Objective assessment of intraoperative tumor fluorescence reveals biological heterogeneity within glioblastomas: a biometric study.

PURPOSE: Heterogeneity within GBMs and variability of visualized fluorescence combine to confer practical limitations to the technique of optical imaging. A biometric analysis was planned to objectively ascertain and analyse this phenomenon METHODS: 25 adult glioblastoma subjects undergoing resection were prospectively accrued. Biopsies were taken from various parts of the tumor and safe peritumoral zones. White light (WL) and visualized fluorescence was subjectively recorded. Corresponding histopathology [coalescent (C) or infiltrating (I) tumor] and protoporphyrin-IX (PPIX) levels were assayed. RESULTS: WL was very sensitive for detecting tumor. SF was more specific and had high positive predictive value for detecting tumor. WF on the other hand had a poor discriminatory efficacy. Mean PPIX levels were 3.0, 2.01 and 0.16 for SF, WF, and NF respectively. WF had a wide variable range of PPIX levels. Within the coalescent tumor areas, there was a variable distribution of fluorescence (both subjective as well as objective PPIX levels) with only 54% samples showing SF and high PPIX. In seven cases this discordance was noted within the same tumor (biological heterogeneity). CONCLUSIONS: Fluorescence may miss important tumor areas even if objective assessment is used. Histologically similar tumor areas may exhibit contrasting fluorescence properties, a phenomenon which needs further investigation and elucidation of underlying mechanisms which could potentially be manipulated to optimize the utility of fluorescence guidance.

Non-invasive measurement of erythrocyte zinc protoporphyrin in children.

BACKGROUND: Reliable screening for iron deficiency (ID) has required a blood sample and cost-intensive laboratory measurements. A novel method to non-invasively measure erythrocyte zinc protoporphyrin (ZnPP), an established marker for ID, is evaluated in children. METHODS: ZnPP was determined non-invasively by fluorescence measurements on the wet vermillion of the lower lip in 99 hospitalized children aged 9 months to 5 years. For comparison, conventional ID parameters and ZnPP were determined from blood samples. RESULTS: The non-invasively measured ZnPP values had limits of agreement (LoA) of 14 µmol ZnPP/mol heme (95% confidence interval: 9-20) compared to fluorescence measurements directly in blood. Repeated high-performance liquid chromatography reference determinations had comparable LoA of 14 µmol ZnPP/mol heme (9-17). Non-invasive ZnPP measurements had sensitivity and specificity of 67% (39-88%) and 97% (91-99%), and negative and positive predictive value of 94% (90-97%) and 80% (55-93%), for detecting ID as defined by the soluble transferrin receptor (sTfR). In groups with more severe ID as defined by serum ferritin and sTfR, higher ZnPP values were found, with the highest ZnPP values for the group with ID anemia. CONCLUSION: Non-invasive ZnPP measurements are reliably feasible in children. The simple and fast method has the potential to enable wide-spread screening for ID.

Spectrophotometric photodynamic diagnosis of prostate cancer cells excreted in voided urine using 5-aminolevulinic acid.

To evaluate the feasibility of photodynamic diagnosis using 5-aminolevulinic acid (PDD-ALA) for detection of prostate cancer (PCa) cells in urine samples after prostate massage in patients who were suspected to have PCa. One hundred and eighty-nine patients with abnormal digital rectal examination and/or an elevated prostate-specific antigen (PSA) level who underwent initial prostate biopsy were recruited. After prostate massage, the first 60 mL of voided urine was collected. For PDD-ALA, 50 mL was used. The rest of collected urine was used for polymerase chain reaction (PCR) of PSA and glyceraldehyde 3-phosphate dehydrogenase (GAPDH). After incubation for 2 h, the intensity was measured at 635 nm under a 405-nm wavelength excitation. The results of PDD-ALA were compared with those of an initial transrectal ultrasound (TRUS)-guided prostate biopsy. Overall, 126/189 (67%) samples that showed bands of both PSA and GAPDH on PCR in urine samples were analyzed. The area under the curve, sensitivity, and specificity of PDD-ALA were 0.74, 77, and 67%, respectively. The value of PDD-ALA was significantly higher in patients with Gleason scores of 6 (p = 0.03), 7 (p = 0.005), and 8-10 (p = 0.0002) than in those with negative biopsy results. In the multivariate analysis, high PSA density, abnormal findings on TRUS, and a high value of PDD-ALA were significant markers for prediction of positive biopsy results. PDD-ALA was useful to predict positive biopsy results in patients who underwent initial prostate biopsy with suspected PCa. This PCa-detection method has potential for clinical use.

Iron deficiency (ID) at both birth and 9 months predicts right frontal EEG asymmetry in infancy.

This study considered effects of timing and duration of iron deficiency (ID) on frontal EEG asymmetry in infancy. In healthy term Chinese infants, EEG was recorded at 9 months in three experimental conditions: baseline, peek-a-boo, and stranger approach. Eighty infants provided data for all conditions. Prenatal ID was defined as low cord ferritin or high ZPP/H. Postnatal ID was defined as ≥ two abnormal iron measures at 9 months. Study groups were pre- and postnatal ID, prenatal ID only, postnatal ID only, and not ID. GLM repeated measure analysis showed a main effect for iron group. The pre- and postnatal ID group had negative asymmetry scores, reflecting right frontal EEG asymmetry (mean ± SE: -.18 ± .07) versus prenatal ID only (.00 ± .04), postnatal ID only (.03 ± .04), and not ID (.02 ± .04). Thus, ID at both birth and 9 months was associated with right frontal EEG asymmetry, a neural correlate of behavioral withdrawal and negative emotions.

[Erythropoietic protoporphyria : Clinical manifestations, diagnosis and new therapeutic possibilities]. / Erythropoetische Protoporphyrie : Klinik, Diagnostik und neue therapeutische Möglichkeiten.

BACKGROUND: Erythropoietic protoporphyria, the second most common type of the cutaneous porphyrias, is due to an enzymatic deficiency of ferrochelatase, the last enzyme in heme biosynthesis. The enzyme defect leads to an accumulation of protoporphyrin IX in erythrocytes and an elevated excretion of this metabolite in the feces. CLINICAL PRESENTATION: Usually, disease onset is in early infancy, characterized by increased photosensitivity. During or shortly after sunlight exposure, affected individuals suffer from burning, stinging, itching, and pain in sun-exposed skin areas. These symptoms lead to a considerably reduced quality of life and strict avoidance of sunlight exposure. Subacute symptoms include visible changes like edema and erythema. In the further course of the disease, chronic signs such as lichenification and scarring may occur. A severe complication of hepatic protoporphyrin IX accumulation is the development of a potentially life-threatening fulminant liver failure. Therefore, hepatic laboratory tests and ultrasound of the liver should be performed regularly. THERAPY: Traditionally, therapy merely consisted of consequent photoprotection and orally administered ß-carotene. A novel treatment option is afamelanotide (Scenesse®), a synthetic analogue of the naturally occurring α-melanocyte stimulating hormone. Afamelanotide, administered as a subcutaneous implant, induces eumelanin production, independent of preceding UV light exposure. This may enable patients with erythropoietic protoporphyria to stay in sunlight significantly longer than previously possible without complaints, thus, substantially improving quality of life.

Analysing avian eggshell pigments with Raman spectroscopy.

Avian eggshells are variable in appearance, including coloration. Here, we demonstrate that Raman spectroscopy can provide accurate diagnostic information about major eggshell constituents, including the pigments biliverdin and protoporphyrin IX. Eggshells pigmented with biliverdin showed a series of pigment-diagnostic Raman peaks under 785 nm excitation. Eggshells pigmented with protoporphyrin IX showed strong emission under 1064 nm and 785 nm excitation, whereas resonance Raman spectra (351 nm excitation) showed a set of protoporphyrin IX informative peaks characteristic of protoporphyrin IX. As representative examples, we identified biliverdin in the olive green eggshells of elegant crested tinamous (Eudromia elegans) and in the blue eggshells of extinct upland moa (Megalapteryx didinus). This study encourages the wider use of Raman spectroscopy in pigment and coloration research and highlights the value of this technique for non-destructive analyses of museum eggshell specimens.

Aminolevulinic acid with gold nanoparticles: a novel theranostic agent for atherosclerosis.

In this study, 5-aminolevulinic acid (ALA) gold nanoparticles (ALA:AuNPs) functionalized with polyethylene glycol (PEG) were synthesized and administered to rabbits to evaluate their use in clinical practice as theranostic agents for atherosclerosis. This was done by measuring the porphyrin fluorescence extracted from the rabbits' blood and feces. An increase in blood and feces porphyrin emission after ALA:AuNP administration suggests that ALA was incorporated by gold nanoparticles, its structure was preserved, and a rapid conversion into endogenous porphyrins occurred, overloading the synthetic pathway that led to protoporphyrin IX (PPIX) accumulation. This finding indicated that this method can aid in the early diagnosis and therapy of atherosclerosis with high sensitivity.

Liquid biopsy of atherosclerosis using protoporphyrin IX as a biomarker.

Protoporphyrin IX (PPIX), a derivative of hematoporphyrin, can accumulate in rapidly growing tissues, including tumors and atherosclerotic plaques. The objective of this study is to employ PPIX fluorescence to detect the changes in blood caused by the formation of atheromatous plaques in arteries; this measurement can function as a liquid biopsy. For this purpose twenty four rabbits were randomly divided into groups: control group (CG)--fed with a normal diet, and an experimental group (EG)--fed with a hypercholesterolemic diet (1% cholesterol). Blood samples were collected before (0 time) and after 22, 43, 64 days to measure biochemical factors. The aortas were removed after 22, 43 and 64 days to assess the atherosclerotic plaques. PPIX was extracted from the blood and fluorescence was measured in the 550-750 nm range from samples that were excited at 405 nm. Aminolevulinic acid (ALA) was administered intravenously to increase the PPIX fluorescence intensity in the arteries and consequently in the liquid biopsy of the atherosclerotic plaques. The results have shown that the PPIX fluorescence increased as the atheromatous plaques grew. The aorta fluorescence and the PPIX fluorescence increased in the animals in the experimental group that received ALA. PPIX that accumulates in atheromatous plaques transfers to the blood and can be analyzed by extracting porphyrin from total blood. Therefore, this method can aid in the early diagnosis of atherosclerosis with high sensitivity.

Fluorescence detection of malignant liver tumors using 5-aminolevulinic acid-mediated photodynamic diagnosis: principles, technique, and clinical experience.

BACKGROUND: Photoactive drugs selectively accumulate in malignant tissue specimens and cause drug-induced fluorescence. Photodynamic diagnosis (PDD) and fluorescence can distinguish normal from malignant tissue. OBJECTIVE METHODS: From May 2012 to September 2013, a total of 70 patients underwent hepatic resections using 5-ALA-mediated PDD for liver tumors at our hospital. RESULTS: 5-ALA fluorescence was detected in all hepatocellular carcinoma cases with serosa invasion. In liver metastasis from colorectal cancer cases with serosa invasion, 18 patients (85.7 %) were detected, and three patients (14.2 %) whose tumors showed complete response to neoadjuvant chemotherapy showed no fluorescence. Both superficial and deep malignant liver tumors were detected with 92.5 % sensitivity. Using 5-ALA-mediated PDD, tumors remaining at the cut surface and postoperative bile leakage were less frequent than in our previous hepatic resections using conventional white-light observation. Moreover, all malignant liver tumors were completely removed with a clear microscopic margin using 5-ALA, with a significant difference in resection margin width between 5-ALA-mediated PDD (6.7 ± 6.9 mm) and white-light observation (9.2 ± 7.0 mm; p = 0.0083). CONCLUSIONS: With the detection of malignant liver tumors, residual tumor and bile leakage at the cut surface of the remnant liver were improved by PDD with 5-ALA. This procedure may provide greater sensitivity than the conventional procedure. Furthermore, 5-ALA-mediated PDD can ensure histological clearance regardless of the resection margin and preserve as much liver parenchyma as possible in patients with impaired liver function.

Determination of selected protoporphyrins in parma ham with use of 5,10,15,20-tetra(4-hydroxyphenyl)porphyrin as a surrogate standard in the recovery study.

A high-performance liquid chromatographic method for the determination of hemin, protoporphyrin IX (PPIX), and zinc(II)protoporphyrin IX (Zn(II)PPIX) in Parma ham was developed. The detection was done by means of a universal DAD-detector, whereby quantification of the three naturally occurring protoporphyrins was carried out at lambda = 414 nm, i.e., very close to the respective maxima of their Soret bands. The extraction thereof from the meat matrix was done by a mixture of acetone and chloroacetic acid (100 mL + 0.2 g). Usage of 5,10,15,20-tetra(4-hydroxyphenyl)porphyrin (THPP) as a surrogate standard and its detection fixed at lambda = 444 nm, allowed to obtain accurate (ca. 96%) recovery results. Established concentrations of hemin, Zn(II)PPIX, and PPIX in the Parma ham samples were 15.97, 19.96 and 1.52 µg g(-1), respectively.

Zinc-protoporphyrin formation in nitrite-free Parma Ham and its relationship with intrinsic parameters and red color profile of processed hams.

A total of 134 fresh hams, assayed for Ferrochelatase (FeCH) activity and ultimate pH (pH48), were processed in compliance with the procedures established for PDO Parma ham and finally, analyzed for salt, moisture, Zinc Protoporphyrin IX (ZnPP), heme, iron and zinc contents, and proteolysis index (PI). The variation in ZnPP content was related to the intrinsic parameters of fresh and matured hams by a Partial Least Square Regression model. The most favorable factors on the formation of ZnPP were total iron content (representative of the initial hemoprotein content), and FeCH activity, demonstrating the main role played by these raw matter-specific predictors in the long matured dry-cured hams. To a lesser extent, zinc content and pH48 were involved with a positive and negative role, respectively. Salt content and PI of matured hams showed an inhibitory and a favorable influence, respectively, toward the ZnPP formation. Principal Component Analysis showed the associations between the sensory red color profile and the physicochemical traits of matured hams. The red color intensity increased in agreement with the red-violet and red-pink hues scores. The formation of a high amount of ZnPP was associated with the increased perception of the red-violet shade, with a lower lightness (L*) and Hue angle (h°). Moisture increase contributed to the shift in color perception to red-pink, while marked progress in PI strengthened the perception of the red-brown shade. ZnPP and final heme favored the red color of matured hams, although a high concentration of these pigments increased in particular the red-violet perception.

Weather conditions and daylight-mediated photodynamic therapy: protoporphyrin IX-weighted daylight doses measured in six geographical locations.

BACKGROUND: Photodynamic therapy (PDT) is an attractive therapy for nonmelanoma skin cancers and actinic keratoses (AKs). Daylight-mediated methyl aminolaevulinate PDT (daylight-PDT) is a simple and painless treatment procedure for PDT. All daylight-PDT studies have been performed in the Nordic countries. To be able to apply these results in other parts of the world we have to compare the daily protoporphyrin IX (PpIX) light dose in other countries with the PpIX light doses found in Nordic countries. OBJECTIVES: To calculate where and when daylight-PDT of AKs was possible in six different geographical locations using ground stations measuring PpIX-weighted daylight doses. METHODS: PpIX-weighted daylight doses were measured using a dosimeter with a customer-specific photodiode with a detector sensitivity that mimics the PpIX absorption spectrum and measures in 'PpIX doses'. The dosimeters were built into ground stations that were placed in six geographical locations measuring from July to December 2008. Temperature data for each location were obtained from the internet. The maximal ultraviolet (UV) index for Copenhagen was obtained for the measuring period of the dosimeters. RESULTS: If the PpIX light dose should be above 8Jcm(-2) and the maximum temperature of the day at least 10°C, it was possible to treat patients on nearly all days until the middle of September in Reykjavik and Oslo, until the last week of October in Copenhagen and Regensburg, until the middle of November in Turin and all year in Israel. CONCLUSIONS: Where and when to perform daylight-PDT depends on the PpIX light dose and outdoor temperature. The PpIX light dose was influenced by the geographical location (latitude), weather condition and time of year. The UV index was not more suitable than temperature and weather to predict if the intensity of daylight would be sufficient for daylight-PDT.

Synthesis and in vitro cellular uptake of 11C-labeled 5-aminolevulinic acid derivative to estimate the induced cellular accumulation of protoporphyrin IX.

Protoporphyrin IX (PpIX) accumulation induced by exogenous 5-aminolevulinic acid (ALA) in tumors affects the therapeutic efficacy of ALA-based photodynamic and sonodynamic therapies. To develop a new imaging probe to estimate the ALA-induced PpIX accumulation, (11)C-labeled ALA analog (4), an ALA-dehydratase inhibitor, was radiosynthesized via (11)C-methylation of a Schiff-base-activated precursor in the presence of tetrabutylammonium fluoride, followed by the hydrolysis of ester and imine groups. The cellular uptake of 4 linearly increased with time and was inhibited by ALA and other transporter competitors. Monitoring analog 4 with positron emission tomography might be useful to estimate the ALA-induced PpIX accumulation in tumors.

Correlation between protoporphyrin IX fluorescence intensity, photobleaching, pain and clinical outcome of actinic keratosis treated by photodynamic therapy.

BACKGROUND: Photodynamic therapy (PDT) with Metvix® is a good therapeutic option to treat actinic keratosis, but it presents drawbacks (pain, lesion recurrences, heterogeneous outcome), emphasizing the possible need to individualize treatment. OBJECTIVE: We assessed whether PDT clinical outcome and pain during treatment were correlated with protoporphyrin IX fluorescence intensity and photobleaching. METHODS: 25 patients were treated by Metvix PDT. The outcome was evaluated after 1.3 (±0.4), 7.6 (±1.8), 13.2 (±1.2) and 33.6 (±3.0) months. After administration of Metvix, red light (632 ± 10 nm) was delivered with a light-emitting diode panel device. The outcome was assessed on a cosmetoclinical scale. RESULTS: All patients who showed a fluorescence level before PDT treatment above a certain threshold had a complete recovery at 33.6 (±3.0) months. CONCLUSION: Our approach could be used to individualize PDT treatment based on the pretreatment fluorescence level, and to predict its long-term outcome.

Annular elastolytic giant cell granuloma associated to late-onset X-linked dominant protoporphyria.

X-linked dominant protoporphyria (XLDPP) is a genetic disorder that affects the synthesis of the heme group due to an increase in delta-aminolaevulinate synthase 2 (ALAS2) enzyme activity. Moreover, annular elastolytic giant-cell granuloma (AEGCG) is a rare reactive granulomatous dermatosis, usually associated with actinic damage. An 86-year-old man presented with edematous-erythematous lesions in photoexposed areas of the face and on the dorsum of both hands. Protoporphyrin levels in serum and feces were significantly elevated and a heterozygous frameshift mutation in the exon 11 of the ALAS2 gene: c.1706-1709del (p.Glu569GlyfsX24) was identified. Concomitantly, we observed an annular plaque with raised borders on the back of his right hand, clinically and histologically compatible with a diagnosis of AEGCG. Skin lesions disappeared only upon use of a physical sunscreen. We report two rare photodermatoses in an elderly patient and discuss the significance of dermal elastic fiber damage induced by the XLDPP as a main triggering factor of AEGCG.

[Photodynamic diagnosis and preoperative chemotherapy for biliary tract cancer].

BACKGROUND: Cancer cells synthesize substantial amounts of protoporphyrin IX( PPIX) from aminolevulinic acid( ALA). PPIX emits red fluorescence when illuminated under blue light. Photodynamic diagnosis (PDD), based on this phenomenon, is currently used; however, various microorganisms also show the same fluorescence with ALA when illuminated under blue light, resulting in false-positive PDD results. PURPOSE AND METHODS: To avoid misdiagnosis, we incorporated novel systems into the PDD system. ALA, blue light (wavelength, 380-450 nm), different kinds of cell lines, and bacteria were used in this in vitro study. We used a 70% deacetylated chitosan solution (DAC-70 Sol), developed in-house, as an antibacterial agent and prepared ALA/DAC-70 Sol, used as a novel photoimaging agent. The antibacterial function of ALA/DAC-70 Sol was examined in vitro, and the photodiagnostic effects on using the novel systems were clinically evaluated using bile from patients with biliary tract cancer. RESULTS: DAC-70 Sol demonstrated an effective bactericidal function in vitro. Red fluorescence could clearly be identified, enabling the detection of cancer cells in the bile using ALA/DAC-70 Sol. CONCLUSIONS: Our novel systems have a great potential for use in clinical photodynamic cytodiagnosis( PDCD), which plays an important role in preoperative cancer chemotherapy.

The pigments in eggshell with different colour and the pigment regulatory gene expression in corresponding chicken's shell gland.

Eggshell colour is the unique appearance and economically valuable trait of eggs, whereas the colour is often short of uniformity, especially in the blue-shelled breeds, hence, their pigment differences and molecular mechanism need clarity. To investigate the relationship between the pigment content of eggshells and related gene expression in the eggshell glands of chickens, four subtypes of blue-shelled eggs ('Olive', 'Green', 'Blue', and 'Light') from the same blue-eggshell chicken line were selected; Hy-Line 'White' and 'Brown'-shelled eggs were used as control groups. The L*, a*, b* values, and protoporphyrin-IX and biliverdin contents in each group of eggshells were measured. In addition, the shell glands of the corresponding hens were collected to detect SLCO1B3 genotype and mRNA expression, and ABCG2 and HMOX1 transcription and protein expression. Eggshell colour L* values were negatively correlated with protoporphyrin-IX, b* values were positively correlated with total pigment content (P < 0.001), and a* values were positively correlated with protoporphyrin-IX (P < 0.001) but negatively with biliverdin. Moreover, all four blue-eggshell subtypes were SLCO1B3 homozygous, with SLCO1B3 mRNA expression in shell glands being significantly higher than in the White and Brown groups. ABCG2 and HMOX1 mRNA expression were highest in the Brown and Green groups, respectively (P < 0.05), and were positively correlated with protoporphyrin-IX (P < 0.001) and biliverdin contents in eggshells, respectively. Western blot and immunohistochemical results demonstrated that the Brown group had the highest ABCG2 expression (P < 0.05), followed by the Green and Olive groups. HMOX1 protein expression was higher in the Olive and Green groups (P < 0.05), and lowest in the White group. This study suggests that ABCG2 and HMOX1 have important regulatory roles in the production and transport of protoporphyrin-IX and biliverdin in blue-shelled chicken eggs, respectively.

¹¹C-methionine uptake and intraoperative 5-aminolevulinic acid-induced fluorescence as separate index markers of cell density in glioma: a stereotactic image-histological analysis.

BACKGROUND: The extent of tumor resection is acknowledged as 1 of the prognostic factors for glioma. 5-Aminolevulinic acid (5-ALA)-induced fluorescence guidance and neuronavigation integrated with (11) C-methionine positron emission tomography (PET) are widely utilized under the expectation of improving the extent of resection. These 2 novel approaches are beneficial for glioma resections, and the combination of these approaches appears rational. However, biological characteristics reflecting 5-ALA-induced fluorescence and (11) C-methionine uptake have not been clearly elucidated, and studies about the relationship between 5-ALA-induced fluorescence and (11) C-methionine uptake have been limited. The present study aimed to clarify this issue. METHODS: Data from 11 consecutive patients harboring astrocytic tumors were analyzed: 2 grade II and 2 grade III, and 7 grade IV tumors were included. Thirty samples from these patients were obtained from the relative periphery of each tumor. Relationships among histology, 5-ALA-induced fluorescence and (11) C-methionine uptake were analyzed by stereotactic sampling and image analysis. RESULTS: Uptake of (11) C-methionine correlated with cell density (R(2) = 0.322, P = .0059). Cell density was higher in fluorescence-positive areas than in negative areas (2760 ± 1080 vs 1450 ± 1380/mm(2) , P = .0132). Although both (11) C-methionine uptake and fluorescence seemed to correlate with cell density, no significant difference in (11) C-methionine uptake was seen between fluorescence-positive and -negative areas (P = .367). Multiple linear regression analysis revealed (11) C-methionine uptake and 5-ALA-induced fluorescence as independent indices for tumor cell density. CONCLUSIONS: These results indicate that 5-ALA fluorescence and (11) C-methionine PET image are separate index markers for cytoreduction surgery of gliomas.

Zinc erythrocyte protoporphyrin as marker of malaria risk in pregnancy - a retrospective cross-sectional and longitudinal study.

BACKGROUND: The effects of iron interventions and host iron status on infection risk have been a recurrent clinical concern, although there has been little research on this interaction in pregnant women. METHODS: Cross-sectional and longitudinal analyses were undertaken to determine the association of whole blood zinc erythrocyte protoporphyrin (ZPP) with malaria parasitaemia in pregnant women attending antenatal and delivery care at Montfort and Chikwawa Hospitals, Shire Valley, Malawi. Prevalence of antenatal, delivery and placental malaria was assessed in relation to maternal ZPP levels. The main outcome measures were prevalence of peripheral and placental Plasmodium falciparum parasitaemia and odds ratios of malaria risk. RESULTS: A total of 4,103 women were evaluated at first antenatal visit, of whom at delivery 1327 were screened for peripheral and 1285 for placental parasitaemia. Risk of malaria at delivery (peripheral or placental) was higher in primigravidae (p < 0.001), and lower (peripheral) with use of intermittent preventive anti-malarials during pregnancy (p < 0.001). HIV infection was associated with increased malaria parasitaemia (p < 0.02, peripheral or placental). Parasitaemia prevalence was lower in women with normal ZPP levels compared to those with raised concentrations at both first antenatal visit (all gravidae, p = 0.048, and at delivery (all gravidae, p < 0.001; primigravidae, p = 0.056). Between first antenatal visit and delivery women who transitioned from raised (at first antenatal visit) to normal ZPP values (at delivery) had lower peripheral parasitaemia prevalence at delivery compared to those who maintained normal ZPP values at both these visits (all gravidae: 0.70, 95%CI 0.4-1.1; primigravidae: 0.3, 0.1-0.8). In regression analysis this difference was lost with inclusion of HIV infection in the model. CONCLUSIONS: Raised ZPP concentrations in pregnancy were positively associated with P. falciparum parasitaemia and were probably secondary to malaria inflammation, rather than indicating an increased malaria risk with iron deficiency. It was not possible from ZPP measurements alone to determine whether iron deficiency or repletion alters malaria susceptibility in pregnancy.