Monitoring Of Therapy In Patients Research Articles

Establishment of In-House Quantitative Real-Time RT-PCR Assay for HIV-1 Viral Load Measurement: Application to Evaluate Efficacy of ART in Ghanaian Patients in an Urban Setting

The aim of this study was to establish and apply a real-time quantitative reverse transcription polymerase chain reaction (RT-PCR) for human immunodeficiency virus (HIV) RNA quantification in patients on antiretroviral treatment (ART) in Ghana, where recombinant strains including CRF02_AG are prevalent. The primers and TaqMan probe concentrations as well as reaction temperatures were optimized to establish an efficient in-house quantitative assay system for HIV RNA, a tool for HIV viral load measurement in patients. Then an already established HIV-specific PCR amplicon (HIV-1 NL4-3) was used as an external standard to estimate the linearity, amplification efficiency, analytical sensitivity and reproducibility of the in-house real time quantitative assay. Finally, the assay was applied to quantify the viral load in clinical samples of HIV patients on ART. The real time quantitative assay was shown to have good linearity (R2=1.0), high amplification efficiency (E=1.91), high sensitivity (180 copies/ml), and high reproducibility (variation coefficient range, from 1.25% to 3.58%). Analytical specificity and sensitivity of the assay in clinical samples was 96.7% and 95.0%, respectively. The established tool is reliable and covers all relevant genotypes including rare and recombinant forms that circulate in the sub-region. It could therefore allow general monitoring of antiretroviral therapy in patients living in resource-limited settings due to its simplicity, rapidity and less-labour intensiveness.

Outcomes of Computed Tomography and Magnetic Resonance Enterography in Clinical Practice of Inflammatory Bowel Disease

Computed tomography (CT) and magnetic resonance (MR) enterography are now widely used to diagnose and monitor Crohn's disease. We sought to assess the use of enterography for management of inflammatory bowel disease (IBD) in our medical center. We performed a retrospective review of all patients diagnosed with IBD who underwent MR or CT enterography from November 1, 2010 to October 25, 2012 at our institution. We assessed disease complications identified by enterography, agreement between disease activity determined by endoscopy and enterography, association between inflammatory markers and enterography-determined disease activity and recommended changes in medical and surgical management following enterography. A total of 311 enterography studies (291 MR and 20 CT enterographies) were performed on 270 patients, including 258 (83.0 %) on patients with presumed Crohn's disease and 53 (17.0 %) with presumed ulcerative colitis. Active small bowel (SB) disease was noted in 73/311 (23.5 %) studies. Complications including strictures, perianal fistulas, abscesses and SB fistulas were noted in 108/311 (34.7 %) studies. Endoscopic and enterography defined active disease had an agreement of κ = 0.36 in the ileum (n = 179). A total of 142/311 (45.7 %) enterographies were associated with recommended medication changes within 90 days while surgery or endoscopic dilation of stricture was recommended following 41/311 (13.2 %) enterographies. Enterography resulted in a change in diagnosis from ulcerative colitis to Crohn's in 5/311 (1.6 %) studies. Enterography reveals active disease and complications not evident on endoscopy and should be considered in the initial diagnosis, assessment of disease activity, and monitoring of therapy in patients with IBD.

Monitoring response to therapy in patients with cancer: is circulating DNA the answer?

One of the most frequent uses of tumor markers is in monitoring response to therapy in patients with advanced malignancy. Although serial imaging is the gold standard method for assessing response, the use of circulating markers has several advantages including non-invasive measurement, relatively low costs and convenience for patients. Proposed markers for monitoring therapy in patients with breast cancer include CA 15-3, CEA, TPA, TPS and circulating tumor cells (CTC) (1,2). Although the best marker for monitoring remains to be determined, CA 15-3 is the most widely used in clinical practice.

AB0943 Short-term ultrasound multi-target monitoring of anti-TNF alpha treatment in patients with psoriatic arthritis

BackgroundThere is an increasing evidence supporting power Doppler (PD) ultrasound as a sensitive imaging technique for the assessment of disease activity and therapy monitoring in patients with chronic arthritis, including...

Amiodarone Monitoring Practices in Pediatric Hospitals in the United States

Laboratory monitoring of amiodarone therapy is recommended due to the high incidence of adverse events associated with the drug. The use of appropriate monitoring is unknown at pediatric hospitals. The Pediatric Health Information System database was queried during a 5-year period for all patients who received amiodarone while hospitalized. Use of thyroid function testing, hepatic function testing, electrocardiogram, pulmonary function testing, and chest X-ray for patients was identified. Incidence of individual monitoring tests and complete monitoring profile was identified and compared across patient demographic and clinical factors and pediatric hospital. A total of 1,703 patients met the study criteria, and the incidence of complete amiodarone monitoring for all patients was 7.6 %. The least common monitoring test performed was triiodothyronine at 19.4 %, and the most common was electrocardiogram at 89.7 %. Critically ill patients and neonates were more likely to have amiodarone monitoring. Considerable variation in monitoring practices between pediatric hospitals was identified. Monitoring of amiodarone therapy in patients admitted to pediatric hospitals is low. Future efforts to standardize care are warranted.

MRI assessment of relapsed glioblastoma during treatment with bevacizumab: Volumetric measurement of enhanced and FLAIR lesions for evaluation of response and progression—A pilot study

PurposeTo develop a magnetic resonance imaging (MRI) metric that is useful for therapy monitoring in patients with relapsed glioblastoma (GBM) during treatment with the antiangiogenic monoclonal antibody bevacizumab (Bev). We evaluated the feasibility of tumour volume measurement with our software tool in clinical routine and tried to establish reproducible and quantitative parameters for surveillance of patients on treatment with antiangiogenic drugs. Materials and methodsIn this retrospective institutional pilot study, 18 patients (11 men, 7 women; mean age 53.5) with recurrent GBM received bevacizumab and irinotecan every two weeks as second line therapy. Follow up scans were assessed every two to four months. Data were collected on a 1.5T MR System (Siemens, Symphony) with the standard head coil using our standardized tumour protocol.Volumetric measurement was performed with a commercial available software stroketool in FLAIR and T1-c imaging with following procedure: Pre-processing involved cutting noise and electing a Gaussian of 3×3 to smooth images, selecting a ROI (region of interest) in healthy brain area of the contra lateral side with quantifying the intensity value, adding 20% to this value to define the threshold level. Only values above this threshold are left corresponding to the tumour lesion. For the volumetric measurement the detected tumour area was circuited in all slices and finally summing up all values and multiplied by slice thickness to get the whole volume. ResultsWith McDonalds criteria progression was indicated in 14 out of 18 patients. In contrast, volumetric measurement showed an increase of contrast enhancement of >25%, defined as threshold for progression, in 11 patients (78%) and in 12 patients (85%) in FLAIR volume, respectively. 6 patients revealed that volumes in MRI increased earlier than the last scan, which was primarily defined as the date of progression with McDonald criteria, changing PFS after re-evaluation of the tumour volumes from 6.8 to 5.6 months. ConclusionIn this pilot study the applied imaging estimates objectively tumour response and progression compared to the bi-dimensional measurement. The quantitative parameters are reproducible and also applicable for the diffuse infiltrating lesions.

Triptorelin depot stimulation test for central precocious puberty

Acute gonadotropin responses following depot leuprolide acetate injection are useful for monitoring therapeutic efficacy in central precocious puberty. Similar monitoring of therapy in patients treated with another widely used GnRH agonist, depot triptorelin, has not yet been reported. The objective of this study was to test the use of gonadotropin levels after therapeutic injections of depot triptorelin for evaluating efficacy of therapy. Thirty-two patients (29 girls and three boys) were treated with triptorelin depot, 3.75 mg per vial, between 2006 and 2010. Treatment was initiated at 8.27±1.76 years (range, 4.6-11.6 years). Blood was drawn before and at variable times between 30 min and 2 h after injections. Clinical tests were retrospectively collected. After the first injection, the 60-min mean luteinizing hormone (LH) level was 21.6.1±18.0 IU/L and the follicle-stimulating hormone (FSH) was 13.5±3.6 IU/L. After subsequent injections, for those who showed clinical suppression, the standard deviations above the mean were 3.6 IU/L for FSH and 2.1 IU/L for LH. The LH levels of two patients who did not suppress sufficiently were at these limits or higher. Sixty-minute postinjection depot triptorelin levels of LH can be successfully used to evaluate the efficacy of treatment with this agent. Limits for suppressed levels have been determined.

Diagnostic Value of Software-Based Image Fusion of Computed Tomography and F18-FDG PET Scans in Patients with Malignant Lymphoma

Aim. The purpose of this study was to evaluate the accuracy of 2-deoxy-2-[fluorine-18]fluoro-D-glucose (FDG) positron emission tomography (PET), computed tomography (CT), and software-based image fusion of both modalities in the imaging of non-Hodgkin's lymphoma (NHL) and Hodgkin's disease (HD). Methods. 77 patients with NHL (n = 58) or HD (n = 19) underwent a FDG PET scan, a contrast-enhanced CT, and a subsequent digital image fusion during initial staging or followup. 109 examinations of each modality were evaluated and compared to each other. Conventional staging procedures, other imaging techniques, laboratory screening, and follow-up data constituted the reference standard for comparison with image fusion. Sensitivity and specificity were calculated for CT and PET separately. Results. Sensitivity and specificity for detecting malignant lymphoma were 90% and 76% for CT and 94% and 91% for PET, respectively. A lymph node region-based analysis (comprising 14 defined anatomical regions) revealed a sensitivity of 81% and a specificity of 97% for CT and 96% and 99% for FDG PET, respectively. Only three of 109 image fusion findings needed further evaluation (false positive). Conclusion. Digital fusion of PET and CT improves the accuracy of staging, restaging, and therapy monitoring in patients with malignant lymphoma and may reduce the need for invasive diagnostic procedures.

Applications of Fluorescence in Situ Hybridization (FISH) for Detecting Genetic Changes in Hematological Malignancies

Fluorescence in situ hybridization (FISH) has become an important tool both for defining initial chromosomal abnormalities within a disease process, and for monitoring response to therapy as well as minimal residual disease. We report the results of interphase FISH (iFISH) analysis of 92 patients. We have used five different FISH probes to detect common cytogenetic rearrangements associated with hematological malignancies. A total of 83 patients were screened for BCR/ABL gene rearrangements. Displayed iFISH patterns of BCR/ABL gene rearrangements in 37.3% of patients (31/83) ranged between 10% to 98%. In addition, while 3 patients and one patient with AML showed t(15; 17) (12.5%) and inv(16; 16) (8.3%) respectively, t(8; 21) was not found. Furthermore, secondary chromosomal aberrations (6.5% of all cases) were clearly non random in the present study. The diagnosis of BCR/ABL gene rearrangements are likely become an important tool for the monitoring of therapies in patients with CML. Atypical patterns also may have clinical prognostic implications. Further studies in larger groups of patients are needed in order to elucidate the role of AML1/ETO, PML/RARA, CBFB and p53, and to identify the specific chromosomal regions and interacting genes involved in this process.

MxA as biomarker for the activity of interferon-alpha in patients with chronic hepatitis: Measurement by flow cytometry

Background: The antiviral protein MxA is induced in leukocytes by type-I-interferons. An increased expression of MxA has been shown by means of PCR in patients with chronic hepatitis undergoing interferon-alpha therapy. Additionally, it has been demonstrated that the clinical response to interferon-alpha is correlated to the basal expression of MxA. Therefore, MxA has been proposed to serve as a marker for the bioactivity of interferon-alpha. We investigated the utility of flow cytometry (FACS) to measure the expression of MxA in different leukocyte cell types in patients with chronic hepatitis. Methods: The expression of MxA was determined in permeabilized whole blood samples by FACS analysis using a FITC-conjugated antibody (clone 383, An der Grub, Austria). The mean channel flourescence was determined after gating for neutrophils (PMN), monocytes (Mono) and lymphocytes (Lympho). Data are given as mean and standard deviation. Statistical analysis was done by t-test. Results: Blood samples were obtained from patients with chronic hepatitis B (CHB, n=7), chronic hepatitis C (CHC, n=10), CHC under treatment with interferon alpha (IFN, n=10), and healthy subjects (Contr., n=15). MxA expression was significantly increased in IFN (PMN: 15228, p<0.0001; Mono: 34873, p<0.0001; Lympho: 9220, p<0.0001) but not in CHB (PMN: 355, p=0.37; Mono: 38 5, p=0.53; Lympho: 243, p=0.33) or CHC (PMN: 5430, p=0.54; Mono: 378, p=0.66; Lympho: 222, p=0.16), as compared to Contr. (PMN: 4632, Mono: 3610, Lympho: 234). Conclusion: Interferon alpha-treatment results in a marked upregulation of MxA expression in patients with CHC. FACS analysis may serve as a convenient method in routine laboratory diagnostics for the monitoring of therapy in patients with chronic viral hepatitis.

Toward a Personalized Pharmacotherapy of Respiratory Diseases

Toward a Personalized Pharmacotherapy of Respiratory Diseases

Circulating Tumor Cells and FDG-PET/CT for the Therapeutic Monitoring of Bone Metastases from Breast Cancer.

Abstract Background: Circulating tumor cells (CTCs) and [18F]fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) are two promising new tools for monitoring therapy in patients with metastatic breast cancer. The two modalities showed high sensitivity in detection of bone relapse/progression from breast cancer (De Giorgi U et al. Ann Oncol 2009). In this study, we sought to evaluate the prognostic significance of two different modalities represented by the detection of CTC and FDG-PET/CT in patients with bone metastases from breast cancer treated with standard therapies. Our objective was to compare the two modalities to identify which technology could be more sensitive in prospectively monitoring such patients.Patients and Methods: This is a retrospective study of 54 patients with bone metastases from breast cancer without visceral metastases treated at The University of Texas M. D. Anderson Cancer Center from September 2004 to May 2008. CTC were detected and enumerated using the CellSearch system (Veridex LLC, Rariten NJ, USA). Patients were categorized according to first follow-up CTC counts as having a favorable (< 5 CTC/7.5 mL of blood) or unfavorable (≥ 5 CTC) outcome. Reassessment of disease status by CTC count and FDG-PET/CT was performed approximately 2-3 months after initiation of the new treatment, depending on treatment type and schedule. Progression-free survival (PFS) and overall survival (OS) were estimated by Kaplan-Meier product limit method, and compared between groups with the log-rank test.Results: In 54 evaluable patients, the median overall survival time was 17 months (range, 3 to >36). Follow-up CTC levels and FDG-PET/CT response predicted both PFS (p = 0.02 and p = 0.0001, respectively) and OS (p = 0.01 and p = 0.02, respectively), while baseline CTC predicted neither PFS (p = 0.8) nor OS (p = 0.76). In patients with either CTC or FDG-PET/CT response PFS has been 13 months, while in patients with discordant CTC and FDG-PET/CT response PFS has been 6 months and in patients with neither CTC nor FDG-PET/CT response PFS has been 5 months (p = <0.00002). In patients with either CTC or FDG-PET/CT response, OS has not been reached (>31 months); in patients with discordant CTC and FDG-PET/CT response, OS has been 24 months; and in patients with neither CTC nor FDG-PET/CT response, OS has been 18 months (p = 0.02).Conclusions: CTC and FDG-PET/CT are useful tools for therapeutic monitoring of bone metastases from breast cancer. Prospective studies in this specific clinical context are needed to assess the critical roles that CTC and FDG-PET/CT individually as well as collectively play in the prognostic and therapeutic monitoring of bone metastases from breast cancer. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1109.

Iron-Oxide Nanoparticles as Magnetic Resonance Contrast Agents: Expanding Their Potential Beyond Iron Replacement Therapy.

Abstract 1998Poster Board I-1020Ferumoxytol (Feraheme™), an iron oxide nanoparticle, was approved as an iron replacement product for the treatment of iron deficiency anemia in adult patients with chronic kidney disease (CKD) (United States Food and Drug Administration, June 2009). Potential uses of ferumoxytol extend beyond the treatment of iron deficiency anemia and may have important implications for hematology-oncology. Following administration, iron oxide nanoparticles initially serve as blood pool agents which is an ideal characteristic for assessing blood volume and blood flow. Subsequently, because of their long plasma half-life and ability to target inflammatory cells in the central nervous system (CNS), these compounds serve as excellent anatomic imaging agents. We have given adult patients with malignant CNS tumors and other CNS inflammatory lesions, ferumoxytol (n = 68) and ferumoxytran-10 [Combidex™' (n = 97) as magnetic resonance (MR) contrast agents, on Institutional Review Board approved protocols. We hypothesize that iron oxide nanoparticles provide additional MR imaging information which may be beneficial in the differential diagnosis and in monitoring therapy in patients with CNS lesions. This report focuses on our experience with 16 patients with central nervous system lymphoma (CNSL). The patients underwent brain MR with gadolinium followed in 10 ± 9 days (mean ± SD) by MR with ferumoxytran-10 (2.6 mg/kg, intravenous [IV' over 30 min) (n = 11) or ferumoxytol (510 mg, IV bolus) (n = 5). Findings of interest include: 1) in 3 patients, MR with iron oxide nanoparticles showed additional areas of CNS enhancement when compared with MR with gadolinium; 2) in 2 patients, increased enhancement patterns with iron oxide nanoparticles were diagnostically useful in distinguishing lymphoma from non-lymphomatous inflammatory conditions; and 3) in 2 patients with histories of CKD and post-renal transplant lymphoproliferative disorder confined to the CNS, MR with ferumoxytol was used to monitor therapy, as this agent appears to avoid the risk of nephrogenic systemic fibrosis (NSF), which is associated with exposure to gadolinium-containing contrast agents. Of note, in 1 patient with thromboembolic complications during therapy, brain MR enhancement was seen approximately 5 weeks after ferumoxytol infusion. The enhancement was initially interpreted as a hemorrhagic brainstem event and led to insertion of a superior vena cava filter rather than anticoagulation. This is an example of MR alteration which generally resolves in 3 to 5 days following ferumoxytol, however in rare instances may persist for up to 3 months. In summary, in addition to their use as iron replacement agents in iron deficiency anemia, the use of iron oxide compounds as MR contrast agents compliment the use of gadolinium. These agents offer exciting potential in the differential diagnosis of CNS inflammatory lesions versus CNSL, in monitoring CNS therapy, and may provide dual benefit in patients with CKD by possibly eliminating the gadolinium-associated risk of NSF. Disclosures:Off Label Use: Feraheme is an iron replacement product indicated for the treatment of iron deficiency in adult patients with chronic kidney disease (CKD).

Monitoring of therapy in patients with chronic hepatitis B virus

The aims of this study were to evaluate therapy with lamivudine (LAM) and adefovir dipivoxil (ADV) monotherapy in chronic hepatitis B virus (HBV)-infected patients with frequent measurements of DNA levels, to characterize HBV genotypes, and to determine the emergence of nucleos(t)ide analogue mutants before and during the therapy by direct-sequencing the reverse transcriptase region and by INNO-LiPA HBV DR v3. A total of 15 chronic HBV patients were analysed: 11 were treated with ADV and four were treated with LAM. Viral genotype was determined, showing the presence of genotype D (73%) in 11 patients and genotype A (27%) in four patients. In the viral response to treatment, three patients developed substitutions at rtM204I associated with LAM resistance and one of these patients presented rtM204V/I plus rtL180M mutation. In contrast, of the 11 patients treated with ADV, three patients developed mutations (rtN236T; rtA181V; rtA181V plus rtN236T). With regard to this case, the same results were observed by INNO-LiPA HBV DR v3 and direct sequencing, but by direct sequencing we detected an extra mutation rtQ215S that was present in two patients: one patient who was on treatment with LAM had an rtQ215S mutation in addition to an rtM204I, and the second patient treated with ADV had rtA181V. Direct sequence analysis is an essential tool to optimize therapeutic management of HBV chronic infection in clinical practice to choose the appropriate nucleos(t)ide analogues and to detect extra mutations that are not included in the commercial kit.

Utility of single luteinizing hormone determination 3 h after depot leuprolide in monitoring therapy of gonadotropin-dependent precocious puberty

To determine utility of luteinizing hormone (LH) estimation, post intramuscular (IM) depot leuprolide in comparison with subcutaneous leuprolide stimulation test. Test for monitoring therapy in patients with gonadotropin dependent precocious puberty (GDPP). In seven patients of GDPP, who were treated with 11.25 mg depot leuprolide, the LH peak after subcutaneous (sc) test was compared with LH at hourly interval for 4 h after IM depot leuprolide for 13 tests and 3rd hour value for next ten tests. These two values were compared both before and after therapy. Before therapy, the mean +/- SD LH peak after subcutaneous leuprolide stimulation test was 20.6 +/- 7.85 IU/l (range 9.64-30.4 IU/l), and it was 27.3 +/- 12.21 IU/l 3 h after the first depot leuprolide injection (range 10.5-45.4 IU/l). During therapy, the mean +/- SD of LH peak after sc stimulation test was 1.96 +/- 0.75 IU/l (range 1.1-3.1 IU/l), and it was 2.58 +/- 0.54 IU/l (range 1.4-3.4 IU/l) 3 h after depot leuprolide injection. Three-hour LH value following IM depot leuprolide injection (11.25 mg) can be used for monitoring therapy in patients with GDPP because of its convenience and cost effectiveness.

DNA methylation changes in prostate cancer: current developments and future clinical implementation

Promoter hypermethylation is associated with the loss of expression of tumor-suppressor genes in cancer. Currently, several genome-wide technologies are available and have been utilized to examine the extent of DNA methylation in discovery-based studies involving several physiological and disease states. Although early in the process, aberrant DNA methylation is gaining strength in the fields of cancer risk assessment, diagnosis and therapy monitoring in different cancer types. There is a need to improve existing methods for early diagnosis of prostate cancer and to identify men at risk for developing aggressive disease. Because of the ubiquity of DNA methylation changes and the ability to detect methylated DNA in several body fluids (e.g., blood and urine), this specifically altered DNA may serve, on one hand, as a possible new screening marker for prostate cancer and, on the other hand, as a tool for therapy monitoring in patients having had neoplastic disease of the prostate. Since many prostate cancer patients present with advanced disease and some present with nonspecific elevation of prostate-specific antigen without prostate cancer, early detection with high specificity and sensitivity is considered to be one of the most important approaches to reduce mortality and unwanted tension of the men with high prostate-specific antigen. Therefore, an effective screening test would have substantial clinical benefits. Furthermore, methylation markers of risk of progression of disease in patients having prostate cancer permits immediate commencement of specific treatment regimens and probably longer survival and better quality of life. This review illustrates the current benefits and limitations of potentially useful prostate cancer methylation markers that have considerable existing data and touches upon other future markers as well as the field of methylation in prostate cancer.

CA 27.29 as a tumour marker for risk evaluation and therapy monitoring in patients with primary breast cancer.

Abstract Abstract #2004 Background:
 Several trials show that the use of tumor markers leads to an early diagnosis of tumor dissemination in breast cancer patients. Whether this improves the prognosis is still under discussion. In the SUCCESS Trial CA27.29 has been examined before and after adjuvant chemotherapy (n=3754).
 Methods:
 The SUCCESS Trial compares FEC-Docetaxel (Doc) vs. FEC-Doc-Gemcitabine (Doc-G) regime and two vs. five year treatment with Zoledronat in patients with primary breast cancer (N+ or high risk). CA27.29 has been measured with ST AIA-PACK Ca27.29 reagent using MUC-1 for AIA-600II (Tosoh Bioscience, Tessenderlo, Belgium). The cutoff for positivity of CA27.29 is 24 U/ml.
 Results:
 2669 patients have been examined prospectively before and after chemotherapy. 22% of patients had a marker >24 U/ml (n=587, mean 19.00, range 3.04-410.00) before and 40% (n=1058, mean 23.34, range 2.70-330.76) after chemotherapy. The correlation between both values was significant (p<0.0005).
 While 17% showed elevated CA27.29 before and after therapy, 5% patients changed from positive to negative for CA27.29 afterwards. 55% were negative before and after therapy whereas 23% became positive after treatment.
 
 Before treatment the prevalence of elevated CA27.29 was equally distributed between the FEC-Doc and the FEC-Doc-G arm. After treatment 34.1% in the FEC-Doc arm showed an increased level vs. 45.6% in the FEC-Doc-G arm. The correlation analysis showed no significant coherence between hormonal status (ER: p<0.323; PR: p<0.078), HER2/neu status (p<0.308), Grading (p<0.565) and CA27.29 level. However, tumor size (p<0.020) and the nodal status (p<0.022) were significant associated with Ca27.29 levels.
 Conclusion:
 These results might indicate a close relation between Ca27.29 and tumour mass at primary diagnosis. Whether this marker will be useful for treatment monitoring will be shown by further follow-up in the Success-trial. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2004.

Activated Partial Thromboplastin Time: New Tricks for an Old Dogma

The activated partial thromboplastin time (APTT) is the most common coagulation test procedure performed in routine laboratories, apart from the prothrombin time. The test is traditionally used for identifying quantitative and qualitative abnormalities in the intrinsic and common pathways of coagulation, monitoring anticoagulant therapy with unfractionated heparin, and detecting inhibitors of blood coagulation, the most common of which is the lupus anticoagulant. Whereas short APTT values have been mostly overlooked in the past, recent evidence suggests that these might be associated with hypercoagulability. Although clinical relevance is yet to be clearly defined, hypercoagulability detected by a shortened APTT appears to be significantly associated with a major risk of venous thromboembolism independently from other variables such as blood group, the presence of inherited thrombophilia, and factor VIII levels. This novel finding suggests that this traditional, simple, and inexpensive test might have renewed utility along with traditional thrombophilic tests in the evaluation of venous thromboembolic risk. In addition, APTT waveform analysis is also providing mounting evidence of added utility, in particular for identifying sepsis and disseminated intravascular coagulation in critically ill patients (particularly where this might worsen the prognosis), for monitoring therapy in patients with inhibitors, and as a diagnostic aid to identify patients with antiphospholipid antibodies. In total, such emerging evidence suggests that the APTT is either an old dogma displaying new tricks or else might describe a new dogma for an old laboratory trick.

Whole-body T2⁎ mapping at 1.5 T

This study investigated the feasibility of an MRI protocol providing whole-body T2* maps at 1.5 T. Seven healthy volunteers (mean age=30.1+/-3.7, three women and four men) and two patients (both male, 53 and 46 years old) affected by transfusion-dependent anemias participated in the study. Coronally oriented images of five subsequent body levels were acquired using a fat-suppressed multiecho 2D gradient-echo sequence (12 echo times ranging from 4.8 to 76.3 ms were selected) and afterwards composed. Parametrical T2* maps of the whole body were reconstructed on a pixel-by-pixel basis. For both, healthy volunteers and patients, representative T2* values were computed from extended regions of interest (ROIs). Good-quality whole-body T2* maps were computed in all volunteers and patients. In healthy volunteers, T2* values were assessed in the cerebral white (58.5+/-4.2 ms) and gray (81.4+/-5.5 ms) matter, liver (34.3+/-7.0 ms), spleen (63.5+/-3.3 ms), kidneys (65.4+/-10.3 ms) and skeletal muscles (~30 ms). The liver presented faster relaxation rates in males as compared to females. One patient (serum ferritin concentration=927 microg/dl) showed shortened T2* values in liver (3.6+/-5.5 ms), spleen (3.1+/-4.8 ms), kidneys (11.1+/-7.1 ms) and muscles (25.1+/-3.4 ms). The second patient (serum ferritin concentration=346 microg/dl) presented reduced T2* values in liver (3.9+/-7.3 ms), spleen (20.1+/-9.8 ms) and kidneys (24.6+/-7.7 ms). The presented technique may find clinical application in the assessment of the iron burden in the entire body, and in monitoring of chelation therapies in patients treated with frequent blood transfusions.

Liquid chromatography‐mass spectrometry method for quantification of caspofungin in clinical plasma samples

Caspofungin [(CASPO) MK-0991] is the first broad-spectrum anti-fungal agent of the echinocandin class approved for clinical use. Measurement of CASPO levels in blood might help monitor therapy in patients who are critically ill, in particular, if high-dose regimens or combinations of CASPO with other anti-fungals are used. The objective of this study was to develop a fast method for the measurement of CASPO levels in clinical blood samples using liquid chromatography coupled to a triple-quadrupole mass spectrometer. Stock solutions were prepared in plasma to avoid CASPO adsorption to glass and plastic surfaces during processing. CASPO and the internal standard (IS) were extracted from 100 microl of plasma using acetonitrile protein precipitation. The supernatant was diluted and directly injected into an analytical column (C8; 2.1 x 30 mm). The total run time was 15 min. CASPO was ionized by electrospray in the positive mode. CASPO and IS [M + 2H]2+ parent ions (m/z 547.3 and 547.8, respectively) and specific product ions (m/z 137.1 and 62.2, respectively) were used for the ion transitions. No carry over or cross-talk was observed on the column. The mean method recovery was 90 +/- 3%. Neither blood from different individuals (n = 6) nor the presence of concomitant drugs (n = 33) in plasma samples interfered with CASPO quantification. Quantification over time of the CASPO levels in plasma and whole blood was investigated at different pre-analysis storage conditions. The calibration curve included the clinically relevant CASPO concentration range from 0.04 to 20 microg/ml. Mean intra- and inter-day accuracy was 96.1 +/- 2.2% and 102.5 +/- 2.4%, respectively. Mean intra- and inter-day precision was 7.9 +/- 3.2% and 6.3 +/- 1.8%, respectively. This simple and robust liquid chromatography-tandem mass spectrometry (LC-MS/MS) method may easily be implemented for monitoring CASPO therapy.