Temporal patterns of patient-reported trismus and associated mouth-opening distances in radiotherapy for head and neck cancer: A prospective cohort study.

OBJECTIVES: To identify temporal patterns of patient-reported trismus during the first year post-radiotherapy, and to study their associations with maximal interincisal opening distances (MIOs). DESIGN: Single institution case series. SETTING: University hospital ENT clinic. PARTICIPANTS: One hundred and ninety-six subjects who received radiotherapy (RT) for head and neck cancer (HNC) with or without chemotherapy in 2007-2012 to a total dose of 64.6/68 Gy in 38/34 fractions, respectively. All subjects were prospectively assessed for mouth-opening ability (Gothenburg Trismus Questionnaire (GTQ), European Organization for Research and Treatment of Cancer quality of life Questionnaire (EORTC QLQ-H&N35), and MIO) pre-RT and at 3, 6 and 12 months after RT. MAIN OUTCOME MEASURES: Correlations between temporally robust GTQ symptoms and MIO as given by Pearson's correlation coefficients (Pr ); temporally robust GTQ-symptom domains as given by factor analysis; rates of trismus with respect to baseline by risk ratios (RRs). RESULTS: Four temporally robust domains were identified: Eating (3-7 symptoms), Jaw (3-7), Pain (2-5) and Quality of Life (QoL, 2-5), and included 2-3 persistent symptoms across all post-RT assessments. The median RR for a moderate/severe (>2/>3) cut-off was the highest for Jaw (3.7/3.6) and QoL (3.2/2.9). The median Pr between temporally robust symptoms and MIO post-radiotherapy was 0.25-0.35/0.34-0.43/0.24-0.31/0.34-0.50 for Eating/Jaw/Pain/QoL, respectively. CONCLUSIONS: Mouth-opening distances in patients with HNC post-RT can be understood in terms of associated patient-reported outcomes on trismus-related difficulties. Our data suggest that a reduction in MIO can be expected as patients communicate their mouth-opening status to interfere with private/social life, a clinical warning signal for emerging or worsening trismus as patients are being followed after RT.

Quantification of electroporative uptake kinetics and electric field heterogeneity effects in cells.

We have conducted experiments quantitatively investigating electroporative uptake kinetics of a fluorescent plasma membrane integrity indicator, propidium iodide (PI), in HL60 human leukemia cells resulting from exposure to 40 mus pulsed electric fields (PEFs). These experiments were possible through the use of calibrated, real-time fluorescence microscopy and the development of a microcuvette: a specialized device designed for exposing cell cultures to intense PEFs while carrying out real-time microscopy. A finite-element electrostatic simulation was carried out to assess the degree of electric field heterogeneity between the microcuvette's electrodes allowing us to correlate trends in electroporative response to electric field distribution. Analysis of experimental data identified two distinctive electroporative uptake signatures: one characterized by low-level, decelerating uptake beginning immediately after PEF exposure and the other by high-level, accelerating fluorescence that is manifested sometimes hundreds of seconds after PEF exposure. The qualitative nature of these fluorescence signatures was used to isolate the conditions required to induce exclusively transient electroporation and to discuss electropore stability and persistence. A range of electric field strengths resulting in transient electroporation was identified for HL60s under our experimental conditions existing between 1.6 and 2 kV/cm. Quantitative analysis was used to determine that HL60s experiencing transient electroporation internalized between 50 and 125 million nucleic acid-bound PI molecules per cell. Finally, we show that electric field heterogeneity may be used to elicit asymmetric electroporative PI uptake within cell cultures and within individual cells.

Quantitative detection of low-copy-number mRNAs differing at single nucleotide positions.

Accurate analysis of mRNA expression levels of SNPs, highly homologous genes, and splicing variants requires techniques capable of quantifying low-copy-number mRNAs differing at single nucleotide positions. We have used an RT-PCR-based technique based on co-amplification of closely related target mRNA transcripts and assessed the effect of the stochastic distribution of low-copy-number templates on sampling variation when quantifying rare mRNA transcripts. The technique was optimized for maximal sensitivity to enable the analysis of samples containing a subpopulation of target cells and small microdissected samples. We demonstrate that the input level of template molecules is a critical determinant of the achievable assay precision. A minimum of approximately 50 molecules of template is required to discriminate between 2-fold differences in the expression levels of two transcripts. At levels above 1000 molecules of input template, the stochastic effects on sampling variation become negligible.

Comparison of urine trypsinogen-2 test strip with serum lipase in the diagnosis of acute pancreatitis.

BACKGROUND/AIMS: The accuracy of a new rapid urinary trypsinogen-2 test strip (actim Pancreatitis) was compared with that of serum lipase for detection of acute pancreatitis in patients with acute abdominal pain. METHODOLOGY: A prospective study was conducted which consisted of 237 consecutive patients with acute abdominal pain admitted to the emergency unit at Helsinki University Central Hospital. The patients were tested on admission with the actim Pancreatitis test strip. Serum amylase, serum lipase, and urine trypsinogen-2 concentrations were also determined quantitatively. RESULTS: The actim Pancreatitis test strip result was positive in 27 out of 29 patients with acute pancreatitis (sensitivity 93%) and in 16 of 208 patients with non-pancreatic abdominal pain (specificity 92%). This was superior to that of serum lipase (sensitivity 79% and specificity 88%). With a cut-off > 3x the upper reference limit, the sensitivity of serum lipase was only 55% while the specificity was 99%. The high sensitivity for the actim Pancreatitis test strip resulted in a very high negative predictive value of 99%. All six patients with severe acute pancreatitis were detected by the dipstick. With a higher cut-off value (> 3x upper reference limit) for lipase, two patients with severe acute pancreatitis remained undetected. Combining the actim Pancreatitis dipstick with serum lipase a positive predictive value of 94% was obtained. CONCLUSIONS: Acute pancreatitis can be excluded with a higher probability with the actim Pancreatitis strip than with serum lipase determination, and therefore appears to be more suitable for screening of acute pancreatitis. With its high specificity with a cut-off > 3x the upper reference limit, serum lipase is suitable as a confirmatory test for pancreatitis when a positive dipstick result is obtained.

Elevated levels of trypsinogen-2 and trypsin-2-alpha1-antitrypsin in sera of infants and children after cardiac surgery.

Acute pancreatitis is a known complication of cardiac surgery with cardiopulmonary bypass but amylase is not a reliable marker in infants. We evaluated whether the serum concentrations of trypsinogen-2 and trypsin-2-alpha1-antitrypsin (AAT) can be used to study disturbances in pancreatic function in children and infants undergoing cardiac surgery. The study comprised 21 infants < 1 year and 25 children aged 1-16 years undergoing cardiopulmonary bypass at the Children's Hospital, Helsinki University Central Hospital. Consecutive serum samples were taken before surgery, at 12 h, 1, 2 and 3 days after surgery, and before discharge from the hospital. A moderate increase in trypsinogen-2 and trypsin-2-AAT in serum was found in more than two-thirds of the patients. On day 3, there was a 4.3-fold mean increase (CI 95% 2.8-6.5) in trypsinogen-2 and a 2.4-fold mean increase (CI 95% 1.8-3.1) in trypsin-2-AAT. In 4 patients trypsinogen-2 was elevated by more than 20-fold. One patient had clinical pancreatitis, but there were no clinical signs of pancreatitis in the other three patients. The changes in trypsinogen-2 and trypsin-2-AAT were similar in infants and children. The moderate increase in the serum concentrations of trypsinogen-2 and trypsin-2-AAT after cardiac surgery in the absence of signs of pancreatitis may be due to a subclinical pancreatic disturbance, but it could also be caused by an inflammatory response and expression of extrapancreatic trypsin. Contrary to amylase, trypsinogen-2 is expressed in the pancreas of infants.

Analysis of the segmental stability of helical peptides by isotope-edited infrared spectroscopy.

Isotope-edited infrared spectroscopy has the ability to probe the segmental properties of long biopolymers. In this work, we have compared the infrared spectra of a model helical peptide ((12)C) Ac-W-(E-A-A-A-R)(6)-A-NH(2), described originally by Merutka et al. (Biochemistry 1991;30:4245-4248) and three derivatives that are (13)C labeled at the backbone carbonyl of alanines. The locations of six isotopically labeled alanines are at the N-terminal, C-terminal, and the middle two repeating units of the peptide. Variation in temperature from 1 degrees to 91 degrees C transformed the peptides from predominantly helical to predominantly disordered state. Amplitude and position of the infrared amide I' absorption bands from (12)C- and (13)C-labeled segments provided information about the helical content. Temperature dependence of infrared spectra was used to estimate segmental stability. As a control measure of overall peptide stability and helicity (independent of labeling), the temperature dependence of circular dichroism spectra in the far-UV range at identical conditions (temperature and solvent) as infrared spectra was measured. The results indicate that the central quarter of the 32 amino acids helix has the maximal helicity and stability. The midpoint of the melting curve of the central quarter of the helix is 5.4 +/- 0.8 degrees C higher than that of the termini. The N-terminal third of the helix is more helical and is 2.0 +/- 1.4 degrees C more stable than the C-terminus.

Trypsinogen-1, -2 and tumour-associated trypsin-inhibitor in bile and biliary tract tissues from patients with biliary tract diseases and pancreatic carcinomas.

The bile concentrations of trypsinogen-1, -2 and tumour-associated trypsin-inhibitor (TATI) were determined in 23 patients with benign biliary tract disease, two with biliary tract cancer, and in 15 with pancreatic cancer. We also examined the trypsinogen and TATI expression by immunohistochemistry in tissue specimens from biliary tract cancer and non-neoplastic extrahepatic biliary tract. High levels of trypsinogen-1, trypsinogen-2, and TATI occur in bile of most patients. In contrast to the trypsinogens, the levels of TATI were significantly higher in patients with malignant disease than in those with benign diseases (p=0.04). There was no significant correlation between trypsinogen-2 and amylase (r=0.13, p=0.40), indicating that the occurrence of trypsinogen in bile is not a result of reflux of pancreatic fluid into the bile duct. Immunohistochemically, trypsinogen-2 was detected in five and TATI in 12 out of 15 non-neoplastic biliary tract specimens, and in four and seven out of 11 cholangiocarcinomas, respectively. High concentrations of trypsinogen-1, trypsinogen-2 and TATI occur in the bile of patients with non-neoplastic and malignant biliary tract disease and in patients with pancreatic cancer. At least part of the trypsinogen-2 and TATI found in bile appears to be derived from the biliary epithelium itself.

Relative levels of SCCA2 and SCCA1 mRNA in primary tumors predicts recurrent disease in squamous cell cancer of the head and neck.

Squamous cell carcinoma antigen (SCCA) is widely used as a serum marker in cancers of the uterine cervix, the head and neck, lung and esophagus. Two isoforms of SCCA, deriving from 2 highly homologous serine proteinase inhibitor genes, are co-expressed in normal and malignant squamous epithelium, but it is mainly the acidic isoform SCCA2 that is present in the circulation of cancer patients. We studied the relative levels of SCCA2 and SCCA1 mRNA in frozen sections of squamous cell carcinomas of the head and neck (SCCHN) in relation to disease recurrence, using a new reverse transcription-polymerase chain reaction-based technique for accurate quantitation of relative mRNA levels. Primary tumors from 30 SCCHN patients, recurrent tumors from 11 patients and normal epithelium from 16 controls were examined. In patients responding to initial therapy (n = 26), an elevated SCCA2/SCCA1 mRNA ratio in the primary tumor predicted recurrence independent of clinical stage (p = 0.011). The relative risk of developing a recurrence was 7.2 (CI 1.2-13.3) in patients with elevated vs. normal SCCA2/SCCA1 mRNA ratios. We demonstrate that subtle differences in expression levels of the SCCA genes are reflected in the course of the SCCHN disease and may provide a target for molecular grading of SCCHN tumors. If this finding can be confirmed in a larger study the SCCA2/SCCA1 mRNA ratio in primary tumors could be useful for individual selection of treatment strategy for patients with head and neck cancer.

A comparison of serum trypsinogen-2 and trypsin-2-alpha1-antitrypsin complex with lipase and amylase in the diagnosis and assessment of severity in the early phase of acute pancreatitis.

OBJECTIVE: The aim of the study was to compare the recently introduced laboratory markers trypsinogen-2 and trypsin-2-alpha1 antitrypsin complex (trypsin-2-AAT) in serum with lipase and amylase in the diagnostic and prognostic evaluation of patients with acute pancreatitis (AP). METHODS: The analytes were measured on admission in 64 consecutive patients with AP and in 30 controls with acute abdominal disease of extrapancreatic origin. Twenty-one patients had severe and 43 mild AP. As reference methods we used serum amylase and C-reactive protein. RESULTS: In subjects with AP, elevated trypsinogen-2 values (> or = 90 microg/L) were observed in 63 patients (98%), trypsin-2-AAT values (> or = 12 microg/L) in 64 patients (100%), lipase values (> or = 200 U/L) in 64 patients (100%), and amylase values (> or = 300 IU/L) in 62 patients (97%). The diagnostic accuracy of the markers was evaluated by receiver operating characteristic (ROC) analysis. On admission, trypsinogen-2, trypsin-2-AAT, lipase, and amylase differentiated patients with AP from controls with high accuracy and ROC analyses showed similar areas under the ROC curves (AUC) for trypsinogen-2 (AUC 0.960), trypsin-2-AAT (0.948), lipase (AUC 0.947), and amylase (AUC 0.930). For differentiation between severe and mild AP, trypsin-2-AAT (AUC 0.805) was slightly better than trypsinogen-2 (AUC 0.792), and they were both clearly better than lipase (AUC 0.583), C-reactive protein (AUC 0.519), or amylase (AUC 0.632) (p < 0.05). CONCLUSIONS: All the markers studied showed high accuracy for differentiating between AP and extrapancreatic diseases. However, trypsinogen-2 and trypsin-2-AAT displayed the best accuracy for predicting a severe AP already at admission, which makes these markers superior for clinical purposes.

The ratio of trypsin-2-alpha(1)-antitrypsin to trypsinogen-1 discriminates biliary and alcohol-induced acute pancreatitis.

BACKGROUND: Rapid determination of the etiology of acute pancreatitis (AP) enables institution of appropriate treatment. We evaluated the ability of trypsinogen-1, trypsinogen-2, trypsin-1-alpha(1)-antitrypsin (AAT), and trypsin-2-AAT in serum to identify the etiology of AP. METHODS: The study consisted of 67 consecutive patients with AP admitted to Helsinki University Central Hospital. Forty-two had alcohol-induced AP, 16 had biliary AP, and 9 had unexplained etiology. Serum samples were drawn within 12 h after admission. Trypsinogen-1, trypsinogen-2, trypsin-1-AAT, and trypsin-2-AAT were determined by time-resolved immunofluorometric assays. Logistic regression was used to estimate the ability of the serum analytes to discriminate between alcohol-induced and biliary AP. The validity of the tests was evaluated by ROC curve analysis. RESULTS: Patients with alcohol-induced AP had higher median values of trypsin-1-AAT (P = 0.065), trypsinogen-2 (P = 0.034), and trypsin-2-AAT (P <0.001) than those with biliary AP, who had higher values of amylase (P = 0.002), lipase (P = 0.012), and alanine aminotransferase (P = 0.036). The ratios of trypsin-2-AAT to trypsinogen-1, lipase, or amylase efficiently discriminated between biliary and alcohol-induced AP (areas under ROC curves, 0.92-0.96). CONCLUSIONS: Trypsinogen-2 and trypsin-2-AAT are markedly increased in AP of all etiologies, whereas trypsinogen-1 is increased preferentially in biliary AP. The trypsin-2-AAT/trypsinogen-1 ratio is a promising new marker for discrimination between biliary and alcohol-induced AP.

Reliable screening for acute pancreatitis with rapid urine trypsinogen-2 test strip.

BACKGROUND: This study was designed to evaluate the validity of a new rapid urinary trypsinogen-2 test strip (Actim Pancreatitis) for detection of acute pancreatitis in patients with acute abdominal pain. METHODS: A total of 525 consecutive patients presenting with abdominal pain at two emergency units was included prospectively and tested with the Actim Pancreatitis test strip. Urine trypsinogen-2 concentrations were also determined by a quantitative method. The diagnosis and assessment of severity of acute pancreatitis was based on raised serum and urinary amylase levels, clinical features and findings on dynamic contrast-enhanced computed tomography. RESULTS: In 45 patients the diagnosis of acute pancreatitis could be established. The Actim Pancreatitis test strip result was positive in 43 of them resulting in a sensitivity of 96 per cent. Thirty-seven false-positive Actim Pancreatitis test strips were obtained in patients with non-pancreatic abdominal pain resulting in a specificity of 92 per cent. Nine patients with severe acute pancreatitis were all detected by the dipstick. CONCLUSION: A negative Actim Pancreatitis strip result excludes acute pancreatitis with high probability. Positive results indicate the need for further evaluation, i.e. other enzyme measurements and/or radiological examinations. The test is easy and rapid to perform, unequivocal in its interpretation and can be used in healthcare units lacking laboratory facilities.

Time course profile of serum trypsinogen-2 and trypsin-2-alpha1-antitrypsin in patients with acute pancreatitis.

BACKGROUND: Trypsinogen-2 and the trypsin-2-alpha1-antitrypsin complex are recently introduced new laboratory markers for acute pancreatitis. They show high sensitivity and specificity for acute pancreatitis on admission, but little is known on their time course profiles. METHODS: The serum concentrations of trypsinogen-2 and trypsin-2-alpha1-antitrypsin were monitored in 92 patients with verified acute pancreatitis. The follow-up period was 42 days in patients with severe acute pancreatitis (N = 73) and 9 days in mild disease (N = 19). RESULTS: On admission the mean serum concentration of trypsinogen-2 was 2880 microg/l in severe and 920 microg/l in mild acute pancreatitis. These values were 32- and 10-fold the upper reference limit, respectively. Trypsin-2-alpha1-antitrypsin concentrations were 1250 microg/l (100-fold the upper reference limit) and 635 microg/l (52-fold), respectively. The differences were statistically significant (P = 0.026-0.001). The concentrations of trypsinogen-2 and trypsin-2-alpha1-antitrypsin decreased gradually during the follow-up period, but they remained elevated for the entire study period in patients with severe and mild disease. CONCLUSIONS: The time course profile of trypsinogen-2 and trypsin-2-alpha1-antitrypsin is favorable for diagnosing acute pancreatitis. The elevation starts within hours after the onset of the disease and it is very steep. Both markers remain elevated longer than amylase and the magnitude of the elevation correlates with the severity of the disease. This is further evidence to support the use of trypsinogen-2 and trypsin-2-alpha1-antitrypsin for the evaluation of patients suspected of having acute pancreatitis.

Time-resolved immunofluorometric assay of trypsin-1 complexed with alpha(1)-antitrypsin in serum: increased immunoreactivity in patients with biliary tract cancer.

BACKGROUND: Increased serum concentrations of trypsin immunoreactivity occur in patients with biliary tract cancer. To characterize this trypsin, we developed a sensitive time-resolved immunofluorometric assay for trypsin-1 complexed with alpha(1)-antitrypsin (AAT) and studied the concentrations of this complex in sera from healthy individuals (n = 130) and patients with benign biliary disease (n = 32), biliary tract cancer (n = 17), pancreatic cancer (n = 27), and hepatocellular cancer (n = 12). METHODS: We used a trypsin-1-specific monoclonal antibody on the solid phase and a europium-labeled polyclonal antibody to AAT as tracer. The detection limit was 0.42 microgram/L. The validity of the trypsin-1-AAT test for detection of biliary tract cancer was compared with trypsin-2-AAT and CA19-9. RESULTS: Increased concentrations of trypsin-1-AAT (>33 microgram/L) were found in 76% of patients with biliary tract cancer, and the concentrations were significantly higher than in those with benign biliary disease (P <0. 0001). The median concentration of trypsin-1-AAT in serum from patients with biliary tract cancer was 3.7-fold higher than in healthy controls, 2.6-fold higher than in patients with benign biliary tract disease, 1.7-fold higher than in patients with pancreatic cancer, and 2.0-fold higher than in patients with hepatocellular cancer. CONCLUSIONS: Of the markers studied, trypsin-1-AAT had the largest area (0.83) under the receiver operating curve in differentiating biliary tract cancer from benign biliary tract disease. Our results suggest that trypsin-1-AAT is a new potential marker for biliary tract cancer.

Concentration of free hCGbeta subunit in serum as a prognostic marker for squamous-cell carcinoma of the oral cavity and oropharynx.

This study was conducted to evaluate the clinical usefulness of serum hCGbeta in the diagnosis and prognosis of patients (n = 59) with cancers of the oral cavity and oropharynx. As a reference marker we used squamous-cell carcinoma antigen (SCCAg). A blood sample was obtained from all patients before primary surgery. Serum hCGbeta was determined by a time-resolved immunofluorometric assay (IFMA) and SCCAg by a solid phase immunoenzymometric assay. Elevated preoperative hCGbeta levels were observed in 8 (14%) and elevated SCCAg in 12 (20%) out of 59 patients. Patients with preoperatively elevated hCGbeta had a shorter recurrence-free survival when compared with those with normal hCGbeta levels (log-rank Chi-squared = 6.83, p =.009), and the risk-ratio for recurrence during follow-up for those was 3.6 (95% CI = 1.29-9.94). In a Cox multivariate model hCGbeta (p = 0.039) and stage (p = 0.044) were independent prognostic factors. SCCAg showed no correlation with recurrence-free survival. We conclude that determination of hCGbeta in serum is a potential marker in the prognostic evaluation of patients with SCC of the oral cavity and oropharynx.

Studies on sulfation of synthesized metabolites from the local anesthetics ropivacaine and lidocaine using human cloned sulfotransferases.

The metabolism of the local anesthetics lidocaine and ropivacaine (ropi) involves several steps in humans. Lidocaine is mainly hydrolyzed and hydroxylated to 4-OH-2,6-xylidine (4-OH-xyl). The metabolism of ropi, involving dealkylation and hydroxylation, gives rise to 3-OH-ropi, 4-OH-ropi, 3-OH-2'6'-pipecoloxylidide (3-OH-PPX), and 2-OH-methyl-ropi. Because the metabolites are hydroxylated, they are particularly prone to subsequent Phase II conjugation reactions such as sulfation and glucuronidation. This study focused on the in vitro sulfation of these metabolites as well as another suspected metabolite of ropi, 2-carboxyl-ropi. All the metabolites were synthesized for the subsequent enzymatic studies. Five cloned human sulfotransferases (STs) were used in this study, namely, the phenol-sulfating form of ST (P-PST-1), the monoamine-sulfating form of ST (M-PST), estrogen-ST (EST), ST1B2, and dehydroepiandrosterone-ST (DHEA-ST), all of which are expressed in human liver. The results demonstrate that all of the metabolites except 2-OH-methyl-ropi and 2-carboxyl-ropi can be sulfated. It was also found that all of the STs can conjugate the remaining hydroxylated metabolites except DHEA-ST. However, there are large differences in the capacity of the individual human ST isoforms to conjugate the different metabolites. P-PST-1 sulfates 3-OH-PPX, 3-OH-ropi, and 4-OH-xyl; M-PST and EST conjugate 3-OH-PPX, 3-OH-ropi, and 4-OH-ropi whereas ST1B2 sulfates only 4-OH-xyl. The most extensively sulfated ropi metabolite is 3-OH-PPX. In conclusion, all of the hydroxylated metabolites of lidocaine and ropi can be sulfated if the hydroxyl group is attached to the aromatic ring in the metabolites. The human ST enzymes that are considered to be responsible for the sulfation of these metabolites in vivo are P-PST-1, M-PST, EST, and ST1B2. These enzymes are also found in the liver; this is the most important tissue for the metabolism of ropi in humans, demonstrated by.

Advances in the laboratory diagnostics of acute pancreatitis.

Acute pancreatitis is a rather common abdominal disorder. In most patients the disease is mild, but about 20% of cases develop a severe necrotizing form of the disease with complications. In an emergency setting, the diagnosis of acute pancreatitis remains problematic and several patients with severe disease are diagnosed only at autopsy. Measurements of amylase or lipase are the principal laboratory methods for diagnosing acute pancreatitis. However, their sensitivity and specificity are generally considered unsatisfactory. Recent advances in the knowledge of the pathogenesis of acute pancreatitis and advances in laboratory technology have revealed new diagnostic possibilities. Especially assays based on trypsin pathophysiology have brought new alternatives for diagnostics and severity grading of the disease. Additionally, development of phospholipase A2 determinations and discovery of a new pancreatic protein, pancreatitis-associated protein, are very interesting. This article summarizes the value of new methods in the laboratory diagnostics of acute pancreatitis.

Evaluation of a new urinary amylase test strip in the diagnosis of acute pancreatitis.

We have developed a novel rapid test strip for detecting pancreatic amylase in urine and prospectively evaluated its accuracy in screening for acute pancreatitis (AP). The test strip is based on the immunochromatography principle and uses two monoclonal antibodies specific for pancreatic amylase. Urine samples were collected from 500 consecutive patients with acute abdominal disease (52 with AP) and prospectively tested with the strip. The accuracy of the test strip was compared with that of two quantitative urine amylase determinations and a urinary dipstick test for amylase (Rapignost). Sensitivity of the test was 69% and specificity was 97% in differentiating patients with AP from those with acute abdominal extrapancreatic disease at admission. The negative predictive value was 0.986. The test showed moderate agreement both with an assay measuring total amylase activity and with another measuring pancreatic amylase immunoreactivity. At similar high specificity (97%), quantitative determination of total amylase activity (cut-off 3960 U/L) and pancreatic amylase (cut-off 2180 micrograms/L) showed lower sensitivity (54% and 41%) than the test strip (69%). The test is specific and rapid to perform, and it rules out AP with high probability. It could therefore be useful in an emergency setting without laboratory facilities in the differential diagnosis of acute abdominal pain.

Rapid measurement of urinary trypsinogen-2 as a screening test for acute pancreatitis.

BACKGROUND: Acute pancreatitis can be difficult to diagnose. We developed a rapid dipstick screening test for pancreatitis, based on the immunochromatographic measurement of urinary trypsinogen-2. METHODS: We prospectively compared the urinary trypsinogen-2 dipstick test with a quantitative urinary trypsinogen-2 assay, a urinary dipstick test for amylase, and serum and urinary amylase assays in 500 consecutive patients with acute abdominal pain at two emergency departments. Acute pancreatitis was diagnosed according to standardized criteria. RESULTS: The urinary trypsinogen-2 dipstick test was positive in 50 of the 53 patients with acute pancreatitis (sensitivity, 94 percent), including all 7 with severe pancreatitis. Two patients with urinary trypsinogen-2 concentrations below the sensitivity threshold of the test (50 ng per milliliter) and one with a very high concentration had false negative results. The test was also positive in 21 of the 447 patients without pancreatitis (specificity, 95 percent), including 7 with abdominal cancers, 3 with cholangitis, and 2 with chronic pancreatitis. The sensitivity and specificity of the dipstick test were similar to those of the quantitative urinary trypsinogen-2 assay and higher than those of the urinary amylase dipstick test. The serum amylase assay had a sensitivity of 85 percent (with a cutoff value of 300 U per liter for the upper reference limit) and a specificity of 91 percent. The sensitivity and specificity of the urinary amylase assay (cutoff value, 2000 U per liter) were 83 and 88 percent, respectively. CONCLUSIONS: In patients with acute abdominal pain seen in the emergency department, a negative dipstick test for urinary trypsinogen-2 rules out acute pancreatitis with a high degree of probability. A positive test usually identifies patients in need of further evaluation.

Urinary trypsinogen-2 test strip in detecting ERCP-induced pancreatitis.

BACKGROUND AND STUDY AIMS: We have evaluated a new urinary trypsinogen-2 test strip, based on the principle of immunochromatography, in the diagnosis of acute pancreatitis induced by endoscopic retrograde cholangiopancreatography (ERCP). PATIENTS AND METHODS: One hundred six consecutive patients undergoing ERCP (with opacification of the pancreatic duct) at the Helsinki University Central Hospital were included in the study. Patients were tested with a urinary trypsinogen-2 test strip six hours after ERCP. Quantitative trypsinogen-2 as well as serum and urine amylase values were measured before the procedure and six hours after it. RESULTS: In patients developing pancreatitis after ERCP, the median urinary trypsinogen-2 concentration six hours after the endoscopic procedure was 1780 micrograms/l (range 29-10,700 micrograms/l), and in patients without pancreatitis the median concentration was 3.6 micrograms/l (range 0.1-3390 micrograms/l; P < 0.0001). The sensitivity and specificity figures for the urinary trypsinogen-2 test strip results in diagnosing post-ERCP pancreatitis were comparable (81% and 97%, respectively) to those for serum amylase (91% and 96%) and urine amylase measurements (81% and 95%). The test strip showed a good correlation (kappa = 0.75) with the quantitative trypsinogen-2 assay. CONCLUSIONS: The increase in urinary trypsinogen-2 concentration after ERCP reflects pancreatic injury, and can be detected by the test strip. Patients should be tested before the ERCP procedure as well, since elevated baseline values occur. The test is reliable and easy to perform even on an outpatient basis. However, its clinical usefulness requires evaluation in further trials.

Increased serum trypsinogen 2 and trypsin 2-alpha 1 antitrypsin complex values identify endoscopic retrograde cholangiopancreatography induced pancreatitis with high accuracy.

AIMS: To evaluate the clinical utility of two new tests for serum trypsinogen 2 and trypsin 2-alpha 1 antitrypsin complex (trypsin 2-AAT) in diagnosing and assessing the severity of acute pancreatitis (AP) induced by endoscopic retrograde cholangiopancreatography (ERCP). PATIENTS: Three hundred and eight consecutive patients undergoing ERCP at Helsinki University Central Hospital in 1994 and 1995. METHODS: Patients were followed prospectively for pancreatitis and clinical outcome. They were tested for serum trypsinogen 2, trypsin 2-AAT, and amylase in samples obtained before and one, six, and 24 hours after ERCP. RESULTS: Pancreatitis developed in 31 patients (10%). Their median serum trypsinogen 2 increased 26-fold to 1401 micrograms/l at six hours after the procedure and trypsin 2-AAT showed an 11-fold increase to 88 micrograms/l at 24 hours. The increase in both markers was stronger in severe than in mild pancreatitis, and in patients without pancreatitis there was no significant increase. Baseline trypsinogen 2 and trypsin 2-AAT concentrations were elevated in 29% and 32% of patients, respectively. The diagnostic accuracy of a threefold elevation over the baseline value was therefore analysed. The sensitivity and specificity of these parameters in the diagnosis of post-ERCP pancreatitis was 93% and 91%, respectively, for serum trypsinogen 2 at six hours after the examination, and 93% and 90%, for trypsin 2-AAT at 24 hours. CONCLUSIONS: Serum trypsinogen 2 and trypsin 2-AAT reflect pancreatic injury after ERCP. High concentrations are associated with severe pancreatic damage. The delayed increase in trypsin 2-AAT compared with trypsinogen 2 appears to reflect the pathophysiology of AP. A greater than threefold increase in trypsinogen 2 six hours after ERCP is an accurate indicator of pancreatitis.