactoferrin (Lf) is an 80 kDa, iron (Fe(3+))-binding immunoregulatory glycoprotein secreted into most exocrine fluids, found in high concentrations in colostrum and milk, and released from neutrophil secondary granules at sites of infection and inflammation. In a number of cell types, Lf is internalized through receptor-mediated endocytosis and targeted to the nucleus where it has been demonstrated to act as a transcriptional trans-activator. Here we characterize human Lf's interaction with calmodulin (CaM), a ubiquitous, 17 kDa regulatory calcium (Ca(2+))-binding protein localized in the cytoplasm and nucleus of activated cells. Due to the size of this intermolecular complex (∼100 kDa), TROSY-based NMR techniques were employed to structurally characterize Ca(2+)-CaM when bound to intact apo-Lf. Both CaM's backbone amides and the ε-methyl group of key methionine residues were used as probes in chemical shift perturbation and cross-saturation experiments to define the binding interface of apo-Lf on Ca(2+)-CaM. Unlike the collapsed conformation through which Ca(2+)-CaM binds the CaM-binding domains of its classical targets, Ca(2+)-CaM assumes an extended structure when bound to apo-Lf. Apo-Lf appears to interact predominantly with the C-terminal lobe of Ca(2+)-CaM, enabling the N-terminal lobe to potentially bind another target. Our use of intact apo-Lf has made possible the identification of a secondary interaction interface, removed from CaM's primary binding domain. Secondary interfaces play a key role in the target's response to CaM binding, highlighting the importance of studying intact complexes. This solution-based approach can be applied to study other regulatory calcium-binding EF-hand proteins in intact intermolecular complexes.

Structural insights into calmodulin-regulated L-selectin ectodomain shedding.

The L-selectin glycoprotein receptor mediates the initial steps of leukocyte migration into secondary lymphoid organs and sites of inflammation. Following cell activation through the engagement of G-protein-coupled receptors or immunoreceptors, the extracellular domains of L-selectin are rapidly shed, a process negatively controlled via the binding of the ubiquitous eukaryotic calcium-binding protein calmodulin to the cytoplasmic tail of L-selectin. Here we present the solution structure of calcium-calmodulin bound to a peptide encompassing the cytoplasmic tail and part of the transmembrane domain of L-selectin. The structure and accompanying biophysical study highlight the importance of both calcium and the transmembrane segment of L-selectin in the interaction between these two proteins, suggesting that by binding this region, calmodulin regulates in an "inside-out" fashion the ectodomain shedding of the receptor. Our structure provides the first molecular insight into the emerging new role for calmodulin as a transmembrane signaling partner.

Fast methionine-based solution structure determination of calcium-calmodulin complexes.

Here we present a novel NMR method for the structure determination of calcium-calmodulin (Ca(2+)-CaM)-peptide complexes from a limited set of experimental restraints. A comparison of solved CaM-peptide structures reveals invariability in CaM's backbone conformation and a structural plasticity in CaM's domain orientation enabled by a flexible linker. Knowing this, the collection and analysis of an extensive set of NOESY spectra is redundant. Although RDCs can define CaM domain orientation in the complex, they lack the translational information required to position the domains on the bound peptide and highlight the necessity of intermolecular NOEs. Here we employ a specific isotope labeling strategy in which the role of methionine in CaM-peptide interactions is exploited to collect these critical NOEs. By (1)H, (13)C-labeling the methyl groups of deuterated methionine against a (2)H, (12)C background, we can acquire a (13)C-edited NOESY characterized by simplified, easily analyzable spectra. Together with measured CaM backbone H(N)-N RDCs and intrapeptide NOE-based distances, these intermolecular NOEs provide restraints for a low temperature torsion-angle dynamics and simulated annealing protocol used to calculate the complex structure. We have applied our method to a CaM complex previously solved through X-ray crystallography: Ca(2+)-CaM bound to the CaM kinase I peptide (PDB code: 1MXE). The resulting structure has a backbone RMSD of 1.6 Å to that previously published. We have also used this test complex to investigate the importance of homologous model selection on the calculated outcome. In addition to having application for fast complex structure determination, this method can be used to determine the structures of difficult complexes characterized by chemical shift overlap and broad signals for which the traditional method based on the use of fully (13)C, (15)N-labeled CaM fails.

Effects of metal-binding loop mutations on ligand binding to calcium- and integrin-binding protein 1. Evolution of the EF-hand?

Calcium- and integrin-binding protein 1 (CIB1) is a ubiquitous, multifunctional regulatory protein consisting of four helix-loop-helix EF-hand motifs. Neither EF-I nor EF-II binds divalent metal ions; however, EF-III is a mixed Mg2+/Ca2+-binding site, and EF-IV is a higher-affinity Ca2+-specific site. Through the generation of several CIB1 mutant proteins, we have investigated the importance of the last (-Z) metal-coordinating position of EF-III (D127) and EF-IV (E172) with respect to the binding of CIB1 to Mg2+, Ca2+, and its biological target, the cytoplasmic domain of the platelet alphaIIb integrin. A D127N mutant had reduced Mg2+ and Ca2+ affinity at EF-III but retained affinity for the alphaIIb domain. A D127E mutant had increased Mg2+ and Ca2+ affinity at EF-III, but unexpectedly, the affinity for the alphaIIb domain was too low for binding to be observed. E172Q and E172D mutants showed no and weak Mg2+ binding at EF-IV, respectively, and each mutant had reduced Ca2+ affinity at EF-IV and showed moderate metal-dependent differences in affinity for the alphaIIb domain. Finally, a D127Q mutant bound Mg2+ and Ca2+ in a manner similar to that of D127N, but like that of D127E, the affinity for the alphaIIb domain was reduced below the detection limit. These data, combined with a NMR-based structural comparison of the Mg2+- and Ca2+-loaded CIB1-alphaIIb peptide complexes, suggest that the D127E and D127Q mutations have a disruptive effect on alphaIIb binding since they expand the metal-binding loop and change the alpha-helix positions in EF-III. Conversely, upon replacement of the ancestral Glu with Asp at the -Z position of EF-III, CIB1 gained affinity for alphaIIb, and the Ca2+ affinity of CIB1 shifted into a range where the protein is able to act as an intracellular Ca2+ sensor.

Structures and metal-ion-binding properties of the Ca2+-binding helix-loop-helix EF-hand motifs.

The 'EF-hand' Ca2+-binding motif plays an essential role in eukaryotic cellular signalling, and the proteins containing this motif constitute a large and functionally diverse family. The EF-hand is defined by its helix-loop-helix secondary structure as well as the ligands presented by the loop to bind the Ca2+ ion. The identity of these ligands is semi-conserved in the most common (the 'canonical') EF-hand; however, several non-canonical EF-hands exist that bind Ca2+ by a different co-ordination mechanism. EF-hands tend to occur in pairs, which form a discrete domain so that most family members have two, four or six EF-hands. This pairing also enables communication, and many EF-hands display positive co-operativity, thereby minimizing the Ca2+ signal required to reach protein saturation. The conformational effects of Ca2+ binding are varied, function-dependent and, in some cases, minimal, but can lead to the creation of a protein target interaction site or structure formation from a molten-globule apo state. EF-hand proteins exhibit various sensitivities to Ca2+, reflecting the intrinsic binding ability of the EF-hand as well as the degree of co-operativity in Ca2+ binding to paired EF-hands. Two additional factors can influence the ability of an EF-hand to bind Ca2+: selectivity over Mg2+ (a cation with very similar chemical properties to Ca2+ and with a cytoplasmic concentration several orders of magnitude higher) and interaction with a protein target. A structural approach is used in this review to examine the diversity of family members, and a biophysical perspective provides insight into the ability of the EF-hand motif to bind Ca2+ with a wide range of affinities.