Performance of the Roche Total Mycophenolic Acid® assay on the Cobas Integra 400®, Cobas 6000® and comparison to LC-MS/MS in liver transplant patients

Background: Mycophenolic acid (MPA) is an immunosuppressant for which therapeutic drug monitoring (TDM) is performed for optimal prophylaxis and avoidance of toxicity in transplant patients. Liquid chromatography-tandem mass spectrometry (LC-MS/MS) is ideally suited for TDM of MPA. There have been several method comparisons of the Roche Total MPA assay, but none have been performed with respect to liver transplant patients. Methods: We validated the Roche Total MPA assay on the Cobas Integra 400 and Cobas 6000 and compared it to a validated LC-MS/MS (API 2000 (TM)) method. Fifty-five EDTA plasma samples from liver transplant patients were measured with the Roche assay on these platforms and compared to the LC-MS/MS results. Results: Validation of the LC-MS/MS, Cobas Integra 400 and 6000 was performed with good results. The LC-MS/MS/Integra 400/Cobas 6000 were linear up to 30, 15 and 17 mg/L, respectively. Imprecision was <10% for LC-MS/MS and <7% for the Roche assay on both platforms. The samples showed good agreement with LC-MS/MS. Passing-Bablok regression analysis showed Cobas Integra (mg/L) = 1.02 x LC-MS/MS (mg/L)-0.50 and Cobas 6000 (mg/L) = 0.98 x LC-MS/MS-0.47. Conclusions: The Roche Total Mycophenolic Acid-assay is suitable for measuring total MPA in plasma from liver transplant patients and is a good alternative for LC-MS/MS

Disulfiram inhibition of cyanide formation after acetonitrile poisoning

Context: Cyanide poisoning may be caused by acetonitrile, a common industrial organic solvent and laboratory agent. Objective: To describe the potential use of disulfiram in treating acetonitrile poisoning in a human clinical case and to further study its effect in human liver microsomes in vitro. Case details: A 30-year-old man initially presented with a cholinergic toxic syndrome following ingestion of aldicarb. Toxicological analysis revealed coingestion of ethanol. He subsequently developed severe metabolic acidosis caused by the cyanogenic compound acetonitrile which was erroneously interpreted as acetone in the chromatogram. After three treatments with hydroxocobalamin (5 g i.v.) and sodium thiosulfate (12.5 g i.v.) on days 2, 3, and 5, he had transient improvement but recurrent lactic acidosis. Treatment with disulfiram was associated on day 7 with resolution of metabolic acidosis and slowing of the decrease in acetonitrile concentration. He recovered from acetonitrile toxicity completely. The time course of acetonitrile, thiocyanate, and cyanide concentrations suggested that disulfiram inhibited cyanide formation. Results: In vitro experiments with human liver microsomes showed the cyanide concentration was significantly lower after incubation with acetonitrile and disulfiram than acetonitrile alone (a mean 60% reduction in cyanide level). Discussion: Although disulfiram was given late in the course of the poisoning it is possible that it contributed to the recovery

Queen Elizabeth’s Leadership Abroad: The Netherlands in the 1570s

In 1576, after Edmund Grindal, archbishop of Canterbury, presumed to lecture Queen Elizabeth on the importance of preaching and on her duty to listen to such lectures, his influence diminished precipitously, and leadership of the established English church fell to Bishop Aylmer. Grindal’s friends on the queen’s Privy Council, “forward” Calvinists (or ultra-Protestants), were powerless to save him from the consequences of his indiscretion, which damaged the ultras’ other initiatives’ chances of success. This paper concerns one of those initiatives. From the late 1560s, they urged their queen “actively” to intervene in the Dutch wars. They collaborated with Calvinists on the Continent who befriended Prince William of Orange and who hoped to help him hold together a coalition of religiously reformed and Roman Catholic insurgents in the seventeen provinces of the Low Countries. The English ultra-Protestants would have their government send money, munitions, and men in arms to the Netherlands, to tip the balance against viceroys sent by King Philip II of Spain. Grindal’s setback undermined the English Calvinists’ efforts to form an Anglo-Dutch alliance which, they assumed, would boost the prospects for an international Protestant league. Yet Elizabeth did assist the Dutch as they wrestled with decisions forced on them by developments in the Netherlands during the 1570s, and she did so more consistently and more cleverly than many historians of Tudor diplomacy have thought. Two competing assessments determine the way questions are formulated in the study of the queen’s and regime’s Dutch diplomacy. The general consensus is that she was indecisive and inconsistent. Paul Hammer characterizes Elizabeth’s responses to the crises in the Low Countries as a “zigzag of different” (“even contradictory”) maneuvers. Wallace McCaffrey and R. B. Wernham agree that England’s “hesitations and gyrations” do not pass as coherent, creditable policy. Charles Wilson scolds Elizabeth for being timid and tepid--incapable of enthusiasm for “a great cause.” But David J.B. Trim’s striking counterthrust depicts the queen’s overtures to Netherlanders as part of her courageous – and “confessionally driven” – foreign policy; Trim replaces “hesitation” and “zigzag” with a coherent “Protestant programme of action prioritized by the Elizabethan government” with the aim of improving prospects for “Calvinist internationalism.” What follows is an alternative to all these characterizations, one that, as noted, finds evidence for greater consistency and coherence in Elizabeth’s leadership and less confessional “drive.” That she would have been uneasy around religious extremists ought not to astonish us; her father’s, step-brother’s, and step-sister’s reigns as well as the start of her own were disturbed by zealous subjects, who were bent on shoring up or dismantling the realm’s religious settlements

Personalized therapy for mycophenolate:Consensus report by the international association of therapeutic drug monitoring and clinical toxicology

When mycophenolic acid (MPA) was originally marketed for immunosuppressive therapy, fixed doses were recommended by the manufacturer. Awareness of the potential for a more personalized dosing has led to development of methods to estimate MPA area under the curve based on the measurement of drug concentrations in only a few samples. This approach is feasible in the clinical routine and has proven successful in terms of correlation with outcome. However, the search for superior correlates has continued, and numerous studies in search of biomarkers that could better predict the perfect dosage for the individual patient have been published. As it was considered timely for an updated and comprehensive presentation of consensus on the status for personalized treatment with MPA, this report was prepared following an initiative from members of the International Association of Therapeutic Drug Monitoring and Clinical Toxicology (IATDMCT). Topics included are the criteria for analytics, methods to estimate exposure including pharmacometrics, the potential influence of pharmacogenetics, development of biomarkers, and the practical aspects of implementation of target concentration intervention. For selected topics with sufficient evidence, such as the application of limited sampling strategies for MPA area under the curve, graded recommendations on target ranges are presented. To provide a comprehensive review, this report also includes updates on the status of potential biomarkers including those which may be promising but with a low level of evidence. In view of the fact that there are very few new immunosuppressive drugs under development for the transplant field, it is likely that MPA will continue to be prescribed on a large scale in the upcoming years. Discontinuation of therapy due to adverse effects is relatively common, increasing the risk for late rejections, which may contribute to graft loss. Therefore, the continued search for innovative methods to better personalize MPA dosage is warranted.</p