A high-resolution transcriptomic and spatial atlas of cell types in the whole mouse brain.

The mammalian brain consists of millions to billions of cells that are organized into many cell types with specific spatial distribution patterns and structural and functional properties1-3. Here we report a comprehensive and high-resolution transcriptomic and spatial cell-type atlas for the whole adult mouse brain. The cell-type atlas was created by combining a single-cell RNA-sequencing (scRNA-seq) dataset of around 7 million cells profiled (approximately 4.0 million cells passing quality control), and a spatial transcriptomic dataset of approximately 4.3 million cells using multiplexed error-robust fluorescence in situ hybridization (MERFISH). The atlas is hierarchically organized into 4 nested levels of classification: 34 classes, 338 subclasses, 1,201 supertypes and 5,322 clusters. We present an online platform, Allen Brain Cell Atlas, to visualize the mouse whole-brain cell-type atlas along with the single-cell RNA-sequencing and MERFISH datasets. We systematically analysed the neuronal and non-neuronal cell types across the brain and identified a high degree of correspondence between transcriptomic identity and spatial specificity for each cell type. The results reveal unique features of cell-type organization in different brain regions-in particular, a dichotomy between the dorsal and ventral parts of the brain. The dorsal part contains relatively fewer yet highly divergent neuronal types, whereas the ventral part contains more numerous neuronal types that are more closely related to each other. Our study also uncovered extraordinary diversity and heterogeneity in neurotransmitter and neuropeptide expression and co-expression patterns in different cell types. Finally, we found that transcription factors are major determinants of cell-type classification and identified a combinatorial transcription factor code that defines cell types across all parts of the brain. The whole mouse brain transcriptomic and spatial cell-type atlas establishes a benchmark reference atlas and a foundational resource for integrative investigations of cellular and circuit function, development and evolution of the mammalian brain.

Quantitation of P450 3A4 endogenous biomarker - 4ß-hydroxycholesterol - in human plasma using LC/ESI-MS/MS.

4ß-Hydroxycholesterol (4ß-HC) has been proposed as a new endogenous biomarker for cytochrome P450 3A4/5 activity. Therefore, it is important to have a robust method for its accurate determination in human plasma. Here a liquid chromatography-tandem mass spectrometry with electrospray ionization (LC/ESI-MS/MS) assay for the quantitation of 4ß-HC in human plasma is described. While the calibration standards were prepared in a surrogate matrix for human plasma, the quality control samples were prepared in human plasma to mimic the incurred study samples. In order to achieve accurate determination of 4ß-HC, the chromatographic separation of 4ß-HC from its isomers, especially 4α-hydroxycholesterol (4α-HC), was crucial. In the absence of an authentic 4α-HC standard at the time of this study, an alternative selectivity test strategy was developed to confirm the separation. After being alkalized with potassium hydroxide, the human plasma sample (50 µL) was extracted with hexane, derivatized into picolinyl esters using picolinic acid, extracted again with hexane, and then analyzed by LC/ESI-MS/MS. The calibration curve range was 5-500 ng/mL and the chromatographic separation was achieved on a 50 × 2.1 mm Thermal Hypersil Gold column with a gradient elution. The assay accuracy, precision, linearity, selectivity and analyte stability throughout the analysis were established. The validated assay was successfully applied to a Phase I clinical study for the measurement of 4ß-HC in human plasma.

The transcriptomic and spatial organization of telencephalic GABAergic neuronal types.

The telencephalon of the mammalian brain comprises multiple regions and circuit pathways that play adaptive and integrative roles in a variety of brain functions. There is a wide array of GABAergic neurons in the telencephalon; they play a multitude of circuit functions, and dysfunction of these neurons has been implicated in diverse brain disorders. In this study, we conducted a systematic and in-depth analysis of the transcriptomic and spatial organization of GABAergic neuronal types in all regions of the mouse telencephalon and their developmental origins. This was accomplished by utilizing 611,423 single-cell transcriptomes from the comprehensive and high-resolution transcriptomic and spatial cell type atlas for the adult whole mouse brain we have generated, supplemented with an additional single-cell RNA-sequencing dataset containing 99,438 high-quality single-cell transcriptomes collected from the pre- and postnatal developing mouse brain. We present a hierarchically organized adult telencephalic GABAergic neuronal cell type taxonomy of 7 classes, 52 subclasses, 284 supertypes, and 1,051 clusters, as well as a corresponding developmental taxonomy of 450 clusters across different ages. Detailed charting efforts reveal extraordinary complexity where relationships among cell types reflect both spatial locations and developmental origins. Transcriptomically and developmentally related cell types can often be found in distant and diverse brain regions indicating that long-distance migration and dispersion is a common characteristic of nearly all classes of telencephalic GABAergic neurons. Additionally, we find various spatial dimensions of both discrete and continuous variations among related cell types that are correlated with gene expression gradients. Lastly, we find that cortical, striatal and some pallidal GABAergic neurons undergo extensive postnatal diversification, whereas septal and most pallidal GABAergic neuronal types emerge simultaneously during the embryonic stage with limited postnatal diversification. Overall, the telencephalic GABAergic cell type taxonomy can serve as a foundational reference for molecular, structural and functional studies of cell types and circuits by the entire community.

A highly sensitive and selective UPLC-MS/MS assay for the determination of enarodustat (JTZ-951) in human plasma.

Enarodustat, a potent, orally bioavailable, selective inhibitor of hypoxia inducible factor-Prolyl hydroxylase (HIF-PH), has been approved recently in Japan for the treatment of anemia in patients with chronic kidney disease (CKD). To evaluate the pharmacokinetics of enarodustat, a bioanalytical assay in human plasma was needed for the quantitation of enarodustat for both healthy subjects and patients with CKD. The UPLC-MS/MS method for the quantitation of enarodustat was initially validated in a bioanalytical laboratory in Japan to support clinical studies conducted in Japan, and then was transferred and validated in a bioanalytical laboratory in United States to support clinical studies conducted here. A cross-validation was successfully performed between the two bioanalytical laboratories using both quality control (QC) samples and incurred study samples. Enarodustat was fortified with its isotopically labeled internal standard in a 25 µL plasma aliquot and extracted with protein precipitation. The chromatographic separation was achieved on an Acquity UPLC BEH C18 (1.7 µm, 2.1 × 50 mm) column with gradient elution. The calibration curve range for the assay was 1.00-500 ng/mL. Assay precision, accuracy, linearity, selectivity, sensitivity and analyte stability covering sample storage and analysis were established. No interferences were observed from medications that may be co-administered along with enarodustat. The validated UPLC-MS-MS method at the US bioanalytical laboratory has been successfully applied to eight clinical studies for the determination of enarodustat concentrations in human plasma for both healthy subjects and patients with CKD.

A sensitive LC-MS-MS assay for the determination of lapatinib in human plasma in subjects with end-stage renal disease receiving hemodialysis.

Most bioanalytical methods reported in literature for the quantitation of lapatinib in human plasma are either for lapatinib alone or lapatinib administered along with other tyrosine kinase inhibitors (TKIs) for therapeutic drug monitoring (TDM) in cancer patients. Recently there was a need for the quantitation of lapatinib in patients with end-stage renal disease (ESRD) receiving hemodialysis (HD). This special patient population normally receives many concomitant medications which have the potential to interfere with the quantitation of lapatinib. Here we describe an LC-MS-MS bioanalytical assay for the quantitation of lapatinib in human plasma containing potential concomitant medications which are commonly given to patients with ESRD receiving HD. The lapatinib calibration curve range was 2.50-1000 ng/mL. Lapatinib was fortified with its isotopically labeled internal standard in a 50 µL plasma aliquot and extracted with protein precipitation. The chromatographic separation was achieved on a Zorbax SB-C18 (5 µm, 2.1 × 50 mm) column with isocratic elution. Assay precision, accuracy, linearity, selectivity, sensitivity and analyte stability covering sample storage and analysis were established. No interferences were observed for the quantitation of lapatinib in the presence of concomitant medications. The validated LC-MS-MS method has been successfully applied to a clinical study for the determination of lapatinib concentrations in human plasma for patients with ESRD receiving HD.

High-throughput quantitation of nefazodone and its metabolites in human plasma by high flow direct-injection LC-MS/MS.

A rapid, selective and sensitive high-performance liquid chromatography tandem mass spectrometry (LC-MS/MS) method coupled with high flow direct-injection on-line extraction has been developed and validated for the simultaneous quantitation of nefazodone and its three active metabolites, hydroxynefazodone, triazole-dione (BMS-180492) and m-chlorophyenylpiperazine (mCPP) in human plasma. The method utilized d7-nefazodone, d7-hydroxynefazodone, d4-BMS-180492 and d4-mCPP as internal standards (IS). The plasma samples were injected into the LC-MS/MS system after simply adding the internal standard solution and centrifuging. The required extraction and chromatographic separation of the analytes were achieved on an Oasis HLB column (on-line extraction column, 1 mm x 50 mm, 30 microm) and a conventional Luna C8 column (analytical column, 4.6 mm x 50 mm, 5 microm). Detection was by positive ion electrospray tandem mass spectrometry. The total analysis run time for each sample was 2 min, which included the time needed for on-line extraction, chromatographic separation and LC-MS/MS analysis. The assay was validated for each analyte and the concentrations ranged from 2.0 to 500 ng/ml for nefazodone, hydroxynefazodone and mCPP and from 4.0 to 1000 ng/ml for BMS-180492, respectively. The assay was used for the high-throughput sample analysis of thousands of pharmacokinetic study samples and was proven to be rapid, accurate, precise, sensitive, specific and rugged.

UPLC-MS/MS assay for the simultaneous determination of ethinyl estradiol, norgestimate and 17-Desacetyl norgestimate at low pg/mL in human plasma.

Previously, because of the difficulty of measuring very low levels (pg/mL) of norgestimate (NGM) due to rapid metabolism to its active and major metabolite, 17-Desacetyl norgestimate (DNGM), only DNGM and the co-administered ethinyl estradiol (EE2) were required to be analyzed in bioequivalence (BE) studies for oral contraceptive NGM/EE2 tablets. Recently, with more sensitive assays available, health authorities have requested that bioequivalence of NGM be also demonstrated in addition to DNGM and EE2. Therefore, it was important to establish a 3-in-1 method for the quantitation of EE2, NGM and DNGM in human plasma. Here a UPLC-MS/MS method for the simultaneous quantitation of EE2, NGM and DNGM in human plasma at low pg/mL range is described. EE2, NGM, DNGM and their isotopic labeled internal standards (IS) EE2-d4, NGM-d6 and DNGM-d6 in 0.4mL of human plasma were extracted with hexane/ethyl acetate. The extracts were evaporated to dryness and derivatized with dansyl chloride, to enhance the mass spec response. The derivatives were reconstituted with methanol and analyzed by UPLC-MS/MS. In order to minimize the ex-vivo conversion of NGM to DNGM, sodium fluoride/potassium oxalate was used as anti-coagulant. To achieve desirable throughput for sample analysis, UPLC-MS/MS with a run time of 4.4min was utilized. The calibration curve ranges were 5-500pg/mL for EE2 and NGM, and 25-2500pg/mL for DNGM, respectively. The chromatographic separation was achieved on a Waters Acquity UPLC HSS T3 (100×2.1mm, 1.8µm) column with a gradient elution. Assay accuracy, precision, linearity, selectivity, sensitivity and analyte stability covering sample storage and analysis were established. This validated UPLC-MS/MS method has been applied to a BE study for the determination of EE2, NGM and DNGM concentrations in human plasma.

Bioanalysis of ibrutinib and its active metabolite in human plasma: selectivity issue, impact assessment and resolution.

Ronald de Vries graduated in Organic and Analytical Chemistry at the Free University of Amsterdam, The Netherlands. After working in a Contract Laboratory (CRO) for 7 years, he joined Janssen R&D in 1998. At Janssen R&D, Belgium, Ronald worked in the bioanalytical department that supports both clinical and nonclinical bioanalysis. In this department he had several roles, such as providing the bioanalytical support for various drug development programs and leading the method establishment group. He has done numerous global assay transfers to/from Janssen from/to other laboratories and plays an important role in the introduction and application of new technologies and applied innovation in the department. In 2014 he started in the drug metabolism and pharmacokinetics department of Janssen R&D, where his main tasks are in vivo and in vitro metabolite identification using high resolution MS and Radiodetection.

Bioanalysis of chiral compounds during drug development using a tiered approach.

Significant differences in the pharmacodynamic activity and pharmacokinetic properties could exist for a pair of enantiomeric drugs. In order to evaluate the activity, toxicity, absorption, distribution, metabolism, and excretion properties of the individual enantiomers, and any potential for chiral inversion caused by the biotransformation process, chiral bioanalytical assays are necessary for individual enantiomers and/or their metabolites for in vivo samples. However, development and validation of chiral quantitative assays are highly challenging in comparison to typical nonchiral assays. Therefore, a tiered approach should be used to address specific needs arising in different scenarios of chiral drug development, including development of racemate or fixed-ratio (nonracemic) enantiomers, development of a single enantiomer, racemic switches, and quantitation of enantiomeric metabolites. The choice of a nonchiral quantitative assay, a chiral qualitative assay, or a chiral quantitative assay should be based on the development strategy and on the molecular properties of the drug candidate.

A comparison between direct and indirect measurements of neurotransmitter vesicle release dynamics: a computational study.

Presynaptic vesicular release of neurotransmitters is a stochastic process involving complex mechanisms triggered by an elevation of calcium concentration. The mechanisms behind neurotransmitters release play a critical role in synaptic function and plasticity. Understanding its properties, both in term of its dynamics and its underlying mechanisms, may therefore help further our understanding of synaptic plasticity. However, measuring vesicle release dynamics is experimentally challenging. One experimental protocol used to determine the dynamic properties of vesicle release is to measure postsynaptic current. However, this method inherently not only captures properties of the release itself, but also the contributions from the postsynaptic receptors. Here we propose to use a synapse simulation platform known as EONS/RHENOMS to capture the functional properties of vesicle release, separate from the dynamics known to be associated with postsynaptic receptors, and compare the results with those determined experimentally. We find that despite attempts to reduce interference of postsynaptic dynamics, the receptor channel properties, particularly desensitization, may influence the overall measured results significantly. Re-estimating release rate by taking into account the contributions of postsynaptic receptors may give further insight into release dynamics and further our overall understanding on synaptic plasticity.

Applications of high-resolution MS in bioanalysis.

High-resolution MS (HRMS) in conjunction with LC (LC-HRMS) has become available to many laboratories in the pharmaceutical industry. Due to its enhanced, though sometime perceived, specificity using the high-resolution power and its capability of simultaneous quantitation and structural elucidation using the post-acquisition data mining feature, utilization of LC-HRMS for bioanalysis could lead to potential rapid and reliable method development as well as sample analysis, thus generating both cost and resource savings. Here, we would like to share our perspectives about several current and future applications of LC-HRMS in bioanalysis. We will also discuss the factors influencing the quality of method establishment and potential pitfalls that need to be considered for the utilization of LC-HRMS in the field of regulated bioanalysis. We believe when utilized appropriately, LC-HRMS will play a significant role in the future landscape of quantitative bioanalysis.

Quantitation of leukotriene B(4) in human sputum as a biomarker using UPLC-MS/MS.

Leukotriene B4 (LTB4) is a potent mediator of inflammation and has been recognized as an important target for therapeutic intervention for treatment of diseases such as asthma. In the current work, a highly selective and sensitive UPLC-MS/MS assay was developed for quantitation of LTB4 in human sputum as a biomarker for LTB4 biosynthesis inhibition. A fit-for-purpose strategy for method development, assay qualification, and study support was adopted for this biomarker project. A surrogate matrix (protein buffer) was used for preparation of calibration samples and certain levels of quality control (QC) samples to avoid interference from endogenous analyte, while the low QC was prepared in authentic matrix, human sputum. The analytical methodology utilized a liquid-liquid extraction procedure in 96-well plate format. Chromatographic separation was achieved with a reversed-phase ultra high pressure liquid chromatography (UPLC) column using gradient elution, and the run time was 4.5min per sample. The lower limit of quantitation (LLOQ) was 0.2ng/mL, and the calibration curve range was 0.2-20ng/mL. Acceptable accuracy, precision, linearity, specificity, recovery, and matrix effect was obtained. Bench-top stability (6h), freeze-thaw stability (3 cycles at -20°C), and autosampler stability (97h at ambient temperature) all met acceptance criteria. Frozen long-term stability for 166 days at -20°C in sputum did not meet acceptance criteria by showing only ≥75% of nominal concentration and the information was taken into consideration for study support. Two important observations in the current work were: (1) LTB4 was unstable in sputum in the presence of liquification reagent dithiothreitol (DTT). Therefore, a non-DTT treatment method for sputum processing was developed and applied to the bioanalytical assay and clinical study support; and (2) chromatographic separation of LTB4 from its three non-enzymatically derived isomers, i.e. 6-trans-LTB4, 12-epi-LTB4, and 6-trans-12-epi-LTB4, was achieved. This assay was successfully applied to a Phase II clinical study for proof-of-concept of a LTA4 hydrolase inhibitor for treatment of asthma.

A highly sensitive and selective method for the determination of leukotriene B4 (LTB4) in ex vivo stimulated human plasma by ultra fast liquid chromatography-tandem mass spectrometry.

Leukotriene B4 (LTB4) is an important inflammatory component in a number of diseases and has been used as a pharmacodynamic (PD) biomarker. In this report, a highly sensitive and selective ultra fast liquid chromatography-tandem mass spectrometry (UFLC-MS/MS) method for the determination of LTB4 in plasma from ex vivo stimulated human blood, using leukotriene B4-d4 (LTB4-d4, contains four deuterium atoms at the 6, 7, 14, and 15 positions) as the internal standard (IS), was developed and validated. The chromatographic separation of LTB4 from its three isomers and an unknown interference peak from human plasma was crucial to achieve accurate determination of 0.2 ng/mL (LLOQ) of LTB4. LTB4 and the IS were extracted with methyl tertiary butyl ether (MTBE) from 200 µL human plasma. Reversed-phase HPLC separation was carried out with a Phenomenex Synergi Hydro-RP column (100mm×3mm, 2.5 µm). MS/MS detection was set at mass transitions of 335.0→194.9 m/z for LTB4 and 339.0→196.9 m/z for LTB4-d4 in Turbo Ionization Spray (TIS) negative mode. The dynamic range of the method is 0.2-200 ng/mL. LTB4 was found to be stable in human plasma for at least three freeze (-20 °C)/thaw cycles, and on the benchtop (room temperature) for at least 6h. The stock solution storage stability study demonstrated that the LTB4 stock solution, in 50:50 acetonitrile:water, was stable at 4 °C for at least 198 days. The processed samples were found to be stable for at least 72 h at room temperature. The long-term sample storage stability test demonstrated that LTB4 human plasma samples were stable at a storage temperature of -20 °C for at least 198 days. In addition, intraday and interday accuracy and precision, sensitivity, linearity, and recovery were evaluated. An additional partial validation was conducted to decrease the plasma sample volume from 200 to 100 µL. All the data reported in this study fulfilled the requirements and recommendations in the FDA guidance for bioanalytical method validation. Comparison of the validated UFLC-MS/MS method with an ELISA method using ex vivo stimulated samples indicated that although results from the two assays correlated relatively well, the UFLC-MS/MS method has been shown to be superior in selectivity and dynamic range to an ELISA method in our study. The validated UFLC-MS/MS method was successfully used to analyze samples generated from two clinical studies. The excellent assay performance and incurred sample reproducibility (ISR) results obtained from the study sample analysis demonstrated the assay is robust and reliable.

Conference report: current bioanalytical topics from the ASMS conference 2011.

The American Society For MS annual conference, the largest meeting for the MS-related topics, has welcomed its 59th birthday. The conference was well attended (over 6600 attendees) from academy, government and industry. In addition to 336 oral presentations from 56 sessions, 2820 posters were presented. Preceding the main conference, tutorial short courses ran on both Saturday and Sunday. There were 11 2-day and two 1-day short courses. The short courses were well diversified and well suited for scientists working in various fields related to MS. Various workshops (total 28) on specific topics were also well organized on Monday, Tuesday and Wednesday. There were 60 bioanalysis-related positions posted at the Employment Center - approximately 20 positions from CROs and the rest mainly from pharmaceutical and biotech companies.

Simultaneous determination of tolbutamide, omeprazole, midazolam and dextromethorphan in human plasma by LC-MS/MS--a high throughput approach to evaluate drug-drug interactions.

Drug-drug interactions involving cytochrome P450 (CYP450s) are an important factor for evaluation of a new chemical entity (NCE) in drug development. To evaluate the potential inhibitory effects of a NCE on the pharmacokinetics of a cocktail of representative probes of CYP enzymes (midazolam for CYP3A4, tolbutamide for CYP2C9, omeprazole for CYP2C19 and dextromethorphan for CYP2D6) and the safety and tolerability of the NCE in the presence of probe substrates, a high throughput liquid chromatography/tandem mass spectrometry (LC-MS/MS) method was developed and validated for the simultaneous determination of tolbutamide, omeprazole, midazolam and dextromethorphan in human plasma using tolbutamide-d(9), midazolam-d(4), (+/-)-omeprazole-d(3), and dextromethorphan-d(3) as the internal standards (ISs). Human plasma samples of 50 microL were extracted by a simple protein-precipitation procedure and analyzed using a high performance liquid chromatography electrospray tandem mass spectrometer system. Reversed-phase HPLC separation was achieved with a Hypersil GOLD AQ column (50 mm x 4.6 mm, 5 microm). MS/MS detection was set at mass transitions of 271-->172 m/z for tolbutamide, 346-->198 m/z for omeprazole, 326-->291 m/z for midazolam, 272-->171 m/z for dextromethorphan, 280-->172 m/z for tolbutamide-d(9) (IS), 349-->198 m/z for (+/-)-omeprazole-d(3) (IS), 330-->295 m/z for midazolam-d(4) (IS), and 275-->171 m/z for dextromethorphan-d(3) (IS) in positive mode. The high throughput LC-MS/MS method was validated for accuracy, precision, sensitivity, stability, recovery, matrix effects, and calibration range. Acceptable intra-run and inter-run assay precision (<10%) and accuracy (<10%) were achieved over a linear range of 50-50,000 ng/mL for tolbutamide, 1-1000 ng/mL for omeprazole, 0.1-100 ng/mL for midazolam and 0.05-50 ng/mL for dextromethorphan in human plasma. Method robustness was demonstrated by the 100% pass rate of 24 incurred sample analysis runs and all of the 50 clinical study samples used for incurred sample reproducibility (ISR) test having met the acceptance criterion (%Diff within 20%). The overall ISR results for all compounds showed that over 95% of the samples had a %Diff of less than 10%. The method is simple, rapid and rugged, and has been applied successfully to sample analysis in support of a drug-drug interaction study.

Increased productivity in quantitative bioanalysis using a monolithic column coupled with high-flow direct-injection liquid chromatography/tandem mass spectrometry.

The feasibility of using a monolithic column as the analytical column in conjunction with high-flow direct-injection liquid chromatography/tandem mass spectrometry (LC/MS/MS) to increase productivity for quantitative bioanalysis has been investigated using plasma samples containing a drug and its epimer metabolite. Since the chosen drug and its epimer metabolite have the same selected reaction monitoring (SRM) transitions, chromatographic baseline separation of these two compounds was required. The results obtained from this monolithic column system were directly compared with the results obtained from a previously validated assay using a conventional C18 column as the analytical column. Both systems have the same sample preparation, mobile phases and MS conditions. The eluting flow rate for the monolithic column system was 3.2 mL/min (with 4:1 splitting) and for the C18 column system was 1.2 mL/min (with 3:1 splitting). The monolithic column system had a run time of 5 min and the conventional C18 column system had a run time of 10 min. The methods on the two systems were found to be equivalent in terms of accuracy, precision, sensitivity and chromatographic separation. Without sacrificing the chromatographic separation, sensitivity, accuracy and precision of the method, the reduced run time of the monolithic column method increased the sample throughput by a factor of two.

Risk factors for hypertensive crisis: importance of out-patient blood pressure control.

OBJECTIVES: The purpose of this study was to identify independent risk factors for development of hypertensive crisis. METHODS: This was a retrospective, case-controlled study. Cases were 143 patients who presented during a 3-year period to the Emergency Department with the diagnosis of hypertensive crisis, defined as systolic pressure >/=180 mmHg and/or diastolic pressure >/=110 mmHg and symptoms of hypertensive emergency during the Emergency Department presentation. Controls were 485 patients with hypertension, matched to cases on the basis of age, sex and race, who were not admitted to the Emergency Department with an episode of hypertensive crisis during the study period. Co-morbid conditions were identified from computerized health system databases and medical records. Out-patient blood pressures were obtained from medical records from randomly selected out-patient clinic visits. RESULTS: The average blood pressure during Emergency Department presentation in patients with hypertensive crisis was 197 +/- 21/108 +/- 14 mmHg. Less successful out-patient systolic blood pressure control was an independent risk factor for hypertensive crisis [odds ratio (OR) 1.30 (1.18-1.42), per 10 mmHg, P < 0.001]. Higher out-patient diastolic blood pressures [OR 1.21 (0.99-1.43 per 10 mmHg, P = 0.07] and history of heart failure [OR 3.48 (0.94-12.94), P = 0.06] trended towards independence as risk factors. CONCLUSION: Less effective blood pressure control, based on out-patient systolic blood pressure measurements, is an independent risk factor for an Emergency Department presentation due to hypertensive crisis.