Diagnostic Approach to Patients with Low Serum Alkaline Phosphatase

Safety assessment of the ethanolic extract of Siparuna guianensis: Cell viability, molecular risk predictions and toxicity risk for acute and sub-chronic oral ingestion

ETHNOPHARMACOLOGICAL RELEVANCE

The species Siparuna guianensis Aublet (family Siparunaceae) is traditionally used by indigenous peoples and riverine communities in Central and South America to treat migraines, flu, respiratory diseases, fever, pain, edema and inflammatory and infectious diseases. Scientific studies on the species have proven its antiparasitic, insecticidal, antimicrobial, neuroprotective, anti-inflammatory, antioxidant and antinociceptive action. However, the safety profile of the species has not yet been established.

AIM OF THE STUDY

To verify the levels of cytotoxicity, evaluate the molecular toxicological prediction in silico, determine the median lethal dose and verify the possible acute and sub-chronic toxicological effects of S. guianensis in rats.

MATERIALS AND METHODS

After obtaining the aqueous and ethanolic extracts of S. guianensis leaves, the total phenolic content, ABTS radical scavenging activity and cytotoxicity in fibroblasts were evaluated. The ethanolic extract was used in chromatography and in the in silico and in vivo studies. The in silico test evaluated carcinogenicity, mutagenicity and skin irritation. Acute oral toxicity and LD50 were evaluated after the single dose of 2000 mg/kg, with monitoring for 14 days. Sub-chronic toxicity was evaluated at doses of 200, 400 and 800 mg/kg for 30 days. Murinometric parameters, water and food consumption and feed efficiency were evaluated. At the end of the experiments, hematological, biochemical, macroscopic organ and histopathological analyses were performed.

RESULTS

Cell viability was greater than 90 %, without cytotoxicity up to 25 μg/mL. In the in silico predictions, the molecules 2-undecanone, decanoic acid, decanoic acid ethyl ester and 2-tetradecanone showed no risk of carcinogenicity, mutagenicity, skin sensitization or eye irritation. The estimated LD50 was greater than 2000 mg/kg and daily oral use for 30 days was safe up to a limit of 800 mg/kg. The SG2000 group showed weight loss (p<0.01). In the hematological parameters, there was no difference between the groups (p>0.05), but in the biochemical findings, the urea rate was higher in the SG800 group (p<0.05), total proteins were higher in the SG400 group (p<0.05), while alkaline phosphatase was higher in the control group compared to the SG200, SG800 (p<0.01) and SG400 (p<0.05) groups. Triglycerides and VLDL-C were higher in the SG400 group, while non-HDL-C was higher in the SG800 group (p<0.05). The SG2000 group showed the lowest relative weights of the liver, spleen (p<0.05) and lungs (p<0.01), and the SG800 group showed increased weights for the liver (p<0.05) and lungs (p<0.01). Only the animals treated with a single dose of 2000 mg/kg showed histopathological changes in the liver, with slight cytoplasmic and tubular vacuolization in the kidneys.

CONCLUSIONS

The concentration of 25 μg/mL showed no cytotoxicity. Four molecules were detected in silico did not present a risk of carcinogenicity in female mice, nor mutagenicity, skin sensitization or ocular irritation. In rats, the LD50 is greater than 2000 mg/kg. Daily oral use for 30 days at up to 800 mg/kg was considered safe, with no significant hematological or histological alterations. These results may support further studies and pre-clinical trials.

Family mapping of previously identified patients with pathogenic or likely pathogenic ALPL variants using predictive genotyping and detailed phenotyping approach: the FAME case-control study

Hypophosphatasia (HPP) is an inborn error of metabolism caused by loss-of-function variants in the ALPL gene, which encodes the tissue nonspecific isozyme of alkaline phosphatase (ALP). There is no typical phenotype in adults. We used a genotyping first approach to determine whether ALPL pathogenic variants were associated with musculoskeletal symptoms, mineral metabolism abnormalities, and an impact on quality of life. We recruited individuals with a pathogenic (or likely pathogenic) variant in ALPL gene (n = 26) and their relatives (n = 44). We performed genetic tests and compared the relatives with positive (n = 20) and negative (n = 24) genetic test. We applied standard questionnaires and physical tests (Brief Pain Inventory [BPI]; Western Ontario and McMaster Universities Arthritis [WOMAC]; Modified Hypophosphatasia Impact Patient Survey; Short Form of 36 Survey [SF-36]; and the Short Physical Performance Battery). In fasting blood samples, we measured creatinine, calcium, phosphate (P), parathyroid hormone (PTH), ALP, bone ALP, 25OHD-, 1,25(OH)2D, CTX, type 1 procollagen N-terminal peptide (PINP), osteocalcin, and tartrate-resistant acid phosphatase5b (TRACP5b). Relatives with positive genetic test had lower ALP (IU/L) [32.5(12.8) vs 87.8(32.6) p < .001], bone ALP (ng/mL) [6.3(4.3, 9.8) vs 17.5 (13.12-25.7) p < .001], PTH (pg/L) [28.6(20.6, 38.1) vs 40.05(25.7, 52.3) p = .03], and higher PLP(nmol/L) [162.0 (91.75, 337.5) vs 37.5 (18.25, 60.5) p < .001] and P(mmol/L) [1.36 (0.18) vs 1.05 (0.2) p < .001]. We did not find significant differences in fractures or musculoskeletal features between the groups. Greater pain scores were observed on BPI in relatives with positive genetic tests, and bone and muscle pain were more often reported by this group, but statistical tests were not significant. No differences were found in physical performance or quality of life. In conclusion, we assessed relatives of individuals with pathogenic or likely pathogenic variants in the ALPL gene regardless of the presence of signs and symptoms. Biochemical abnormalities were more common in gene-positive relatives, but the prevalence of musculoskeletal symptoms was comparable in relatives with positive and negative genetic tests.

Flexible Screen-Printed Electrochemical Sensor for Alkaline Phosphatase Detection in Biofluids for Biomedical Applications

Alkaline phosphatase (ALP) is an enzyme present in the human body responsible for the dephosphorylation of phosphorylated chemical species. It is primarily expressed in organs such as bones, liver, intestine, and placenta during pregnancy, playing a crucial role in cellular processes like gene expression, transport, and metabolism. Physiological ALP levels vary with age and sex, with normal serum ranges for healthy adults between 40 and 190 U/L. Alterations in ALP levels can be indicative of several pathologies, including cancer diagnosis and metastasis, as well as bone growth dysfunctions and hypophosphatasia. Conventional methods for ALP detection often require complex assay principles, extensive sample pretreatment, and trained personnel. Herein, the development of a portable, flexible electrochemical sensor fabricated through screen-printing to monitor ALP levels in biological samples is introduced. The flexible electrochemical sensor, characterized by high efficiency, sustainability, low cost, and ease of disposal, achieves detection limit as low as 0.03 and 0.08 U/L, respectively, in buffer solution and human serum samples, and a satisfactory repeatability lower than 10%. This simple sensor configuration approach enables real-time disease monitoring and improves access to point-of-care diagnostics, paving the way for affordable, decentralized sensors that support early diagnosis and better healthcare.

Therapeutic efficacy of zoledronic acid combined with calcium and calcitriol in the treatment of senile osteoporosis in elderly patients

OBJECTIVE

To investigate the effectiveness and safety of combining zoledronic acid with calcium supplements and calcitriol in treating primary osteoporosis in elderly patients.

METHODS

Seventy-eight elderly patients with primary osteoporosis were recruited. They were randomly assigned in a 1:1 ratio to either the CC group (calcium carbonate D3 tablets + calcitriol soft capsules) or the CCZ group (calcium carbonate D3 tablets + calcitriol soft capsules + zoledronic acid injection). The treatment duration was 1 year. Bone mineral density (BMD), bone metabolism markers, quality of life (QoL), clinical efficacy, and incidence of adverse reactions (ARs) were assessed.

RESULTS

CCZ group showed increased BMD in the lumbar spine (L1~L4 segments), femoral neck, and hip after treatment relative to CC group. Serum levels of bone-specific alkaline phosphatase, cross-linked type 1 collagen C-terminal peptide, and N-terminal propeptide of type 1 procollagen decreased, while osteocalcin levels increased. The QoL Questionnaire of the European Foundation for Osteoporosis scores decreased (P < 0.05 for all comparisons). The clinical effective rates were 76.93% in the CC group and 92.31% in the CCZ group, with AR rates of 23.08% and 12.82%, respectively (P < 0.05 for both).

CONCLUSION

Zoledronic acid treatment in elderly patients with primary osteoporosis demonstrates significant efficacy by increasing bone density, improving bone metabolism, enhancing QoL, and exhibiting high safety.

Diagnostic Approach to Abnormal Alkaline Phosphatase Value

Alkaline phosphatase (ALP) is abundantly represented in nature, being fundamental for a number of processes. In addition to its fundamental function in skeletal mineralization, its roles in the pathogenesis of other diseases are being explored. The measurement of total ALP activity in serum or in plasma is a useful biomarker in clinical practice. Indeed, routine measurement of serum total ALP is a long-standing established part of initial biochemical evaluation of patients both in the hospital setting and on an ambulatory basis. Raised or reduced values of this enzyme activity are indicative of a number of diseases, most commonly affecting the skeleton and the biliary tract. Electrophoretic assays are preferable for visualizing and investigating the cause of increased serum total ALP activities, and bone ALP immunoassays are preferable for investigating and monitoring individuals with bone and mineral metabolic abnormalities. Here, we give a holistic vision of this fundamental enzyme, suggesting a clinical approach to the identification of diseases causing abnormal values. Finally, a therapeutic role has emerged as substitutive therapy in patients with hypophosphatasia, even though ongoing and future studies are exploring its role in other therapeutic areas. This narrative review was based on articles found by searching PubMed from its inception until July 2024 for the terms alkaline phosphatases, isozymes, isoforms, bone alkaline phosphatase, liver alkaline phosphatase, intestinal alkaline phosphatase, placental alkaline phosphatase, liver function tests, γ-glutamyltransferase, skeletal diseases, and liver diseases. We limited our research to papers published in the English language, with emphasis placed on those describing differential diagnosis whenever available.

Diagnosis and Treatment of Hypophosphatasia

Hypophosphatasia (HPP) is a rare inherited metabolic disorder characterized by deficient activity of tissue-nonspecific alkaline phosphatase (TNAP) caused by variants in the ALPL gene. Disease manifestations encompass skeletal hypomineralization with rickets and lung hypoplasia, vitamin B6-dependent seizures, craniosynostosis, and premature loss of deciduous teeth. The clinical presentation can comprise failure to thrive with muscular hypotonia, delayed motor development, and gait disturbances later in childhood. In adults, pseudofractures are a characteristic indicator of severely compromised enzyme activity, but non-canonical symptoms like generalized musculoskeletal pain, weakness, and fatigue, frequently accompanied by neuropsychiatric and gastrointestinal issues are increasingly recognized as key findings in patients with HPP. The diagnosis is based on clinical manifestations in combination with persistently low alkaline phosphatase (ALP) activity, elevated levels of ALP substrates, specifically inorganic pyrophosphate (PPi), pyridoxal 5'-phosphate (PLP) or urine phosphoethanolamine (PEA), and genetic confirmation of a causative ALPL variant. Considering the wide range of manifestations, treatment must be multimodal and tailored to individual needs. The multidisciplinary team for comprehensive management of HPP patients should include expertise to ensure disease state metabolic and musculoskeletal treatment, dental care, neurological and neurosurgical surveillance, pain management, physical therapy, and psychological care. Asfotase alfa as first-in-class enzyme replacement therapy (ERT) for HPP has been shown to improve survival, rickets, and functional outcomes in severely affected children, but further research is needed to refine how enzyme replacement can also address emerging manifestations of the disease. Prospectively, further elucidating the pathophysiology behind the diverse clinical manifestations of HPP is instrumental for improving diagnostic concepts, establishing novel means for substituting enzyme activity, and developing integrative, multimodal care.

Prognostic Value of Combined Detection of MMP-7 and ALP Levels in Children With Biliary Atresia Post-Kasai Surgery

OBJECTIVE

Biliary atresia (BA) remains a prevalent indication for pediatric liver transplantation (LT). We investigated the prognostic value of the serum matrix metalloproteinases 7 (MMP-7) and alkaline phosphatase (ALP) level combined detection for BA children post-Kasai surgery.

METHODS

This study retrospectively enrolled 85 BA children who underwent Kasai surgery. They were divided into the native liver (NL) and LT groups based on their three-year postoperative prognosis. Serum MMP-7 and ALP levels were measured by ELISA. The relationship of intraoperative serum MMP-7 and ALP levels with preoperative gamma-glutamyltransferase (GGT), and their impact on the risk of postoperative LT were analyzed by Pearson's correlation coefficient and Kaplan-Meier curves. The independent risk factors (IRFs) for postoperative LT and the predictive value of the serum MMP-7 and ALP level combined detection for postoperative LT in BA children were analyzed by Cox regression analysis and receiver operating characteristic (ROC) curves. MedCalc software compared the areas under the ROC curves (AUC).

RESULTS

Significant differences were observed between the two groups in BA classification, postoperative jaundice clearance rate, and cholangitis occurrence. Intraoperative serum MMP-7 and ALP levels were higher in the LT group and positively correlated with preoperative GGT. High MMP-7 and ALP levels were IRFs for postoperative LT, while significant jaundice clearance was a protective factor. Combined MMP-7 and ALP detection (0.926 AUC, 91.30% sensitivity, 87.18% specificity) significantly improved the prediction for LT.

CONCLUSION

High MMP-7 and ALP levels are IRFs for post-Kasai surgery LT in BA children, with their combination providing superior predictive value.

Serum Alkaline Phosphatase Levels in Pediatric Kikuchi-Fujimoto Disease: A Retrospective Observational Analysis

AIM

Kikuchi-Fujimoto disease (KFD) rarely affects pediatric patients and is characterized by prolonged fever and cervical lymphadenopathy. The diagnosis of KFD remains challenging and often requires an invasive biopsy. Low serum alkaline phosphatase levels have frequently been observed in patients with KFD; however, the clinical significance of low serum alkaline phosphatase levels remains unclear.

METHODS

This retrospective study included pediatric patients aged < 16 years who were pathologically or clinically diagnosed with KFD and infectious mononucleosis between April 2016 and March 2023. Serum alkaline phosphatase levels were analyzed employing age- and sex-specific reference intervals. Clinical and laboratory data were evaluated to determine their association with serum alkaline phosphatase levels.

RESULTS

Thirty patients with KFD and 23 patients with infectious mononucleosis were included in the study. Seventeen patients with KFD (56.7%) had serum alkaline phosphatase levels below the 2.5th percentile of the age- and sex-specific reference intervals. Serum alkaline phosphatase levels were significantly lower in patients with KFD than in those with infectious mononucleosis. Clinical and other laboratory findings were not significantly different between patients with KFD with or without a decline in serum alkaline phosphatase levels.

CONCLUSION

A decrease in serum alkaline phosphatase levels, particularly when assessed as a percentage of age- and sex-specific reference intervals, may be a valuable and noninvasive supportive feature of KFD in pediatric patients.

Possible role of bone turnover markers in the diagnosis of adult hypophosphatasia

Hypophosphatasia (HPP) is a rare disorder of the bone metabolism, characterized by genetically determined low alkaline phosphatase (ALP) activity. Low ALP may also be observed in some common causes of bone fragility, such as in osteoporosis treated with antiresorptive drugs. This study aimed to verify whether differences in bone turnover markers (BTMs) could help differentiate adult patients with HPP from those with osteoporosis undergoing antiresorptive treatment. In this multicenter study, we enrolled 23 adult patients with a diagnosis of HPP and compared them with 46 osteoporotic subjects previously treated with zoledronic acid or denosumab. BTMs such as CTX, N-terminal propeptide of type I procollagen (P1NP), total ALP, and bone ALP (bALP) were measured, and ratios between BTMs were also calculated. Considering that the control group included only females, in the primary analysis we compared their characteristics with that of the 16 female patients with HPP. Both individual BTMs (CTX and P1NP) and 4 BTM ratios (ALP/P1NP, bALP/P1NP, ALP/CTX, and bALP/CTX) showed satisfactory discriminatory power, outperforming ALP alone. P1NP, in particular, had an area under the curve (AUC) of 0.962 with a cut-off of 32 μg/L, while as for the BTMs ratios, the ALP/P1NP ratio had an AUC of 0.964 with a cut-off of 1.114. Similar results were confirmed when including male HPP patients, when adjusting for age and sex, and finally when performing a sensitivity analysis only in patients with ALP less than or equal to 32 U/L (ie, the median of the distribution of the entire population). In cases of low ALP and bone fragility, BTM and their ratios could help distinguish HPP patients from osteoporotic individuals treated with antiresorptive drugs, aiding in accurate diagnosis and reducing the risk of inappropriate treatment.

Clinical Characteristics of Persistent Hypophosphatasemia Uncovered in Adult Patients: A Retrospective Study at a Japanese Tertiary Hospital

Background: Hypophosphatasemia is often overlooked despite its potential to indicate underlying pathologies. The aim of this study was to determine the prevalence of persistent hypophosphatasemia in a large, urban, multi-specialty hospital population and characterize the clinical and laboratory findings in adult patients with this condition. Methods: In this retrospective observational study, the results of 424,434 alkaline phosphatase (ALP) tests in 50,136 patients aged ≥18 years that were performed at Okayama University Hospital between July 2020 and October 2023 were analyzed. Persistent hypophosphatasemia was defined as consistently low ALP levels (≤40 IU/L) for 28 days with a minimum recorded level of ≤35 IU/L. Results: Persistent hypophosphatasemia was detected in 273 patients (0.54% of the tested patients), and the patients with persistent hypophosphatasemia included a higher proportion of females (72.5% vs. 52.9% in the people without persistent hypophosphatasemia; chi-squared test, p < 0.01) and had a younger median age (51 years vs. 63 years; Mann-Whitney U test, p < 0.01) than those in the overall tested population. The common causes of persistent hypophosphatasemia were cancer (30%), glucocorticoid use (21%), and immunosuppressants (16%). Notably, 38 patients (14%) had no apparent cause for low ALP values. These patients were categorized on the basis of their clinical characteristics, with some patients presenting symptoms potentially related to adult hypophosphatasia. Conclusions: This study provides prevalence and insights into the causes and characteristics of persistent hypophosphatasemia in a Japanese tertiary care setting. While most cases were associated with known causes, patients with unexplained hypophosphatasemia and symptoms such as chronic pain, muscle weakness, and general fatigue could have adult hypophosphatasia. In such cases, comprehensive evaluation and further investigation for hypophosphatasia should be considered. Persistent hypophosphatasemia of undetermined etiology could be a crucial initial step in diagnostic algorithms for this condition.

Bilateral or Unilateral Aldosterone Hypersecretion and Responsiveness to Therapy Are Associated with Differences in Calcium/Phosphate Homeostasis in Patients with Primary Aldosteronism

Introduction Primary aldosteronism is characterized by the autonomous excretion of aldosterone, which may induce bone mineral disorders. Methods A total of 96 patients with primary aldosteronism were analyzed to identify differences in the regulation of serum calcium/phosphate balance between patients with unilateral and bilateral aldosterone hypersecretion and to determine whether or not adrenalectomy or mineralocorticoid receptor blockers affected such differences. Results Serum phosphate concentrations were significantly lower in patients with unilateral aldosterone hypersecretion than in patients with bilateral aldosterone hypersecretion (2.96±0.45 vs. 3.36±0.55 mg/dL, p<0.05), and recovered after adrenalectomy (2.96±0.45 vs. 3.49±0.32 mg/dL, p<0.01). In patients with bilateral aldosterone hypersecretion, the baseline serum phosphate levels were significantly lower in responders to mineralocorticoid receptor blocker treatment, defined as post-treatment plasma renin activity ≥1 ng/mL/h, than in non-responders. In responders, these levels tended to recover after treatment. A weak negative correlation between the plasma aldosterone concentration (PAC) and serum phosphate was observed, but there were no associations between the PAC and serum calcium concentration or between the aldosterone renin ratio and serum calcium and phosphate concentrations. Conclusion The effects on calcium/phosphate homeostasis may differ according to the primary aldosteronism subtype.

Longitudinal course of circulating miRNAs in a patient with hypophosphatasia and asfotase alfa treatment: a case report

Hypophosphatasia (HPP) is characterized by low activity of tissue nonspecific alkaline phosphatase (TNSALP). The enzyme replacement therapy asfotase alfa has been approved for childhood-onset forms of HPP. MicroRNAs (miRNAs) have emerged as a novel disease biomarker, with potential application in therapy monitoring. Circulating miRNAs were analyzed at baseline, months 1, 2, 4, and 16 in a 49-yr-old woman with childhood-onset HPP, chronic musculoskeletal pain, and non-traumatic fractures prior to enzyme replacement therapy. Serum RNA was extracted and sequenced using miRNeasy Mini Kit (Qiagen, Germany), RealSeq Biosciences Kit (Santa Cruz, US) together with miND spike-in control kit (TAmiRNA, Austria) and Illumina NovaSeq 6000 SP1 flow cell (San Diego, US). Brief Pain Inventory Severity and Interference scores (BPI-S/BPI-I), fatigue severity scale (FSS), Patient Global Impression of Improvement (PGI-I), Western Ontario and McMaster university hip disability and osteoarthritis outcome score (WOMAC), fibromyalgia impact questionnaire (FIQ), 6-Minute Walking Test (6-MWT), chair-rise-test (CRT), and handgrip dynamometry (HD) were performed at baseline and different timepoints during the therapy. Out of >800 screened, 84 miRNAs were selected based on differences in expression profiles between 24 HPP patients and 24 healthy controls. Six miRNAs showed a clear graphic trend and were up- or downregulated by ≥50% reads per million (rpm). These included hsa-let-7i-5p (+50%), hsa-miR-1-3p (-66.66%), hsa-miR-1294 (+63.63%), hsa-miR-206 (-85.57%), hsa-miR-375-3p (-71.43%), and hsa-miR-624-5p (+69.44%). hsa-miR-1-3p and hsa-miR-206 were identified as muscle-specific miRNAs. hsa-mir-375-3p, which negatively regulates osteogenesis, was significantly downregulated. In terms of patient-reported outcomes, BPI-S, BPI-I, FSS, PGI-I, WOMAC, and FIQ showed a reduction by -58.62%, -68.29%, -33.33%, -75.00%, -63.29%, and -43.02%, respectively. 6-MWT improved by +33.89% and CRT by -44.46%. Mean hand grip strength of the right/left hand measured by HD improved by +12.50% and + 23.53%, respectively. miRNA profile changes during the therapy with asfotase alfa, accompanying improvements in functionality tests and quality of life scores.

Neonatal Gut and Immune Responses to β-Casein Enriched Formula in Piglets

BACKGROUND

β-casein is the main casein constituent in human milk (HM) and a source of bioactive peptides for the developing gastrointestinal tract and immune system. Infant formulas contain less β-casein than HM, but whether different concentrations of β-casein affect tolerability and gut and immune maturation in newborns is unknown.

OBJECTIVES

Using near-term piglets as a model for newborn infants, we investigated whether increasing the β-casein fraction in bovine-based formula is clinically safe and may improve gut and immune maturation.

METHODS

Three groups of near-term pigs (96% gestation) were fed formula with bovine casein and whey protein (ratio 40:60): 1) standard skim milk casein (BCN-standard, 35% β-casein of total casein, n = 18); 2) β-casein enrichment to HM concentrations (BCN-medium, 65%, n = 19); and 3) high β-casein enrichment (BCN-high, 91%, n = 19). A reference group was fed 100% whey protein concentrate (WPC) as protein (WPC, n = 18). Intestinal and immune parameters were assessed before and after euthanasia on day 5.

RESULTS

Clinical variables (mortality, activity, body growth, and diarrhea) were similar among the groups, and no differences in intestinal or biochemical parameters were observed between BCN-standard and BCN-medium pigs. However, pigs receiving high amounts of β-casein (BCN-high) had lower small intestine weight and tended to have more intestinal complications (highest gut pathology score, permeability, and interleukin-8) than the other groups, particularly those receiving no casein (WPC pigs). Blood lymphocyte, thrombocyte, and reticulocyte counts were increased with higher β-casein, whereas eosinophil counts were reduced. In vitro blood immune cell responses were similar among groups.

CONCLUSIONS

β-casein enrichment of bovine-based formula to HM concentrations is clinically safe, as judged from newborn, near-term pigs, whereas no additional benefits to gut maturation were observed. However, excessive β-casein supplementation, beyond concentrations in HM, may potentially induce gut inflammation together with increased blood cell populations relative to natural β-casein concentrations or pure whey-based formula.

Detection of alkaline phosphatase activity with a CsPbBr3/Y6 heterojunction-based photoelectrochemical sensor

An ultra-sensitive photoelectrochemical (PEC) sensor based on perovskite composite was developed for the determination of alkaline phosphatase (ALP) in human serum. In contrast to CsPbBr3 or Y6 that generated anodic current, the heterojunction of CsPbBr3/Y6 promoted photocarriers to separate and generated cathodic photocurrent. Ascorbic acid (AA) was produced by ALP hydrolyzing L-ascorbic acid 2-phosphate trisodium salt (AAP), which can combine with the holes on the photoelectrode surface, accelerating the transmission of photogenerated carriers, leading to enhanced photocurrent intensity. Thus, the enhancement of PEC current was linked to ALP activity. The PEC sensor exhibits good sensitivity for detection of ALP owing to the unique photoelectric properties of the CsPbBr3/Y6 heterojunction. The detection limit of the sensor was 0.012 U·L-1 with a linear dynamic range of 0.02-2000 U·L-1. Therefore, this PEC sensing platform shows great potential for the development of different PEC sensors.

In Vivo Biocompatibility Study on Functional Nanostructures Containing Bioactive Glass and Plant Extracts for Implantology

In this paper, the in vivo behavior of orthopedic implants covered with thin films obtained by matrix-assisted pulsed laser evaporation and containing bioactive glass, a polymer, and natural plant extract was evaluated. In vivo testing was performed by carrying out a study on guinea pigs who had coated metallic screws inserted in them and also controls, following the regulations of European laws regarding the use of animals in scientific studies. After 26 weeks from implantation, the guinea pigs were subjected to X-ray analyses to observe the evolution of osteointegration over time; the guinea pigs' blood was collected for the detection of enzymatic activity and to measure values for urea, creatinine, blood glucose, alkaline phosphatase, pancreatic amylase, total protein, and glutamate pyruvate transaminase to see the extent to which the body was affected by the introduction of the implant. Moreover, a histopathological assessment of the following vital organs was carried out: heart, brain, liver, and spleen. We also assessed implanted bone with adjacent tissue. Our studies did not find significant variations in biochemical and histological results compared to the control group or significant adverse effects caused by the implant coating in terms of tissue compatibility, inflammatory reactions, and systemic effects.

Serum alkaline phosphatase can be elevated in patients with hypophosphatasia due to liver disease

BACKGROUND

Hypophosphatasia (HPP) is a rare inherited disorder caused by pathogenic loss-of-function variants in the ALPL gene, encoding the tissue-nonspecific isoenzym of alkaline phosphatase (ALP; TNSALP). Low serum ALP is the biochemical hallmark of HPP, but it is unknown whether ALP levels can increase due to concurring liver disease, which may lead to a missed diagnose of HPP. We present a patient with genetically confirmed HPP, who showed a transient increase of serum ALP levels due to alcohol-induced hepatitis.

CLINICAL REPORT

A 71-year old man was seen at our Bone Center for surveillance of HPP. Serum ALP was always low (23 U/L; reference value: <115 U/L). During follow-up, his serum ALP increased (156 U/L, further rising to 204 U/L), with concomitantly elevated serum gamma-glutamyl transferase and transaminases, and a rise in bone specific ALP (18.7 μg/L; reference value: 5.7-32.9 μg/L). This was attributed to alcohol-induced hepatitis. After refraining from alcohol intake, both serum ALP and bone specific ALP levels returned to initial low levels (30 U/L and 4.3 μg/L respectively).

CONCLUSIONS

We demonstrated the history of a 71-year old patient with HPP, presenting during routine follow-up with an elevated serum ALP level up to 204 U/L due to alcohol-induced hepatitis. This case illustrates that the diagnosis of HPP can potentially be missed when ALP levels are normal or elevated due to a concomitant liver disease.

Comparison of the Efficacy of Longer versus Shorter Pulsed High Dose Dapsone Combination Therapy in the Treatment of Chronic Lyme Disease/Post Treatment Lyme Disease Syndrome with Bartonellosis and Associated Coinfections

Twenty-five patients with relapsing and remitting Borreliosis, Babesiosis, and bartonellosis despite extended anti-infective therapy were prescribed double-dose dapsone combination therapy (DDDCT), followed by one or several courses of High Dose Dapsone Combination Therapy (HDDCT). A retrospective chart review of these 25 patients undergoing DDDCT therapy and HDDCT demonstrated that 100% improved their tick-borne symptoms, and patients completing 6-7 day pulses of HDDCT had superior levels of improvement versus 4-day pulses if Bartonella was present. At the completion of treatment, 7/23 (30.5%) who completed 8 weeks of DDDCT followed by a 5-7 day pulse of HDDCT remained in remission for 3-9 months, and 3/23 patients (13%) who recently finished treatment were 1 ½ months in full remission. In conclusion, DDDCT followed by 6-7 day pulses of HDDCT could represent a novel, effective anti-infective strategy in chronic Lyme disease/Post Treatment Lyme Disease Syndrome (PTLDS) and associated co-infections, including Bartonella, especially in individuals who have failed standard antibiotic protocols.