P J Foxall

University of London, Londinium, England, United Kingdom

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Publications (30)163.61 Total impact

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    ABSTRACT: Blood plasma is the major vehicle by which metabolites are transported around the body in mammalian species, and chemical analysis of plasma can provide a wealth of information relating to the biochemical status of an individual and is important for diagnostic purposes. However, plasma is very complex in physicochemical terms because it is composed of a range of organic and inorganic constituents with a wide range of molecular weights and chemical classes and this makes analysis non-trivial. It is now well established that high-resolution (1)H NMR spectroscopy of blood plasma provides useful qualitative and quantitative biochemical information relating to metabolic disorders. However, one of the problems encountered in NMR spectroscopic analysis of blood plasma is the extensive peak overlap or presence of broad macromolecule peaks in the (1)H NMR spectrum, which can severely limit the amount of obtainable information. Even with spectroscopic editing, information relating to low-molecular-weight (MW) metabolites is frequently lost. Therefore, the efficiency of a range of conventional protein removal methods, in combination with the use of one- and two-dimensional NMR spectroscopic methods for evaluation, have been compared for the extraction of NMR-observable low-MW metabolites. It has been shown that these "deproteinization" methods vary considerably in recovery of low MW metabolites and a judicious choice is crucial for optimal extraction of a given analyte. The results presented here show that while ultrafiltration provides the "safest" method of plasma deproteinization, the signal-to-noise ratio of the resultant (1)H NMR spectra is poor. On the other hand, acetonitrile precipitation at physiological pH allows the detection of more low-MW metabolites and at higher concentrations than any other method and provides the further advantages of being a rapid and simple procedure.
    Analytical Biochemistry 06/2002; 304(2):220-30. · 2.58 Impact Factor
  • Analytical Biochemistry 05/2002; 304(2). · 2.58 Impact Factor
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    ABSTRACT: The technique of magic angle spinning (MAS) high resolution (1)H NMR spectroscopy applied to intact tissues provides excellent peak resolution and thus much biochemical information. The use of computer-based pattern recognition techniques to classify human renal cortex tissue samples as normal or tumour based on their (1)H MAS NMR spectra has been investigated. In this preliminary study of 22 paired control and tumour samples, exploratory data analysis using principal components based on NMR spectral intensities showed clear separation of the two classes. Furthermore, using the supervised method of linear discriminant analysis, based on individual data point intensities or on integrated spectral regions, it was possible to distinguish between the normal and tumour kidney cortex tissue with 100% accuracy, including a single example of a metastatic tumour from a primary lung carcinoma. A tumour sample from the collecting duct of the kidney showed a different NMR spectral profile, and pattern recognition indicated that this sample did not classify with the cortical tumours.
    NMR in Biomedicine 05/2000; 13(2):64-71. · 3.45 Impact Factor
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    ABSTRACT: The technique of magic angle spinning (MAS) high resolution 1H NMR spectroscopy applied to intact tissues provides excellent peak resolution and thus much biochemical information. The use of computer-based pattern recognition techniques to classify human renal cortex tissue samples as normal or tumour based on their 1H MAS NMR spectra has been investigated. In this preliminary study of 22 paired control and tumour samples, exploratory data analysis using principal components based on NMR spectral intensities showed clear separation of the two classes. Furthermore, using the supervised method of linear discriminant analysis, based on individual data point intensities or on integrated spectral regions, it was possible to distinguish between the normal and tumour kidney cortex tissue with 100% accuracy, including a single example of a metastatic tumour from a primary lung carcinoma. A tumour sample from the collecting duct of the kidney showed a different NMR spectral profile, and pattern recognition indicated that this sample did not classify with the cortical tumours.© 2000 John Wiley & Sons, Ltd.
    NMR in Biomedicine 03/2000; 13(2):64 - 71. · 3.45 Impact Factor
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    ABSTRACT: High resolution 1H nuclear magnetic resonance (NMR) spectra using spinning at the magic angle (1H MAS NMR) have been obtained on intact normal and pathological kidney tissue samples from patients undergoing surgery for renal cell carcinoma (RCC). The spectra were measured on ca. 80 mg samples and provided high resolution 1H NMR spectra in which effects of dipolar couplings, chemical shift anisotropy and magnetic susceptibility differences are minimised thus yielding high spectral resolution. Conventional one-dimensional and spin-echo spectra and two-dimensional J-resolved, TOCSY and 1H-13C HMQC spectra were also measured on selected samples and these allowed the assignment of resonances of endogenous substances comprising both cytosolic and membrane components. The tumour tissues were characterised principally by an increased lipid content. These are the first reported results on human tumour tissues using this technique and the approach offers potential for the rapid classification of different types of tumour tissue.
    Journal of Pharmaceutical and Biomedical Analysis 06/1998; 17(1):125-32. · 2.95 Impact Factor
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    ABSTRACT: 1H NMR spectroscopy of urine combined with pattern recognition (PR) methods of data analysis has been used to investigate the time-related biochemical changes induced in Sprague-Dawley rats by three model hepatotoxins: alpha-naphthyl isothiocyanate (ANIT), d-(+)-galactosamine (GalN), and butylated hydroxytoluene (BHT). The development of hepatic lesions was monitored by conventional plasma analysis and liver histopathology. Urine was collected continuously postdosing up to 144 h and analyzed by 600-MHz 1H NMR spectroscopy. NMR spectra of the urine samples showed a number of time-dependent perturbations of endogenous metabolite levels that were characteristic for each hepatotoxin. Biochemical changes common to all three hepatotoxins included a reduction in the urinary excretion of citrate and 2-oxoglutarate and an increased excretion of taurine and creatine. Increased urinary excretion of betaine, urocanic acid, tyrosine, threonine, and glutamate was characteristic of GalN toxicity. Both GalN and ANIT caused increased urinary excretion of bile acids, while glycosuria was evident in BHT- and ANIT-treated rats. Data reduction of the NMR spectra into 256 integrated regions was used to further analyze the data. Mean values of each integrated region were analyzed by principal components analysis (PCA). Each toxin gave a unique time-related metabolic trajectory that could be visualized in two-dimensional PCA maps and in which the maximum distance from the control point corresponded to the time of greatest cellular injury (confirmed by conventional toxicological tests). Thereafter, the metabolic trajectories changed direction and moved back toward the control region of the PR map during the postdose recovery phase. The combination of urinary metabolites which were significantly altered at various time points allowed for differentiation between biliary and parenchymal injury. This NMR-PR approach to the noninvasive detection of liver lesions will be of value in furthering the understanding of hepatotoxic mechanisms and assisting in the discovery of novel biomarkers of hepatotoxicity.
    Chemical Research in Toxicology 04/1998; 11(4):260-72. · 3.67 Impact Factor
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    ABSTRACT: High resolution 600 MHz 1H NMR spectroscopy was used to investigate the changes in biochemical composition of whole human seminal fluid (SF) and an artificial mixture of prostatic (PF) and seminal vesicle fluid (SVF). A variety of time-related biochemical changes were monitored simultaneously and non-invasively in SF, including enzymatic hydrolysis of phosphorylcholine to choline and polypeptides to amino acids. The fastest NMR-observable reactions in SF were the conversion of phosphorylcholine to choline (t1/2 approximately equal to 9 min) and uridine-5'-monophosphate (UMP) to uridine (t1/2 < 2 min). UMP has not previously been detected in SF because of its rapid hydrolysis. Artificial mixtures of separately obtained prostatic and SVF showed very similar biochemical changes to those observed in whole SF. Addition of EDTA to SF incubated for 2 min post ejaculation strongly inhibited peptide hydrolysis. Zn2+, present in whole SF was shown to be non EDTA-chelatable 2 min after ejaculation, whereas after 7 min, a singlet signal from the ethylenic protons of the Zn-EDTA2- complex was clearly observed which remained constant after 7 min. This indicates that soon after ejaculation (< 5 min) Zn2+ is immobilised in a macromolecular complex which is rapidly broken down by proteolytic enzymes, the released Zn2+ then being free to react with EDTA. Mg- and Ca-EDTA2- complexes were observed at 2 min and remained constant (at 1.4 and 2.1 mM, respectively) throughout the entire time course of the experiment. These studies cast new light on the time-related biochemical changes occurring in the post-ejaculatory SF which may have an important role in reproductive function.
    Biochimica et Biophysica Acta 03/1998; 1379(3):367-80. · 4.66 Impact Factor
  • P J Foxall, J K Nicholson
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    ABSTRACT: Major advances in nuclear magnetic resonance (NMR) spectroscopic methods and technology have led to the increased use of this technique to study kidney metabolism and function. These studies include: (1) the identification of organic osmolytes in the renal medulla and their role as potential markers of medullary development and damage; (2) changes in renal epithelial cell organic solute transport, such as autosomal dominant polycystic kidney disease, and (3) the biochemical heterogeneity of the nephron and identification of markers of site-specific renal damage in experimental animals and man. The present review summarises these data with the aim of demonstrating how NMR can be used as an indirect, and non-invasive probe of homeostatic mechanisms in vivo and in vitro.
    Experimental nephrology 01/1998; 6(5):409-14.
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    ABSTRACT: High resolution magic angle spinning (MAS) 1H nuclear magnetic resonance (NMR) spectra of whole pieces of human prostatic tissue (<40 mg per sample) from patients with benign prostatic hyperplasia (BPH) and malignant tumours have been obtained and compared with high resolution NMR solution state spectra obtained via a standard tissue extraction method. Well resolved MAS-NMR spectra of the tissue samples were obtained in which both cytosolic and membrane-related compounds could be identified. Two-dimensional 1H MAS-NMR measurements, including J-resolved and shift correlation spectra, were also obtained to allow metabolite signal assignment. In all cases high quality spectra were obtained that were rich in bioanalytical information on a wide range of intracellular metabolites and lipids. Marked differences were observed between MAS spectra from tumours versus BPH tissue, particularly in the lipid signals, which were much more intense in tumours. This was in contrast to the protein-free extracts of the same samples which showed much more similar NMR profiles for the two disease classes. These data indicate that MAS-NMR spectra of intact tissue biopsy samples give a wider range of bioanalytical information on small and large molecules than conventional, more labour intensive cell extraction procedures, and this strengthens the case for the use of MAS-NMR in clinical diagnostics.
    Analytical Communications 01/1998; 35(3):113-115.
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    ABSTRACT: Ifosfamide is an oxazophosphorine widely used in the treatment of cancer in children and adults. Nephrotoxicity and neurotoxicity are major side effects. The aim of this study was to use high-resolution proton nuclear magnetic resonance (1H NMR) spectroscopy of urine to identify novel biochemical markers of ifosfamide-induced toxicity. Urine samples were collected from 10 nonencephalopathic patients (who had not previously received nephrotoxic chemotherapy) immediately prior to the first ifosfamide dose and at timed intervals for up to four treatment cycles. The findings were compared with those for urine samples collected from five patients during acute encephalopathic episodes. 1H NMR urinalysis identified a series of characteristic time-related changes in the excretion profiles of low molecular weight endogenous metabolites during ifosfamide therapy. These changes included a decreased excretion of hippurate and an increased excretion of glycine, histidine, glucose, lactate, and trimethylamine-N-oxide. Two nonencephalopathic patients had marked but transient glutaric or adipic aciduria during the second cycle of ifosfamide treatment. Urinary retinol-binding protein rose acutely after each treatment cycle but usually returned to baseline levels. Maximum renal toxicity was observed by the fourth treatment cycle. The ratio of the urinary excretion of the uroprotectant mesna (active form) to dimesna (inactive form) correlated with the degree of renal toxicity. For the encephalopathic patients, the ifosfamide-induced changes in the urinary low molecular weight metabolite profile were similar to those for the nonencephalopathic group. In contrast to previous reports, none of the encephalopathic group developed glutaric aciduria, and i.v. methylene blue did not reverse neurotoxicity in the two patients who received it. The results suggest that ifosfamide nephrotoxicity involves both cortical and medullary regions of the nephron and that the urinary mesna:dimesna ratio may be important in assessing the degree of cytoprotection. This study demonstrates that 1H NMR can provide novel biochemical information on ifosfamide-induced toxicity and will be of value in the optimization of ifosfamide therapy.
    Clinical Cancer Research 10/1997; 3(9):1507-18. · 7.84 Impact Factor
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    ABSTRACT: 750 MHz 1H NMR spectroscopy has been used to characterise in detail the abnormal low molecular weight metabolites of urine from two patients with inborn errors of metabolism. One case of the rare condition 2-hydroxyglutaric aciduria has been examined. There is at present no rapid routine method to detect this genetic defect, although NMR spectroscopy of urine is shown to provide a distinctive pattern of resonances. Assignment of a number of prominent urinary metabolites not normally seen in control urine could be made on the basis of their known NMR spectral parameters including the diagnostic marker 2-hydroxyglutaric acid, which served to confirm the condition. In addition, 750 MHz 1H NMR spectroscopy has been used to characterise further the abnormal metabolic profile of urine from a patient with maple syrup urine disease. This abnormality arises from a defect in branched chain keto-acid decarboxylase activity and results in a build up in the urine of high levels of branched chain oxo- and hydroxy-acids resulting from altered metabolism of the branched chain amino acids, valine, leucine and isoleucine. A number of previously undetected abnormal metabolites have been identified through the use of one-dimensional and two-dimensional J-resolved and COSY 750 MHz 1H NMR spectroscopy, including ethanol, 2-hydroxy-isovalerate, 2,3-dihydroxy-valerate, 2-oxo-3-methyl-n-valerate and 2-oxo-isocaproate. NMR spectroscopy of urine, particularly when combined with automatic data reduction and computer pattern recognition using a combination of biochemical markers, promises to provide an efficient alternative to other techniques for the diagnosis of inborn errors of metabolism.
    Journal of Pharmaceutical and Biomedical Analysis 08/1997; 15(11):1647-59. · 2.95 Impact Factor
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    ABSTRACT: From the experiments described, it can be seen that there are different research approaches that can be taken and these are summarized in Table 1. Whereas much scientific research is principally hypothesis led, there remains, nevertheless, an important place for exploratory research. High resolution NMR can measure, directly and simultaneously, a wide range of endogenous metabolites in biological fluids and has the unique capability of providing structural information on the metabolites detected. It has proved to be a powerful research tool with which to study inherited metabolic diseases, renal disease, drug metabolism, and toxicity, and can be used to monitor the effects of drug therapy. For instance, by using a library of experimental toxins one can map the metabolic profile of site-specific nephron injury. With this approach in man one could eventually take an unknown disease such as Balkan nephropathy and predict the initial site of tubular injury, the mode of injury and therefore the kind of toxin capable of producing that injury. NMR spectroscopic techniques are still advancing rapidly, with ever increasing sensitivity and sophistication of NMR pulse sequences to enhance structural elucidation in complex mixtures. Given the advances in directly coupled HPLC-NMR and even HPLC-NMR-mass spectroscopy it is likely that these technologies in conjunction with pattern recognition will make major contribution to our understanding of renal processes and provide new diagnostic insights in the 21st century.
    Nephrology Dialysis Transplantation 04/1997; 12(3):404-17. · 3.37 Impact Factor
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    ABSTRACT: The direct coupling of HPLC with NMR spectroscopy has been extended by splitting the HPLC eluent after conventional UV detection and sending part to a NMR spectrometer and part to an ion-trap mass spectrometer in a "triplehyphenated" HPLC-NMR-MS system. Combined UV, 1H NMR, and positive-ion electrospray MS detection was achieved in the continuous-flow mode using whole human urine from a subject dosed with acetaminophen. By means of HPLC-NMR-MS, the structural information available from the complementary spectroscopic techniques provided rapid confirmation of the identity of the acetaminophen glucuronide and sulfate metabolites, together with a number of endogenous metabolites. In particular, the HPLC-NMR-MS approach allowed the unequivocal identification of phenylacetylglutamine in human urine, an endogenous metabolite not previously observed in 1H NMR spectra of urine because of extensive overlap with resonances from other metabolites. The analytical advantages and complementarity of NMR and MS techniques in direct hyphenation with HPLC are discussed. The new technique of HPLC-NMR-MS will provide the scope for more comprehensive and fully automated analysis of biofluids and other complex mixtures than was previously available from single hyphenation of these instruments.
    Analytical Chemistry 01/1997; 68(24):4431-5. · 5.70 Impact Factor
  • Analytical Communications 01/1997; 34(4):107-109.
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    ABSTRACT: A combination of high-resolution nuclear magnetic resonance (NMR) and high-performance liquid chromatography (HPLC)-NMR spectroscopic methods has been used to analyse urine from humans and rats treated with the anticancer drug ifosfamide. It was possible to detect a range of abnormal endogenous metabolites in urine after ifosfamide administration to human subjects undergoing cancer therapy and to relate the metabolic perturbations to the nephrotoxic effects of the drug. Changes observed by 1H NMR included increases in levels of urinary glucose, glycine, alanine, histidine, lactate, acetate, succinate, and trimethylamine-N-oxide and decreases in the levels of hippurate and citrate. Additional evidence was gained that ifosfamide-induced nephrotoxicity might be related to the level of oxidation of the coadministered drug mesna. By using both directly coupled continuous-flow 31P HPLC-NMR spectroscopy to determine the retention times of the phosphorus-containing metabolites and, subsequently, stop-flow 1H HPLC-NMR of the urine, it was possible to isolate and identify on-line the metabolites ifosfamide mustard, 4-hydroxy-ifosfamide, 2-dechloroethylifosfamide, and the parent compound itself. These studies illustrate the potential of combining 1H NMR spectroscopy of biofluids and HPLC-NMR spectroscopy for the investigation of drug metabolism and toxicity in humans and animals.
    Therapeutic Drug Monitoring 09/1996; 18(4):498-505. · 2.23 Impact Factor
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    ABSTRACT: To use high field proton nuclear magnetic resonance spectroscopy (1H NMR) to characterise the low molecular weight metabolite composition of neonatal and fetal urine in relation to gestational age and perinatal outcome. The first urine passed by two neonatal groups, six full term and five preterm infants with normal renal function, was analysed by 1H NMR and compared with fetal urine from 14 cases with obstructive uropathy. The mean ratios of taurine, myo-inositol, and trimethylamine-N-oxide (TMAO) to creatinine were 4.3, 10.1, and 14.1 times higher, respectively, in the preterm group when compared with those of the full term group. Fetal obstructive uropathy was characterised by glycosuria, amino and organic aciduria, regardless of gestational age (13-30 weeks). Samples of the first urine passed--that is, urine produced in fetal life--by normal preterm infants are useful controls for cases of obstructive uropathy detected in the third trimester. 1H NMR will become a clinically useful tool for monitoring renal development and abnormalities in utero.
    Archives of Disease in Childhood - Fetal and Neonatal Edition 12/1995; 73(3):F153-7. · 3.45 Impact Factor
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    ABSTRACT: High-resolution 750 MHz 1H NMR spectra of control human blood plasma have been measured and assigned by the concerted use of a range of spin-echo, two-dimensional J-resolved, and homonuclear and heteronuclear (1H-13C) correlation methods. The increased spectral dispersion and sensitivity at 750 MHz enable the assignment of numerous 1H and 13C resonances from many molecular species that cannot be detected at lower frequencies. This work presents the most comprehensive assignment of the 1H NMR spectra of blood plasma yet achieved and includes the assignment of signals from 43 low M(r) metabolites, including many with complex or strongly coupled spin systems. New assignments are also provided from the 1H and 13C NMR signals from several important macromolecular species in whole blood plasma, i.e., very-low-density, low-density, and high-density lipoproteins, albumin, and alpha 1-acid glycoprotein. The temperature dependence of the one-dimensional and spin-echo 750 MHz 1H NMR spectra of plasma was investigated over the range 292-310 K. The 1H NMR signals from the fatty acyl side chains of the lipoproteins increased substantially with temperature (hence also molecular mobility), with a disproportionate increase from lipids in low-density lipoprotein. Two-dimensional 1H-13C heteronuclear multiple quantum coherence spectroscopy at 292 and 310 K allowed both the direct detection of cholesterol and choline species bound in high-density lipoprotein and the assignment of their signals and confirmed the assignment of most of the lipoprotein resonances.
    Analytical Chemistry 04/1995; 67(5):793-811. · 5.70 Impact Factor
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    ABSTRACT: Multivariate data analysis techniques have been used to compare 600-MHz 1H nuclear magnetic resonance (NMR) spectra of urine obtained from patients with inborn errors of metabolism (IEM) and urine obtained from healthy subjects. These spectra are very complex; each contains many thousands of resonances with a high dynamic range. A consistent method of reducing this wealth of data to manageable proportions is presented as a two-stage process. Computer-based spectral descriptors are automatically generated and then reduced to two-dimensional maps for visualization of clustering. Data-scaling methodology has been developed to achieve complete separation between spectra from control adults and those from adult patients with independently diagnosed IEM. The methods were refined by relating IEM samples to the mean of the control samples and applying supervised learning techniques to identify descriptors contributing to class separation. This approach allowed separation of the various classes of IEM and achieved optimal separation of patients with cystinuria from those with oxalic aciduria; the principal metabolites responsible for this separation were determined as lysine and glyoxalate. The methods developed were then extended by application to the more subtle problem of classifying urine collected from healthy subjects under different physiological conditions (i.e., pre- and post-exercise and in different stages of hydration) where, unlike the IEM case, any underlying biochemical differences were not known at the outset. Fluid-loaded and fluid-deprived samples could be partially separated as well as fluid-deprived and fluid-restored samples. Partial classification of samples on the basis of subject was also observed. Therefore, intersubject differences were liable to obscure the separation by physiological state. However, by relating each sample to a mean of the normal daily urine samples for the same person and applying a form of "range scaling" to exclude data which contributed least to class separation, improved classification of the hydration states resulted, from which it was possible to deduce those biochemical substances which were altered. These novel techniques for the data reduction and classification of NMR spectra make comprehensive use of all of the NMR spectral information and have clear potential to assist in clinical diagnosis.
    Analytical Biochemistry 09/1994; 220(2):284-96. · 2.58 Impact Factor
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    ABSTRACT: Ultra high field 1H-NMR spectroscopic methods have been used to analyse the composition of seminal fluid and its component secretions, prostatic and seminal vesicle fluids from normal human subjects and those with vasal aplasia and non-obstructive infertility. The 1H-NMR spectrum of whole seminal fluid is extremely complex and many resonances are extensively overlapped in single pulse spectra even when measured at 600 or 750 MHz 1H resonance frequency. A combination of 2-D 1H-NMR methods (including J-Resolved and various 1H homonuclear correlation and 1H-13C heteronuclear correlation techniques) were applied at 600 or 750 MHz in order to extensively assign the signals from the organic components of seminal fluid. Prostatic fluid (PF) gives a much less complex metabolite profile than whole seminal fluid and can be completely analysed using 500 MHz 1H-NMR spectroscopy. The 1H-NMR spectra of prostatic fluid are dominated by signals from citrate, spermine and myo-inositol, whereas the spectra of seminal vesicle fluid (SVF) show extensively overlapped signals from complex peptide mixtures together with strong signals for glycerophosphocholine (GPC) and lactate. Whole seminal fluid is a combination of the PF and SVF constituents together with further substances that appear after mixing due to the operation of PF enzymes on SVF, e.g. peptidase activity causes rapid cleavage of peptides to amino acids and GPC is hydrolysed to choline, glycerol and inorganic phosphate. It is also shown that vasal aplasia leads to highly characteristic abnormal metabolite profiles in seminal fluid that can be readily observed in single-pulse 500 and 600 MHz 1H-NMR spectra. Measurement of the molar citrate to choline, or spermine to choline ratios in seminal fluid both show differences of 2 orders of magnitude between vasal aplasia (greater for both ratios) and non-obstructed infertile patients. This work gives an indication of the potential of high field 1H-NMR spectroscopy in the investigation and assessment of the secretory functions of the male genital tract and the evaluation of the infertile male subject.
    Journal of Pharmaceutical and Biomedical Analysis 02/1994; 12(1):5-19. · 2.95 Impact Factor
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    ABSTRACT: Urinary proteins have been found to be a sensitive marker of renal damage caused by nephrotoxic agents. An electrophoretic method was used to investigate the potential value of the pattern of urinary protein excretion in 14 cyclosporin-treated renal transplant patients, to differentiate between graft rejection episodes and other causes of renal dysfunction. Urinary protein excretion consistent with renal damage was observed in all of the patients studied, with no marked differences between those with signs of graft rejection, those with renal dysfunction, or those with stable renal function.
    Human &amp Experimental Toxicology 10/1993; 12(5):407-9. · 1.45 Impact Factor

Publication Stats

1k Citations
163.61 Total Impact Points

Institutions

  • 1993–2000
    • University of London
      Londinium, England, United Kingdom
  • 1998
    • University of Cologne
      • Department of Nuclear Medicine
      Köln, North Rhine-Westphalia, Germany
  • 1990–1998
    • Birkbeck, University of London
      Londinium, England, United Kingdom
  • 1994
    • St. Peter's Hospital
      Helena, Montana, United States
  • 1987–1989
    • Epsom and St Helier University Hospitals NHS Trust
      Эпсом, England, United Kingdom