Serum potassium is associated with prediabetes and newly diagnosed diabetes in hypertensive adults from the general population: the KORA F4-study.

AIMS/HYPOTHESIS: Evidence suggests that low serum potassium concentrations or hypokalaemia induced by the intake of diuretics are associated with incident diabetes and increased risk for diabetes in persons with hypertension. We examined a possible association between serum potassium and prediabetes (defined as isolated impaired fasting glucose [i-IFG], isolated impaired glucose tolerance [i-IGT] or combined IFG/IGT), as well as known and newly diagnosed diabetes (NDD), in 32- to 81-year-old men and women with and without hypertension. METHODS: This cross-sectional analysis was based on 2,948 participants in the Cooperative Health Research in the Region of Augsburg (KORA) F4 study conducted in 2006-2008 in southern Germany. Serum concentrations of potassium were measured by indirect potentiometry. RESULTS: In the total sample there was no association between serum potassium concentrations and prediabetes. In hypertensive persons however serum potassium levels in the first and second quartile compared with the highest quartile were independently significantly associated with prediabetes after multivariable adjustment (OR for prediabetes, 2.02 [95% CI 1.27, 3.21] for quartile 2 and 2.00 [95% CI 1.27, 3.15] for quartile 1), while in persons without hypertension no association was found. In multinomial logistic regression analysis these findings could be confirmed. In hypertensive participants after multivariable adjustment the associations were statistically significant for i-IGT and NDD (i-IGT OR 1.23; NDD OR 1.41). However, in non-hypertensive persons, all associations between serum potassium levels and each of the categories of impaired glucose regulation were non-significant. CONCLUSIONS/INTERPRETATION: Serum potassium levels were independently associated with prediabetes and NDD in hypertensive adults from the general population.

Age at menarche is associated with prediabetes and diabetes in women (aged 32-81 years) from the general population: the KORA F4 Study.

AIMS/HYPOTHESIS: The aim of this study was to examine the association between age at menarche and prediabetes as well as diabetes, considering confounding factors and the possible mediating role of adult obesity. METHODS: This cross-sectional study analysed data on 1,503 women aged 32-81 years from the German population-based KORA (Cooperative Health Research in the Region of Augsburg, South Germany) F4 Study (2006-2008). Data were collected by standardised interviews, physical examinations, and whole blood and serum measurements, including administration of an OGTT in non-diabetic participants. RESULTS: Of the 1,503 women, 226 showed a prediabetic state (impaired fasting glucose and/or impaired glucose tolerance) and 140 persons had diabetes (45 participants with previously undiagnosed diabetes and 95 with known diabetes). In Poisson regression analysis, age at menarche was significantly inversely associated with prediabetes or diabetes after adjustment for year of birth (RR 0.88; 95% CI 0.82, 0.94, p < 0.0001 per additional year of menarche) and after additional adjustment for a number of confounding factors (RR 0.88; 95% CI 0.83, 0.94, p = 0.0001). Further adjustment for current BMI slightly attenuated the association with prediabetes or diabetes (RR 0.89; 95% CI 0.83, 0.95, p = 0.0009), but the association remained clearly significant. CONCLUSIONS/INTERPRETATION: Age at menarche seems to be inversely associated with prediabetes and diabetes independent of confounding factors including current BMI. Women at risk for diabetes might be identified by a history of young age at menarche.

The use of porcine acellular dermal matrix in silicone implant-based breast reconstruction.

INTRODUCTION: The most frequently occurring long-term complication in implant-based breast reconstruction is fibrotic capsule formation at the recipient site, with concurrent dysesthesia and poor aesthetic results. Using porcine acellular dermal matrix (PADM) as a connective tissue graft material is supposed to improve the quality and quantity of soft tissue in implant-based breast reconstruction. This study investigates the indications for and the results and the costs of using PADM for the correction or prevention of implant-associated breast deformities. MATERIALS AND METHODS: This study reviewed a single surgeon's experience in the correction or prevention of implant-associated breast deformities with PADM in breast cancer-related breast reconstruction from 2009 to 2011. A total of 23 patients (27 breasts) were included in the study. The aesthetic outcome, the incidence and the type of complication were analysed. Twenty-three women underwent breast cancer-related breast reconstruction: 19 women underwent single-breast reconstruction and four women underwent bilateral reconstruction. RESULTS: Of the 23 patients who underwent breast reconstruction, 18 (78%) were "satisfied" with the aesthetic and haptic outcome after implant-based reconstruction with PADM. One patient (one breast) required another breast operation because of ipsilateral breast cancer recurrence during the follow-up period. PADM-assisted implant-based breast reconstruction has a satisfactory safety profile. CONCLUSION: The use of PADM as an interface matrix for implant-based breast reconstruction yielded predictable and acceptable aesthetic and haptic results by preventing capsular contracture, rippling, implant malposition, soft-tissue thinning and failure of the silicone implant-based breast augmentation.

Validation of 5 routine assays for serum free testosterone with a candidate reference measurement procedure based on ultrafiltration and isotope dilution-gas chromatography-mass spectrometry.

BACKGROUND/METHOD: The analytical validity of free testosterone (FTe) analog immunoassays is subject to much controversy. We revisited the validation of 4 analog assays and 1 FTe calculation procedure with a metrologically traceable reference measurement procedure (RMP) based on ultrafiltration and isotope dilution-mass spectrometry for direct measurement of Te in the ultrafiltrate. To this end, we performed split-sample measurements of 40 male sera. RESULTS: Deming regression showed that 3 of the immunoassays had moderate to good correlation (0.8474 < or = r < or = 0.9241) with the RMP; however, the slope was markedly below 1. The FTe calculation procedure was in good agreement with this result. The Sy/x values for all assays were higher than the combined imprecision values, which indicate their susceptibility to matrix-related effects. CONCLUSIONS: The study demonstrated substantial differences in analytical quality of FTe assays; however, the results suggested that after extending the validation with a larger variety of samples, recalibration of some analog assays might be worth further investigation.

Novel perfluoroacyl derivatives of corticosteroids and related substances for potential use in quantitative gas chromatography mass spectrometry.

We investigated the potential of perfluoroacylation for gas chromatographic mass spectrometric determination of corticosteroids and related substances. Structure elucidation of the reaction products was performed with high and low resolution mass spectrometry and with proton and carbon nuclear magnetic resonance spectrometry. Besides the well known 3-enol ester formation, 17ß-methyl-18-nor-13(14)-ene steroids were formed via loss of the 17-α hydroxyl group followed by a Wagner-Meerwein rearrangement. Compounds that bear an 11ß-hydroxy group formed additionally a 9(11) double bond when acetone was used as solvent, whereas acetonitrile or cyclohexane led to formation of 11ß-perfluoroacyl esters. In particular, perfluoroacylation of cortisol led to a clearly defined product instead of complex mixtures observed before, which thus makes it a valuable alternative to methoxime formation-silylation of cortisol for quantitative gas chromatographic mass spectrometric analyses.

Validation of candidate reference methods based on ion chromatography for determination of total sodium, potassium, calcium and magnesium in serum through comparison with flame atomic emission and absorption spectrometry.

OBJECTIVES: We report on the validation of candidate reference methods based on ion chromatography for the determination of total sodium, potassium, calcium, and magnesium in serum. The current study is a continuation of previous investigations in which we were able to show the potential of ion chromatography to serve as a reference method principle. The validation consisted of comparison of the ion chromatographic methods with generally recognized reference methods based on flame atomic emission (for sodium/ potassium) and absorption (for calcium/magnesium) spectrometry. METHODS: Sample preparation consisted of acidic dilution and pre-purification with reversed phase cartridges. Ion chromatography with suppressed conductivity was performed with polymeric stationary phases chemically modified with carboxylate and sulfonate functional groups for sodium/potassium and calcium/magnesium, respectively. Single-point calibration was used in combination with individual adaptation of serum sampling and diluting to give similar responses in samples and standards. In the study, more than 25 control sera were analyzed in parallel with the ion chromatographic methods and the traditional reference methods. The measurement protocol consisted of quadruplicate analysis of each sample per run, in 3 different runs. In each measurement series, internal quality control with certified reference materials from the National Institute of Standards and Technology and the Bureau Communautaire de Référence was applied. The performance criteria to fulfill were pre-defined (i.e., the maximum within-day and overall coefficient of variation, the confidence interval, the daily and overall deviation from the certified value and the maximum total analytical error). RESULTS: The comparison is presented as difference plot (i.e., % deviation of the results obtained with ion chromatography from those obtained with the respective traditional reference methods). The mean deviations were +0.9% for sodium, +1.0% for potassium, +/- 0.0% for calcium, and +0.1% for magnesium. With the exception of 2 values each for sodium and potassium, all deviations were within the limit of 2 times the allowed total analytical error. From the data obtained for internal quality control during the different measurement campaigns, we further estimated the long-term precision and accuracy of our methods. The overall coefficient of variation (respectively the bias) amounted to 0.7% (+0.1%) for sodium, 0.9% (-0.3%) for potassium, 1.3% (-0.1%) for calcium, and 1.0% (+/- 0.0%) for magnesium. CONCLUSION: From the precision and accuracy reached by our ion chromatographic methods, we conclude that they can be proposed as candidate reference methods for the determination of total sodium, potassium, calcium, and magnesium in serum.

Evaluation of intrinsic and routine quality of serum total magnesium measurement.

We investigated the intrinsic (as delivered by the manufacturer) and routine quality of four systems for measurement of serum total magnesium (t-Mg(2+)) by method comparison with an ion chromatography reference method. The results of the study were interpreted on the basis of analytical quality specifications derived from the biological variation of t-Mg(2+), expanded by the analytical uncertainty of the reference measurements. This resulted in limits for systematic error of 2.1% and for total error of 4.3%. The study demonstrated that those limits were challenging for all routine systems. Most of them met the total error criterium just borderline and one showed a considerable systematic error (-5.2%). Concerning the measurement quality in the routine laboratories, the study showed that many were unable to preserve the intrinsic quality of the respective manufacturer. Consequently, loss of system performance in the routine laboratory mostly led to violation of the analytical specifications. Most strikingly, the study revealed enormous quality differences between routine laboratories. This indicates that, still, many routine laboratories do not make adequate use of currently available internal and external quality control tools. Moreover, some laboratories considerably expanded the high end of the reference interval, thereby reducing the diagnostic potential of t-Mg(2+).

Ion chromatography as potential reference methodology for the determination of total sodium and potassium in human serum.

The potential of ion chromatography to serve as a new reference method principle for the determination of total sodium and potassium in human serum was investigated. Sample pretreatment consisted of acidic dilution and filtration and detection was based on conductivity. Methods for the separate and simultaneous determination of both analytes were investigated. Further, the influence of calibration (using either a single-point calibration or a standard curve) on method imprecision, inaccuracy and analysis time was examined. The best method performance was achieved by separate analysis using single-point calibration with bracketing analysis scheme. For this variant, the mean total coefficient of variation for sodium and potassium was 1.0% and the mean method bias was -0.2% for sodium and 2% for potassium, as determined with three control materials from the National Institute of Standards and Technology. Our results are comparable to those of reference methods based on flame atomic emission spectrometry. Therefore, we consider ion chromatography as a valuable reference methodology for the determination of total sodium potassium in human serum.

Practical aspects of suppressed ion chromatography for cations in human serum.

In spite of the good accuracy and precision of ion chromatographic methods for the determination of mono- and divalent cations in human serum, the major drawback with these methods were problems with the membrane suppressor's performance. Here, we describe experiments undertaken to solve these problems. We address in particular the use of histidine-sulfuric acid eluents, sample purification with OnGuard-A cartridges and chromatographic "front-cut" for divalent cations. The latter two adaptations, resulting in removal of the anionic species from the sample, were successful in solving the observed suppressor problems. The eluent substitution, moreover, allowed us to switch from the chemical to the electric suppression mode. We believe that these adaptations will allow secure and robust determination of cations in human serum samples with ion chromatography.

Quantitative analysis of urinary C-peptide by liquid chromatography-tandem mass spectrometry with a stable isotopically labelled internal standard.

We describe the first results of a quantitative LC-tandem mass spectrometry method for urinary C-peptide with the use of [2H14]C-peptide as internal standard. LC was based on gradient elution of a Hypersil PEP C18 column. Mass spectrometry was performed in the negative electrospray ionization mode and by monitoring of the transitions at m/z 1514/1334 ([2H14]C-peptide) and 1507/1320 (C-peptide). For sample preparation, we applied ultrafiltration. The analytical performance of the method in terms of measurement precision gave an RSD of <2% (n=10). The overall imprecision was investigated from independent analysis of two urine samples in six-fold and resulted in an RSD<5%. The limit of detection, expressed as signal-to-noise ratio 3, was approximately 0.15 ng C-peptide injected. Analysis of 10 random urine samples from laboratory volunteers showed interference-free ion chromatograms at a signal-to-noise ratio of approximately 75 on average. The C-peptide concentrations calculated from quantification by the bracketing calibration technique ranged from 32 to 165 ng/ml.

Survey of serum potassium reference measurements.

We compared the quality of reference measurements for serum potassium in four reference laboratories from three different European countries, using a panel of 60 native patients' samples. The reference methods were based on either ion chromatography (one laboratory) or flame atomic emission spectrometry (three laboratories). Performance specifications for serum potassium measurements were defined as a maximum overall coefficient of variation (CV) of 1.5%, a maximum bias of 0.65% and a maximum total error of 3.0%. The overall imprecision for all laboratories was in the range of 0.7 to 1.3%, and was thus below the proposed specification of 1.5%. However, two laboratories reported 12 and 13 quadruplicates with CVs exceeding this limit. The mean bias (expressed as deviation from the overall mean of all laboratories) for all reference laboratories was < 0.65%. In the lower concentration range, however, one laboratory exceeded this limit. No laboratory measured samples with a total error above 3.0%. From these results, it can be concluded that the reference measurements, and, thus, also the reference methodologies, based on ion chromatography and flame atomic emission spectrometry were equivalent, and able to satisfy current analytical specifications for serum potassium measurements.

The ionized fraction of serum total magnesium in hemodialysis patients: is it really lower than in healthy subjects?

AIM OF THE STUDY: Based on data in the literature, it remains unclear whether the ionized fraction of serum total magnesium (Mg) is lower in chronic hemodialysis (HD) patients compared to healthy subjects. PATIENTS AND METHODS: The ionized fraction of serum total Mg was investigated in 49 HD patients, pre- and post-dialysis, and compared to 30 healthy controls. The quality of the analytical performance of the Mg measurements has been emphasized by applying a reference method and/or rigorous internal quality control (IQC). In addition, the ionized fraction of serum total calcium (Ca) was measured in both populations, because the results for Mg should be related to those of Ca. RESULTS: In HD patients, the ionized fraction of serum total Mg was on average 65% (pre-dialysis 64.2% and post-dialysis 66.2%). In healthy controls, the ionized fraction was 64.9%. When the analytical variability was taken into account, no significant differences (p > 0.05) were observed between pre- and post-dialysis samples and controls. For Ca, an ionized fraction of 55.3% was found in HD patients, which was not significantly different from the fraction obtained in the control group (55.7%). CONCLUSION: The present study demonstrates that, compared to healthy controls, the ionized fraction of serum total Mg is not different in hemodialysis patients.

Development of criteria for the evaluation of reference method values.

We present a uniform concept for the requirements of reference methods (RMs) used for target-setting in the German external quality assessment (EQA) scheme. It is proposed that the total allowable error (TAE) of the RMs shall be 0.2 times the acceptance limits in the EQA-scheme. From the TAE are derived limits for maximum RM-bias, RM-imprecision, and the number of measurements.

Medication costs by glucose tolerance stage in younger and older women and men: results from the population-based KORA survey in Germany.

To estimate medication costs in individuals with diagnosed diabetes, undetected diabetes, impaired glucose regulation and normal blood glucose values in a population-based sample by age and sex.Using the KORA F4 follow-up survey, conducted in 2006-2008 (n=2611, age 40-82 years), we identified individuals' glucose tolerance status by means of an oral glucose tolerance test. We assessed all medications taken regularly, calculated age-sex specific medication costs and estimated cost ratios for total, total without antihyperglycemic drugs, and cardiovascular medication, using multiple 2-part regression models.Compared to individuals with normal glucose values, costs were increased in known diabetes, undetected diabetes and impaired glucose regulation, which was more pronounced in participants aged 40-59 years than in those aged 60-82 years (cost ratios for all medications: 40-59 years: 2.85; 95%-confidence interval: 1.78-4.54, 2.00; 1.22-3.29 and 1.53; 1.12-2.09; 60-82 years: 2.04; 1.71-2.43, 1.17; 0.90-1.51 and 1.09; 0.94-1.28). Compared to individuals with diagnosed diabetes, costs were significantly lower among individuals with impaired glucose regulation across all age and sex strata, also when antihyperglycemic medication was excluded (40-59 years: 0.60; 0.36-0.98, 60-82 years: 0.74; 0.60-0.90; men: 0.72; 0.56-0.93; women: 0.72; 0.54-0.96).We could quantify age- and sex-specific medication costs and cost ratios in individuals with diagnosed diabetes, undetected diabetes and impaired glucose regulation compared to those with normal glucose values, using data of a population-based sample, with oral glucose tolerance test-based identification of diabetes states. These results may help to validly estimate cost-effectiveness of screening and early treatment or prevention of diabetes.

Metrology and analysis in laboratory medicine: a criticism from the workbench.

Metrological concepts and terminology, in particular the Vocabulaire International des Termes Fondamentaux et Généraux de Métrologie and the Guide to the Expression of Uncertainty in Measurement, are discussed from the viewpoint of analytical practice. Especially addressed are terms such as error, uncertainty, accuracy, trueness, bias, and precision. Evidence is presented that the new definition of accuracy, being now a joint index of systematic and random errors, is extremely impractical and has no advantages over the old definition of accuracy. Therefore, instead of re-education of analysts, a return to the old definition is proposed. Further, arguments are presented that the error concept is still an extremely useful metrological concept and does not need to be replaced by the uncertainty concept. Rather, both concepts are complementary.