Validation of bioelectrical impedance analysis for body composition assessment in children with obesity aged 8-14y.

BACKGROUND & AIMS: The aim was to generate a predictive equation to assess body composition (BC) in children with obesity using bioimpedance (BIA), and avoid bias produced by different density levels of fat free mass (FFM) in this population. METHODS: This was a cross-sectional validation study using baseline data from a randomized intervention trial to treat childhood obesity. Participants were 8 to 14y (n = 315), underwent assessments on anthropometry and BC through Air Displacement Plethysmography (ADP), Dual X-Ray Absorptiometry and BIA. They were divided into a training (n = 249) and a testing subset (n = 66). In addition, the testing subset underwent a total body water assessment using deuterium dilution, and thus obtained results for the 4-compartment model (4C). A new equation to estimate FFM was created from the BIA outputs by comparison to a validated model of ADP adjusted by FFM density in the training subset. The equation was validated against 4C in the testing subset. As reference, the outputs from the BIA device were also compared to 4C. RESULTS: The predictive equation reduced the bias from the BIA outputs from 14.1% (95%CI: 12.7, 15.4) to 4.6% (95%CI: 3.8, 5.4) for FFM and from 18.4% (95%CI: 16.9, 19.9) to 6.4% (95% CI: 5.3, 7.4) for FM. Bland-Altman plots revealed that the new equation significantly improved the agreement with 4C; furthermore, the observed trend to increase the degree of bias with increasing FM and FFM also disappeared. CONCLUSION: The new predictive equation increases the precision of BC assessment using BIA in children with obesity.

Comparison of four matrixes for diluting insulin in routine clinical measurements.

OBJECTIVE: In our laboratory, 2.36% (6626/280765) samples obtained for insulin evaluation have serum insulin concentrations higher than 300 mU/L, resulting in curves outside the linear range in the insulin release test (IRT). Accordingly, using appropriate dilution protocols to determine insulin concentration accurately is important. Here, we compared the effectiveness and economy of four different solutions for diluting high-insulin serum in routine clinical measurements. METHOD: Residual serum samples with high-insulin concentrations ranging from 200 to 300 mU/L were collected in Peking Union Medical College Hospital from August to November 2017. Four different matrixes including a Siemens original diluent, pure water, 0.9% NaCl, and low-insulin serum (labeled as A to D, respectively) were used to dilute the serum in the ratios of 1:2, 1:5, and 1:10. RESULTS: We found that the linear correlation coefficients of A to D were higher than 0.9. The recovery rates of A to D were 86.4%-104.0%, 73.2%-99.3%, 76.4%-101.3%, and 84.2%-99.7%, respectively. We conclude that the use of 0.9% NaCl, pure water, or low-insulin serum to dilute high-serum insulin (>300 mU/L) is feasible and cost-effective. CONCLUSION: We recommend a dilution factor of 1:5 on a Siemens ADVIA Centaur XP® instrument. The clinically reported range was 0.5-1500 mU/L. For specific samples (>1500 mU/L), we recommended using low-insulin serum samples for dilution.

A two-stage experimental design for dilution assays.

Dilution assays to determine solute concentration have found wide use in biomedical research. Many dilution assays return imprecise concentration estimates because they are only done to orders of magnitude. Previous statistical work has focused on how to design efficient experiments that can return more precise estimates, however this work has not considered the practical difficulties of implementing these designs in the laboratory. We developed a two-stage experiment with a first stage that obtains an order of magnitude estimate and a second stage that concentrates effort on the most informative dilution to increase estimator precision. We show using simulations and an empirical example that the best two-stage experimental designs yield estimates that are remarkably more accurate than standard methods with equivalent effort. This work demonstrates how to utilize previous advances in experimental design in a manner consistent with current laboratory practice. We expect that multi-stage designs will prove to be useful for obtaining precise estimates with minimal experimental effort.

Regression analysis and categorical agreement of fluconazole disk zone diameters and minimum inhibitory concentration by broth microdilution of clinical isolates of Candida.

AIM AND OBJECTIVES: Rampant use of fluconazole in Candida infections has led to predominance of less susceptible non-albicans Candida over Candida albicans. The aim of the study was to determine if zone diameters around fluconazole disk can be used to estimate the minimum inhibitory concentration (MIC) for clinical isolates of Candida species and vice versa. Categorical agreement between the Clinical & Laboratory Standards Institute (CLSI) recommended disk diffusion and CLSI broth microdilution method was sought for. MATERIAL AND METHODS: Antifungal susceptibility testing by disk diffusion and Broth microdilution was done as per CLSI document M44-S3 and CLSI document M27-S4 for Candida isolates respectively. Regression analysis correlating zone diameters to MIC value was done. Pearson's correlation coefficient was calculated to determine correlation between disk zone diameters and MICs. RESULTS: Candida albicans (33.3%) was clearly outnumbered by other non-albicans species predominantly Candida tropicalis (42.5%) and Candida glabrata (18.4%). Ten percent of the strains were resistant to fluconazole by disk diffusion and 13% by broth microdilution. MIC range for Candida albicans and Candida tropicalis ranged from≤0.25-64µg/ml while that of Candida glabrata ranged from≤0.25-128µg/ml. Categorical agreement between disk diffusion and broth microdilution was 86.8%. Pearson's coefficient of correlation was -0.5975 indicating moderate negative correlation between the two variables. CONCLUSION: Zone sizes can be used to estimate the MIC values, although with limited accuracy. There should be a constant effort to upgrade the guidelines in view of new clinical data, and laboratories should make an active effort to incorporate them.

Immunological models in high dilution research following M Bastide.

In 1994, Madeleine Bastide described experimental models in immunology that were used during the 1980s to investigate high dilution effects on several biological systems. She classified the available papers in four categories: High dilutions of antigens; High dilutions of thymus, bursa and other hormones; High dilutions of cytokines; Immunopharmacological activity of silica. The studies about high dilutions of antigens were not continued after this period, but gave rise to a long process of a series of in vitro models on antigens and histamine dilutions, that led to the demonstration of the biological modulation effects of these preparations on basophil degranulation. During this process, a multi-centre study was performed, with a high degree of reproducibility among different independent laboratories. The studies about high diluted cytokines, thymulin and other hormones opened a new line of scientific investigation, about the regulatory properties of endogenous substances prepared according to homeopathic methods. The most frequently studied substance, thymulin, when administered to mice at 5cH potency, is able to improve the activity of phagocytes in different experimental situations, such as viral, bacterial and parasitic infections. The immunopharmacological activity of silica was demonstrated, at that time, as an in vivo illustration of the homeopathic 'similia principle'. More recently, studies on silica have assumed another focus: the putative role of silica as active contaminant present in high dilutions. This paper presents a follow-up summary on these items, considering the evolution of discoveries from 1994 to 2014.

A roadmap to defining the clinical reportable ranges of chemistry analytes: Increasing automation efficiency and decreasing manual dilutions.

BACKGROUND: Proper utilization of resources is an important operational objective for clinical laboratories. To reduce unnecessary manual interventions on automated instruments, we conducted a workflow analysis that optimized dilution parameters and reporting of abnormally high chemistry results for the Beckman AU series of chemistry analyzers while maintaining clinically acceptable reportable ranges. METHODS: Workflow analysis for the Beckman AU680/5812 and DxC800 chemistry analyzers was performed using historical data. Clinical reportable ranges for 53 chemistry analytes were evaluated. Optimized dilution parameters and upper limit of reportable ranges for the AU680/5812 instruments were derived and validated to meet these reportable ranges. The number of specimens that required manual dilutions before and after optimization was determined for both the AU680/5812 and DxC800, with the DxC800 serving as the reference instrument. RESULTS: Retrospective data analysis revealed that 7700 specimens required manual dilutions on the DxC over a 2-y period. Using our optimized AU-specific dilution and reporting parameters, the data-driven simulation analysis showed a 61% reduction in manual dilutions. For the specimens that required manual dilutions on the AU680/5812, we developed standardized dilution procedures to further streamline workflow. CONCLUSIONS: We provide a data-driven, practical outline for clinical laboratories to efficiently optimize their use of automated chemistry analyzers. The outcomes can be used to assist laboratories wishing to improve their existing procedures or to facilitate transitioning into a new line of instrumentation, regardless of the instrument model or manufacturer.

Body composition measures of obese adolescents by the deuterium oxide dilution method and by bioelectrical impedance.

The objectives of the present study were to describe and compare the body composition variables determined by bioelectrical impedance (BIA) and the deuterium dilution method (DDM), to identify possible correlations and agreement between the two methods, and to construct a linear regression model including anthropometric measures. Obese adolescents were evaluated by anthropometric measures, and body composition was assessed by BIA and DDM. Forty obese adolescents were included in the study. Comparison of the mean values for the following variables: fat body mass (FM; kg), fat-free mass (FFM; kg), and total body water (TBW; %) determined by DDM and by BIA revealed significant differences. BIA overestimated FFM and TBW and underestimated FM. When compared with data provided by DDM, the BIA data presented a significant correlation with FFM (r = 0.89; P < 0.001), FM (r = 0.93; P < 0.001) and TBW (r = 0.62; P < 0.001). The Bland-Altman plot showed no agreement for FFM, FM or TBW between data provided by BIA and DDM. The linear regression models proposed in our study with respect to FFM, FM, and TBW were well adjusted. FFM obtained by DDM = 0.842 x FFM obtained by BIA. FM obtained by DDM = 0.855 x FM obtained by BIA + 0.152 x weight (kg). TBW obtained by DDM = 0.813 x TBW obtained by BIA. The body composition results of obese adolescents determined by DDM can be predicted by using the measures provided by BIA through a regression equation.

Body composition measures of obese adolescents by the deuterium oxide dilution method and by bioelectrical impedance

The objectives of the present study were to describe and compare the body composition variables determined by bioelectrical impedance (BIA) and the deuterium dilution method (DDM), to identify possible correlations and agreement between the two methods, and to construct a linear regression model including anthropometric measures. Obese adolescents were evaluated by anthropometric measures, and body composition was assessed by BIA and DDM. Forty obese adolescents were included in the study. Comparison of the mean values for the following variables: fat body mass (FM; kg), fat-free mass (FFM; kg), and total body water (TBW; percent) determined by DDM and by BIA revealed significant differences. BIA overestimated FFM and TBW and underestimated FM. When compared with data provided by DDM, the BIA data presented a significant correlation with FFM (r = 0.89; P < 0.001), FM (r = 0.93; P < 0.001) and TBW (r = 0.62; P < 0.001). The Bland-Altman plot showed no agreement for FFM, FM or TBW between data provided by BIA and DDM. The linear regression models proposed in our study with respect to FFM, FM, and TBW were well adjusted. FFM obtained by DDM = 0.842 x FFM obtained by BIA. FM obtained by DDM = 0.855 x FM obtained by BIA + 0.152 x weight (kg). TBW obtained by DDM = 0.813 x TBW obtained by BIA. The body composition results of obese adolescents determined by DDM can be predicted by using the measures provided by BIA through a regression equation.

Early vascular access blood flow as a predictor of long-term vascular access patency in incident hemodialysis patients.

The long-term clinical benefits of vascular access blood flow (VABF) measurements in hemodialysis (HD) patients have been controversial. We evaluated whether early VABF may predict long-term vascular access (VA) patency in incident HD patients. We enrolled 57 patients, of whom 27 were starting HD with arteriovenous fistulas (AVFs) and 30 with arteriovenous grafts (AVGs). The patients' VABF was measured monthly with the ultrasound dilution technique over the course of the first six months after the VA operation. During the 20.4-month observational period, a total of 40 VA events in 23 patients were documented. The new VA events included 13 cases of stenosis and 10 thrombotic events. The lowest quartile of average early VABF was related to the new VA events. After adjusting for covariates such as gender, age, hypertension, diabetes, VA type, hemoglobin levels, body mass index, parathyroid hormone, and calcium-phosphorus product levels, the hazard ratio of VABF (defined as <853 mL/min in AVF or <830 mL/min in AVG) to incident VA was 3.077 (95% confidence interval, 1.127-8.395; P=0.028). There were no significant relationships between early VABF parameters and VA thrombosis. It is concluded that early VABF may predict long-term VA patency, particularly VA stenosis.

Flow-regulated extracorporeal arteriovenous tubing loop for cardiac output measurements by ultrasound velocity dilution: validation in post-cardiac surgery intensive care unit patients.

Assessment of cardiac output (CO) is crucial in the management of the critically ill, especially in post cardiac surgery intensive care unit (ICU) patients. In this study, we validated CO measured by the novel ultrasound dilution (COUD) with those measured by pulmonary artery (PA) thermodilution (COTD) in 26 adult post cardiac surgery patients. For COUD, blood was circulated through an extracorporeal arteriovenous (AV) loop from the radial artery catheter to the introducer of PA catheter for 5-8 minutes. Three to four injections of 25 ml body temperature isotonic saline were performed into the venous limb of the AV loop. For COTD, five injections of 10 ml ice cold saline were performed. A total of 77 COUD and COTD measurement sets were compared. Cardiac output measured by thermodilution ranged from 3.28 to 9.4 L/min, whereas COUD ranged from 2.85 to 10.1 L/min. The correlation between the methods was found to be r = 0.91, COUD = 0.93(COTD) + 0.42 L/min. Bias and precision (mean difference ± 2SDs) was -0.004 ± 1.34 L/min between the two methods. The percentage error (2SD/mean) was 22.2%, which is below the clinically acceptable limit (<30%). Cardiac output measured by ultrasound dilution and thermodilution methods agreed well in post cardiac surgery ICU patients and hence can be interchangeably used.

Early Vascular Access Blood Flow as a Predictor of Long-term Vascular Access Patency in Incident Hemodialysis Patients

The long-term clinical benefits of vascular access blood flow (VABF) measurements in hemodialysis (HD) patients have been controversial. We evaluated whether early VABF may predict long-term vascular access (VA) patency in incident HD patients. We enrolled 57 patients, of whom 27 were starting HD with arteriovenous fistulas (AVFs) and 30 with arteriovenous grafts (AVGs). The patients' VABF was measured monthly with the ultrasound dilution technique over the course of the first six months after the VA operation. During the 20.4-month observational period, a total of 40 VA events in 23 patients were documented. The new VA events included 13 cases of stenosis and 10 thrombotic events. The lowest quartile of average early VABF was related to the new VA events. After adjusting for covariates such as gender, age, hypertension, diabetes, VA type, hemoglobin levels, body mass index, parathyroid hormone, and calcium-phosphorus product levels, the hazard ratio of VABF (defined as <853 mL/min in AVF or <830 mL/min in AVG) to incident VA was 3.077 (95% confidence interval, 1.127-8.395; P=0.028). There were no significant relationships between early VABF parameters and VA thrombosis. It is concluded that early VABF may predict long-term VA patency, particularly VA stenosis.

On the physical and stochastic representation of an indicator dilution curve as a gamma variate.

The analysis of intravascular indicator dynamics is important for cardiovascular diagnostics as well as for the assessment of tissue perfusion, aimed at the detection of ischemic regions or cancer hypervascularization. To this end, indicator dilution curves are measured after the intravenous injection of an indicator bolus and fitted by parametric models for the estimation of the hemodynamic parameters of interest. Based on heuristic reasoning, the dilution process is often modeled by a gamma variate. In this paper, we provide both a physical and stochastic interpretation of the gamma variate model. The accuracy of the model is compared with the local density random walk model, a known model based on physics principles. Dilution curves were measured by contrast ultrasonography both in vitro and in vivo (20 patients). Blood volume measurements were used to test the accuracy and clinical relevance of the estimated parameters. Both models provided accurate curve fits and volume estimates. In conclusion, the proposed interpretations of the gamma variate model describe physics aspects of the dilution process and lead to a better understanding of the observed parameters, increasing the value and credibility of the model, and possibly expanding its diagnostic applications.

Urinary analysis of 8-oxoguanine, 8-oxoguanosine, fapy-guanine and 8-oxo-2'-deoxyguanosine by high-performance liquid chromatography-electrospray tandem mass spectrometry as a measure of oxidative stress.

A sensitive and specific assay aimed at measuring the oxidized nucleic acids, 8-oxoguanine (8-oxoGua), fapy-guanine (Fapy-Gua), 8-oxoguanosine (8-oxoGuo), 8-oxo-2'-deoxyguanosine (8-oxodG) has been developed by coupling reversed phase liquid chromatography (HPLC) with electrospray tandem mass spectrometry detection (MS/MS) and isotope dilution. The HPLC-MS/MS approach with multiple reaction monitoring (MRM) allowed for the sensitive determination of 8-oxoGua, Fapy-Gua, 8-oxoGuo, and 8-oxodG in human urine samples. There is no sample preparation needed except for the addition of buffer and (13)C- and (15)N-labeled internal standards to the urine prior to sample injection into the HPLC-MS/MS system. This method was tested in urine samples from non-smokers, smokers, non-smokers with chronic kidney disease (CKD) and smokers with CKD, to assess the level of oxidative damage to nucleic acids. Markers of both RNA and DNA damage were significantly increased in the smokers with and without CKD compared to their respective control subjects. These findings suggest that a highly specific and sensitive analytical method such as isotope dilution HPLC-MS/MS may represent a valuable tool for the measurement of oxidative stress in human subjects.

Validation of estimates of total body water in pediatric dialysis patients by deuterium dilution.

BACKGROUND: Current K-DOQI recommendations call for an assessment of dialysis adequacy that depends critically on an estimate of total body water (TBW). Such estimates are problematic in children since the range of patient size is large, and often formulas derived in normals are not validated in end-stage renal disease. Gold standard methods of TBW measurement, such as deuterium dilution ((2)H(2)O), are not appropriate in the clinical setting, yet noninvasive methods such as bioimpedance analysis (BIA) and dual energy x-ray absorptiometry (DEXA) have not been independently validated. METHODS: We studied 14 stable pediatric dialysis patients on 1 to 3 occasions using (2)H(2)O dilution, BIA, DEXA, and anthropometry to measure TBW. We compared our data set to previously published formulae for TBW to determine root mean square error (RMSE) and skew of the estimate. RESULTS: TBW prediction based upon the anthropometric formula proposed by the Pediatric Peritoneal Dialysis Consortium provided the best fit to our independent data set with RMSE = 2.15 L, and no skew by Bland-Altman analysis. Other formulas produced large, clinically relevant errors; obese subjects confounded many estimates. TBW calculated from hydrated lean body mass from DEXA scan was reliable with RMSE = 1.03 L and no skew. BIA-derived estimates can be useful, although the magnitude of RMSE ranged from 1.45 to 6.24 L, and one formula produced skewed results. CONCLUSION: Techniques for estimating TBW in pediatric dialysis patients must be validated by independent data sets before being incorporated into clinical and research practice.

Chromogenic assay of human coagulation factor VIII: statistical comparison of 2 working dilution procedures.

The effect of 2 different practices for preparation of working dilutions in the chromogenic substrate method for potency assay of factor VIII was evaluated. In this study the potency of several concentrate materials was shown to be statistically equivalent, whether performing the assay with independent or serial working dilutions.

Hemodynamic reproducibility during blood flow measurements of hemodialysis synthetic grafts.

We have previously shown that graft blood flow (Qa) has a poor accuracy in predicting graft thrombosis. In this study, we determined whether hemodynamic variation helps explain this poor predictive accuracy. We also determined whether standardized timing of Qa measurements, which is widely recommended, will promote measurement reproducibility. We analyzed variations in mean arterial pressure (MAP) in seven consecutive dialysis sessions for 51 patients and determined the influence of MAP on Qa (by ultrasound dilution). We used a pooled coefficient of variation (CV) to summarize MAP variation within individual patients (computed as +/-2 CVs). MAPs from the seven sessions varied widely, and most variation was present with the first MAPs at the beginning of the sessions. These first MAPs varied by +/-23%, whereas variation for the entire session was +/-28%. The influence of MAP on Qa was determined by measuring the two together during consecutive thirds of a single session. The percentage of change in MAP (DeltaMAP) and Qa (DeltaQa) from the first to middle or last thirds of the session varied over wide ranges: -37% to 86% and -43% to 78%, respectively. The DeltaQa versus DeltaMAP correlation was relatively strong for changes between the first and middle thirds (r = 0.666) and first and last thirds (r = 0.646) of the session (both P: < 0.01). We conclude that MAP varies far more widely during dialysis than previously recognized. This variation is associated with large changes in Qa that may impair accuracy in predicting thrombosis. This wide MAP variation also indicates hemodynamic reproducibility is not feasible when measuring Qa. Thus, we do not recommend standardized timing of Qa measurements during dialysis. A practical method of addressing poor Qa reproducibility may be to take frequent measurements so that trends can be recognized before thrombosis occurs.

Design and estimation in the limiting dilution assay when concentrations vary widely among samples.

Limiting dilution assays (LDA) are used to estimate an unknown cell fraction of interest within a sample. This paper discusses a method for designing an LDA using the distribution of the cell fraction of interest, examining three different design approaches: geometric progression, equally spaced log, and equiprobability. Two common estimation methods, minimum chi-square and maximum likelihood, also are investigated. These designs and estimation methods, coupled with varying numbers of wells per dilution and dilutions per design, are compared quantitatively through computer simulation. Performance measures computed were mean relative bias and mean squared error.

Modificación de un método para colinesterasa plasmática empleando la reducción del ferricianuro como indicador / Modification in the method for serum cholinesterase in ferricyanide reduction how indicatory

Se describe la modificación de un método para la cuantificación de colinesterasa plasmática mediante monitoreo continuo empleando ferricianuro como indicador. La tiocolina liberada de la propioniltiocolina reduce el ferricianuro a ferrocianuro y la disminición de absorbancia a 405 nm es proporcional a la actividad de la enzima. Las precisiones día a día para muestras con valores de colinesterasa bajos y altos mostraron coeficientes de variación de 3,2 y 1,2 por ciento y en un mismo día de 1,1 y 0,52 por ciento respectivamente. La bilirrubina no presenta una interferencia importante y cada 50mg/dL de hemoglobina producen una interferencia de -4 por ciento. El reactivo de ferricianuro almacenado en botella ámbar es estable por al menos 3 meses a temperatura ambiente y 6 meses a 4-8 §C. Al comparar los resultados con un método que emplea la reacción de Ellman se obtuvo una ecuación de regresión lineal de Y = 1,22 (X) - 732, con un coeficiente de correlación (r) de 0,988 y una desviación estándar sobre la línea de regresión (Sy/x) de 378 U/L. (Rev Cost Cienc Med 1999; 20(1,2): 17-27) PALABRAS CLAVE: Colinesterasa sérica, organofosfatos, carbamatos, pesticidas, métodos colorimétrico, toxicología

Reliability and validity of measures of cardiac output during incremental to maximal aerobic exercise. Part I: Conventional techniques.

The assessment of cardiac function, particularly cardiac output (Q) during heavy exercise is essential for the evaluation of cardiovascular factors that might limit oxygen transport. A series of invasive and noninvasive techniques has been developed for the assessment and monitoring of Q during resting and submaximal exercise conditions. However, very few techniques have been found to give accurate and reliable determinations of Q during vigorous to maximum exercise. For exercise physiologists and sport cardiologists, maximal exercise data are of primary importance. The 'gold standard' measures of cardiac function are considered to be the direct Fick and dye-dilution methods. These have been widely shown to give accurate and reliable determinations of Q during resting and submaximal exercise conditions; however, their use during maximal exercise conditions is debatable due to the inherent risks involved with each and their increasing inaccuracy during the later stages of vigorous exercise. Thermodilution has also been considered to be a relatively good method for the determination of Q during rest and exercise conditions, but recent authors have questioned its use due to the nature of the measure and its inaccuracy during strenuous exercise. Various noninvasive measures of cardiac function have been developed to overcome the problems associated with the 'gold standard' measures. The first part of this article discusses conventional techniques used in exercise physiology settings. The majority of these provide accurate and reliable determinations of Q during rest and submaximal exercise. However, very few techniques are suitable for maximal exercise conditions. Perhaps only the foreign gas rebreathe using acetylene (C2H2) meets all the criteria of being noninvasive, simple to use, reliable over repeated measurements, accurate and useful during maximal exercise.

Statistical inference for serial dilution assay data.

Serial dilution assays are widely employed for estimating substance concentrations and minimum inhibitory concentrations. The Poisson-Bernoulli model for such assays is appropriate for count data but not for continuous measurements that are encountered in applications involving substance concentrations. This paper presents practical inference methods based on a log-normal model and illustrates these methods using a case application involving bacterial toxins.