A N A L Y T I C A L CHEMISTRY, VOL. 51, NO. 5, APRIL 1979
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Clinical Chemistry M. A. Evenson” and G.
D. Carmack
Department of Medicine, University of Wisconsin, 1300 University A venue, Madison, Wisconsin 53706
This literature survey from December 1976 through November 1978 amply illustrates the increased analytical competence and influence from chemists. The drug analyses section had the most significant increase in numbers of papers compared to the previous review. We excluded articles on pharmacy research. pharmacology, pharmokinetics, and medicinal chemistry of drugs because those are to be covered in another review in this volume. Some analytical methods for drugs in toxicology journals were included in this review. As in previous years, this review of clinical chemistry is intended to be selective and was not directed a t completely abstracting the field. T h e major purpose of this review is t o serve as a starting point for investigators in the field of clinical chemistry. The review must therefore be broad in scope, yet detailed enough so that the important root references can be located. Hopefully some of the journals and articles often overlooked by chemists will be listed. Hence, the major objective of this review is t o try t o provide some clinical chemistry for the analytical chemist and some analytical chemistry for the clinical chemist. We did not include all of the new volumes available in many of the well established series. For example the “Advances,” the “Annual Reviews.” the “Proteins,“ the “Enzymes,” the “Methods of,” and other such volumes of the biochemical literature were not necessarily included in this review but are excellent sources of analytical information. For a number of reasons, the size of this review is larger than in previous years. Most of the other applied reviews in this volume attempt t o survey a specific subject in analytical chemistry, while we have the assignment of covering the entire field of clinical chemistry. In this past two-year period several chromatography journals have devoted the majority of their pages to liquid chromatography research. T o a growing extent. nonclinical chemists have turned their studies to clinical analysis and published their results in the chromatography journals. T h e use of the mass spectrometer in this field has also increased significantly in the past two years. Finally. there is a significant commercial influence in the literature this time. Many companies are now using publications and reprints as a means t o distribute knowledge about their products. Evaluations of commercial products increased significantly in the past two-year period. T h e analytical aspects of immunochemistry is yet another area that expanded very rapidly in the past two years. Previously, endocrinology, hormone, and drug analyses produced the majority of applications for immunochemical analysis techniques, primarily because these substances could not be measured by other methods. More recently, instrumentation has been developed and kits made available to compete with previous methods of analysis for high volume tests in clinical chemistry. Hence, this area has seen great diversification and increased activity in the past two years and the number of citations has substantially increased.
BOOKS, REVIEWS, A N D SYMPOSIA This section (IA-86A) reflects the increased activity of editors in organizing volumes on selected subjects. Often, these books are a collection of presentations given by selected experts a t a meeting. These books are usually direct reproductions of the typed papers submitted to the editor and are often very diverse in style and subject matter. On the other hand, some of the single author books are excellent reviews of a single subject plus some very up-to-date technical information on specific subjects. I t seems that the time interval necessary for publication of books and monographs of this type has been significantly reduced. T h e greatest number of books again are concerned with the more biologically oriented fields, including human biochemistry. 0003-2700/79/035 1-035R$05.00/0
MEDICAL APPLICATIONS This section (IB-115B) is a brief offering of the diverse subject of clinical studies associated with some aspect of laboratory measurement. Most analytical chemists focus upon the chemistry of a biomedical problem and allow others to pursue the meanings of their analytical result. In several circumstances, evaluation problems of n-ork have resulted where some believe that the medicine is trivial but maybe the chemistry is adequate and, conversely, when a scientist evaluates the same work, the opinion evolves that the chemistry is trivial but maybe the medicine is adequate. Hence, chemists should perhaps try to be more aware and better informed of the overall application of their results. If the logic and scientific component of the prohlem of interest is weak and diffuse, probably the medicine contributions will not be significant. This Medical Applications section is intended only for the briefest introduction to some of the more commonly occuring medical situations facing the clinical chemist. Most of the references listed are from journals readily available to chemists rather than focusing on medical journals.
INSTRUMENTATION ADk’ANCES New instrumentatior, concepts of a genera! nature are listed in this section ( 1 G 7 7 C ) . Analysis of a specific chemical class of compounds may be found in other sections of this review. Liquid chromatography advances were reported primarily in the area of new detector developments. T h e use of novel ionization techniques in mass spectrometry increased the applicability of this technique in the clinical laboratory. Extensive improvements in blood-gas and ion selective electrode systems were described. A number of papers reported the fabrication of immobilized enzyme reactors for automated analysis. .4 new concept in clinical chemistry analysis using multila3 er film elements has tieen described. Papers describing improkements in background applicability have been included in this section
METHOD DEVELOPMENT This section i l D 2 9 5 D ) is exceedingly &\verse in that it reports instruments from as complex as the ma to no instrument at all ia rabbit to prepare reagents) to achieve the analytical result. Hence, this section has a majority cif articles on immunochemical determinations (use of the rabbit) and on the application of the mass spectrometer to biologically important suhstances. T h e trend f o r immunochemical analyses appears to be directed now at substances previously measured by physical-chemical techniques. while previously the principal application of this technique was toward substances that could not be analyzed by other means. Liquid chromatographic methods for drugs are frequently subjects in this section. The development of new detectors for liquid chromatography and the nitrogen--phosphorolis detectors for gas chromatography have resulted in some method development papers and several are included in this section. The use of other techniques-calorimetry, laser nephelometry, fluorescence, and multiwavelength detection were not utilized as much as anticipated in this time interval. Initial instriiment costs and maintenance expenses appear to be curtailing the development of new analytical approaches directed at new method development. More attention is addressed t o adequate performance of previously developed methods and to improved performance of existing methods. This influence may be due to increased governmeni>alcontrol combined with the increased costs mentioned above. C 1979 American Chemical Society
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A N A L Y T I C A L CHEMISTRY, VOL. 51, NO. 5, APRIL 1979
NON-AMINO ACID NITROGEN-CONTAINING COMPOUNDS Nearly all of the studies of non-amino acid nitrogen-containing compounds listed (IE-105E) can be classified into one of seven major groups: polyamines, uric acid, catecholamines, creatinine, brain amines, porphyrins, and urinary purines. High performance liquid chromatography was the predominant analytical technique.
PROTEINS A N D PROTEIN CHEMISTRY This section (IF-329F) is also expanded because of developments in liquid chromatography (LC). The analysis of PTH-amino acids by LC has made it possible to sequence proteins with lesser amounts (micro sequencing techniques). Further, the PTH-amino acid LC analysis on reversed phase columns can easily and unequivocably identify whether the residue is the acid or the amide. The interest and literature productivity in protein chemistry is centered on research by biochemists. Clinical chemists and analytical chemists, except for attempting to find new dyes and improved reagents for selected protein measurements, have not focused their work in this area. T h e majority of studies are directed a t structure-function relationships of individual proteins and oftentimes focus on active center modifications of enzymes.
DRUGS A N D DRUG ANALYSES T h e rapidly expanding acceptability of high performance liquid chromatography (HPLC) in the clinical laboratory is reflected by the large number of reports in this section (lG-564G). New HPLC assays have been developed for a number of antibiotics and the tricyclic antidepressant series of drugs. Ion-pair HPLC techniques have been used for the determination of “ionic” drugs. The related technique of high performance thin-layer chromatography has seen increased use. The role of gas chromatography for drug analyses has been extended by the introduction of nitrogen-sensitive detectors and by the development of new derivatization reagents. Many more drug analyses using gas chromatography/mass spectrometry have been reported. T h e development of radioimmunoassay (RIA) and enzyme-coupled immunoassay (EMIT) procedures for drug assays has also become a n extremely active field. A number of papers are concerned with the determination of the more recent drugs and drugs of abuse; Le., methotrexate, psychotherapeutic drugs, cocaine, tetrahydrocannabinol, and phencyclidine. Interestingly, the largest number of papers concentrated on the assays of theophylline and acetaminophen, perhaps because of the toxic effects of excessive amounts occasionally used.
TRACE ELEMENTS, BLOOD GASES, A N D INORGANIC ANIONS T h e papers in this section (IH-343H) were selected to present a cross section of both analytical techniques and biological studies, thereby increasing their usefulness to the analytical chemist. Calcium, zinc, iron, lead, and cadmium comprise the majority of the trace elements reported. However, methods and studies of more than two dozen trace elements have been described. Of the toxic metals, lead continues to receive much attention. T h e greatly increased number of cadmium papers reflects the concern over its presence in the environment. Similarly, selenium has received greater attention. A number of papers reported the analysis of trace elements in hair or fingernails. Greater emphasis has been placed on the preservation of trace element samples prior to analysis as well as the purity of reagents used in such techniques. Electrothermal (flameless) atomic absorption techniques and ion-selective electrode (ISE) methodologies make up more than two thirds of the reported analytical activities. Microprocessor-based ISE analyzers for sodium and potassium have been introduced as a replacement for conventional flame photometers. Increasingly, ISEs have been used to measure serum calcium. T h e new generation of automated blood-gas instruments
have been extensively evaluated by a number of researchers. Concern over validity of pC0, measurements has been expressed. Methods for inorganic phosphate, sweat chloride, and fluoride lead the list of analyses of clinically important anions.
ENZYME CHEMISTRY A N D ANALYSES This section (IZ-2760 reveals considerable activity generally in the area of modification of methods for the enzymes or isoenzymes of interest. There are several papers adapting enzyme methods to different types of analyzers. T h e most frequently mentioned new instruments are the various centrifugal analyzers and use of electrodes as sensors of enzyme reactions. Several less common enzymes were measured and new attempts were made to make clinical use of the results. Several papers in this section point out the clinical nonspecificity of measurements. Creatine phosphokinase (CPK) and its isoenzymes are the most frequent examples of clinical circumstances that are inconsistent with the accurate laboratory measurements. There were more attempts to use computer-pattern recognition techniques using multiple enzyme tests to obtain meaningful clinical correlations but, as before, these were not as successful as had been anticipated. Finally, several analytical difficulties were corrected during the past two years and several of these articles are in this section.
HORMONES, STEROIDS, A N D VITAMINS This section (15-2405) does not correlate with the amount of activity because we restricted the number of articles listed. Immunochemical analytical techniques were frequently used for hormones and steroids. Some of the biogenic amines and brain peptides were analyzed with liquid chromatography as were several active forms of vitamins. Some of the above articles are included as examples, but many others were excluded. T h e field of endocrinology is very large and very complicated. One can summarize the analytical advances of the last two years by noticing that the clinical problems are even more difficult than originally thought. Further, the immunochemical techniques directed at receptor identification assay have shown that the new laboratory information is still a few years away from clinical application. Hence, the laboratory must become even more sophisticated, more expensive and more long-term in endocrine research. For these reasons, many investigators are turning to improvements of existing methods or to more descriptive areas of research. It can be expected that immunochemistry will continue to be the main thrust of hormone and steroid analysis in the medical centers.
LIPIDS This section (IK-169K) again has the largest number of articles on cholesterol and triglyceride measurements in serum. However, bile acids and bile salts were studied by chromatographic and immunochemical techniques in an attempt to obtain meaningful clinical information about early liver disease. There was considerable effort in the past two-year period to improve the analytical methods for lipid analysis. There was increased interest in fatty acid changes with injury to the heart and/or to the lungs. The analytical interferences caused by fatty acids on the binding of drugs to proteins and the binding changes in immunochemical tests also were frequently studied.
CARBOHYDRATES As before, the most frequently studied carbohydrate
(IL-63L) was glucose. Many of these studies entailed the use
of electrochemical enzymatic analysis. However, a greater diversity of carbohydrate studies is reported here than in the past. A number involve the application of new derivatizing agents for gas chromatographic analyses. Mucopolysaccharides, in several inherited diseases, have received increased attention.
PESTICIDES A N D MISCELLANEOUS COMPOUNDS T h e majority of papers (IM-401M) involved the analysis of
A N A L Y T I C A L CHEMISTRY, VOL. 51, NO. 5, APRIL 1979 Merle A. Evenson is a Professor in the Department of Medicine at the University of Wisconsin-Madison and is also the Director of the Drug and Trace Element Analysis Laboratories at University Hospitals He received his Ph D. degree in Analytical Chemistry in 1966 from the University of WisconsinMadison where he also earned two M S degrees in Education. He has a B S. degree with honors from the University of Wiscon-
Chemistry at Harvard Medical School in 1969-71. Simultaneously, while in Boston he was associated with the Biophysics Research Laboratory at the Peter Bent Brigham Hospital. His research interests include the study of structure-function relationships of metalloproteins important in health and disease, the chemical characterization of uremic toxins, and the development of analytical methods for drugs and trace elements. His service responsibilities center around the use of gas chromatography, liquid chromatography, and mass spectrometry for the aentification and quantitation of drugs and other substances. Trace metal analyses in his service laboratory are usually conducted by flame and nonflame atomic absorption spectrometry. He is a member of the Board of Editors of Clinical Chemistry, Chemical Instrumentation, Selected Methods in Clinical Chemistry. and a past member of the Board of Editors of Analytical Toxicology. He has served a three-year term on the advisory board of Analytical Chemistry. He is currently an editor of the series "Contemporary Topics in Analytical and Clinical Chemistry". He served as chairman of the 1978 Gordon Research Conference on Analytical Chemistry He is a Diplomat in the American Board of Clinical Chemists. Inc., and is currently Vice-President of that organization. He has served on various study sections of the National Instiutes of Heahh (NIH) and is cwently c h a i m n of the Clinical Toxicdogy Section of the Clinical Chemistry and Hematology Medical Device Panel at the Federal Drug Administration (FDA). He has served as an advisor to the Analytical Division of the Oak Ridge National Laboratory. He has been active in developing programs at National Meetings for the Analytical Division of the American Chemical Society. He is a member of the American chemical Society, the American Association for Clinical Chemistry, Sigma Xi, AAAS, and Kappa Delta Phi (Honorary Education Society).
Gary D. Carmack is currently a research chemist w i h DuPont Instruments He received his B S degree in 1972 and his Ph D. degree in 1977, both from the University of Arizona During 1972-73 he was a staff research chemist there He served briefly at the Food and Drug Administration before accepting a NIH postdoctoral fellowship at the clinical laboratories of the University of Wisconsin Hospitals His current research interests are in the areas of laboratory computers, ionselective electrodes, and in the development of analytical methods for drugs and Vace metal analyses He is a member of ACS, American Association of Clinical Chemistry, and Alpha Chi Sigma
pesticides, herbicides, or plasticizers with toxicological significance. Methods for the analysis of small organic metabolites and alcohols are included in this section.
ORGANIC ACIDS Most of the literature ( I N - 3 4 N ) was directed toward the analysis of urinary organic acids. Yew derivatization procedures for carboxylic acids have been reported. Intermediary organic acids of epinephrine metabolism are also included in this section.
METHOD EVALUATIONS, STANDARDIZATION, QUALITY A S S E S S M E N T , A N D STATISTICAL S T U D I E S Many of the papers in this section ( l O - l S S O ) report evaluations of chemical procedures used in automated multitest analyzers. These evaluations included comparison of methodologies, potential sources of interferences, and optimization of reaction conditions. Similar evaluations of commercial clinical kits have been reported. Quality control reference materials and quality assurance programs have received a good deal of attention. Use and misuse of statistical
* 37R
methods for the assessment of laboratory data have been presented.
EDITORIALS, RECOMMENDATIONS, A N D OPINIONS Representative of this section (lP-39P) are scientific letters suggesting modifications of published methods or expressing acceptability of instrumental techniques in the clinical laboratory. Provisionally recommended methods and suggested nomenclature from international commissions have been included.
ACKNOWLEDGMENT The conscientious attitude, knowledge of the literature, and accurate typing skills of Sandra Ramer are sincerely appreciated. BIBLIOGRAPHY
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ANALYTICAL CHEMISTRY, VOL. 51, NO. 5, APRIL 1979
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Edltorlais, Recommendations, and Opinions (1P) Algard. F., Montessori, G. A.. van Netten, J. P., Munn, M., Is There a High-Affinty Estrogen Binder in Human Serum? Clin. Chem ( Winston-Salem, N . C . ) , 24, 1848 (1978). (2P) Banks, P. E. C., Vernon, C. A.. Textbook Errors: Biochemical Abuse of Standard Equilibrium Constants, Trends Biochem. Sci.. 3 , N156 (1978). (3P) Bergmeyer, H. U.. Bowers, G. N., Jr., Horder, M., Moss, D. W., Provisional Recommendations on IFCC Methods for the Measurement of Catalytic Concentrations of Enzymes, Clin. Chem. ( Winston-Salem, N . C . ) ,23, 887 (1977). (4P) Bergmeyer, H. U., Horder, M.. Moss, D. W., Provisional Recommendatioris on IFCC Methods for the Measurement of Catalytic Concentrations of Enzymes. Part 3 Revised IFCC method for Aspartate Aminotransferase (L-Aspartate: 2-Oxoglutarate Aminotransferase, EC 2.6.1.1.) (1977), Clin. Chem. (Winston-Salem, N . C . ) ,24, 720 (1978). (5P) Bogden. J. D., Joselow, M. M.. Cd in Blood: A Misunderstanding of Comparative Methods? Clin. Chem. ( Winston-Salem, N.C ), 23. 1507 (1977). (6P) Bondar. R. J. L., Further Debate on Methods for Creatine Kinase, Clin. Chem. ( Winston-Salem, N . C . ) , 23, 1507 (1977). (7P) Bijttner, H.. Clinical Chemisby: Application of Analytical Chemistry to Problems of Diagnosis, Prognosis, and Theraphy, Fresenius' Z . Anal. Chem., 284, 119 (1977). (8P) Buttner. J.. Borth, R., Boutwell, J. H., Broughton. P. M G.. Bowyer. R. C , IFCC Provisional Recommendation on Quality Control in Clinical Chemistry. Part 3. Calibration and Control Materials. Clin. Chem. ( Winston-Salem, N.C.). 23, 1784 (1977). (9P) Buttner, J, Borth. R., Boutwell, J. H., Broughton. P. M. G.. Bowyer. R . C.. Provisional Recommendation on Quality Control in Clinical Chemistry. Part 5 . External Quality Control, Clin. Chem. ( Winston-Salem. N . C ). 24, 1213 (1978). (1OP) Buttner, J.. Borth, R.. Boutwell, J. H.. Broughton. P M. G , Bowyer. R C., IFCC Provisional Recommendations on Oualty Control in Clinicai Chemistry. Part 6. Clin. Chem. (Winston-Salem. N . C ). 23, 1066 (1977). (11P) Cali, J. P.. Schaffer, R . , Mitchell, F. L , Suggested Modification of The Definitions for Definitive Method. Clin. Chem. ( Winston-Salem, N . C.). 23, 1943 (1977). (12P) Chisolm, J. J . Jr.. Is Lead Poisoning Still a Problem Ciin Chem (Winston-Salem. N C ), 23, 252 (1977)
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13P) Conn, R. B.. Clinical Laboratories: Profit, Production or Patient Care? N . Engl. J . Med.. 298, 422 (1977) 14P) Daigneault, R., Deschamps, Y .. Guest Editorial: The Biochemical Service, The Professional Function of the Clinical Chemist in the Hospital. Glin Chem. ( Winston-Salem, N C.), 24, 5 (1978). 15P) Davis, E. R., Pottgen, P., How Best to Use Computerization ofLaboratory Tests, Clin. Chem. (Winston-Salem. N . C . ) ,24, 1422 (1978). 16P) Dharan. M., Semantics of "Accuracy" vs. "Inaccuracy". Clin. Chem. (Winston-Salem, N . C . ) , 23, 304 (1977). 17P) Godolphin, W., Literature Disagreement as to Identity of Nirvanol, Clin Chem. (Winston-Salem. N . C . ) , 23, 1504 (1977) 18P) IUPAC-IUB Commission on Biochemical Nomenclature (CBN). Nomenclature of Multiple Forms of Enzymes: Recommendation, Clin. Chem. ( Winston-Salem, N . C . ) , 23, 2163 (1977). (19P) IUPAC-IUB Commissiion on Biochemical Nomenclature: Abbreviations and Symbols, Clin. Chem. ( Winston-Salem, N . C . ) . 23, 2334 (1977). (2OP) Glick, D., Guest Editorial: The Future of Clinical Microchemical Analysis. Clin. Chem. (Winston-Salem, N . C . ) ,24, 189 (1978) (21P) Horpaczy, G.. Zinsmeyer. J., Schrijder, K , Mebel. M.. Value of Determining Urinary Enzymes after Human Kidney Transplantation: Early Warning of Rejection of Not? Clin. Chem. (Winston-Salem, N . C . ) ,23, 770 (1977). (22P) Labb6, R . F.. History and Background of Protoporphyrin Testing, C l m Chem. (Winston-Salem, N . C . ) , 23, 256 (1977). (23P) Liebich, H. M., Review: The Place of Gas Chromatography-Mass Spectrometry in Clinical Chemistry. J . Chromatogr.. 146, 185 (1978) (24P) Midgley, D. Criterion for Judging the Acceptability of Analytical Methods, Anal. Chem., 49, 510 (1977). (25P) Owen, C. A., Usefulness of Routine Prothrombin Time Measurements, Clin. Chem. ( Winston-Salem, N . C . ) ,23, 613 (1977). (26P) Oliver, M. F., Editorial: The Shrinking Base of Clinical Science: Where are Tomorrow's Researchers? f o r . J . Clin. Invest.. 7. 1 (19771. (27P) Pardue. H. L., Guest Editorial: A Comprehensive Classification of Kinetic Methods of Analysis Used in Clinical Chemistry, Clin Chem. ( Winston-Salem. N . C . ) , 23. 2189 (1977). (28P) Phillips, P. J., Pain, R. W., Hartley, T F., Duncan, B. M., Atkinson, M. J., Current "Corrected" Calcium Concept Rechallenged, Clm Chem ( Winston-Salem, N . C . ) , 23, 1936 (1977). (29P) Pratt, J. J., More on Documentation of Immunoassay Procedures, Clin Chem. (Winston-Salem, N . C . ) , 23. 1190 (1977) (30P) Roe, C. R., Guest Editorial: Validity of Estimating Myocardial Infarct Size from Serial Measurements of Enzyme Activity in the Serum. Clin Chem. ( Winston-Salem, N . C . ) ,23, 1807 (1977). (31P) Rosenblatt, J. E., Laboratory Tests Used to Guide Antimicrobial Therapy, Mayo Clin. Proc., 52, 611 (1977). (32P) Schoen, I.. For What Fluids Is a Kit Useful? Clin. Chem ( Winston-Salem, N . C . ) , 23, 1360 (1977). (33P) Schoen. I., How Broad Is (Should be) The Kit Producer's Responsibility for Supplying "Normal Values," Clin. Chem. ( Winston-Salem. N . C ). 23. 1373 119771. (34P) Shafrir.' E.. Guest Editorial: Research in the Clinical Biochemistry Department-A Reflection of Its Academic Function. Clin Chem. ( W i n ston-Salem. N . C . ) ,23, 1961 (1977). (35P) Steffes, M. W., Speedy Obsolescence of Methods for Radioassay, C l m Chem. (Winston-Salem. N . C . ) . 23. 1363 (1977) (36P) Thies, R. C., Gxd Laboratmy Practice-A Legal Perspectwe. Clin Toxcoi , 12, 207 (1978). (37P) Wilhelm. A. H , Todd. J. K . , Limited Diagnostic Value of CK-MB, Ciin. Chem. ( Winston-Salem, N . C . ) ,23, 1509 (1977). (38P) Young, D. S.. A New Cateqory of Article, Case Conferences. Clin. Chem ( Winston-Salem, N C.), 24; 128 (1976). (39P) Young, D. S.. SI Units for Clinical Laboratory Data, J Am. Med Assoc . 240, 1618 (1978)
