Trevor A. Walmsley

The significance of haemochromatosis gene mutations in the general population: implications for screening

Background—Haemochromatosis is associated with mutations in the HFE gene but the significance of these mutations in the general population is unknown. Aims—To determine the frequency ofHFE gene mutations in the general population, their effect on serum iron indexes, and their role in screening for haemochromatosis. Methods—Deoxyribonucleic acid (DNA) from 1064 randomly selected subjects was analysed for the C282Y and H63D mutations in the HFE gene. Serum iron, transferrin saturation, and ferritin were measured and individuals with increased iron indexes were investigated to confirm or exclude a clinical diagnosis of haemochromatosis. Results—Mutations were identified in 409 individuals (38.4%) with heterozygote (carrier) frequencies of 13.2% and 24.3% for the C282Y and H63D mutations respectively. Heterozygosity for either mutation significantly increased serum iron and transferrin saturation but despite a similar trend for ferritin, this was only significant for C282Y homozygotes. Five individuals (0.47%) were homozygous for the C282Y mutation, three of whom had haemochromatosis confirmed by liver biopsy (0.28%). The other two C282Y homozygotes would not have been detected by phenotypic screening alone. Conclusions—HFE mutations are present in 38.4% of the population, affect serum iron indexes, and are important determinants of iron status. The population frequency of genetically defined haemochromatosis (C282Y homozygosity) is approximately one in 200 and is higher than the prevalence of clinically apparent haemochromatosis.

The Effect of Hemolysis on Current Troponin Assays—A Confounding Preanalytical Variable?

The universal definition of myocardial infarction stipulates the detection of an increase and/or decrease in cardiac biomarkers [preferably troponin I (TnI)1 or T (TnT)], with at least 1 value >99th percentile of the upper reference limit, together with evidence of myocardial ischemia (1). With the emergence of more sensitive troponin assays, what constitutes a genuine increase and/or decrease becomes critically important(2). For analytical values to be considered different, it has been suggested that such values should vary by >3 SDs of the variance of the measurement method and that a 20% change for troponins is greater than what would be expected from analytical variation(1). At low troponin concentrations, either definition translates into small absolute changes. Good analytical precision is therefore critically important, as is careful consideration of preanalytical variables, such as sample type and particularly hemolysis. Hemolysis is known to be more prevalent in the emergency department environment, with rates of up to 20% of samples(3). Hemolysis …

Haemochromatosis gene mutations Cys282Tyr and His63Asp are not increased in Type 2 diabetic patients compared with the Canterbury (New Zealand) general population

Genetic predisposition to haemochromatosis may be an important aetiological factor in some cases of Type 2 diabetes. Our aim was therefore to test the hypothesis that the haemochromatosis gene mutations Cys282Tyr and His63Asp are more prevalent in Type 2 diabetic patients compared with the Canterbury, New Zealand general population. We studied 230 consecutive patients referred to the Diabetes Services with age > or = 30 years and considered to have Type 2 diabetes. DNA was extracted from whole blood and amplified by polymerase chain reaction prior to restriction fragment length polymorphism analysis. The frequency of the mutations was compared with that observed previously in 1064 subjects from the Canterbury general population by chi2 testing. Iron was measured by a colorimetric method, transferrin by rate nephelometry and ferritin by immunoassay. There were 2/230 (0.8%) Cys282Tyr homozygous subjects in the diabetic group compared with 5/1064 (0.5%) NS in the general population. Although there was a trend to lower incidence of Cys282Tyr heterozygosity in the diabetic group, there was no significant difference for any of the six genotype frequencies between the two groups. Haemochromatosis gene mutations Cys282Tyr and His63Asp are therefore not increased in Type 2 diabetics compared with the general population. Transferrin saturation was a sensitive marker (100%) of genetic haemochromatosis, although ferritin had low specificity (77.8%). Genetic susceptibility to haemochromatosis is not an important aetiological factor for diabetes, and targeted screening of diabetic patients for haemochromatosis is not indicated.

Optimal conditions for 4-hydroxybenzoyl- and 2-furoylhydrazine as reagents for the determination of carbohydrates, including ketosamines

4- Hydroxybenzoylhydrazine ( PAHBAH ) reacts with glucose in hot aqueous solution when alkali exceeds aroylhydrazine concentration. The related 2- furoylhydrazine ( FAH ) reacts at lower alkali concentrations, making this an attractive alternative carbohydrate reagent since it is (unlike PAHBAH ) freely water soluble. FAH reacts with monosaccharides more slowly than does PAHBAH , giving about half the color. Its specificity and behavior with a bismuth catalyst parallel those of PAHBAH . Solutions which contain 0.05 mol/liter PAHBAH with 1.5 mmol/liter bismuth III (as tartrate complex) and 0.5 mol/liter sodium hydroxide, or 0.01 mol/liter FAH with 1.5 mmol/liter bismuth III and 0.1 mol/liter sodium hydroxide are sensitive reagents for quantitative analysis, giving stable colors with many carbohydrates within 10 min at 75 degrees C. Ketosamines react more rapidly than glucose at lower temperatures and undergo similar reactions in less alkaline solutions. At pH less than 8, the reaction is specific for these 1- aminohexoses , and FAH can be used as a reagent for their assay.

Vitamin B1 and B6 method harmonization: comparison of performance between laboratories enrolled in the RCPA Quality Assurance Program.

OBJECTIVES The RCPA Quality Assurance Program (RCPA QAP) offers monthly proficiency testing for vitamins A, B1, B6, β-carotene, C and E to laboratories worldwide. A review of the results submitted for the whole blood vitamin B1/B6 sub-program revealed a wide dispersion. Here we describe the results of a methodology survey for vitamins B1 and B6. DESIGN AND METHODS A questionnaire was sent to thirteen laboratories. Eleven laboratories were returning QAP results for vitamin B1 (thiamine diphosphate) and five were returning results for vitamin B6 (pyridoxal-5-phosphate). RESULTS All nine respondents provided a clinical service for vitamins B1 and B6. HPLC with fluorescence detection was the most common method principle. For vitamin B1, six respondents used a commercial assay whilst three used in-house methods; whole blood was the matrix for all. For vitamin B6, five respondents used commercial assays and four used in-house assays. The choice of matrix for vitamin B6 varied with three respondents using whole blood and five using plasma for analysis. Sample preparation incorporated protein precipitation and derivatization steps. An internal standard was employed in sample preparation by only one survey respondent. CONCLUSIONS The immediate result of this survey was the incorporation of plasma vitamin B6 into the RCPA QAP vitamin program. The absence of an internal standard in current vitamin B1 and B6 assays is a likely contributor to the wide dispersion of results seen in this program. We recommend kit manufacturers and laboratories investigate the inclusion of internal standards to correct the variability that may occur during processing.

A competitive ELISA for lipoprotein(a)

A competitive ELISA for lipoprotein(a) (Lp(a)) is described. The method uses a commercially available polyclonal anti-Lp(a) antibody and an IgG biotinstreptavidin-horseradish peroxidase detection system. The method is simple and robust with an assay sensitivity of 0.7 ng/well (1.4 micrograms/l). The antibody cross-reactivity was 0.14% against LDL and 0.70% against plasminogen. The coefficients of variation obtained with control sera of 266 and 552 mg/l were: 5.0% and 4.6% (n = 6), respectively for the intraassay; and 10.8% and 9.5% (n = 16), respectively for the interassay. The method showed an excellent correlation with a commercial immunoradiometric assay (IRMA), y (ELISA) = 0.94x (IRMA) - 8, (r = 0.98). A recovery study in which a 200 mg/L standard and four plasma samples were diluted with different proportions of a low plasma sample, gave linear relationships and also confirmed the specificity of the antibody.

Folate and vitamin B12 status of women of reproductive age living in Hanoi City and Hai Duong Province of Vietnam.

OBJECTIVES To assess the folate and vitamin B12 status of a group of Vietnamese women of reproductive age and to estimate the rate of neural tube defects (NTD) based on red blood cell (RBC) folate concentrations. DESIGN AND SUBJECTS A representative sample of non-pregnant women (15-49 years) living in Hanoi City (n 244) and Hai Duong Province (n 245). MEASURES RBC folate, plasma vitamin B12 and plasma holo-transcobalamin (holoTC), a sensitive indicator of vitamin B12 status. RESULTS Mean (95% CI) concentrations of RBC folate, plasma B12 and plasma holoTC were 856 (837, 876) nmol/l, 494 (475, 513) pmol/l and 78 (74, 82) pmol/l, respectively. Only 3% and 4% of women had plasma B12 and holoTC concentrations indicative of deficiency. No woman had an RBC folate concentration indicative of deficiency (<317 nmol/l). Only 47% of women had an RBC folate concentration > or = 905 nmol/l. Accordingly, we predict the NTD rate in these regions of Vietnam to be 14.7 (14.2, 15.1) per 10,000 pregnancies. CONCLUSION There was no evidence of folate and vitamin B12 deficiency among this population of Vietnamese women. However, suboptimal folate status may be placing three out of five women at increased risk of NTD. Reductions in NTD rates are still possible and women would benefit from additional folic acid during the periconceptional period from either supplements or fortified foods.

Thiopurine methyltransferase and thiopurine metabolite testing in patients with inflammatory bowel disease who are taking thiopurine drugs

Thiopurine methyltransferase genotyping and thiopurine metabolite testing has been established as an adjunct to monitoring patients taking thiopurine drugs. This special report describes the clinical implications for this type of testing for patients with inflammatory bowel disease who are taking thiopurine drugs. A total of 10% of patients were found to be intermediate metabolizers and the mean dosage (in mg/kg equivalent) was lower in intermediate metabolizers than extensive metabolizers. The metabolite levels did not correlate with scores measuring clinical severity but levels of 6-methylmercaptopurine were related to the dosage of the drugs. Despite considerable study of thiopurine methyltransferase testing in the literature, it is still not widely used in many geographical areas. This study adds to the evidence about using such testing as well as expanding the role of simultaneously measuring thiopurine metabolites. Further work is planned to evaluate the uptake when such testing becomes available locally as a clinical service.

Pseudo-hypertriglyceridaemia: a measurement artefact due to glycerol kinase deficiency

A man presented with elevated plasma triglycerides and was commenced on fibrate treatment. The triglycerides did not fall and compliance was questioned. The triglyceride elevation was inconsistent with the observed lack of turbidity in the plasma sample. Triglyceride elevation was not confirmed by a different analytical method and lipoprotein electrophoresis showed a normal very low density lipoprotein (VLDL) band pattern. Glycerol kinase deficiency was suspected and was supported by elevated urine glycerol, and confirmed by reduced leucocyte enzyme activity and mutational analysis of the GK gene which showed a novel three base pair deletion. Demonstration of a point mutation also excludes a contiguous gene deletion syndrome.

A mass-spectroscopic method for measuring des-Leu albumin--a novel marker for chronic pancreatitis.

OBJECTIVES Chronic pancreatitis is a progressive inflammatory disease leading to pancreatic insufficiency. The diagnosis of chronic pancreatitis is challenging, especially in early disease and the current tests have low sensitivity, may be invasive or have limited availability. We previously identified a truncated form of albumin lacking the C-terminal leucine, des-Leu albumin, which was present at high concentration in pancreatitis. We have developed a liquid-chromatography tandem-mass spectrometry (LC-MS/MS) method for measuring this peptide and make some preliminary observations on patient samples. METHODS Serum samples from patients with established pancreatitis and controls were obtained. Diluted serum samples or prepared standards were digested with trypsin. Aliquots of the digest were separated on a reversed-phase column using water:acetonitrile:formic acid mobile-phase with tandem-mass spectrometry detection. Percentage composition of des-Leu albumin was determined from a response curve. RESULTS The C-terminal peptide, LVAASQAALG- of des-Leu albumin was identified by m/z 901→725, wild type albumin by m/z 1014→825. Additional fragments were monitored as internal reference for digestion and sample integrity. Inter-assay imprecision was estimated at 10%. The percentage composition of des-Leu albumin segregated with the diagnosis of established pancreatitis with median levels of des-Leu albumin of 68% in patients compared to 5% in controls. CONCLUSIONS Des-Leu albumin is a promising novel biomarker for chronic pancreatitis. It allowed clear discrimination of patients with pancreatitis from controls and its long half-life may facilitate monitoring of disease activity. The method described could readily be undertaken in modern clinical chemistry laboratories and will form the basis for further study.