Trace elements in diabetes mellitus. Peculiarities and clinical validity of determinations in blood cells.

Significantly more information about trace element status can be obtained by investigating concentrations in blood cells instead of only evaluating the concentrations in plasma. This can be explained by the fact that essential trace elements such as zinc, copper, chromium and selenium take part in a variety of enzymatic processes on a molecular cellular level. Ignoring these important biochemical roles, trace element concentrations determined in whole blood or plasma very often lead to conclusions contrary to the actual intracellular concentration. Especially in metabolic diseases like diabetes mellitus, conclusions drawn from trace element concentrations in blood cells usually offer more valuable clinical information about the metabolic state than trace element concentrations in plasma or whole blood. In the present investigation copper and zinc concentrations were increased in all blood fractions of diabetic patients (IDDM). In insulin-dependent diabetic children significantly higher values of zinc in erythrocytes were also found, and they were higher in patients with poor metabolic control (HbA1c>9%). When different blood fractions in diabetic patients (NIDDM) were compared with a control group, chromium was significantly increased in plasma and polymorphonuclear cells. Patients with IDDM had pronounced decreased selenium concentrations in erythrocytes as compared to controls.

Serial transplants of DMBA-induced mammary tumors in Fischer rats as a model system for human breast cancer. VI. The role of different forms of tumor-associated stress for the regulation of pineal melatonin secretion.

Previous studies on human breast cancer patients showed a decline in circulating melatonin levels corresponding to primary tumor growth and an increase when relapse occurred. The aim of the current investigation was to study in an experimental model possible mechanisms involved. Inbred female F344 Fischer rats were used for serial passages derived from a chemically induced mammary adenocarcinoma. Animals with slow-growing carcinosarcomas at passage 2 showed a significant elevation of nocturnal urinary melatonin (23. 00-07.00 h; +50%, p < 0.05) and a nominal increase in plasma melatonin (+41%; 02.00-03.00 h). By contrast, these parameters were significantly depressed in animals with fast-growing sarcomas (urinary melatonin: -22%, p < 0.025; plasma melatonin: -56%, p < 0. 01). At passage 2 nocturnal pineal N-acetylserotonin (02.00-03.00 h) was significantly enhanced (+62%, p < 0.05) probably due to an increased activity of serotonin-N-acetyltransferase (SNAT, +45%), the rate-limiting step of pineal melatonin biosynthesis converting serotonin to N-acetylserotonin. The activation of SNAT may be due to a stimulation of the sympathetic nervous system (urinary noradrenaline; NA: +243%, p < 0.005) when the cellular immune system responded towards tumor growth (urinary biopterin, +214%, p < 0.005). At passage 12 SNAT and N-acetylserotonin were unaffected but a depletion of plasma tryptophan (-34%, p < 0.0001), the precursor amino acid of melatonin, was found. The marginal decline in pineal serotonin (-18%, p < 0.05) disputes that the drastic depletion in circulating melatonin (-56%, p < 0.01) can be exclusively explained by a reduced availability of tryptophan. Therefore, the involvement of an additional mechanism has to be postulated, such as a degradation of melatonin via indoleamine 2,3-dioxygenase, an extrahepatic enzyme which has been detected in tumor tissue and is related to tryptophan 2,3-dioxygenase (TDO). TDO occurs only in the liver, is highly specific for L-tryptophan and is induced by glucocorticoids which would account for the observed depletion of plasma tryptophan resulting from a tumor-associated activation of the hypothalamo-pituitary-adrenal axis (urinary corticosterone +208%, p < 0.01). These findings present first explanations for the previously observed modulation of melatonin levels in cancer patients but also illustrate the high degree of complexity of mechanisms involved in the interactions between tumor growth and the immunoneuroendocrine system.

Concepts for a model of good medical laboratory services.

Several international standards and corresponding interpretation documents for quality management systems have been published. Although these standards are found useful to some extent, they are considered to be insufficient in several areas important for medical laboratories particularly in the pre- and post-examinational phases. The normative document for accreditation of laboratories (ISO/IEC Guide 25) is presently being revised and a document for medical laboratories (ISO/TC 212, CD 15189) is at draft stage. Both aim to include aspects of total quality management. The concept of total quality management is rather vague. Generally, its goal has been defined as "business excellence". This term, however, needs some explanation if applied to medical laboratories. Therefore, a project group of the European Confederation of Laboratory Medicine (ECLM) has developed a model for total quality management, which is based on a comprehensive management concept issued by the European Foundation for Quality Management. In the case of a medical laboratory, the term "business excellence" should be replaced by "good medical laboratory services". The proposed model could serve as a basis for future developments of total quality management standards in laboratory medicine. The goal of the "journey" should be clarified before it starts. To the best of our knowledge, this is the first attempt to develop a model of a good medical laboratory.

Reference values for the trace elements copper, manganese, selenium, and zinc in the serum/plasma of children, adolescents, and adults.

Up to now few plasma or serum reference or serum reference values have been available for the assessment of the essential trace element supply status in different age groups covering the whole range of life range. In the present investigation, the concentrations of copper, manganese, selenium, and zinc were determined in the serum of 137 healthy children and in the plasma of 68 blood-donors. The age distribution within these groups ranged from 1 month to 18 years and from 22 to 75 years. The determinations were carried out directly by means of electrothermal atomic absorption spectrophotometry with Zeeman background compensation. The adult plasma reference values (mean +/- 2 SD) were 1.65 +/- 8.6 mumol/1 for copper, 14.3 +/- 11.4 nmol/1 for manganese, 0.80 +/- 0.36 mumol/1 for selenium, and 16.6 +/- mumol/1 for zinc. No correlation between concentration of elements and sex could be established. In the child and adolescent group, the manganese levels exhibited an age-dependent linear decrease (54% of the starting value, slope 0.92, r = 0.4, p < 0.001), the copper and the selenium concentrations, respectively, exhibited an exponential increase (107%, r = 0.59 and 174%, r = 0.61), with the highest value in the age group of 6 to 10 years. Reference ranges are established for 9 different age groups. The results reflect the known physiological data on the trace element content in the tissue of children and their diet. The present study is an important pre-requisite for diagnosis and therapy of trace element deficiencies in all age groups.

Isolation of corpuscular components of whole blood for the determination of selenium in blood cells.

Currently, the determination of trace elements in plasma or whole blood for the evaluation of adequate supply is unsatisfactory as it does not reflect exactly the biochemical processes in the human organism. A method of isolating cell fractions was developed in order to be able to analyze these elements in the corpuscular components of the blood. The separation, which is simple to perform, makes possible a high yield of erythrocytes, thrombocytes, and polymorphnuclear and mononuclear leucocytes, as well as a high purity of the cell fractions. For the first time a precise determination of trace elements in leucocytes has become possible. The concentration in erythrocytes was not calculated but measured directly, avoiding the danger of a compounding of errors by the combination of many steps. The highest relative selenium content of an investigated reference group (n = 25) was found in the erythrocytes (39.7%), followed by the plasma (29.9%) and the thrombocytes (24.9%). The leucocytes had the lowest concentration with < 1.9% in the polymorphonuclear and < 3.7% in the mononuclear cells. A comparison of these results with the distribution of selenium in the blood compartments will show whether the use of erythrocytes resp. thrombocytes for the analysis of this element is of greater value for diagnosis and therapy than currently employed procedures.

Determination of the trace elements zinc, copper, nickel and chromium in bone marrow and plasma of patients with non-Hodgkin lymphomas.

The concentrations of zinc, copper, nickel and chromium were determined in bone marrow and plasma of 37 patients suffering from non-Hodgkin-lymphomas (NHL). The results were compared with a control group of 10 patients with negative histopathologic results in bone marrow. The results demonstrate that all patients with low grade and high grade NHL have elevated trace element levels in bone marrow compared to the control group. In plasma there are also differences in the trace element levels of patients with NHL compared to the control group; the levels, however, are partly higher and lower than those of the control group. Altogether the plasma level differences are not as noticeable as those in the bone marrow. At the moment it is not yet possible to draw final conclusions from these results for the prognosis or therapy of NHL, but the study tends to show that intracellular measurement of trace elements is more reliable than intraplasmic measurement.

Chromatographic separation of serum proteins and estimation of their zinc and copper content.

Human serum proteins of blood donors and dialysis patients were separated by means of gel filtration chromatography. The resulting fractions were analyzed for copper and zinc. Separation resulted in 3 zinc peaks with a molecular weight of about 700,000, 300,000, and 75,000 Dalton, with alpha 2-macroglobulin co-eluting in the first and albumin co-eluting in the third zinc peak. The zinc protein(s) of the second peak remained unidentified. The three peaks contained, in succession, 0.72 +/- 0.30 mumol/L (4.8 +/- 1.6%), 1.26 +/- 0.37 mumol/L (8.5 +/- 1.7/1000) and 12.8 +/- 2.1 mumol/L (86.8 +/- 2.8%) of total zinc in the case of blood donors, and 1.19 +/- 1.05 mumol/L (9.2 +/- 7.2%), 0.97 +/- 0.22 mumol/L (8.0 +/- 2.6%), and 10.4 +/- 1.66 mumol/L (82.7 +/- 6.7%) in the case of dialysis patients. Separation followed by copper analysis resulted in the three peaks, as well, with a molecular weight of about 750,000, 140,000, and 75,000 dalton. The copper protein of the first peak remained unidentified, while coeruloplasmin co-eluted in the second and albumin in the third peak. The three peaks contained, in succession, 0.4 +/- 0.16 mumol/L (2.3 +/- 0.95%), 14.6 +/- 0.7 mumol/L (83.9 +/- 4.1%), and 2.4 +/- 0.6 mumol/L (13.7 +/- 3.5%) of total copper in the case of blood donors, and 0.5 +/- 0.73 mumol/L (2.2 +/- 3.2%), 19.5 +/- 1.1 mumol/L (90.5 +/- 4.9%), and 1.6 +/- 0.66 mumol/L (7.3 +/- 3.0/1000) in the case of dialysis patients. Limitation of the method is shown regarding separation of major from minor proteins and albumin from transferrin.

Post-transcriptional modification of serum creatine kinase in infected intensive care patients.

Low creatine kinase (CK) activities in serum are associated with high fatality rates in intensive care patients. The underlying mechanisms for this phenomenon were investigated. No correlation was found with other biochemical markers of inflammation (CRP, alpha-1 acid glycoprotein, alpha-2 macroglobulin). In the patients' serum a factor is described which is capable of increasing the activation energy of normal CK-MM, indicating molecular changes in CK-structure. This factor is likely to be an enzyme which is present in liver tissue and in fibroblasts. Similar results were obtained after in vitro treatment of normal serum samples with arylsulfatase. Furthermore, bacterial strains isolated in the serum of intensive care patients were found to alter human CK structure. In the investigated patient group, changes in CK activation energy are influenced by serum factors other than carboxypeptidase N activity.

Multivariate determination of glucose in whole blood by attenuated total reflection infrared spectroscopy.

A spectral analysis of whole EDTA blood was undertaken by using attenuated total reflection and Fourier-transform infrared spectroscopy. The concentration of blood glucose was measured by an enzymatic method using glucose dehydrogenase and ranged between 40 and 290 mg/dL with an average concentration of 90.4 mg/dL. Multivariate calibration with the partial least-squares (PLS) algorithm was performed on spectral data between 1500 and 750 cm-1 showing a varying background from different unidentified interfering compounds. Cross validation was carried out for optimizing the PLS model. PRESS was 19.8 mg/dL, which was calculated on the basis of 127 standards, whereas the estimated standard deviation for the calibration fit was computed to be 11.9 mg/dL. Infrared spectroscopy can be used for monitoring glucose levels within the normal physiological range in a complex matrix like whole blood as an alternative to electrochemical sensors.

Multivariate calibration for assays in clinical chemistry using attenuated total reflection infrared spectra of human blood plasma.

A spectral analysis of human blood plasma was undertaken by use of a Fourier-transform infrared spectrometer with a circular attenuated total reflection cell. The concentrations of total protein, glucose, triglycerides, total cholesterol, urea, and uric acid were measured by chemical or enzymatic methods. For these constituents the partial least-squares (PLS) algorithm was used for a multivariate calibration including the infrared fingerprint region of the plasma spectra. Best results were achieved for total protein with an average prediction error (PRESS based on cross validation) of 2.1 g/L; other PRESS results were for glucose 22 mg/dL, triglycerides 33 mg/dL, cholesterol 31 mg/dL, urea 4.4 mg/dL, and uric acid 1.6 mg/dL.

The significance of zinc for humoral and cellular immunity.

Zinc performs a number of unique functions in immunology, which distinguish it from all other trace elements. This special role is based upon its properties as a catalyst of a larger number of enzyme-controlled metabolic processes. Zinc supports, it even enhances, humoral and cell-mediated immunity by facilitating proliferative reactions to stimulus by different mitogens. This is as a result of its acting, above all, on the cell as co-factor for 24 presently known, important enzymes, by exercising a biocatalytic influence and regulatory (in the sense of protective) function. A long-term reduction in food intake, especially extended parenteral feeding, without taking special account of trace elements, leads for all of them, but especially for zinc, to a depletion of body reserves. The latter results in immunological changes that are at first sub-clinical and scarcely recognizable, but which, over the course of time, can lead to life-threatening infections. Cell-mediated immunity, antibody reactions and antibody affinity, complement system and phagocyte activity are perceptibly diminished. The zinc concentration in the blood has an essential influence on the extent and consequences of immunological deficiency.

Evaluation of a new alpha-amylase assay using 4.6-ethylidene-(G7)-1-4-nitrophenyl-(G1)-alpha-D-maltoheptaoside as substrate.

The determination of alpha-amylase activity using an ethylidene-blocked 4-nitrophenyl-maltoheptaoside (EPS) has been evaluated in five laboratories on eight different analysers at 25 degrees C, 30 degrees C and 37 degrees C. The protecting ethylidene group inhibits hydrolysis at the non-reducing end of the substrate molecule by the auxiliary enzyme, alpha-glucosidase. The combined reagent is therefore stable for at least 10 days at 2-8 degrees C. HEPES is used, because the molar absorbance of 4-nitrophenol is independent of temperature in the presence of this buffer. Compared with the method using unprotected substrate 4-nitrophenyl-alpha-D-maltoheptaoside (4NP-G7), the present method is equal or better with respect to the imprecision, linearity and interlaboratory transferability of results in human and control sera. Since the protected and unprotected substrates differ in their turnover rate, the new assay yields activities which differ from those of the 4-nitrophenyl-alpha-D-maltoheptaoside method. Based on the homogeneous results obtained in method comparisons between EPS and 4-nitrophenyl-alpha-D-maltoheptaoside, and in order to maintain the 4-nitrophenyl-alpha-D-maltoheptaoside reference values, a conversion factor was derived to eliminate the above differences: activityEPS x 2.50 = activity4NP-G7. The temperature and instrument independence of this relationship was demonstrated in a total of 720 human sera and plasmas.

Reference ranges for alpha-amylase in serum and urine with 4,6-ethylidene-(G7)-1-4-nitrophenyl-(G1)-alpha,D-maltoheptaoside as substrate.

Reference ranges for alpha-amylase in serum, spontaneously voided urine, and 24 h urine were determined, using 4,6-ethylidene-(G7)-1-4-nitrophenyl-(Gl)-alpha,D-maltoheptaoside as the substrate (EPS method), at 25, 30, and 37 degrees C. The measured values were evaluated with and without the use of a factor which converts the results of the alpha-amylase EPS method into values comparable to those obtained with the alpha-amylase PNP method (substrate: 4-nitrophenyl-alpha,D-maltoheptaoside); comparison with the established reference ranges of the PNP method was therefore possible. The values for urine sometimes deviated markedly from the PNP reference ranges, but the values for serum showed close agreement. With the use of the conversion factor, the following reference ranges are proposed for the new alpha-amylase method: Serum (186 males and 131 females): up to 120 U/l (25 degrees C), up to 160 U/l (30 degrees C), and up to 220 U/l (37 degrees C). Spontaneously voided urine: up to 600 U/l (n = 323, 25 degrees C), up to 800 U/l (n = 373, 30 degrees C), and up to 1000 U/l (n = 373, 37 degrees C). 24 h urine: up to 450 U/24 h (n = 90, 25 degrees C), up to 650 U/24 h (n = 129, 30 degrees C), and up to 900 U/24 h (n = 129, 37 degrees C).

Physicochemical determinations of glucose in vivo.

Conventional methods for the determination of blood glucose are not suitable for application in vivo. It is therefore necessary to seek other methods for monitoring blood glucose as a controlled variable of pancreatic hormonal regulation. Physical methods are preferable to conventional chemical methods, because the chosen methods should not consume or chemically modify glucose. There are two main types of physical chemical methods, which can be considered for this purpose: 1) invasive methods, in which measurements are made directly in the blood stream, and 2) non-invasive methods. The first type is represented by electrochemical catalysts and fuel cells, the latter by spectroscopic procedures (mainly NMR- and IR-spectroscopy).

Ion-selective potentiometry in clinical chemistry. A review.

Ion-selective potentiometry is used more and more in clinical medicine for the determination of electrolytes in various body fluids. With regard to K+, Na+, Ca2+ and Cl- this technique has almost completely displaced flame photometry, atomic absorption spectrophotometry and coulometry. Moreover, reliable automated devices have facilitated routine analyses. Until now there are 6 different types of ion-selective sensors: glass membrane, solid phase, fluid membrane, carrier, gas-sensitive, and enzyme electrodes with immobilized enzymes. The latter are particularly used for in vivo monitoring, especially for continuous blood glucose monitoring. The essential fields of application in the clinical laboratory are the determinations of the cations H+, K+, Na+, Ca2+, Mg2+ and NH3+, and the anions F-, I-, Br-, Cl- and HCO3-. Despite the wide-spread application of ion-selective potentiometry a number of disturbing factors have to be taken into account by the user as well as by the manufacturer in order to get satisfactory results. For instance, there are differences between direct and indirect potentiometry. Moreover, the activities measured cannot be extrapolated readily to the desired concentrations. A careful and accurate calibration, a suitable sample preparation and an adjustment of the measuring conditions to the characteristics of the specimen and the matrix of the sample is necessary before each measurement. Therefore, a consequent internal and external quality control is necessary to achieve an optimal quality of these methods determining vital parameters in medicine. Thus, the technique of ion-selective potentiometry represents an important milestone in clinical chemistry. Moreover, being a very rapid procedure it is indispensable to clinical diagnostics.