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Liu Y, Ma X, Kang L, Jin Y, Li M, Song J, Li H, Cao Y, Yang Y. The utility of methylmalonic acid, methylcitrate acid, and homocysteine in dried blood spots for therapeutic monitoring of three inherited metabolic diseases. Front Nutr 2024; 11:1414681. [PMID: 38966413 PMCID: PMC11222987 DOI: 10.3389/fnut.2024.1414681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 06/11/2024] [Indexed: 07/06/2024] Open
Abstract
Backgroud Routine metabolic assessments for methylmalonic acidemia (MMA), propionic acidemia (PA), and homocysteinemia involve detecting metabolites in dried blood spots (DBS) and analyzing specific biomarkers in serum and urine. This study aimed to establish a liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for the simultaneous detection of three specific biomarkers (methylmalonic acid, methylcitric acid, and homocysteine) in DBS, as well as to appraise the applicability of these three DBS metabolites in monitoring patients with MMA, PA, and homocysteinemia during follow-up. Methods A total of 140 healthy controls and 228 participants were enrolled, including 205 patients with MMA, 17 patients with PA, and 6 patients with homocysteinemia. Clinical data and DBS samples were collected during follow-up visits. Results The reference ranges (25th-95th percentile) for DBS methylmalonic acid, methylcitric acid, and homocysteine were estimated as 0.04-1.02 μmol/L, 0.02-0.27 μmol/L and 1.05-8.22 μmol/L, respectively. Following treatment, some patients achieved normal metabolite concentrations, but the majority still exhibited characteristic biochemical patterns. The concentrations of methylmalonic acid, methylcitric acid, and homocysteine in DBS showed positive correlations with urine methylmalonic acid (r = 0.849, p < 0.001), urine methylcitric acid (r = 0.693, p < 0.001), and serum homocysteine (r = 0.721, p < 0.001) concentrations, respectively. Additionally, higher levels of DBS methylmalonic acid and methylcitric acid may be associated with increased cumulative complication scores. Conclusion The LC-MS/MS method established in this study reliably detects methylmalonic acid, methylcitric acid, and homocysteine in DBS. These three DBS metabolites can be valuable for monitoring patients with MMA, PA, and homocysteinemia during follow-up. Further investigation is required to determine the significance of these DBS biomarkers in assessing disease burden over time.
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Affiliation(s)
- Yi Liu
- Department of Clinical Laboratory, China-Japan Friendship Hospital, Beijing, China
| | - Xue Ma
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Lulu Kang
- Department of Pediatrics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ying Jin
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Mengqiu Li
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Jinqing Song
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Haixia Li
- Department of Clinical Laboratory, Peking University First Hospital, Beijing, China
| | - Yongtong Cao
- Department of Clinical Laboratory, China-Japan Friendship Hospital, Beijing, China
| | - Yanling Yang
- Department of Pediatrics, Peking University First Hospital, Beijing, China
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Pajares-García S, González de Aledo-Castillo JM, Flores-Jiménez JE, Collado T, Pérez J, Paredes-Fuentes AJ, Argudo-Ramírez A, López-Galera RM, Prats B, García-Villoria J. Analysis of a second-tier test panel in dried blood spot samples using liquid chromatography-tandem mass spectrometry in Catalonia's newborn screening programme. Clin Chem Lab Med 2024; 62:493-505. [PMID: 37794778 DOI: 10.1515/cclm-2023-0216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 09/21/2023] [Indexed: 10/06/2023]
Abstract
OBJECTIVES Acylcarnitine and amino acid analyses of dried blood spot (DBS) samples using tandem mass spectrometry in newborn screening (NBS) programmes can generate false positive (FP) results. Therefore, implementation of second-tier tests (2TTs) using DBS samples has become increasingly important to avoid FPs. The most widely used 2TT metabolites include methylmalonic acid, 3-hydroxypropionic acid, methylcitric acid, and homocysteine. METHODS We simultaneously measured 46 underivatised metabolites, including organic acids, acylglycine and acylcarnitine isomers, homocysteine, and orotic acid, in DBS samples using tandem mass spectrometry. To validate this method, we analysed samples from 147 healthy newborns, 160 patients with genetic disorders diagnosed via NBS, 20 patients with acquired vitamin B12 deficiency, 10 newborns receiving antibiotic treatment, and nine external quality control samples. RESULTS The validation study revealed that 31 metabolites showed good analytical performance. Furthermore, this method detected key metabolites for all diseases associated with increased levels of the following acylcarnitines: C3, C4, C5, C4DC/C5OH, and C5DC. The sensitivity of this method to detect all diseases was 100 %, and the specificity was 74-99 %, except for glutaric aciduria type 1. This method can also be used to diagnose mitochondrial fatty acid β-oxidation disorders (FAODs) and urea cycle defects (UCDs). CONCLUSIONS We have described a 2TT panel of 31 metabolites in DBS samples based on an easy and rapid method without derivatisation. Its implementation allowed us to distinguish between different organic acidurias, some FAODs, and UCDs. This new strategy has increased the efficiency of our NBS programme by reducing FP and false negative results, second sample requests, and the time required for diagnosis.
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Affiliation(s)
- Sonia Pajares-García
- Department of Biochemistry and Molecular Genetics, Section of Inborn Errors of Metabolism-IBC, Hospital Clinic, Barcelona, Spain
- Center for Biomedical Research Network on Rare Diseases (CIBERER), Madrid, Spain
| | | | - José Eduardo Flores-Jiménez
- Department of Biochemistry and Molecular Genetics, Section of Inborn Errors of Metabolism-IBC, Hospital Clinic, Barcelona, Spain
| | - Tatiana Collado
- Department of Biochemistry and Molecular Genetics, Section of Inborn Errors of Metabolism-IBC, Hospital Clinic, Barcelona, Spain
| | - Judit Pérez
- Department of Biochemistry and Molecular Genetics, Section of Inborn Errors of Metabolism-IBC, Hospital Clinic, Barcelona, Spain
| | - Abraham José Paredes-Fuentes
- Department of Biochemistry and Molecular Genetics, Section of Inborn Errors of Metabolism-IBC, Hospital Clinic, Barcelona, Spain
| | - Ana Argudo-Ramírez
- Department of Biochemistry and Molecular Genetics, Section of Inborn Errors of Metabolism-IBC, Hospital Clinic, Barcelona, Spain
| | - Rosa María López-Galera
- Department of Biochemistry and Molecular Genetics, Section of Inborn Errors of Metabolism-IBC, Hospital Clinic, Barcelona, Spain
- Center for Biomedical Research Network on Rare Diseases (CIBERER), Madrid, Spain
- Biomedical Research Institute, August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Blanca Prats
- Health Department, Maternal and Child Health Service, Public Health Agency of Catalonia, The Government of Catalonia, Barcelona, Spain
| | - Judit García-Villoria
- Department of Biochemistry and Molecular Genetics, Section of Inborn Errors of Metabolism-IBC, Hospital Clinic, Barcelona, Spain
- Center for Biomedical Research Network on Rare Diseases (CIBERER), Madrid, Spain
- Biomedical Research Institute, August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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Kehar M, Sen Sarma M, Seetharaman J, Jimenez Rivera C, Chakraborty P. Decoding hepatorenal tyrosinemia type 1: Unraveling the impact of early detection, NTBC, and the role of liver transplantation. CANADIAN LIVER JOURNAL 2024; 7:54-63. [PMID: 38505790 PMCID: PMC10946188 DOI: 10.3138/canlivj-2023-0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 09/23/2023] [Indexed: 03/21/2024]
Abstract
Hepatorenal tyrosinemia type 1 (HT-1) is a rare autosomal recessive disease that results from a deficiency of fumaryl acetoacetate hydrolase (FAH), a critical enzyme in the catabolic pathway for tyrosine. This leads to the accumulation of toxic metabolites such as fumaryl and maleylacetoacetate, which can damage the liver, kidneys, and nervous system. The discovery of 2-[2-nitro-4-trifluoromethylbenzoyl]-1,3-cyclohexanedione (NTBC or nitisinone) has significantly improved the management of HT-1, particularly when initiated before the onset of symptoms. Therefore, newborn screening for HT-1 is essential for timely diagnosis and prompt treatment. The analysis of succinyl acetone (SA) in dried blood spots of newborns followed by quantification of SA in blood or urine for high-risk neonates has excellent sensitivity and specificity for the diagnosis of HT-1. NTBC combined with dietary therapy, if initiated early, can provide liver transplant (LT) free survival and reduce the risk of hepatocellular carcinoma (HCC). Patients failing medical treatment (eg, due to non-adherence), and who develop acute liver failure (ALF), have HCC or evidence of histologically proven dysplastic liver nodule(s), or experience poor quality of life secondary to severe dietary restrictions are currently indicated for LT. Children with HT-1 require frequent monitoring of liver and renal function to assess disease progression and treatment compliance. They are also at risk of long-term neurocognitive impairment, which highlights the need for neurocognitive assessment and therapy.
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Affiliation(s)
- Mohit Kehar
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children Hospital of Eastern Ontario, Ottawa, Canada
| | - Moinak Sen Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Jayendra Seetharaman
- Division of Pediatric Gastroenterology and Hepatology, Christian Medical College, Vellore, India
| | - Carolina Jimenez Rivera
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children Hospital of Eastern Ontario, Ottawa, Canada
| | - Pranesh Chakraborty
- Department of Pediatrics, Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, Ontario, Canada
- Newborn Screening Ontario, Ottawa, Ontario, Canada
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Schulze A, Chakraborty P. The Ontario Newborn Screening Program: A novel referral center model. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2023; 66:1205-1213. [PMID: 37792011 DOI: 10.1007/s00103-023-03786-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 09/22/2023] [Indexed: 10/05/2023]
Abstract
Newborn screening (NBS) for inherited and congenital disorders is a form of secondary disease prevention and a public health responsibility. The development of NBS programs is one of the most important achievements in health care. While the scope of the screening targets has expanded and methods have evolved, the screening process has remained essentially unchanged.In 2006, the Canadian province of Ontario implemented a new provincial NBS program that differs from conventional programs. One of the key differences is the structured and fully funded partnership between the ministry of health, the NBS laboratory, and the treatment centers in the province. Each one of these partners has defined roles and accountability. Another difference is the move away from the conventional recall process to an immediate referral system to selected treatment centers.In this article, we report our experience with the new screening structure and discuss it as a model for future NBS programs.
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Affiliation(s)
- Andreas Schulze
- The Hospital for Sick Children, 555 University Avenue, M5G1X8, Toronto, Ontario, Canada.
- Departments of Pediatrics and Biochemistry, University of Toronto, Toronto, Ontario, Canada.
| | - Pranesh Chakraborty
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Departments of Pediatrics and Biochemistry/Microbiology/Immunology, University of Ottawa, Ottawa, Ontario, Canada
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5
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Wang Z, Zhu H, Xiong W. Advances in mass spectrometry-based multi-scale metabolomic methodologies and their applications in biological and clinical investigations. Sci Bull (Beijing) 2023; 68:2268-2284. [PMID: 37666722 DOI: 10.1016/j.scib.2023.08.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/25/2023] [Accepted: 08/22/2023] [Indexed: 09/06/2023]
Abstract
Metabolomics is a nascent field of inquiry that emerged in the late 20th century. It encompasses the comprehensive profiling of metabolites across a spectrum of organisms, ranging from bacteria and cells to tissues. The rapid evolution of analytical methods and data analysis has greatly accelerated progress in this dynamic discipline over recent decades. Sophisticated techniques such as liquid chromatograph mass spectrometry (MS), gas chromatograph MS, capillary electrophoresis MS, and nuclear magnetic resonance serve as the cornerstone of metabolomic analysis. Building upon these methods, a plethora of modifications and combinations have emerged to propel the advancement of metabolomics. Despite this progress, scrutinizing metabolism at the single-cell or single-organelle level remains an arduous task over the decades. Some of the most thrilling advancements, such as single-cell and single-organelle metabolic profiling techniques, offer profound insights into the intricate mechanisms within cells and organelles. This allows for a comprehensive study of metabolic heterogeneity and its pivotal role in multiple biological processes. The progress made in MS imaging has enabled high-resolution in situ metabolic profiling of tissue sections and even individual cells. Spatial reconstruction techniques enable the direct representation of metabolic distribution and alteration in three-dimensional space. The application of novel metabolomic techniques has led to significant breakthroughs in biological and clinical studies, including the discovery of novel metabolic pathways, determination of cell fate in differentiation, anti-aging intervention through modulating metabolism, metabolomics-based clinicopathologic analysis, and surgical decision-making based on on-site intraoperative metabolic analysis. This review presents a comprehensive overview of both conventional and innovative metabolomic techniques, highlighting their applications in groundbreaking biological and clinical studies.
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Affiliation(s)
- Ziyi Wang
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, Hefei National Research Center for Physical Sciences at the Microscale, University of Science and Technology of China, Hefei 230026, China
| | - Hongying Zhu
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, Hefei National Research Center for Physical Sciences at the Microscale, University of Science and Technology of China, Hefei 230026, China; Anhui Province Key Laboratory of Biomedical Imaging and Intelligent Processing, Institute of Artificial Intelligence, Hefei Comprehensive National Science Center, Hefei 230088, China; CAS Key Laboratory of Brain Function and Disease, Hefei 230026, China; Anhui Province Key Laboratory of Biomedical Aging Research, Hefei 230026, China.
| | - Wei Xiong
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, Hefei National Research Center for Physical Sciences at the Microscale, University of Science and Technology of China, Hefei 230026, China; Anhui Province Key Laboratory of Biomedical Imaging and Intelligent Processing, Institute of Artificial Intelligence, Hefei Comprehensive National Science Center, Hefei 230088, China; CAS Key Laboratory of Brain Function and Disease, Hefei 230026, China; Anhui Province Key Laboratory of Biomedical Aging Research, Hefei 230026, China.
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de Hora M, Heather N, Webster D, Albert B, Hofman P. The use of liquid chromatography-tandem mass spectrometry in newborn screening for congenital adrenal hyperplasia: improvements and future perspectives. Front Endocrinol (Lausanne) 2023; 14:1226284. [PMID: 37850096 PMCID: PMC10578435 DOI: 10.3389/fendo.2023.1226284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 09/12/2023] [Indexed: 10/19/2023] Open
Abstract
Newborn screening for congenital adrenal hyperplasia using 17-hydroxyprogesterone by immunoassay remains controversial despite screening been available for almost 40 years. Screening is confounded by poor immunoassay specificity, fetal adrenal physiology, stress, and illness which can result in a large number of false positive screening tests. Screening programmes apply higher screening thresholds based on co-variates such as birthweight or gestational age but the false positive rate using immunoassay remains high. Mass spectrometry was first applied to newborn screening for congenital adrenal hyperplasia over 15 years ago. Elevated 17-hydroxprogesterone by immunoassay can be retested with a specific liquid chromatography tandem mass spectrometry assay that may include additional steroid markers. Laboratories register with quality assurance programme providers to ensure accurate steroid measurements. This has led to improvements in screening but there are additional costs and added laboratory workload. The search for novel steroid markers may inform further improvements to screening. Studies have shown that 11-oxygenated androgens are elevated in untreated patients and that the adrenal steroidogenesis backdoor pathway is more active in babies with congenital adrenal hyperplasia. There is continual interest in 21-deoxycortisol, a specific marker of 21-hydroxylase deficiency. The measurement of androgenic steroids and their precursors by liquid chromatography tandem mass spectrometry in bloodspots may inform improvements for screening, diagnosis, and treatment monitoring. In this review, we describe how liquid chromatography tandem mass spectrometry has improved newborn screening for congenital adrenal hyperplasia and explore how future developments may inform further improvements to screening and diagnosis.
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Affiliation(s)
- Mark de Hora
- Newborn Screening, Specialist Chemical Pathology, LabPlus, Auckland City Hospital, Auckland, New Zealand
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Natasha Heather
- Newborn Screening, Specialist Chemical Pathology, LabPlus, Auckland City Hospital, Auckland, New Zealand
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Dianne Webster
- Newborn Screening, Specialist Chemical Pathology, LabPlus, Auckland City Hospital, Auckland, New Zealand
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Benjamin Albert
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Paul Hofman
- Clinical Research Unit, Liggins Institute, University of Auckland, Auckland, New Zealand
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Moogahi S, Beni FT, Hashemzadeh M, Dezfuli AAZ. Molecular identification and biofilm formation of aerobic and anaerobic coinfection bacterial isolated from cystic fibrosis patients in southwest Iran from 2014 to 2022. Mol Biol Rep 2023; 50:8225-8235. [PMID: 37566205 DOI: 10.1007/s11033-023-08724-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/31/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Coinfections and resistant bacterial infections are more likely to occur in cystic fibrosis patients because their immune systems are weak. The purpose of this study was to identify by molecular means as well as the formation of biofilm of aerobic and anaerobic coinfection bacteria isolated from cystic fibrosis patients in southwest Iran from 2014 to 2022. METHODS In this investigation, 130 clinical specimens were collected from 130 CF patients by universal primer. Biofilm formation was investigated using the microtiter plate method. Antibiotic resistance was measured using Vitec 2 device. In addition, identification of methicillin-resistant Staphylococcus aureus using genes mecA was performed. MAIN FINDINGS In aerobic bacteria, Pseudomonas aeruginosa was detected in (32%) of samples. In anaerobic bacteria (16%) Prevotella spp. was the most frequently isolated anaerobe bacteria found in of the CF patients. In this study, 75% of the bacteria could form biofilms, while 23% were unable to biofilm formation. CONCLUSION In conclusion, P. aeruginosa was found to be the most frequently isolated bacterium from patients with CF, and many of these bacteria could form biofilms. Additionally, the high prevalence of antibiotic resistance indicates the urgent need for increased attention to antibiotic preparation and patient screening concerning bacterial coinfections and the virulence and adhesion factors of these bacteria. Furthermore, the present study demonstrates that the coinfection of bacteria with high antibiotic resistance and a high capacity for biofilm formation can pose a life-threatening risk to CF patients, mainly due to their weakened immune systems.
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Affiliation(s)
- Sasan Moogahi
- Infectious and Tropical Diseases Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Fateme Tadi Beni
- Infectious and Tropical Diseases Research Center, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mohammad Hashemzadeh
- Infectious and Tropical Diseases Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
- Department of Microbiology, Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Aram Asareh Zadegan Dezfuli
- Department of Microbiology, Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
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Schnabel E, Kölker S, Gleich F, Feyh P, Hörster F, Haas D, Fang-Hoffmann J, Morath M, Gramer G, Röschinger W, Garbade SF, Hoffmann GF, Okun JG, Mütze U. Combined Newborn Screening Allows Comprehensive Identification also of Attenuated Phenotypes for Methylmalonic Acidurias and Homocystinuria. Nutrients 2023; 15:3355. [PMID: 37571294 PMCID: PMC10420807 DOI: 10.3390/nu15153355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/18/2023] [Accepted: 07/21/2023] [Indexed: 08/13/2023] Open
Abstract
Newborn screening (NBS) programs are effective measures of secondary prevention and have been successively extended. We aimed to evaluate NBS for methylmalonic acidurias, propionic acidemia, homocystinuria, remethylation disorders and neonatal vitamin B12 deficiency, and report on the identification of cofactor-responsive disease variants. This evaluation of the previously established combined multiple-tier NBS algorithm is part of the prospective pilot study "NGS2025" from August 2016 to September 2022. In 548,707 newborns, the combined algorithm was applied and led to positive NBS results in 458 of them. Overall, 166 newborns (prevalence 1: 3305) were confirmed (positive predictive value: 0.36); specifically, methylmalonic acidurias (N = 5), propionic acidemia (N = 4), remethylation disorders (N = 4), cystathionine beta-synthase (CBS) deficiency (N = 1) and neonatal vitamin B12 deficiency (N = 153). The majority of the identified newborns were asymptomatic at the time of the first NBS report (total: 161/166, inherited metabolic diseases: 9/14, vitamin B12 deficiency: 153/153). Three individuals were cofactor-responsive (methylmalonic acidurias: 2, CBS deficiency: 1), and could be treated by vitamin B12, vitamin B6 respectively, only. In conclusion, the combined NBS algorithm is technically feasible, allows the identification of attenuated and severe disease courses and can be considered to be evaluated for inclusion in national NBS panels.
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Affiliation(s)
- Elena Schnabel
- Division of Child Neurology and Metabolic Medicine, Dietmar Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany; (E.S.); (J.G.O.)
| | - Stefan Kölker
- Division of Child Neurology and Metabolic Medicine, Dietmar Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany; (E.S.); (J.G.O.)
| | - Florian Gleich
- Division of Child Neurology and Metabolic Medicine, Dietmar Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany; (E.S.); (J.G.O.)
| | - Patrik Feyh
- Division of Child Neurology and Metabolic Medicine, Dietmar Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany; (E.S.); (J.G.O.)
| | - Friederike Hörster
- Division of Child Neurology and Metabolic Medicine, Dietmar Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany; (E.S.); (J.G.O.)
| | - Dorothea Haas
- Division of Child Neurology and Metabolic Medicine, Dietmar Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany; (E.S.); (J.G.O.)
| | - Junmin Fang-Hoffmann
- Division of Child Neurology and Metabolic Medicine, Dietmar Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany; (E.S.); (J.G.O.)
| | - Marina Morath
- Division of Child Neurology and Metabolic Medicine, Dietmar Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany; (E.S.); (J.G.O.)
| | - Gwendolyn Gramer
- Division of Child Neurology and Metabolic Medicine, Dietmar Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany; (E.S.); (J.G.O.)
- Department for Inborn Metabolic Diseases, University Children’s Hospital, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Wulf Röschinger
- Labor Becker MVZ GbR, Newborn Screening Unit, 81671 Munich, Germany
| | - Sven F. Garbade
- Division of Child Neurology and Metabolic Medicine, Dietmar Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany; (E.S.); (J.G.O.)
| | - Georg F. Hoffmann
- Division of Child Neurology and Metabolic Medicine, Dietmar Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany; (E.S.); (J.G.O.)
| | - Jürgen G. Okun
- Division of Child Neurology and Metabolic Medicine, Dietmar Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany; (E.S.); (J.G.O.)
| | - Ulrike Mütze
- Division of Child Neurology and Metabolic Medicine, Dietmar Hopp Metabolic Center, Center for Child and Adolescent Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany; (E.S.); (J.G.O.)
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Mak J, Peng G, Le A, Gandotra N, Enns GM, Scharfe C, Cowan TM. Validation of a targeted metabolomics panel for improved second-tier newborn screening. J Inherit Metab Dis 2023; 46:194-205. [PMID: 36680545 PMCID: PMC10023470 DOI: 10.1002/jimd.12591] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 01/22/2023]
Abstract
Improved second-tier assays are needed to reduce the number of false positives in newborn screening (NBS) for inherited metabolic disorders including those on the Recommended Uniform Screening Panel (RUSP). We developed an expanded metabolite panel for second-tier testing of dried blood spot (DBS) samples from screen-positive cases reported by the California NBS program, consisting of true- and false-positives from four disorders: glutaric acidemia type I (GA1), methylmalonic acidemia (MMA), ornithine transcarbamylase deficiency (OTCD), and very long-chain acyl-CoA dehydrogenase deficiency (VLCADD). This panel was assembled from known disease markers and new features discovered by untargeted metabolomics and applied to second-tier analysis of single DBS punches using liquid chromatography-tandem mass spectrometry (LC-MS/MS) in a 3-min run. Additionally, we trained a Random Forest (RF) machine learning classifier to improve separation of true- and false positive cases. Targeted metabolomic analysis of 121 analytes from DBS extracts in combination with RF classification at a sensitivity of 100% reduced false positives for GA1 by 83%, MMA by 84%, OTCD by 100%, and VLCADD by 51%. This performance was driven by a combination of known disease markers (3-hydroxyglutaric acid, methylmalonic acid, citrulline, and C14:1), other amino acids and acylcarnitines, and novel metabolites identified to be isobaric to several long-chain acylcarnitine and hydroxy-acylcarnitine species. These findings establish the effectiveness of this second-tier test to improve screening for these four conditions and demonstrate the utility of supervised machine learning in reducing false-positives for conditions lacking clearly discriminating markers, with future studies aimed at optimizing and expanding the panel to additional disease targets.
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Affiliation(s)
- Justin Mak
- Clinical Biochemical Genetics Laboratory, Stanford Health Care, Stanford, CA, USA
| | - Gang Peng
- Department of Genetics, Yale University School of Medicine, New Haven, CT, USA
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT, USA
| | - Anthony Le
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Neeru Gandotra
- Department of Genetics, Yale University School of Medicine, New Haven, CT, USA
| | - Gregory M. Enns
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Curt Scharfe
- Department of Genetics, Yale University School of Medicine, New Haven, CT, USA
| | - Tina M. Cowan
- Clinical Biochemical Genetics Laboratory, Stanford Health Care, Stanford, CA, USA
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
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Tippabathani J, Seenappa V, Murugan A, Phani NM, Hampe MH, Appaswamy G, Sadashiv Gambhir P. Neonatal Screening for Congenital Adrenal Hyperplasia in Indian Newborns with Reflex Genetic Analysis of 21-Hydroxylase Deficiency. Int J Neonatal Screen 2023; 9:ijns9010009. [PMID: 36975848 PMCID: PMC10053538 DOI: 10.3390/ijns9010009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 01/26/2023] [Accepted: 02/01/2023] [Indexed: 02/25/2023] Open
Abstract
Congenital adrenal hyperplasia (CAH), screened for in neonates, is the second most common endocrinopathy after congenital hypothyroidism.Newborn screening for CAH due to CYP21A2 deficiency is performed by immunologic assay for 17-hydroxyprogesterone (17-OHP). The second-tier test for confirmation of diagnosis is carried out on recall venous blood sample from screen positives measuring 17-OHP, or other metabolites of steroid metabolism by liquid chromatography–tandem mass spectroscopy. However, as steroid metabolism is dynamic, it can affect these parameters even in the recall sample of a stressed neonate. Moreover, there is some time delay in recalling the neonate for repeat testing. Reflex genetic analysis of blood spot from the initial Guthrie cards of screen positive neonates, if used for confirmatory testing, can avoid this time delay as well as the effect of stress on steroid metabolism. In this study, we used Sanger sequencing and MLPA in a reflex manner for molecular genetic analysis to confirm CYP21A2-mediated CAH. Out of 220,000 newborns screened, 97 were positive on the initial biochemical screen, of which 54 were confirmed true positives with genetic reflex testing, giving incidence of CAH as 1:4074. Point mutations were more common than deletions, indicating that Sanger sequencing should be used ahead of MLPA for molecular diagnosis in India. Amongst the variants detected, the most common was I2G-Splice variant (44.5%), followed by c.955C>T (p.Gln319Ter) (21.2%); Del 8 bp and c.-113G>A were detected with frequencies of 20.3% and 20%, respectively. In conclusion, reflex genetic testing is an effective strategy for identifying true positives in CAH screening in neonates. This will obviate need for recall samples and also aid effective counselling and timely prenatal diagnosis in the future. In Indian newborns, as point mutations are more common than large deletions, Sanger sequencing should be the initial method of choice for genotyping, ahead of MLPA.
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Affiliation(s)
| | - Venu Seenappa
- Lifecell International Pvt Ltd., Vandalur, Kelambakkam Road, Chennai 600127, India
| | - Alagupandian Murugan
- Lifecell International Pvt Ltd., Vandalur, Kelambakkam Road, Chennai 600127, India
| | | | - Mahesh H. Hampe
- Lifecell International Pvt Ltd., Vandalur, Kelambakkam Road, Chennai 600127, India
| | - Giridharan Appaswamy
- Lifecell International Pvt Ltd., Vandalur, Kelambakkam Road, Chennai 600127, India
| | - Prakash Sadashiv Gambhir
- Lifecell International Pvt Ltd., Vandalur, Kelambakkam Road, Chennai 600127, India
- Chief Medical Scientist, Lifecell, West Regional Lab, Pune 411048, India
- Correspondence:
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11
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Kilgore M, Platis D, Lim T, Isenberg S, Pickens CA, Cuthbert C, Petritis K. Development of a Universal Second-Tier Newborn Screening LC-MS/MS Method for Amino Acids, Lysophosphatidylcholines, and Organic Acids. Anal Chem 2023; 95:3187-3194. [PMID: 36724346 PMCID: PMC9933048 DOI: 10.1021/acs.analchem.2c03098] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
First-tier MS-based newborn screening by flow injection analysis can have high presumptive positive rates, often due to isomeric/isobaric compounds or poor biomarker specificity. These presumptive positive samples can be analyzed by second-tier screening assays employing separations such as liquid chromatography-mass spectrometry (LC-MS/MS), which increases test specificity and drastically reduces false positive referrals. The ability to screen for multiple disorders in a single multiplexed test simplifies workflows and maximizes public health laboratories' resources. In this study, we developed and validated a highly multiplexed second-tier method for dried blood spots using a hydrophilic interaction liquid chromatography (HILIC) column coupled to an MS/MS system. The LC-MS/MS method was capable of simultaneously detecting second-tier biomarkers for maple syrup urine disease, homocystinuria, methylmalonic acidemia, propionic acidemia, glutaric acidemia type 1, glutaric acidemia type 2, guanidinoacetate methyltransferase deficiency, short-chain acyl-CoA dehydrogenase deficiency, adrenoleukodystrophy, and Pompe disease.
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Affiliation(s)
- Matthew
B. Kilgore
- Newborn
Screening and Molecular Biology Branch, US Centers for Disease Control and Prevention, Atlanta, Georgia 30341, United States
| | - Dimitrios Platis
- Department
of Newborn Screening, Institute of Child
Health, Athens 115 26, Greece
| | - Timothy Lim
- Newborn
Screening and Molecular Biology Branch, US Centers for Disease Control and Prevention, Atlanta, Georgia 30341, United States
| | - Samantha Isenberg
- Newborn
Screening and Molecular Biology Branch, US Centers for Disease Control and Prevention, Atlanta, Georgia 30341, United States
| | - C. Austin Pickens
- Newborn
Screening and Molecular Biology Branch, US Centers for Disease Control and Prevention, Atlanta, Georgia 30341, United States
| | - Carla Cuthbert
- Newborn
Screening and Molecular Biology Branch, US Centers for Disease Control and Prevention, Atlanta, Georgia 30341, United States
| | - Konstantinos Petritis
- Newborn
Screening and Molecular Biology Branch, US Centers for Disease Control and Prevention, Atlanta, Georgia 30341, United States,
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12
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Auer MK, Nordenström A, Lajic S, Reisch N. Congenital adrenal hyperplasia. Lancet 2023; 401:227-244. [PMID: 36502822 DOI: 10.1016/s0140-6736(22)01330-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 05/17/2022] [Accepted: 06/13/2022] [Indexed: 12/13/2022]
Abstract
Congenital adrenal hyperplasia is a group of autosomal recessive disorders leading to multiple complex hormonal imbalances caused by various enzyme deficiencies in the adrenal steroidogenic pathway. The most common type of congenital adrenal hyperplasia is due to steroid 21-hydroxylase (21-OHase, henceforth 21OH) deficiency. The rare, classic (severe) form caused by 21OH deficiency is characterised by life-threatening adrenal crises and is the most common cause of atypical genitalia in neonates with 46,XX karyotype. After the introduction of life-saving hormone replacement therapy in the 1950s and neonatal screening programmes in many countries, nowadays neonatal survival rates in patients with congenital adrenal hyperplasia are high. However, disease-related mortality is increased and therapeutic management remains challenging, with multiple long-term complications related to treatment and disease affecting growth and development, metabolic and cardiovascular health, and fertility. Non-classic (mild) forms of congenital adrenal hyperplasia caused by 21OH deficiency are more common than the classic ones; they are detected clinically and primarily identified in female patients with hirsutism or impaired fertility. Novel treatment approaches are emerging with the aim of mimicking physiological circadian cortisol rhythm or to reduce adrenal hyperandrogenism independent of the suppressive effect of glucocorticoids.
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Affiliation(s)
- Matthias K Auer
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - Anna Nordenström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Division of Paediatrics, Unit for Paediatric Endocrinology and Metabolic Disorders, Karolinska University Hospital, Stockholm, Sweden
| | - Svetlana Lajic
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Division of Paediatrics, Unit for Paediatric Endocrinology and Metabolic Disorders, Karolinska University Hospital, Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany.
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13
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Identification of potential interferents of methylmalonic acid: A previously unrecognized pitfall in clinical diagnostics and newborn screening. Clin Biochem 2023; 111:72-80. [PMID: 36202155 DOI: 10.1016/j.clinbiochem.2022.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/26/2022] [Accepted: 09/30/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Determination of methylmalonic acid (MMA) from dried blood spots (DBS) is commonly performed in clinical diagnostics and newborn screening for propionic acidemia (PA) and methylmalonic acidemia. Isobaric compounds of MMA having the same mass can affect diagnostic reliability and quantitative results, which represents a previously unrecognized pitfall in clinical assays for MMA. We set out to identify interfering substances of MMA in DBS, serum and urine samples from confirmed patients with PA and methylmalonic acidemia. METHODS Techniques included quadrupole time-of-flight high-resolution mass spectrometry (QTOF HR-MS), nuclear magnetic resonance (NMR) spectroscopy, liquid chromatography (LC) and tandem mass spectrometry (MS/MS). RESULTS The five isobaric metabolites detected in DBS, serum and urine from PA and methylmalonic acidemia patients were confirmed as 2-methyl-3-hydroxybutyrate, 3-hydroxyisovalerate, 2-hydroxyisovalerate, 3-hydroxyvalerate and succinate using a series of experiments. An additional unknown substance with low abundance remained unidentified. CONCLUSIONS The presented results facilitate the diagnostic and quantitative reliability of the MMA determination in clinical assays. Isobaric species should be investigated in assays for MMA to eliminate possible interference in a wide range of conditions including PA, methylmalonic acidemia, a vitamin B12 deficiency, ketosis and lactic acidosis.
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14
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Liquid Chromatography-Tandem Mass Spectrometry in Newborn Screening Laboratories. Int J Neonatal Screen 2022; 8:ijns8040062. [PMID: 36547379 PMCID: PMC9781967 DOI: 10.3390/ijns8040062] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 11/11/2022] [Accepted: 11/16/2022] [Indexed: 11/29/2022] Open
Abstract
Tandem mass spectrometry (MS/MS) is the most universal platform currently available for the analysis of enzymatic activities and biomarkers in dried blood spots (DBS) for applications in newborn screening (NBS). Among the MS/MS applications in NBS, the most common is flow-injection analysis (FIA-) MS/MS, where the sample is introduced as a bolus injection into the mass spectrometer without the prior fractionation of analytes. Liquid chromatography combined with MS/MS (LC-MS/MS) has been employed for second-tier tests to reduce the false-positive rate associated with several nonspecific screening markers, beginning two decades ago. More recently, LC-MS/MS has been applied to primary screening for new conditions for which FIA-MS/MS or other methods, including genomic screening, are not yet adequate. In addition to providing a list of the currently used LC-MS/MS-based assays for NBS, the authors share their experience regarding the maintenance requirements of LC-MS/MS vs. FIA-MS/MS systems. The consensus is that the maintenance of LC-MS/MS and FIA-MS/MS instrumentation is similar, and LC-MS/MS has the advantage of allowing for a larger number of diseases to be screened for in a multiplex, cost-effective fashion with a high throughput and an adequate turnaround time.
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15
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Martín-Rivada Á, Cambra Conejero A, Martín-Hernández E, Moráis López A, Bélanger-Quintana A, Cañedo Villarroya E, Quijada-Fraile P, Bellusci M, Chumillas Calzada S, Bergua Martínez A, Stanescu S, Martínez-Pardo Casanova M, Ruíz-Sala P, Ugarte M, Pérez González B, Pedrón-Giner C. Newborn screening for propionic, methylmalonic acidemia and vitamin B12 deficiency. Analysis of 588,793 newborns. J Pediatr Endocrinol Metab 2022; 35:1223-1231. [PMID: 36112821 DOI: 10.1515/jpem-2022-0340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 08/13/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES We present the results of our experience in the diagnosis and follow up of the positive cases for propionic, methylmalonic acidemias and cobalamin deficiencies (PA/MMA/MMAHC) since the Expanded Newborn Screening was implemented in Madrid Region. METHODS Dried blood samples were collected 48 h after birth. Amino acids and acylcarnitines were quantitated by MS/MS. Newborns with alterations were referred to the clinical centers for follow-up. Biochemical and molecular genetic studies for confirmation of a disease were performed. RESULTS In the period 2011-2020, 588,793 children were screened, being 953 of them were referred to clinical units for abnormal result (192 for elevated C3 levels). Among them, 88 were false positive cases, 85 maternal vitamin B12 deficiencies and 19 were confirmed to suffer an IEM (8 PA, 4 MMA, 7 MMAHC). Ten out 19 cases displayed symptoms before the NBS results (6 PA, 1 MMA, 3 MMAHC). C3, C16:1OH+C17 levels and C3/C2 and C3/Met ratios were higher in newborns with PA/MMA/MMAHC. Cases diagnosed with B12 deficiency had mean B12 levels of 187.6 ± 76.9 pg/mL and their mothers 213.7 ± 95.0; 5% of the mothers were vegetarian or had poor eating while 15% were diagnosed of pernicious anemia. Newborns and their mothers received treatment with B12 with different posology, normalizing their levels and the secondary alterations disappeared. CONCLUSIONS Elevated C3 are a frequent cause for abnormal result in newborn screening with a high rate of false positive cases. Presymptomatic diagnosis of most of PA and some MMA/MMAHC is difficult. Vitamin B12 deficiency secondary to maternal deprivation is frequent with an heterogenous clinical and biochemical spectrum.
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Affiliation(s)
- Álvaro Martín-Rivada
- Sección de Gastroenterología y Nutrición, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Ana Cambra Conejero
- Laboratorio de Cribado Neonatal de la Comunidad de Madrid, Servicio de Bioquímica Clínica, Hospital General Universitario GregorioMarañón, Madrid, Spain
| | - Elena Martín-Hernández
- Unidad de Enfermedades Mitocondriales-Metabólicas Hereditarias, Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) en Enfermedades Metabólicas, Madrid, Spain
| | - Ana Moráis López
- Unidad de Nutrición Infantil y Enfermedades Metabólicas, Hospital Universitario La Paz, Madrid, Spain
| | - Amaya Bélanger-Quintana
- Centro de Referencia Nacional (CSUR) en Enfermedades Metabólicas, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Elvira Cañedo Villarroya
- Sección de Gastroenterología y Nutrición, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Pilar Quijada-Fraile
- Unidad de Enfermedades Mitocondriales-Metabólicas Hereditarias, Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) en Enfermedades Metabólicas, Madrid, Spain
| | - Marcelo Bellusci
- Unidad de Enfermedades Mitocondriales-Metabólicas Hereditarias, Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) en Enfermedades Metabólicas, Madrid, Spain
| | - Silvia Chumillas Calzada
- Unidad de Enfermedades Mitocondriales-Metabólicas Hereditarias, Centro de Referencia Nacional (CSUR) y Europeo (MetabERN) en Enfermedades Metabólicas, Madrid, Spain
| | - Ana Bergua Martínez
- Unidad de Nutrición Infantil y Enfermedades Metabólicas, Hospital Universitario La Paz, Madrid, Spain
| | - Sinziana Stanescu
- Centro de Referencia Nacional (CSUR) en Enfermedades Metabólicas, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Pedro Ruíz-Sala
- Centro de Diagnóstico de Enfermedades Moleculares, Universidad Autónoma de Madrid, IdiPAZ, CIBERER, Madrid, Spain
| | - Magdalena Ugarte
- Centro de Diagnóstico de Enfermedades Moleculares, Universidad Autónoma de Madrid, IdiPAZ, CIBERER, Madrid, Spain
| | - Belén Pérez González
- Centro de Diagnóstico de Enfermedades Moleculares, Universidad Autónoma de Madrid, IdiPAZ, CIBERER, Madrid, Spain
| | - Consuelo Pedrón-Giner
- Sección de Gastroenterología y Nutrición, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
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16
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Matharu PK, Held PK, Allen DB. Multiple 17-OHP Cutoff Co-Variates Fail to Improve 21-Hydroxylase Deficiency Screening Accuracy. Int J Neonatal Screen 2022; 8:ijns8040057. [PMID: 36412583 PMCID: PMC9680344 DOI: 10.3390/ijns8040057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 10/18/2022] [Accepted: 10/21/2022] [Indexed: 12/14/2022] Open
Abstract
To improve the positive predictive value (PPV) of newborn screening for 21-hydroxylase deficiency (21OHD), co-variates have been used to modify 17-hydroxyprogesterone (17OHP) cutoffs. The objective of this study is to evaluate whether 17OHP screening cutoffs adjusted for both collection time (CT) and birth weight (BW) improved the sensitivity and PPV of 21OHD screening. Unaffected newborn screening samples were stratified based on BW and CT to establish 17OHP concentration cutoffs at the 95th and 99th percentile. These cutoffs were applied to a cohort of confirmed cases of 21OHD to determine the sensitivity and PPV of the modified screening parameters. 17OHP cutoffs at the 99th percentile, adjusted for BW and CT, had a sensitivity of 96.3% and a specificity of 98.9%, but a relatively low PPV (0.130) for the identification of 21OHD and did not detect all cases. Use of the 95th percentile further increased sensitivity to 98.1% but resulted in a notably lower PPV (0.027). Alternative approaches that do not rely exclusively on 17OHP are needed to improve newborn screening accuracy for 21OHD.
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Affiliation(s)
- Preet K. Matharu
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI 53726, USA
| | - Patrice K. Held
- Oregon State Public Health Laboratory, Oregon Health Authority, Hillsboro, OR 97124, USA
| | - David B. Allen
- Department of Pediatrics, Division of Endocrinology and Diabetes, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA
- Correspondence: ; Tel.: +1-608-263-5835
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17
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Zhan X, Han L, Qiu W, Gu X, Guo J, Chang S, Wang Y, Zhang H. Steroid profile in dried blood spots by liquid chromatography tandem mass spectrometry: Application to newborn screening for congenital adrenal hyperplasia in China. Steroids 2022; 185:109056. [PMID: 35660382 DOI: 10.1016/j.steroids.2022.109056] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 04/09/2022] [Accepted: 05/27/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Newborn screening for congenital adrenal hyperplasia (CAH) using 17-hydroxyprogesterone dissociation-enhanced, lanthanide fluorescence immunoassay (DELFIA) generates a large number of false-positive results. The present study aimed to improve the sensitivity of the CAH neonatal screening by including second-tier steroid profiling in dried blood spots (DBS) using liquid chromatography tandem mass spectrometry (LC-MS/MS). METHODS We developed and validated a LC-MS/MS method for simultaneous determination of six steroids in DBS, including androstenedione, testosterone, 17-hydroxyprogesterone, 11-deoxycortisol, 21-deoxycortisol, and cortisol. Two 5-mm blood spots were eluted by internal standard working solution. We analyzed 1170 DBS samples from neonates to determine gestational age-specific reference intervals. In order to test the specificity of the second-tier method, we analyzed 707 cards with a positive screening by DELFIA. RESULTS Values of intra- and inter-day precision coefficients of variance and accuracy were 2.0%-13.3% and 85.8%-114.5%, respectively. Recovery ranged from 85.0% to 106.9%. The lower limit of quantification was 0.5 ng/mL for 21-deoxycortisol, 0.25 ng/mL for 17-hydroxyprogesterone and cortisol, and 0.1 ng/mL for testosterone, androstenedione, and 11-deoxycortisol. In addition, the linearity range was 0.25-50 ng/mL (R2 > 0.99). According to the 17-hydroxyprogesterone levels and ratios of (androstenedione + 17-hydroxyprogesterone)/cortisol in the 707 positive screening samples, 77 neonates should receive recall visit. The number of false-positive results reduced by 89.1%. Totally, 18 newborns were diagnosed with 21-hydroxylase deficiency, one with P450 oxidoreductase deficiency and one with 11β-hydroxylase deficiency. With two-tier screening, the positive predictive value increased to 26.0%. CONCLUSIONS The second-tier steroid profiling by LC-MS/MS reduced the false-positive rate and improved the positive predictive value of CAH screening. We suggest applying this steroid profiling assay as a second-tier test for CAH screening in China.
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Affiliation(s)
- Xia Zhan
- Pediatric Endocrinology and Genetic, Xinhua Hospital, Shanghai Institute for Pediatric Research, Shanghai Jiao Tong University School of Medicine, China
| | - Lianshu Han
- Pediatric Endocrinology and Genetic, Xinhua Hospital, Shanghai Institute for Pediatric Research, Shanghai Jiao Tong University School of Medicine, China
| | - Wenjuan Qiu
- Pediatric Endocrinology and Genetic, Xinhua Hospital, Shanghai Institute for Pediatric Research, Shanghai Jiao Tong University School of Medicine, China
| | - Xuefan Gu
- Pediatric Endocrinology and Genetic, Xinhua Hospital, Shanghai Institute for Pediatric Research, Shanghai Jiao Tong University School of Medicine, China
| | - Jun Guo
- Pediatric Endocrinology and Genetic, Xinhua Hospital, Shanghai Institute for Pediatric Research, Shanghai Jiao Tong University School of Medicine, China
| | - Siyu Chang
- Pediatric Endocrinology and Genetic, Xinhua Hospital, Shanghai Institute for Pediatric Research, Shanghai Jiao Tong University School of Medicine, China
| | - Yu Wang
- Pediatric Endocrinology and Genetic, Xinhua Hospital, Shanghai Institute for Pediatric Research, Shanghai Jiao Tong University School of Medicine, China
| | - Huiwen Zhang
- Pediatric Endocrinology and Genetic, Xinhua Hospital, Shanghai Institute for Pediatric Research, Shanghai Jiao Tong University School of Medicine, China.
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18
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Cavarzere P, Camilot M, Palma L, Lauriola S, Gaudino R, Vincenzi M, Antoniazzi F, Teofoli F, Piacentini G. Twenty Years of Neonatal Screening for Congenital Adrenal Hyperplasia in North-Eastern Italy: Role of Liquid Chromatography-Tandem Mass Spectrometry as a Second-Tier Test. Horm Res Paediatr 2022; 95:255-263. [PMID: 35350013 DOI: 10.1159/000524170] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 03/14/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Newborn screening for congenital adrenal hyperplasia (CAH) based on 17-hydroxyprogesterone (17-OHP) concentration in dried blood spots has been taking place in North-Eastern Italy since 2001. Since 2017, liquid chromatography-tandem mass spectrometry (LC-MS/MS) has been introduced, for the first time in Italy, as a second-tier test. AIMS Our study aims to evaluate, on the one hand, the effectiveness of the newborn screening for CAH after 20 years of testing and, on the other, the impact that the introduction of the second-tier test had on the diagnostic accuracy of the screening program. METHODS Since 2001 dried blood spots taken from newborns have been screened with a time-resolved fluoroimmunoassay for 17-OHP determination. Over the years, the cut-off levels of 17-OHP were adjusted according to gestational age. Since 2017, a second-tier test in LC-MS/MS was introduced for samples displaying fluoroimmunoassay 17-OHP exceeding the cut-off. RESULTS In total, 862,521 newborns have been screened over a period of 20 years. The total incidence of 21-hydroxylase deficiency (21-OHD) was 1:25,368, moreover, a case of 11-β-hydroxylase deficiency was identified. All these diagnoses were genetically confirmed. The sensitivity and specificity of the screening program were 97% and 99.4%, respectively. The use of LC-MS/MS as a second-tier test significantly reduced the recall rate and increased the positive predictive value. CONCLUSIONS Screening for CAH is useful in the neonatal diagnosis of a classic form of 21-OHD, allowing a precocious treatment of affected children. The introduction of an LC-MS/MS second-tier reduced the recall rate, avoiding unnecessary blood withdrawal and medical evaluations and preventing stress to families. Furthermore, it helped identify rarer forms of CAH.
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Affiliation(s)
- Paolo Cavarzere
- Pediatric Division, Department of Pediatrics, University Hospital of Verona, Verona, Italy
| | - Marta Camilot
- Pediatric Section, Department Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy.,Regional Center for Newborn Screening, Diagnosis and Treatment of Congenital Metabolic and Endocrinological Diseases, Verona, Italy
| | - Laura Palma
- Pediatric Division, Department of Pediatrics, University Hospital of Verona, Verona, Italy
| | - Silvana Lauriola
- Neonatal Division, Department of Pediatrics, University Hospital of Verona, Verona, Italy
| | - Rossella Gaudino
- Pediatric Division, Department of Pediatrics, University Hospital of Verona, Verona, Italy.,Pediatric Section, Department Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Monica Vincenzi
- Pediatric Section, Department Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy.,Regional Center for Newborn Screening, Diagnosis and Treatment of Congenital Metabolic and Endocrinological Diseases, Verona, Italy
| | - Franco Antoniazzi
- Pediatric Division, Department of Pediatrics, University Hospital of Verona, Verona, Italy.,Pediatric Section, Department Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy.,Regional Center for the Diagnosis and Treatment of Children and Adolescents Rare Skeletal Disorders, Pediatric Clinic, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Francesca Teofoli
- Pediatric Section, Department Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy.,Regional Center for Newborn Screening, Diagnosis and Treatment of Congenital Metabolic and Endocrinological Diseases, Verona, Italy
| | - Giorgio Piacentini
- Pediatric Division, Department of Pediatrics, University Hospital of Verona, Verona, Italy.,Pediatric Section, Department Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy.,Regional Center for Newborn Screening, Diagnosis and Treatment of Congenital Metabolic and Endocrinological Diseases, Verona, Italy
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19
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Gramer G, Hoffmann GF. Second-tier strategies in newborn screening - potential and limitations. MED GENET-BERLIN 2022; 34:21-28. [PMID: 38836011 PMCID: PMC11006380 DOI: 10.1515/medgen-2022-2117] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 03/14/2022] [Indexed: 06/06/2024]
Abstract
Newborn screening (NBS) is a public health measure to identify children with treatable disorders within the first days of life allowing presymptomatic treatment. It is the most successful measure of secondary medical prevention and part of public health programs in many countries worldwide. Application of second-tier strategies in NBS allows for increased specificity and consecutively a higher positive predictive value. Second-tier strategies can include analysis of specific biomarkers for a target disorder or may be based on molecular genetic analyses. Improving the quality of NBS, for example by second-tier strategies, is of utmost importance to maintain the high acceptance of NBS by families - especially as an increasing number of target disorders is being consecutively included into NBS programs.
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Affiliation(s)
- Gwendolyn Gramer
- University Medical Center Hamburg-Eppendorf, University Children's Hospital, Martinistraße 52, 20246 Hamburg, Germany
| | - Georg F Hoffmann
- University Hospital Heidelberg, Center for Pediatric and Adolescent Medicine, Division of Neuropediatrics and Metabolic Medicine, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
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Held PK, Singh E, Scott Schwoerer J. Screening for Methylmalonic and Propionic Acidemia: Clinical Outcomes and Follow-Up Recommendations. Int J Neonatal Screen 2022; 8:ijns8010013. [PMID: 35225935 PMCID: PMC8883915 DOI: 10.3390/ijns8010013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/20/2022] [Accepted: 02/01/2022] [Indexed: 11/30/2022] Open
Abstract
Wisconsin's newborn screening program implemented second-tier testing on specimens with elevated propionylcarnitine (C3) to aid in the identification of newborns with propionic and methylmalonic acidemias. The differential diagnosis for elevated C3 also includes acquired vitamin B12 deficiency, which is currently categorized as a false positive screen. The goal of this study was to summarize screening data and evaluate their effectiveness at establishing diagnoses and categorizing false positive cases. All Wisconsin newborns born between 2013 and 2019 with a positive first-tier screen for C3 were included in this study. For each case the first- and second-tier newborn screening data and confirmatory test results were compiled. The clinical determination for each case was reviewed and categorized into groups: inborn error of metabolism, maternal B12 deficiency, infant B12 deficiency, and false positive. A review of the screening data showed a significant overlap in the concentration of biomarkers for newborns with genetic versus acquired disease. Additionally, a review of confirmatory test results showed incomplete ascertainment of maternal vitamin B12 status. The Wisconsin newborn screening program recommended a confirmatory testing algorithm to aid in the diagnosis of inborn errors of metabolism and acquired vitamin B12 deficiency.
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Affiliation(s)
- Patrice K. Held
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI 53706, USA;
- Wisconsin State Laboratory of Hygiene, University of Wisconsin School of Medicine and Public Health, Madison, WI 53706, USA
- Correspondence: ; Tel.: +1-608-265-5968
| | - Emily Singh
- Division of Genetics, Medical College of Wisconsin with Children’s Wisconsin, Milwaukee, WI 53226, USA;
| | - Jessica Scott Schwoerer
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI 53706, USA;
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21
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Nordenström A, Falhammar H, Lajic S. Current and Novel Treatment Strategies in Children with Congenital Adrenal Hyperplasia. Horm Res Paediatr 2022; 96:560-572. [PMID: 35086098 DOI: 10.1159/000522260] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/19/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The standard treatment for congenital adrenal hyperplasia (CAH) in children is still hydrocortisone. Improved strategies for timing of the dose during the day and the dose per square meter body surface area used in children of different ages and developmental phases have improved the situation and outcome for the patients. Neonatal screening enables an earlier diagnosis and initiation of treatment, prevents from adrenal crisis, and improves growth and development also for children with the less severe forms of CAH. SUMMARY This review describes the current treatment strategies for children with CAH and discusses some potential treatment options that have been developed with the primary aim to decrease the adrenal androgen production. Novel modified release glucocorticoid therapies are also discussed. KEY MESSAGES The long-term effects of the new adjunct therapies are unknown, and some are not suitable for use in children and adolescents. The effects of the new therapies on bone mineral density, gonadal functions, and long-term cognitive development are yet to be assessed. It is not known what levels of adrenal androgens are optimal for normal growth, puberty, and bone health. The basis of using glucocorticoids and mineralocorticoids in the treatment of CAH remains, and in some individuals, it may be beneficial to add therapies to reduce the androgen load during certain life stages.
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Affiliation(s)
- Anna Nordenström
- Pediatric Endocrinology Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Department of Endocrinology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Svetlana Lajic
- Pediatric Endocrinology Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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22
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Claahsen - van der Grinten HL, Speiser PW, Ahmed SF, Arlt W, Auchus RJ, Falhammar H, Flück CE, Guasti L, Huebner A, Kortmann BBM, Krone N, Merke DP, Miller WL, Nordenström A, Reisch N, Sandberg DE, Stikkelbroeck NMML, Touraine P, Utari A, Wudy SA, White PC. Congenital Adrenal Hyperplasia-Current Insights in Pathophysiology, Diagnostics, and Management. Endocr Rev 2022; 43:91-159. [PMID: 33961029 PMCID: PMC8755999 DOI: 10.1210/endrev/bnab016] [Citation(s) in RCA: 172] [Impact Index Per Article: 86.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Indexed: 11/19/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders affecting cortisol biosynthesis. Reduced activity of an enzyme required for cortisol production leads to chronic overstimulation of the adrenal cortex and accumulation of precursors proximal to the blocked enzymatic step. The most common form of CAH is caused by steroid 21-hydroxylase deficiency due to mutations in CYP21A2. Since the last publication summarizing CAH in Endocrine Reviews in 2000, there have been numerous new developments. These include more detailed understanding of steroidogenic pathways, refinements in neonatal screening, improved diagnostic measurements utilizing chromatography and mass spectrometry coupled with steroid profiling, and improved genotyping methods. Clinical trials of alternative medications and modes of delivery have been recently completed or are under way. Genetic and cell-based treatments are being explored. A large body of data concerning long-term outcomes in patients affected by CAH, including psychosexual well-being, has been enhanced by the establishment of disease registries. This review provides the reader with current insights in CAH with special attention to these new developments.
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Affiliation(s)
| | - Phyllis W Speiser
- Cohen Children’s Medical Center of NY, Feinstein Institute, Northwell Health, Zucker School of Medicine, New Hyde Park, NY 11040, USA
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Departments of Internal Medicine and Pharmacology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Intitutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Christa E Flück
- Pediatric Endocrinology, Diabetology and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Leonardo Guasti
- Centre for Endocrinology, William Harvey Research Institute, Bart’s and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Angela Huebner
- Division of Paediatric Endocrinology and Diabetology, Department of Paediatrics, Universitätsklinikum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Barbara B M Kortmann
- Radboud University Medical Centre, Amalia Childrens Hospital, Department of Pediatric Urology, Nijmegen, The Netherlands
| | - Nils Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Deborah P Merke
- National Institutes of Health Clinical Center and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
| | - Walter L Miller
- Department of Pediatrics, Center for Reproductive Sciences, and Institute for Human Genetics, University of California, San Francisco, CA 94143, USA
| | - Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - David E Sandberg
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI 48109, USA
| | | | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Center for Rare Endocrine Diseases of Growth and Development, Center for Rare Gynecological Diseases, Hôpital Pitié Salpêtrière, Sorbonne University Medicine, Paris, France
| | - Agustini Utari
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Stefan A Wudy
- Steroid Research & Mass Spectrometry Unit, Laboratory of Translational Hormone Analytics, Division of Paediatric Endocrinology & Diabetology, Justus Liebig University, Giessen, Germany
| | - Perrin C White
- Division of Pediatric Endocrinology, UT Southwestern Medical Center, Dallas TX 75390, USA
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23
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Varughese B, Madrewar D, Polipalli SK, Kapoor S. Development of Flow Injection Analysis Method for the Second-Tier Estimation of Succinylacetone in Dried Blood Spot of Newborn Screening. Indian J Clin Biochem 2022; 37:40-50. [PMID: 35125692 PMCID: PMC8799791 DOI: 10.1007/s12291-020-00944-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 12/08/2020] [Indexed: 01/03/2023]
Abstract
Tyrosinemia type 1 (TYR1) is a devastating aminoacidopathy, leading to mortality without medical intervention. Although, detection and quantification of tyrosine in dried blood spot (DBS) is possible, but being a non-specific marker for TYR1 and its frequent association with transient neonatal tyrosinemia limits its applicability. Despite, Succinylacetone (SUAC) being a pathognomonic marker for TYR1, but not often detectable by routine newborn screening (NBS). We envisaged to determine SUAC in DBS by an in-house flow injection analysis method on a liquid chromatography/tandem mass spectrometry (LC-MS/MS). Succinylacetone was eluted from the residual 3.2 mm DBS of primary NBS by an extraction solution containing acetonitrile-water-formic acid mixture containing stable-isotope labelled internal standard (IS) for SUAC and hydrazine. Detection and quantification was performed by the mass spectrometer using multiple reaction monitoring mode at m/z 155.1 → 109.1 for SUAC and m/z 160.1 → 114.1 for the SUAC IS. The assay was linear over a calibration range of 0.122-117.434 µmol/L. The Intra-day and Inter-day precision and accuracy for the assay was determined at two different levels of SUAC (2.542 µmol/L and 14.641 µmol/L), which showed a coefficient of variation of (6.91% and 12.65%) and (8.57% and 12.27%) respectively. The accuracy also ranged between 101.2 and 103.87%.This method provided the necessary sensitivity, precision, accuracy, recovery and linearity and hence, has the potential to reduce the false positive, false negative results which significantly minimise the cost involved in the screening and follow up of TYR1 patients. SUPPLEMENTARY INFORMATION The online version of this article (10.1007/s12291-020-00944-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bijo Varughese
- Department of Paediatrics, Paediatrics Research and Genetic Lab, Maulana Azad Medical College (University of Delhi) and Associated Lok Nayak Hospital, New Delhi, 110002 India
| | | | - Sunil Kumar Polipalli
- Department of Paediatrics, Paediatrics Research and Genetic Lab, Maulana Azad Medical College (University of Delhi) and Associated Lok Nayak Hospital, New Delhi, 110002 India
| | - Seema Kapoor
- Department of Paediatrics, Paediatrics Research and Genetic Lab, Maulana Azad Medical College (University of Delhi) and Associated Lok Nayak Hospital, New Delhi, 110002 India
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24
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Ishii T, Kashimada K, Amano N, Takasawa K, Nakamura-Utsunomiya A, Yatsuga S, Mukai T, Ida S, Isobe M, Fukushi M, Satoh H, Yoshino K, Otsuki M, Katabami T, Tajima T. Clinical guidelines for the diagnosis and treatment of 21-hydroxylase deficiency (2021 revision). Clin Pediatr Endocrinol 2022; 31:116-143. [PMID: 35928387 PMCID: PMC9297175 DOI: 10.1297/cpe.2022-0009] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/29/2022] [Indexed: 11/25/2022] Open
Abstract
Congenital adrenal hyperplasia is a category of disorders characterized by impaired
adrenocortical steroidogenesis. The most frequent disorder of congenital adrenal
hyperplasia is 21-hydroxylase deficiency, which is caused by pathogenic variants of
CAY21A2 and is prevalent between 1 in 18,000 and 20,000 in Japan. The
clinical guidelines for 21-hydroxylase deficiency in Japan have been revised twice since a
diagnostic handbook in Japan was published in 1989. On behalf of the Japanese Society for
Pediatric Endocrinology, the Japanese Society for Mass Screening, the Japanese Society for
Urology, and the Japan Endocrine Society, the working committee updated the guidelines for
the diagnosis and treatment of 21-hydroxylase deficiency published in 2014, based on
recent evidence and knowledge related to this disorder. The recommendations in the updated
guidelines can be applied in clinical practice considering the risks and benefits to each
patient.
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Affiliation(s)
- Tomohiro Ishii
- Differences of Sex Development (DSD) and Adrenal Disorders Committee, Japanese Society for Pediatric Endocrinology
| | - Kenichi Kashimada
- Differences of Sex Development (DSD) and Adrenal Disorders Committee, Japanese Society for Pediatric Endocrinology
| | - Naoko Amano
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Kei Takasawa
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | | | - Shuichi Yatsuga
- Committee on Mass Screening, Japanese Society for Pediatric Endocrinology
| | - Tokuo Mukai
- Differences of Sex Development (DSD) and Adrenal Disorders Committee, Japanese Society for Pediatric Endocrinology
| | - Shinobu Ida
- Differences of Sex Development (DSD) and Adrenal Disorders Committee, Japanese Society for Pediatric Endocrinology
| | | | | | | | | | | | | | - Toshihiro Tajima
- Committee on Mass Screening, Japanese Society for Pediatric Endocrinology
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25
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Tsang KY, Chan TCH, Yeung MCW, Wong TK, Lau WT, Mak CM. Validation of amplicon-based next generation sequencing panel for second-tier test in newborn screening for inborn errors of metabolism. J LAB MED 2021. [DOI: 10.1515/labmed-2021-0115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Objectives
Next generation sequencing (NGS) technology has allowed cost-effective massive parallel DNA sequencing. To evaluate the utility of NGS for newborn screening (NBS) of inborn errors of metabolism (IEM), a custom panel was designed to target 87 disease-related genes. The pilot study was primarily proposed for second-tier testing under the NBSIEM program in Hong Kong.
Methods
The validation of the panel was performed with two reference genomes and an external quality assurance (EQA) sample. Sequencing libraries were synthesized with amplicon-based approach. The libraries were pooled, spiked-in with 2% PhiX DNA as technical control, for 16-plex sequencing runs. Sequenced reads were analyzed using a commercially available pipeline.
Results
The average target region coverage was 208× and the fraction of region with target depth ≥20× was 95.7%, with a sensitivity of 91.2%. There were 85 out of 87 genes with acceptable coverage, and EQA result was satisfactory. The turnaround time from DNA extraction to completion of variant calling and quality control (QC) procedures was 2.5 days.
Conclusions
The NGS approach with the amplicon-based panel has been validated for analytical performance and is suitable for second-tier NBSIEM test.
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Affiliation(s)
- Kwok Yeung Tsang
- Newborn Screening for Inborn Errors of Metabolism Laboratory, Hong Kong Children's Hospital , Hong Kong SAR , P.R. China
- Department of Pathology, Division of Chemical Pathology , Hong Kong Children’s Hospital , Hong Kong SAR , P.R. China
| | - Toby Chun Hei Chan
- Newborn Screening for Inborn Errors of Metabolism Laboratory, Hong Kong Children's Hospital , Hong Kong SAR , P.R. China
- Department of Pathology, Division of Chemical Pathology , Hong Kong Children’s Hospital , Hong Kong SAR , P.R. China
| | - Matthew Chun Wing Yeung
- Newborn Screening for Inborn Errors of Metabolism Laboratory, Hong Kong Children's Hospital , Hong Kong SAR , P.R. China
- Department of Pathology, Division of Chemical Pathology , Hong Kong Children’s Hospital , Hong Kong SAR , P.R. China
| | - Tsz Ki Wong
- Newborn Screening for Inborn Errors of Metabolism Laboratory, Hong Kong Children's Hospital , Hong Kong SAR , P.R. China
| | - Wan Ting Lau
- Newborn Screening for Inborn Errors of Metabolism Laboratory, Hong Kong Children's Hospital , Hong Kong SAR , P.R. China
| | - Chloe Miu Mak
- Newborn Screening for Inborn Errors of Metabolism Laboratory, Hong Kong Children's Hospital , Hong Kong SAR , P.R. China
- Department of Pathology, Division of Chemical Pathology , Hong Kong Children’s Hospital , Hong Kong SAR , P.R. China
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26
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Early Development of Newborn Screening for HCU and Current Challenges. Int J Neonatal Screen 2021; 7:ijns7040067. [PMID: 34842599 PMCID: PMC8628950 DOI: 10.3390/ijns7040067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 10/16/2021] [Accepted: 10/21/2021] [Indexed: 11/17/2022] Open
Abstract
Classic homocystinuria (HCU) was added to newborn screening (NBS) by Robert Guthrie a few years after the disorder was first described. The justification for NBS was similar to that for PKU, that presymptomatic identification and early dietary treatment would prevent the clinical consequences, which, for HCU, are mental deficiency, ectopia lentis, skeletal abnormalities, and thromboembolism. It was assumed that identifying increased methionine in the screening blood specimen would identify all affected neonates. However, it is now clear that many with HCU are missed by NBS, mainly because the methionine level in the first days of life is normal or below the cutoff level in the NBS program. This includes virtually all of those with B6-responsive HCU. Thus, a more effective method of NBS for HCU should be considered. Included among the possibilities are decreasing the methionine cutoff level, requiring an increase in the Met/Phe ratio if the methionine level is not at or greater than the cutoff level, using methionine as the primary screen with homocysteine as a second-tier test, or replacing methionine with homocysteine as the primary screen. Homocysteine is the primary metabolite that increases in HCU, while the methionine increase is secondary, so homocysteine is usually increased before the increase in methionine, almost always during the first few days of life. Finally, targeted gene screening might be considered. All of these possibilities would impose added expense and labor to NBS, so meeting these challenges would likely require a regional or national effort.
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Diagnosis of Classic Homocystinuria in Two Boys Presenting with Acute Cerebral Venous Thrombosis and Neurologic Dysfunction after Normal Newborn Screening. Int J Neonatal Screen 2021; 7:ijns7030048. [PMID: 34449521 PMCID: PMC8395908 DOI: 10.3390/ijns7030048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/15/2021] [Accepted: 07/16/2021] [Indexed: 11/17/2022] Open
Abstract
Homocystinuria, caused by cystathionine β-synthase deficiency, is a rare inherited disorder involving metabolism of methionine. Impaired synthesis of cystathionine leads to accumulation of homocysteine that affects several organ systems leading to abnormalities in the skeletal, cardiovascular, ophthalmic and central nervous systems. We report a 14-month-old and a 7-year-old boy who presented with neurologic dysfunction and were found to have cerebral venous sinus thromboses on brain magnetic resonance imaging (MRI)/magnetic resonance venogram (MRV) and metabolic and hypercoagulable work-up were consistent with classic homocystinuria. The 14-month-old boy had normal newborn screening. The 7-year-old boy initially had an abnormal newborn screen for homocystinuria but second tier test that consisted of total homocysteine was normal, so his newborn screen was reported as normal. With the advent of expanded newborn screening many treatable metabolic disorders are detected before affected infants and children become symptomatic. Methionine is the primary target in newborn screening for homocystinuria and total homocysteine is a secondary target. Screening is usually performed after 24-48 h of life in most states in the US and some states perform a second screen as a policy on all tested newborns or based on when the initial newborn screen was performed. This is done in hopes of detecting infants who may have been missed on their first screen. In the United Kingdom, NBS using dried blood spot is performed at 5 to 8 days after birth. It is universally known that methionine is a poor target and newborn screening laboratories have used different cutoffs for a positive screen. Reducing the methionine cutoff increases the sensitivity but not necessarily the specificity of the test and increasing the cutoff will miss babies who may have HCU whose levels may not be high enough to be detected at their age of ascertainment. It is not clear whether adjusting methionine level to decrease the false negative rates combined with total homocysteine as a second-tier test can be used effectively and feasibly to detect newborns with HCU. Between December 2005 and December 2020, 827,083 newborns were screened in Kentucky by MS/MS. Kentucky NBS program uses the postanalytical tools offered by the Collaborative Laboratory Integrated Reports (CLIR) project which considers gestational age and birthweight. One case of classical homocystinuria was detected and two were missed on first and second tier tests respectively. The newborn that had confirmed classical homocystinuria was one of twenty-three newborns that were referred for second tier test because of elevated methionine (cutoff is >60 µmol/L) and/or Met/Phe ratio (cutoff is >1.0); all 23 dried blood spots had elevated total homocysteine. One of the subjects of this case report had a normal methionine on initial screen and the other had a normal second-tier total homocysteine level. The performance of methionine and total homocysteine as screening analytes for homocystinuria suggest that it may be time for newborn screening programs to consider adopting next generation sequencing (NGS) platforms as alternate modality of metabolic newborn screening. Because of cost considerations, newborn screening programs may not want to adopt NGS, but the downstream healthcare cost incurred due to missed cases and the associated morbidity of affected persons far exceed costs to newborn screen programs. Since NGS is becoming more widely available and inexpensive, it may be feasible to change testing algorithms to use Newborn Metabolic NGS as the primary mode of testing on dry blood specimens with confirmation with biochemical testing. Some commercial laboratories have Newborn Screening Metabolic gene panel that includes all metabolic disorders on the most comprehensive newborn screening panel in addition to many other conditions that are not on the panel. A more targeted NGS panel can be designed that may not cost much and eventually help avoid the pitfalls associated with delayed diagnosis and cost of screening.
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Development of Second-Tier Liquid Chromatography-Tandem Mass Spectrometry Analysis for Expanded Newborn Screening in Japan. Int J Neonatal Screen 2021; 7:ijns7030044. [PMID: 34287228 PMCID: PMC8293176 DOI: 10.3390/ijns7030044] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 07/09/2021] [Accepted: 07/09/2021] [Indexed: 11/17/2022] Open
Abstract
To minimize false-positive cases in newborn screening by tandem mass spectrometry in Japan, practical second-tier liquid chromatography-tandem mass spectrometry analyses have been developed using a multimode ODS column with a single set of mobile phases and different gradient elution programs specific to the analysis of acylcarnitines, acylglycines, amino acids, and organic acids. Most analyses were performed using underivatized samples, except for analysis of methylcitric acid, and careful conditioning of the column was necessary for analyses of organic acids. Our second-tier tests enabled us to measure many metabolites useful for detection of target disorders, including allo-isoleucine, homocysteine, methylmalonic acid, and methylcitric acid. We found that accumulation of 3-hydroxyglutaric acid was specific to glutaric acidemia type I and that the ratio of 3-hydroxyisovaleric acid to 3-hydroxyisovalerylcarnitine was useful to detect newborns of mothers with 3-methylcrotonyl-CoA carboxylase deficiency. Data from the analysis of short-chain acylcarnitine and acylglycine were useful for differential diagnosis in cases positive for C5-OH-acylcarnitine or C5-acylcarnitine.
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29
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Emerging Data from a Newborn Hearing Screening Program in Sharjah, United Arab Emirates. Int J Pediatr 2021; 2021:2616890. [PMID: 34257673 PMCID: PMC8257347 DOI: 10.1155/2021/2616890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/05/2021] [Accepted: 06/09/2021] [Indexed: 11/17/2022] Open
Abstract
Objectives Newborn hearing screening (NHS) plays a critical role in early identification of hearing loss and subsequent early habilitation. Active parental involvement influences the success of NHS, particularly the initial NHS and follow-up. The current study reports the results of an NHS program in a cohort of babies born in a tertiary care hospital in Sharjah, United Arab Emirates (UAE). Further, it explores a two-stage NHS model to reduce false responses, thereby alleviating parental anxiety. Methods Retrospective observational study was conducted for a period of five years from January 2017 to December 2020. NHS was done as a two-stage model. All the healthy newborn babies were screened using Automated Auditory Brainstem Response (AABR) by trained audiology professionals. Babies who failed the first NHS were followed up after two weeks. Further, babies that failed the follow-up NHS were sent for diagnostic hearing evaluation and intervention as necessary. Results A total of 1821 newborn babies were screened during the study period. Eighty-one percent of babies passed the initial NHS. Four hundred and twenty-three (23.22%) babies were referred on the first NHS and were followed up after 2 weeks. Among these babies, 7.03% (24) failed second NHS. Nine (37.50%) of the 24 babies were confirmed to have hearing loss in both ears. The incidence of hearing loss in our cohort was 4.94 per 1000. Confirmed hearing loss was statistically higher in boys than girls (p < 0.05). Conclusion Current study was an attempt to report the emerging NHS data as part of the implementation of an NHS program. The study findings emphasize the need for a two-stage model of NHS to rule out false responses.
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30
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Qasrawi DO, Boyd JM, Sadrzadeh SMH. Measuring steroids from dried blood spots using tandem mass spectrometry to diagnose congenital adrenal hyperplasia. Clin Chim Acta 2021; 520:202-207. [PMID: 34097883 DOI: 10.1016/j.cca.2021.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 05/14/2021] [Accepted: 06/02/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders that occur due to defects in the steroidogenesis pathway. Approximately 90% of CAH cases can be diagnosed by the measurement of serum 17-hydroxyprogesterone alone. However, the quantification of six additional steroids could significantly improve CAH laboratory diagnosis. Using dried blood spot (DBS) as specimen of choice can further improve patient care due to the small sample volume required for CAH diagnosis in neonates. METHODS An optimized DBS sample preparation method was employed for steroids quantification without the need of derivatization. A LC-MS/MS assay was developed and optimized using a reverse phase-ultra high-pressure liquid chromatography (RP-UHPLC) system combined with triple quadrupole mass spectrometry using positive electrospray ionization mode. RESULTS The assay was validated according to CLSI analytical guidelines, including lower limit of quantification (LLOQ), linearity, precision, accuracy, carryover, and method comparison. The analytical measuring range of the method for all steroids was 2.5, 5, or 10 ng/ml to 250 ng/ml in DBS, r2 ≥ 0.995. The LLOQ, intra-day and inter-day precision were 0.11-1.8 ng/ml, 1.2-6.4 ng/ml, 1.8-11.5%, and 5.3-13.8%, respectively. CONCLUSIONS Our LC-MS/MS assay simultaneously detects 7 steroids for the diagnosis of CAH and can be readily implemented in clinical laboratories to provide superior analytical performance over traditional immunoassays.
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Affiliation(s)
- Deema O Qasrawi
- Segal Cancer Proteomics Centre, Lady Davis Institute for Medical Research, Jewish General Hospital, 3755 Côte Ste-Catherine Road, Montreal, QC, H3T 1E2, Canada; Alberta Precision Laboratories - Calgary and Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, 9-3535 Research Road NW, Calgary, AB T2L 2K8, Canada.
| | - Jessica M Boyd
- Alberta Precision Laboratories - Calgary and Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, 9-3535 Research Road NW, Calgary, AB T2L 2K8, Canada
| | - S M H Sadrzadeh
- Alberta Precision Laboratories - Calgary and Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, 9-3535 Research Road NW, Calgary, AB T2L 2K8, Canada
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Touati G, Gorce M, Oliver-Petit I, Broué P, Ausseil J. [New Inborn Errors of Metabolism added in the French program of neonatal screening]. Med Sci (Paris) 2021; 37:507-518. [PMID: 34003097 DOI: 10.1051/medsci/2021057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Inborn Errors of Metabolism (IEM) are rare and heterogenous disorders. For most IEMs, clinical signs are non-specific or belated. Late diagnosis is frequent, leading to death or severe sequelae. Some IEM induce intermediate metabolites circulating in the blood. They may be detected by tandem mass spectrometry. This method allows the simultaneous detection of many IEM in different metabolic pathways. In France, newborn screening (NBS) program for IEM, limited to phenylketonuria for decades, has been recently extended to medium chain acyl-CoA dehydrogenase deficiency. Rationale, methodology and organization of this new NBS program are described. Seven other IEM (maple syrup urine disease, homocystinuria, tyrosinemia type I, glutaric aciduria type I, isovaleric acidemia, long chain hydroxy-acyl-CoA dehydrogenase deficiency, carnitine uptake disorder) should be screened in the next program extension. Efforts are needed to fully understand the predictive value of each abnormal testing at birth, decrease the false positive rate, and develop the adequate management strategies.
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Affiliation(s)
- Guy Touati
- Centre de référence en maladies héréditaires du métabolisme, Hôpital des enfants, 330 avenue de Grande-Bretagne, 31059 Toulouse Cedex 9, France
| | - Magali Gorce
- Centre de référence en maladies héréditaires du métabolisme, Hôpital des enfants, 330 avenue de Grande-Bretagne, 31059 Toulouse Cedex 9, France
| | - Isabelle Oliver-Petit
- Centre régional de dépistage néonatal. Groupe hospitalier Purpan, 330 avenue de Grande-Bretagne, 31059 Toulouse Cedex 9, France
| | - Pierre Broué
- Centre de référence en maladies héréditaires du métabolisme, Hôpital des enfants, 330 avenue de Grande-Bretagne, 31059 Toulouse Cedex 9, France
| | - Jérôme Ausseil
- Infinity, Inserm UMR1291, CNRS UMR5051, Université de Toulouse III, 31000 Toulouse, France. - Centre régional de dépistage néonatal, Institut fédératif de biologie, Groupe hospitalier Purpan, 330 avenue de Grande-Bretagne, 31059 Toulouse Cedex 9, France
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Severity modeling of propionic acidemia using clinical and laboratory biomarkers. Genet Med 2021; 23:1534-1542. [PMID: 34007002 PMCID: PMC8354856 DOI: 10.1038/s41436-021-01173-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 03/26/2021] [Accepted: 03/29/2021] [Indexed: 01/18/2023] Open
Abstract
Purpose To conduct a proof-of-principle study to identify subtypes of propionic acidemia (PA) and associated biomarkers. Methods Data from a clinically diverse PA patient population (https://clinicaltrials.gov/ct2/show/NCT02890342) were used to train and test machine learning models, identify PA-relevant biomarkers, and perform validation analysis using data from liver-transplanted participants. k-Means clustering was used to test for the existence of PA subtypes. Expert knowledge was used to define PA subtypes (mild and severe). Given expert classification, supervised machine learning (support vector machine with a polynomial kernel, svmPoly) performed dimensional reduction to define relevant features of each PA subtype. Results Forty participants enrolled in the study; five underwent liver transplant. Analysis with k-means clustering indicated that several PA subtypes may exist on the biochemical continuum. The conventional PA biomarkers, plasma total 2-methylctirate and propionylcarnitine, were not statistically significantly different between nontransplanted and transplanted participants motivating us to search for other biomarkers. Unbiased dimensional reduction using svmPoly revealed that plasma transthyretin, alanine:serine ratio, GDF15, FGF21, and in vivo 1-13C-propionate oxidation, play roles in defining PA subtypes. Conclusion Support vector machine prioritized biomarkers that helped classify propionic acidemia patients according to severity subtypes, with important ramifications for future clinical trials and management of PA. Graphical Abstract ![]()
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Lotz-Havla AS, Weiß KJ, Schiergens KA, Brunet T, Kohlhase J, Regenauer-Vandewiele S, Maier EM. Subcutaneous vitamin B12 administration using a portable infusion pump in cobalamin-related remethylation disorders: a gentle and easy to use alternative to intramuscular injections. Orphanet J Rare Dis 2021; 16:215. [PMID: 33980297 PMCID: PMC8114704 DOI: 10.1186/s13023-021-01847-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 05/04/2021] [Indexed: 12/03/2022] Open
Abstract
Background Cobalamin (cbl)-related remethylation disorders are a heterogeneous group of inherited disorders comprising the remethylation of homocysteine to methionine and affecting multiple organ systems, most prominently the nervous system and the bone marrow. To date, the parenteral, generally intramuscular, lifelong administration of hydroxycobalamin (OHCbl) is the mainstay of therapy in these disorders. The dosage and frequency of OHCbl is titrated in each patient to the minimum effective dose in order to account for the painful injections. This may result in undertreatment, a possible risk factor for disease progression and disease-related complications. Results We describe parenteral administration of OHCbl using a subcutaneous catheter together with a portable infusion pump in a home therapy setting in four pediatric patients with remethylation disorders, two patients with cblC, one patient with cblG, and one patient with cblE deficiency, in whom intramuscular injections were not or no longer feasible. The placement of the subcutaneous catheters and handling of the infusion pump were readily accomplished and well accepted by the patients and their families. No adverse events occurred. The use of a small, portable syringe driver pump allowed for a most flexible administration of OHCbl in everyday life. The concentrations of total homocysteine levels were determined at regular patient visits and remained within the therapeutic target range. This approach allowed for the continuation of OHCbl therapy or the adjustment of therapy required to improve metabolic control in our patients. Conclusions Subcutaneous infusion using a subcutaneous catheter system and a portable pump for OHCbl administration in combined and isolated remethylation disorders is safe, acceptable, and effective. It decreases disease burden in preventing frequent single injections and providing patient independence. Thus, it may promote long-term adherence to therapy in patients and parents.
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Affiliation(s)
- Amelie S Lotz-Havla
- Department of Inborn Errors of Metabolism, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Lindwurmstr. 4, 80337, Munich, Germany
| | - Katharina J Weiß
- Department of Inborn Errors of Metabolism, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Lindwurmstr. 4, 80337, Munich, Germany
| | - Katharina A Schiergens
- Department of Inborn Errors of Metabolism, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Lindwurmstr. 4, 80337, Munich, Germany
| | - Theresa Brunet
- Institute of Human Genetics, Technische Universität München, Trogerstr. 32, 81675, Munich, Germany
| | - Jürgen Kohlhase
- SYNLAB Center for Human Genetics, Heinrich-von-Stephan-Str. 5, 79100, Freiburg, Germany
| | - Stephanie Regenauer-Vandewiele
- Department of Inborn Errors of Metabolism, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Lindwurmstr. 4, 80337, Munich, Germany
| | - Esther M Maier
- Department of Inborn Errors of Metabolism, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Lindwurmstr. 4, 80337, Munich, Germany.
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Pajares S, Arranz JA, Ormazabal A, Del Toro M, García-Cazorla Á, Navarro-Sastre A, López RM, Meavilla SM, de Los Santos MM, García-Volpe C, de Aledo-Castillo JMG, Argudo A, Marín JL, Carnicer C, Artuch R, Tort F, Gort L, Fernández R, García-Villoria J, Ribes A. Implementation of second-tier tests in newborn screening for the detection of vitamin B 12 related acquired and genetic disorders: results on 258,637 newborns. Orphanet J Rare Dis 2021; 16:195. [PMID: 33931066 PMCID: PMC8086297 DOI: 10.1186/s13023-021-01784-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/16/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Alteration of vitamin B12 metabolism can be genetic or acquired, and can result in anemia, failure to thrive, developmental regression and even irreversible neurologic damage. Therefore, early diagnosis and intervention is critical. Most of the neonatal cases with acquired vitamin B12 deficiency have been detected by clinical symptoms and only few of them trough NBS programs. We aim to assess the usefulness of the second-tier test: methylmalonic acid (MMA), methylcitric acid (MCA) and homocysteine (Hcys) in our newborn screening program and explore the implications on the detection of cobalamin (vitamin B12) related disorders, both genetic and acquired conditions. METHODS A screening strategy using the usual primary markers followed by the analysis of MMA, MCA and Hcys as second tier-test in the first dried blood spot (DBS) was developed and evaluated. RESULTS During the period 2015-2018 a total of 258,637 newborns were screened resulting in 130 newborns with acquired vitamin B12 deficiency (incidence 1:1989), 19 with genetic disorders (incidence 1:13,613) and 13 were false positive. No false negatives were notified. Concerning the second-tier test, the percentage of cases with MMA above the cut-off levels, both for genetic and acquired conditions was very similar (58% and 60%, respectively). Interestingly, the percentage of cases with increased levels of Hcys was higher in acquired conditions than in genetic disorders (87% and 47%, respectively). In contrast, MCA was high only in 5% of the acquired conditions versus in 53% of the genetic disorders, and it was always very high in all patients with propionic acidemia. CONCLUSIONS When screening for methylmalonic acidemia and homocystinuria, differential diagnosis with acquired vitamin B12 deficiency should be done. The results of our strategy support the inclusion of this acquired condition in the NBS programs, as it is easily detectable and allows the adoption of corrective measures to avoid the consequences of its deficiency.
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Affiliation(s)
- Sonia Pajares
- Sección de Errores Congénitos del Metabolismo-IBC, Servicio de Bioquímica Y Genética Molecular, Hospital Clínic de Barcelona, C/ Mejía Lequerica S/N, Edificio Helios III, 08028, Barcelona, Spain.,Center for Biomedical Research Network on Rare Diseases (CIBERER), Madrid, Spain
| | | | - Aida Ormazabal
- Center for Biomedical Research Network on Rare Diseases (CIBERER), Madrid, Spain.,Inborn Errors of Metabolism Unit, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Mireia Del Toro
- Unit of Metabolic Diseases, Hospital Vall D'Hebrón, Barcelona, Spain
| | - Ángeles García-Cazorla
- Center for Biomedical Research Network on Rare Diseases (CIBERER), Madrid, Spain.,Inborn Errors of Metabolism Unit, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Aleix Navarro-Sastre
- Sección de Errores Congénitos del Metabolismo-IBC, Servicio de Bioquímica Y Genética Molecular, Hospital Clínic de Barcelona, C/ Mejía Lequerica S/N, Edificio Helios III, 08028, Barcelona, Spain
| | - Rosa María López
- Sección de Errores Congénitos del Metabolismo-IBC, Servicio de Bioquímica Y Genética Molecular, Hospital Clínic de Barcelona, C/ Mejía Lequerica S/N, Edificio Helios III, 08028, Barcelona, Spain.,Biomedical Research Institute, August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | | | | | - Camila García-Volpe
- Inborn Errors of Metabolism Unit, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Jose Manuel González de Aledo-Castillo
- Sección de Errores Congénitos del Metabolismo-IBC, Servicio de Bioquímica Y Genética Molecular, Hospital Clínic de Barcelona, C/ Mejía Lequerica S/N, Edificio Helios III, 08028, Barcelona, Spain
| | - Ana Argudo
- Sección de Errores Congénitos del Metabolismo-IBC, Servicio de Bioquímica Y Genética Molecular, Hospital Clínic de Barcelona, C/ Mejía Lequerica S/N, Edificio Helios III, 08028, Barcelona, Spain
| | - Jose Luís Marín
- Sección de Errores Congénitos del Metabolismo-IBC, Servicio de Bioquímica Y Genética Molecular, Hospital Clínic de Barcelona, C/ Mejía Lequerica S/N, Edificio Helios III, 08028, Barcelona, Spain
| | - Clara Carnicer
- Unit of Metabolic Diseases, Hospital Vall D'Hebrón, Barcelona, Spain
| | - Rafael Artuch
- Center for Biomedical Research Network on Rare Diseases (CIBERER), Madrid, Spain.,Inborn Errors of Metabolism Unit, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Frederic Tort
- Sección de Errores Congénitos del Metabolismo-IBC, Servicio de Bioquímica Y Genética Molecular, Hospital Clínic de Barcelona, C/ Mejía Lequerica S/N, Edificio Helios III, 08028, Barcelona, Spain.,Center for Biomedical Research Network on Rare Diseases (CIBERER), Madrid, Spain.,Biomedical Research Institute, August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Laura Gort
- Sección de Errores Congénitos del Metabolismo-IBC, Servicio de Bioquímica Y Genética Molecular, Hospital Clínic de Barcelona, C/ Mejía Lequerica S/N, Edificio Helios III, 08028, Barcelona, Spain.,Center for Biomedical Research Network on Rare Diseases (CIBERER), Madrid, Spain.,Biomedical Research Institute, August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Rosa Fernández
- Maternal and Child Health Service, Public Health Agency of Catalonia, Health Department, Government of Catalonia, Barcelona, Spain
| | - Judit García-Villoria
- Sección de Errores Congénitos del Metabolismo-IBC, Servicio de Bioquímica Y Genética Molecular, Hospital Clínic de Barcelona, C/ Mejía Lequerica S/N, Edificio Helios III, 08028, Barcelona, Spain.,Center for Biomedical Research Network on Rare Diseases (CIBERER), Madrid, Spain.,Biomedical Research Institute, August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Antonia Ribes
- Sección de Errores Congénitos del Metabolismo-IBC, Servicio de Bioquímica Y Genética Molecular, Hospital Clínic de Barcelona, C/ Mejía Lequerica S/N, Edificio Helios III, 08028, Barcelona, Spain. .,Center for Biomedical Research Network on Rare Diseases (CIBERER), Madrid, Spain. .,Biomedical Research Institute, August Pi I Sunyer (IDIBAPS), Barcelona, Spain.
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Rowe AD, Stoway SD, Åhlman H, Arora V, Caggana M, Fornari A, Hagar A, Hall PL, Marquardt GC, Miller BJ, Nixon C, Norgan AP, Orsini JJ, Pettersen RD, Piazza AL, Schubauer NR, Smith AC, Tang H, Tavakoli NP, Wei S, Zetterström RH, Currier RJ, Mørkrid L, Rinaldo P. A Novel Approach to Improve Newborn Screening for Congenital Hypothyroidism by Integrating Covariate-Adjusted Results of Different Tests into CLIR Customized Interpretive Tools. Int J Neonatal Screen 2021; 7:23. [PMID: 33922835 PMCID: PMC8167643 DOI: 10.3390/ijns7020023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/07/2021] [Accepted: 04/19/2021] [Indexed: 02/06/2023] Open
Abstract
Newborn screening for congenital hypothyroidism remains challenging decades after broad implementation worldwide. Testing protocols are not uniform in terms of targets (TSH and/or T4) and protocols (parallel vs. sequential testing; one or two specimen collection times), and specificity (with or without collection of a second specimen) is overall poor. The purpose of this retrospective study is to investigate the potential impact of multivariate pattern recognition software (CLIR) to improve the post-analytical interpretation of screening results. Seven programs contributed reference data (N = 1,970,536) and two sets of true (TP, N = 1369 combined) and false (FP, N = 15,201) positive cases for validation and verification purposes, respectively. Data were adjusted for age at collection, birth weight, and location using polynomial regression models of the fifth degree to create three-dimensional regression surfaces. Customized Single Condition Tools and Dual Scatter Plots were created using CLIR to optimize the differential diagnosis between TP and FP cases in the validation set. Verification testing correctly identified 446/454 (98%) of the TP cases, and could have prevented 1931/5447 (35%) of the FP cases, with variable impact among locations (range 4% to 50%). CLIR tools either as made here or preferably standardized to the recommended uniform screening panel could improve performance of newborn screening for congenital hypothyroidism.
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Affiliation(s)
- Alexander D. Rowe
- Norwegian National Unit for Newborn Screening, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, 0424 Oslo, Norway; (A.D.R.); (S.D.S.); (R.D.P.)
| | - Stephanie D. Stoway
- Norwegian National Unit for Newborn Screening, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, 0424 Oslo, Norway; (A.D.R.); (S.D.S.); (R.D.P.)
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (A.F.); (A.P.N.); (A.L.P.)
| | - Henrik Åhlman
- Centre for Inherited Metabolic Diseases, Karolinska University Hospital, 17177 Solna, Sweden; (H.Å.); (R.H.Z.)
| | - Vaneet Arora
- Division of Laboratory Services, Kentucky Department for Public Health, Frankfort, KY 40601, USA; (V.A.); (A.C.S.); (S.W.)
| | - Michele Caggana
- Wadsworth Center, New York State Department of Health, Albany, NY 12237, USA; (M.C.); (J.J.O.); (N.P.T.)
| | - Anna Fornari
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (A.F.); (A.P.N.); (A.L.P.)
- Fondazione MBBM/Ospedale San Gerardo, University of Milano-Bicocca, 20900 Monza, Italy
| | - Arthur Hagar
- Georgia Department of Public Health, Atlanta, GA 30303, USA; (A.H.); (P.L.H.)
| | - Patricia L. Hall
- Georgia Department of Public Health, Atlanta, GA 30303, USA; (A.H.); (P.L.H.)
| | - Gregg C. Marquardt
- Division of Laboratory Pathology External Applications, Department of Information Technology, Mayo Clinic, Rochester, MN 55905, USA; (G.C.M.); (B.J.M.); (N.R.S.)
| | - Bobby J. Miller
- Division of Laboratory Pathology External Applications, Department of Information Technology, Mayo Clinic, Rochester, MN 55905, USA; (G.C.M.); (B.J.M.); (N.R.S.)
| | - Christopher Nixon
- Virginia Department of General Services, Division of Consolidated Laboratory Services, Richmond, VA 23219, USA;
| | - Andrew P. Norgan
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (A.F.); (A.P.N.); (A.L.P.)
| | - Joseph J. Orsini
- Wadsworth Center, New York State Department of Health, Albany, NY 12237, USA; (M.C.); (J.J.O.); (N.P.T.)
| | - Rolf D. Pettersen
- Norwegian National Unit for Newborn Screening, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, 0424 Oslo, Norway; (A.D.R.); (S.D.S.); (R.D.P.)
| | - Amy L. Piazza
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (A.F.); (A.P.N.); (A.L.P.)
| | - Neil R. Schubauer
- Division of Laboratory Pathology External Applications, Department of Information Technology, Mayo Clinic, Rochester, MN 55905, USA; (G.C.M.); (B.J.M.); (N.R.S.)
| | - Amy C. Smith
- Division of Laboratory Services, Kentucky Department for Public Health, Frankfort, KY 40601, USA; (V.A.); (A.C.S.); (S.W.)
| | - Hao Tang
- Genetic Disease Screening Program, California Department of Public Health, Richmond, CA 94804, USA;
| | - Norma P. Tavakoli
- Wadsworth Center, New York State Department of Health, Albany, NY 12237, USA; (M.C.); (J.J.O.); (N.P.T.)
| | - Sainan Wei
- Division of Laboratory Services, Kentucky Department for Public Health, Frankfort, KY 40601, USA; (V.A.); (A.C.S.); (S.W.)
| | - Rolf H. Zetterström
- Centre for Inherited Metabolic Diseases, Karolinska University Hospital, 17177 Solna, Sweden; (H.Å.); (R.H.Z.)
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Robert J. Currier
- Department of Pediatrics, University of California, San Francisco, CA 94143, USA;
| | - Lars Mørkrid
- Department of Medical Biochemistry, Division of Laboratory Medicine, Oslo University Hospital HF, 0424 Oslo, Norway;
- Department of Medical Biochemistry, Institute for Clinical Medicine, University of Oslo, 0130 Oslo, Norway
| | - Piero Rinaldo
- Norwegian National Unit for Newborn Screening, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, 0424 Oslo, Norway; (A.D.R.); (S.D.S.); (R.D.P.)
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (A.F.); (A.P.N.); (A.L.P.)
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Fuenzalida K, Valiente A, Faundez A, Guerrero P, Soto V, Leal-Witt M, Cabello J, Cornejo V. Quantitative Determination of Branched-Chain Amino Acids in Dried Blood Spot Samples by LC-MSMS and its Application in Diagnosis and Follow-Up of Chilean Patients with Maple Syrup Urine Disease. JOURNAL OF INBORN ERRORS OF METABOLISM AND SCREENING 2021. [DOI: 10.1590/2326-4594-jiems-2021-0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Woerner AC, Gallagher RC, Vockley J, Adhikari AN. The Use of Whole Genome and Exome Sequencing for Newborn Screening: Challenges and Opportunities for Population Health. Front Pediatr 2021; 9:663752. [PMID: 34350142 PMCID: PMC8326411 DOI: 10.3389/fped.2021.663752] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 06/07/2021] [Indexed: 01/01/2023] Open
Abstract
Newborn screening (NBS) is a population-based program with a goal of reducing the burden of disease for conditions with significant clinical impact on neonates. Screening tests were originally developed and implemented one at a time, but newer methods have allowed the use of multiplex technologies to expand additions more rapidly to standard panels. Recent improvements in next-generation sequencing are also evolving rapidly from first focusing on individual genes, then panels, and finally all genes as encompassed by whole exome and genome sequencing. The intersection of these two technologies brings the revolutionary possibility of identifying all genetic disorders in newborns, allowing implementation of therapies at the optimum time regardless of symptoms. This article reviews the history of newborn screening and early studies examining the use of whole genome and exome sequencing as a screening tool. Lessons learned from these studies are discussed, along with technical, ethical, and societal challenges to broad implementation.
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Affiliation(s)
- Audrey C Woerner
- Department of Pediatrics, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Renata C Gallagher
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States
| | - Jerry Vockley
- Department of Pediatrics, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.,Department of Human Genetics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, United States
| | - Aashish N Adhikari
- Institute for Human Genetics, University of California, San Francisco, San Francisco, CA, United States.,Artificial Intelligence Lab, Illumina Inc, Foster City, CA, United States
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Zhou W, Cai H, Li H, Ji Z, Gu M. Quantification of Differential Metabolites in Dried Blood Spots Using Second-Tier Testing for SCADD/IBDD Disorders Based on Large-Scale Newborn Screening in a Chinese Population. Front Pediatr 2021; 9:757424. [PMID: 34869113 PMCID: PMC8639864 DOI: 10.3389/fped.2021.757424] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/20/2021] [Indexed: 12/14/2022] Open
Abstract
Background: Although newborn screening (NBS) for metabolic defects using the marker butyl carnitine (C4) combined with the C4-to-acetylcarnitine ratio is adequate, the incorporation of novel parameters may improve differential testing for these disorders without compromising sensitivity. Methods: Analytical and clinical performance was evaluated by MS/MS using 237 initially positive neonatal samples between March 2019 and March 2020 at the Newborn Screening Center of Xuzhou Maternity and Child Health Care Hospital. Additionally, second-tier testing by ultraperformance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) combined with the quantification of ethylmalonate (EMA) or isobutyryl-glycine (IBG) in dried blood spots (DBSs) was performed to reduce the false-positive rate. Results: We reviewed initial MS/MS data for DBSs from 469,730 neonates, and a second-tier test was performed using 237 samples that exceeded the C4 concentration cutoff value. Eleven variants of the ACADS gene were identified, with c.1031A>G (p.E344G) being the most common. Fifteen ACAD8 mutations were identified in seven patients, and Swiss modeling and amino acid conservation analyses were conducted for the novel variants. Based on a retrospective analysis of EMA and IBG, the application of second-tier tests before the release of neonatal screening results reduced referrals by over 91.89% and improved the positive predictive value (PPV) for short-chain acyl-CoA dehydrogenase deficiency/isobutyryl-CoA dehydrogenase deficiency (SCADD/IBDD) screening. Conclusion: A screening algorithm including EMA/IBG improves target differential testing for NBS and may eliminate unnecessary referrals while maintaining 100% sensitivity. Second-tier screening using UPLC-MS/MS as a rapid and convenient supplemental DNA sequencing method may be beneficial for differential detection.
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Affiliation(s)
- Wei Zhou
- Newborn Screening Center, The Affiliated Xuzhou Maternity and Child Health Care Hospital of Xuzhou Medical University, Xuzhou, China.,Research Center for Biochemistry and Molecular Biology and Jiangsu Key Laboratory of Brain Disease Bioinformation, Xuzhou Medical University, Xuzhou, China
| | - Heng Cai
- Pharmacology College, Xuzhou Medical University, Xuzhou, China
| | - Huizhong Li
- Newborn Screening Center, The Affiliated Xuzhou Maternity and Child Health Care Hospital of Xuzhou Medical University, Xuzhou, China
| | - Zhe Ji
- The First Clinical College, Xuzhou Medical University, Xuzhou, China
| | - Maosheng Gu
- Newborn Screening Center, The Affiliated Xuzhou Maternity and Child Health Care Hospital of Xuzhou Medical University, Xuzhou, China
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Vitamin B 12 Deficiency in Newborns and their Mothers-Novel Approaches to Early Detection, Treatment and Prevention of a Global Health Issue. Curr Med Sci 2020; 40:801-809. [PMID: 33123894 DOI: 10.1007/s11596-020-2260-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 09/01/2020] [Indexed: 02/06/2023]
Abstract
Vitamin B12 deficiency, mostly of maternal origin in newborns, is a well treatable condition but can cause severe neurologic sequelae. In women of childbearing age and pregnant women worldwide vitamin B12 deficiency has been reported with frequencies of 10%-50%. Children with vitamin B12 deficiency are asymptomatic at birth but may develop severe multisystemic symptoms, including irreversible developmental impairment in the second half-year of life. Early detection of vitamin B12 deficiency allows for presymptomatic treatment. This article provides an overview over the function of vitamin B12 and discusses causes and frequency of vitamin B12 deficiency in newborns, infants, and women of childbearing age. It describes novel successful approaches to newborn screening (NBS) for vitamin B12 deficiency and results of a pilot study which performed systematic NBS for vitamin B12 deficiency using so-called second-tier strategies by measuring homocysteine and methylmalonic acid in dried blood spots. Recommendations for diagnostics in mothers of children with vitamin B12 deficiency are described as well as results of systematic work-up in mothers and treatment and follow-up of children with vitamin B12 deficiency detected by NBS. Treatment options of vitamin B12 deficiency are presented including a newly developed standardized supplementation scheme with exclusively oral vitamin B12 supplementation. Recommendations for preventive approaches to vitamin B12 deficiency for children and mothers are stated. Many children worldwide could benefit from systematic inclusion of vitamin B12 deficiency into NBS panels. In addition, preventive approaches to maternal vitamin B12 deficiency should be implemented systematically during maternal care.
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Ames EG, Fisher R, Kleyn M, Ahmad A. Current Practices for U.S. Newborn Screening of Pompe Disease and MPSI. Int J Neonatal Screen 2020; 6:ijns6030072. [PMID: 33239598 PMCID: PMC7569971 DOI: 10.3390/ijns6030072] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 08/19/2020] [Accepted: 08/27/2020] [Indexed: 11/16/2022] Open
Abstract
Two lysosomal storage disorders (LSDs), Pompe disease and Mucopolysaccharidosis type I (MPSI) were added to the Recommended Uniform Screening Panel (RUSP) for newborn screening (NBS) in 2015 and 2016, respectively. These conditions are being screened with variable practice in terms of primary and reflex analytes (either biochemical or molecular testing) as well as collection of short- and long-term follow-up elements. The goal of this study is to evaluate practices of state health departments in regards to screening methods and follow-up data collected. We conducted online surveys and phone questionnaires to determine each U.S. state's practices for screening and follow-up of positive newborn screens. We report the first snapshot of practices for NBS for the LSDs included on the RUSP. All 50 U.S. states responded to our survey. The majority of U.S. states are not currently screening for Pompe disease and MPSI as of March 2020, but this number will increase to 38 states in the coming 1-3 years based on survey results. Our survey identifies data elements used by state health departments for short-and long-term follow-up that could serve as the basis of common elements for larger, public health-based analyses of the benefits and efficacy of screening for Pompe disease and MPSI.
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Affiliation(s)
- Elizabeth G. Ames
- Division of Pediatric Genetics, Metabolism and Genomic Medicine, Department of Pediatrics, University of Michigan Health System, D5240 Medical Professional Building, 1500 E. Medical Center Dr, Ann Arbor, MI 48109, USA; (R.F.); (A.A.)
- Correspondence: ; Tel.: +1-(734)-764-0579
| | - Rachel Fisher
- Division of Pediatric Genetics, Metabolism and Genomic Medicine, Department of Pediatrics, University of Michigan Health System, D5240 Medical Professional Building, 1500 E. Medical Center Dr, Ann Arbor, MI 48109, USA; (R.F.); (A.A.)
| | - Mary Kleyn
- Newborn Screening Follow-up Section, Michigan Department of Health and Human Services, 333 South Grand Avenue, Lansing, MI 48933, USA;
| | - Ayesha Ahmad
- Division of Pediatric Genetics, Metabolism and Genomic Medicine, Department of Pediatrics, University of Michigan Health System, D5240 Medical Professional Building, 1500 E. Medical Center Dr, Ann Arbor, MI 48109, USA; (R.F.); (A.A.)
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Peng G, Tang Y, Gandotra N, Enns GM, Cowan TM, Zhao H, Scharfe C. Ethnic variability in newborn metabolic screening markers associated with false-positive outcomes. J Inherit Metab Dis 2020; 43:934-943. [PMID: 32216101 PMCID: PMC7540352 DOI: 10.1002/jimd.12236] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 03/18/2020] [Accepted: 03/23/2020] [Indexed: 12/23/2022]
Abstract
Newborn screening (NBS) programmes utilise information on a variety of clinical variables such as gestational age, sex, and birth weight to reduce false-positive screens for inborn metabolic disorders. Here we study the influence of ethnicity on metabolic marker levels in a diverse newborn population. NBS data from screen-negative singleton babies (n = 100 000) were analysed, which included blood metabolic markers measured by tandem mass spectrometry and ethnicity status reported by the parents. Metabolic marker levels were compared between major ethnic groups (Asian, Black, Hispanic, White) using effect size analysis, which controlled for group size differences and influence from clinical variables. Marker level differences found between ethnic groups were correlated to NBS data from 2532 false-positive cases for four metabolic diseases: glutaric acidemia type 1 (GA-1), methylmalonic acidemia (MMA), ornithine transcarbamylase deficiency (OTCD), and very long-chain acyl-CoA dehydrogenase deficiency (VLCADD). In the result, 79% of the metabolic markers (34 of 43) had ethnicity-related differences. Compared to the other groups, Black infants had elevated GA-1 markers (C5DC, Cohen's d = .37, P < .001), Hispanics had elevated MMA markers (C3, Cohen's d = .13, P < .001, and C3/C2, Cohen's d = .27, P < .001); and Whites had elevated VLCADD markers (C14, Cohen's d = .28, P < .001, and C14:1, Cohen's d = .22, P < .001) and decreased OTCD markers (citrulline, Cohen's d = -.26, P < .001). These findings correlated with the higher false-positive rates in Black infants for GA-1, in Hispanics for MMA, and in Whites for OTCD and for VLCADD. Web-based tools are available to analyse ethnicity-related changes in newborn metabolism and to support developing methods to identify false-positives in metabolic screening.
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Affiliation(s)
- Gang Peng
- Department of GeneticsYale University School of MedicineNew HavenConnecticutUSA
- Department of BiostatisticsYale University School of Public HealthNew HavenConnecticutUSA
| | - Yishuo Tang
- Department of GeneticsYale University School of MedicineNew HavenConnecticutUSA
| | - Neeru Gandotra
- Department of GeneticsYale University School of MedicineNew HavenConnecticutUSA
| | - Gregory M. Enns
- Department of PediatricsStanford University School of MedicineStanfordCaliforniaUSA
| | - Tina M. Cowan
- Department of PathologyStanford University School of MedicineStanfordCaliforniaUSA
| | - Hongyu Zhao
- Department of GeneticsYale University School of MedicineNew HavenConnecticutUSA
- Department of BiostatisticsYale University School of Public HealthNew HavenConnecticutUSA
| | - Curt Scharfe
- Department of GeneticsYale University School of MedicineNew HavenConnecticutUSA
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Schultz MJ, Netzel BC, Singh RH, Pino GB, Gavrilov DK, Oglesbee D, Raymond KM, Rinaldo P, Tortorelli S, Smith WE, Matern D. Laboratory monitoring of patients with hereditary tyrosinemia type I. Mol Genet Metab 2020; 130:247-254. [PMID: 32546364 DOI: 10.1016/j.ymgme.2020.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 05/31/2020] [Accepted: 06/01/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The prognosis of patients with Hereditary Tyrosinemia Type 1 (HT-1) has greatly improved with early detection through newborn screening and the introduction of nitisinone (NTBC) therapy. A recent guideline calls for periodic monitoring of biochemical markers and NTBC levels to tailor treatment; however, this is currently only achieved through a combination of clinical laboratory tests. We developed a multiplexed assay measuring relevant amino acids, succinylacetone (SUAC), and NTBC in dried blood spots (DBS) to facilitate treatment monitoring. METHODS Tyrosine, phenylalanine, methionine, NTBC and SUAC were eluted from DBS with methanol containing internal standards for each analyte and analyzed by liquid chromatography tandem mass spectrometry over 6.5 min in the multiple reaction monitoring positive mode. RESULTS Pre-analytical and analytical factors were studied and demonstrated a reliable assay. Chromatography resolved an unknown substance that falsely elevates SUAC concentrations and was present in all samples. To establish control and disease ranges, the method was applied to DBS collected from controls (n = 284) and affected patients before (n = 2) and after initiation of treatment (n = 29). In the treated patients SUAC concentrations were within the normal range over a wide range of NTBC levels. CONCLUSIONS This assay enables combined, accurate measurement of revelevant metabolites and NTBC in order to simplify treatment monitoring of patients with HT-1. In addition, the use of DBS allows for specimen collection at home to facilitate more standardization in relation to drug and dietary treatment.
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Affiliation(s)
- Matthew J Schultz
- Biochemical Genetics Laboratory, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Brian C Netzel
- Biochemical Genetics Laboratory, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Rani H Singh
- Department of Human Genetics and Pediatrics, Emory University, Atlanta, GA, USA
| | - Gisele B Pino
- Biochemical Genetics Laboratory, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Dimitar K Gavrilov
- Biochemical Genetics Laboratory, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Devin Oglesbee
- Biochemical Genetics Laboratory, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Kimiyo M Raymond
- Biochemical Genetics Laboratory, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Piero Rinaldo
- Biochemical Genetics Laboratory, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Silvia Tortorelli
- Biochemical Genetics Laboratory, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Wendy E Smith
- Maine Medical Partners Pediatrics Specialty Care, Portland, ME, USA
| | - Dietrich Matern
- Biochemical Genetics Laboratory, Mayo Clinic College of Medicine, Rochester, MN, USA.
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González-Irazabal Y, Hernandez de Abajo G, Martínez-Morillo E. Identifying and overcoming barriers to harmonize newborn screening programs through consensus strategies. Crit Rev Clin Lab Sci 2020; 58:29-48. [PMID: 32692303 DOI: 10.1080/10408363.2020.1781778] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The benefits of newborn screening (NBS) programs have been widely demonstrated after more than 50 years since first established. NBS enables the detection of the disease before the child shows clinical symptoms, allowing clinicians to act early and facilitating appropriate interventions to prevent or improve adverse outcomes. Delay or lack of medical intervention in these infants may lead to developmental delay, severe disability, or premature death. NBS programs have grown exponentially both in the number of diseases screened and in complexity, creating controversy. New technological advances, as well as the emergence of new therapies that require early disease detection, have allowed for the inclusion of new diseases in NBS screening programs. However, different countries and even different regions have in turn adopted very diverse strategies and diagnostic algorithms when it comes to NBS. There are many factors responsible for these differences, such as the health care system, available funds, local politics, professional groups, and others that depend on the position taken by policymakers. These differences in NBS have led to discrepancies in detection opportunities between countries or regions, which has led to many varied attempts to harmonize NBS programs but not all have been equally satisfactory. Some countries have achieved good results, but always within their borders. Therefore, there are still many differences between NBS programs at the international level that must be overcome. These advances have also brought considerable uncertainty regarding ethical aspects and balance between benefits and harms. For this reason, and so that the situation of disparity in the global NBS programs can be minimized, health authorities must work to develop uniform criteria for decision-making and to take a further step toward harmonization. To do so, it is necessary to identify the crucial factors that lead to the adoption of different NBS programs worldwide, in order to analyze their influence and find ways to overcome them.
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Weiss KJ, Röschinger W, Blessing H, Lotz-Havla AS, Schiergens KA, Maier EM. Diagnostic Challenges Using a 2-Tier Strategy for Methylmalonic Acidurias: Data from 1.2 Million Dried Blood Spots. ANNALS OF NUTRITION AND METABOLISM 2020; 76:268-276. [PMID: 32683363 DOI: 10.1159/000508838] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 05/19/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND The detection of methylmalonic acid (MMA) by second-tier analysis has been shown to reduce the number of false positives in newborn screening (NBS) for genetically determined methylmalonic acidurias (MMAuria). In addition to genetic conditions, MMA is an indicator of vitamin B12 status, thus applicable to detect maternal vitamin B12 deficiency in the newborns screened. METHODS Biochemical and clinical follow-up data of a 7.5-year pilot study with 1.2 million newborns screened were reviewed. RESULTS Among 1,195,850 NBS samples, 3,595 (0.3%) fulfilled criteria for second-tier analysis of MMA. In 37 (0.003%; 1/32,000) samples, elevated concentrations of MMA were detected, resulting in diagnostic workup at a metabolic center in 21 newborns. In 6 infants (1/199,000), genetic conditions were established, 1 infant with cobalamin C deficiency (CblC) showed only a moderate elevation of MMA. The remaining 15 newborns (1/79,000) displayed significantly lower concentrations of MMA and were evaluated for maternal vitamin B12 deficiency. In 9 mothers, vitamin B12 deficiency was verified, and 6 showed no indication for vitamin B12 deficiency. Treatment with vitamin B12 normalized biochemical parameters in all 15 infants. CONCLUSIONS Applying a 2-tier strategy measuring MMA in NBS identified genetic conditions of MMAuria. It was possible to separate severe, early-onset phenotypes from maternal vitamin B12 deficiency. However, the detection of CblC deficiency with mildly elevated MMA interferes with impaired vitamin B12 status of unknown relevance and thus burdens possibly healthy newborns. Regarding maternal vitamin B12 deficiency, testing and supplementing mothers-to-be is preferable. This might decrease straining follow-up of newborns and improve quality and overall perception of NBS.
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Affiliation(s)
- Katharina J Weiss
- Department of Inborn Errors of Metabolism, Dr. von Hauner Children's Hospital, Ludwig Maximilian University, Munich, Germany
| | - Wulf Röschinger
- Newborn Screening Unit, Becker and Colleagues Laboratory, Munich, Germany
| | - Holger Blessing
- Department of Inborn Errors of Metabolism, Children's and Adolescents' Hospital, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Amelie S Lotz-Havla
- Department of Inborn Errors of Metabolism, Dr. von Hauner Children's Hospital, Ludwig Maximilian University, Munich, Germany
| | - Katharina A Schiergens
- Department of Inborn Errors of Metabolism, Dr. von Hauner Children's Hospital, Ludwig Maximilian University, Munich, Germany
| | - Esther M Maier
- Department of Inborn Errors of Metabolism, Dr. von Hauner Children's Hospital, Ludwig Maximilian University, Munich, Germany,
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Hu Z, Yang J, Lin Y, Wang J, Hu L, Zhang C, Zhang Y, Huang X. Determination of methylmalonic acid, 2-methylcitric acid, and total homocysteine in dried blood spots by liquid chromatography-tandem mass spectrometry: A reliable follow-up method for propionylcarnitine-related disorders in newborn screening. J Med Screen 2020; 28:93-99. [PMID: 32615850 DOI: 10.1177/0969141320937725] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Determination of methylmalonic acid, 2-methylcitric acid, and total homocysteine in dried blood spots by liquid chromatography-tandem mass spectrometry has usually been used as a second-tier test to improve performance of newborn screening for propionylcarnitine-related disorders. However, factors that potentially affect its detection results have not been investigated, and we aimed to evaluate these influencing factors and explore their potential utility in newborn screening and initial follow-up for propionylcarnitine-related disorders. METHODS This study comprised a prospective group (1998 healthy infants, to establish cutoff values and investigate the influencing factors) and a retrospective group (804 suspected positive cases screened from 381, 399 newborns for propionylcarnitine-related disorders by tandem mass spectrometry, to evaluate the performance of newborn screening and initial follow-up). RESULTS Cutoff values for methylmalonic acid, 2-methylcitric acid, and total homocysteine were 2.12, 0.70, and 10.05 µmol/l, respectively. Concentration of methylmalonic acid, 2-methylcitric acid, and total homocysteine in dried blood spots is not impacted by sex, age, birth weight, gestational age, or dried blood spot storage time. A total of 75 of 804 cases were screened positive by combined tandem mass spectrometry and liquid chromatography-tandem mass spectrometry, thus eliminating 90% of the false positives without compromising sensitivity. Eighteen propionylcarnitine-related disorders were successfully identified, including one CblX case missed in the initial follow-up by tandem mass spectrometry. CONCLUSIONS Methylmalonic acid, 2-methylcitric acid, and total homocysteine detected in dried blood spots by liquid chromatography-tandem mass spectrometry is a reliable, specific, and sensitive approach for identifying propionylcarnitine-related disorders. We recommend this assay should be performed rather than tandem mass spectrometry in follow-up for propionylcarnitine-related disorders besides second-tier tests in newborn screening.
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Affiliation(s)
- Zhenzhen Hu
- Department of Genetics and Metabolism, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Jianbin Yang
- Department of Genetics and Metabolism, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Yiming Lin
- Neonatal Disease Screening Center, Quanzhou Maternity and Children's Hospital, Quanzhou, China
| | - Junjuan Wang
- Department of Epidemiology and Bio-Statistics, 535300Zhejiang University School of Public Health, Hangzhou, China.,Zhejiang BiosanBiochemical Technologies Co. Ltd, Hangzhou, China
| | - Lingwei Hu
- Department of Genetics and Metabolism, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Chao Zhang
- Department of Genetics and Metabolism, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Yu Zhang
- Zhejiang BiosanBiochemical Technologies Co. Ltd, Hangzhou, China
| | - Xinwen Huang
- Department of Genetics and Metabolism, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
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Sörensen L, von Döbeln U, Åhlman H, Ohlsson A, Engvall M, Naess K, Backman-Johansson C, Nordqvist Y, Wedell A, Zetterström RH. Expanded Screening of One Million Swedish Babies with R4S and CLIR for Post-Analytical Evaluation of Data. Int J Neonatal Screen 2020; 6:42. [PMID: 33073033 PMCID: PMC7423009 DOI: 10.3390/ijns6020042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 05/24/2020] [Indexed: 11/16/2022] Open
Abstract
Sweden has one neonatal screening laboratory, receiving 115 to 120 thousand samples per year. Among the one million babies screened by tandem mass spectrometry from November 2010 until July 2019, a total of 665 babies were recalled and 311 verified as having one of the diseases screened for with this methodology, giving a positive predictive value (PPV) of 47% and an incidence of 1:3200. The PPV was high (41%) already in the first year after start of screening, thanks to the availability of the collaborative project Region 4 Stork database. The PPV is presently 58%. This improvement was achieved by the implementation of second-tier analyses in the screening for methylmalonic aciduria, propionic aciduria, isovaleric aciduria, and homocystinuria, and the employment of various post analytical tools of the Region 4 Stork, and its successor the collaborative laboratory integrated reports.
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Affiliation(s)
- Lene Sörensen
- Centre for Inherited Metabolic Diseases, Karolinska University Hospital Solna, SE-171 76 Stockholm, Sweden; (U.v.D.); (H.Å.); (A.O.); (M.E.); (K.N.); (C.B.-J.); (Y.N.); (A.W.); (R.H.Z.)
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-171 76 Stockholm, Sweden
| | - Ulrika von Döbeln
- Centre for Inherited Metabolic Diseases, Karolinska University Hospital Solna, SE-171 76 Stockholm, Sweden; (U.v.D.); (H.Å.); (A.O.); (M.E.); (K.N.); (C.B.-J.); (Y.N.); (A.W.); (R.H.Z.)
- Department of Medical Biochemistry and Biophysics, Division of Molecular Metabolism, Karolinska Institutet, SE-171 77 Stockholm, Sweden
| | - Henrik Åhlman
- Centre for Inherited Metabolic Diseases, Karolinska University Hospital Solna, SE-171 76 Stockholm, Sweden; (U.v.D.); (H.Å.); (A.O.); (M.E.); (K.N.); (C.B.-J.); (Y.N.); (A.W.); (R.H.Z.)
| | - Annika Ohlsson
- Centre for Inherited Metabolic Diseases, Karolinska University Hospital Solna, SE-171 76 Stockholm, Sweden; (U.v.D.); (H.Å.); (A.O.); (M.E.); (K.N.); (C.B.-J.); (Y.N.); (A.W.); (R.H.Z.)
- Department of Medical Biochemistry and Biophysics, Division of Molecular Metabolism, Karolinska Institutet, SE-171 77 Stockholm, Sweden
| | - Martin Engvall
- Centre for Inherited Metabolic Diseases, Karolinska University Hospital Solna, SE-171 76 Stockholm, Sweden; (U.v.D.); (H.Å.); (A.O.); (M.E.); (K.N.); (C.B.-J.); (Y.N.); (A.W.); (R.H.Z.)
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-171 76 Stockholm, Sweden
| | - Karin Naess
- Centre for Inherited Metabolic Diseases, Karolinska University Hospital Solna, SE-171 76 Stockholm, Sweden; (U.v.D.); (H.Å.); (A.O.); (M.E.); (K.N.); (C.B.-J.); (Y.N.); (A.W.); (R.H.Z.)
- Department of Medical Biochemistry and Biophysics, Division of Molecular Metabolism, Karolinska Institutet, SE-171 77 Stockholm, Sweden
| | - Carolina Backman-Johansson
- Centre for Inherited Metabolic Diseases, Karolinska University Hospital Solna, SE-171 76 Stockholm, Sweden; (U.v.D.); (H.Å.); (A.O.); (M.E.); (K.N.); (C.B.-J.); (Y.N.); (A.W.); (R.H.Z.)
| | - Yvonne Nordqvist
- Centre for Inherited Metabolic Diseases, Karolinska University Hospital Solna, SE-171 76 Stockholm, Sweden; (U.v.D.); (H.Å.); (A.O.); (M.E.); (K.N.); (C.B.-J.); (Y.N.); (A.W.); (R.H.Z.)
- Department of Medical Biochemistry and Biophysics, Division of Molecular Metabolism, Karolinska Institutet, SE-171 77 Stockholm, Sweden
| | - Anna Wedell
- Centre for Inherited Metabolic Diseases, Karolinska University Hospital Solna, SE-171 76 Stockholm, Sweden; (U.v.D.); (H.Å.); (A.O.); (M.E.); (K.N.); (C.B.-J.); (Y.N.); (A.W.); (R.H.Z.)
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-171 76 Stockholm, Sweden
| | - Rolf H Zetterström
- Centre for Inherited Metabolic Diseases, Karolinska University Hospital Solna, SE-171 76 Stockholm, Sweden; (U.v.D.); (H.Å.); (A.O.); (M.E.); (K.N.); (C.B.-J.); (Y.N.); (A.W.); (R.H.Z.)
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-171 76 Stockholm, Sweden
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Gavrilov DK, Piazza AL, Pino G, Turgeon C, Matern D, Oglesbee D, Raymond K, Tortorelli S, Rinaldo P. The Combined Impact of CLIR Post-Analytical Tools and Second Tier Testing on the Performance of Newborn Screening for Disorders of Propionate, Methionine, and Cobalamin Metabolism. Int J Neonatal Screen 2020; 6:33. [PMID: 33073028 PMCID: PMC7423003 DOI: 10.3390/ijns6020033] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/07/2020] [Indexed: 12/13/2022] Open
Abstract
The expansion of the recommend uniform screening panel to include more than 50 primary and secondary target conditions has resulted in a substantial increase of false positive results. As an alternative to subjective manipulation of cutoff values and overutilization of molecular testing, here we describe the performance outcome of an algorithm for disorders of methionine, cobalamin, and propionate metabolism that includes: (1) first tier screening inclusive of the broadest available spectrum of markers measured by tandem mass spectrometry; (2) integration of all results into a score of likelihood of disease for each target condition calculated by post-analytical interpretive tools created byCollaborative Laboratory Integrated Reports (CLIR), a multivariate pattern recognition software; and (3) further evaluation of abnormal scores by a second tier test measuring homocysteine, methylmalonic acid, and methylcitric acid. This approach can consistently reduce false positive rates to a <0.01% level, which is the threshold of precision newborn screening. We postulate that broader adoption of this algorithm could lead to substantial savings in health care expenditures. More importantly, it could prevent the stress and anxiety experienced by many families when faced with an abnormal newborn screening result that is later resolved as a false positive outcome.
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Affiliation(s)
- Dimitar K Gavrilov
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (A.L.P.); (G.P.); (C.T.); (D.M.); (D.O.); (K.R.); (S.T.); (P.R.)
| | - Amy L Piazza
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (A.L.P.); (G.P.); (C.T.); (D.M.); (D.O.); (K.R.); (S.T.); (P.R.)
| | - Gisele Pino
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (A.L.P.); (G.P.); (C.T.); (D.M.); (D.O.); (K.R.); (S.T.); (P.R.)
| | - Coleman Turgeon
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (A.L.P.); (G.P.); (C.T.); (D.M.); (D.O.); (K.R.); (S.T.); (P.R.)
| | - Dietrich Matern
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (A.L.P.); (G.P.); (C.T.); (D.M.); (D.O.); (K.R.); (S.T.); (P.R.)
| | - Devin Oglesbee
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (A.L.P.); (G.P.); (C.T.); (D.M.); (D.O.); (K.R.); (S.T.); (P.R.)
| | - Kimiyo Raymond
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (A.L.P.); (G.P.); (C.T.); (D.M.); (D.O.); (K.R.); (S.T.); (P.R.)
| | - Silvia Tortorelli
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (A.L.P.); (G.P.); (C.T.); (D.M.); (D.O.); (K.R.); (S.T.); (P.R.)
| | - Piero Rinaldo
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (A.L.P.); (G.P.); (C.T.); (D.M.); (D.O.); (K.R.); (S.T.); (P.R.)
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de Hora MR, Heather NL, Patel T, Bresnahan LG, Webster D, Hofman PL. Measurement of 17-Hydroxyprogesterone by LCMSMS Improves Newborn Screening for CAH Due to 21-Hydroxylase Deficiency in New Zealand. Int J Neonatal Screen 2020; 6:6. [PMID: 33073005 PMCID: PMC7422986 DOI: 10.3390/ijns6010006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 01/24/2020] [Indexed: 11/26/2022] Open
Abstract
The positive predictive value of newborn screening for congenital adrenal hyperplasia due to 21-hydroxylase deficiency was <2% in New Zealand. This is despite a bloodspot second-tier immunoassay method for 17-hydroxyprogesterone measurement with an additional solvent extract step to reduce the number of false positive screening tests. We developed a liquid chromatography tandem mass spectrometry (LCMSMS) method to measure 17-hydroxyprogesterone in bloodspots to replace our current second-tier immunoassay method. The method was assessed using reference material and residual samples with a positive newborn screening result. Correlation with the second-tier immunoassay was determined and the method was implemented. Newborn screening performance was assessed by comparing screening metrics 2 years before and 2 years after LCMSMS implementation. Screening data analysis demonstrated the number of false positive screening tests was reduced from 172 to 40 in the 2 years after LCMSMS implementation. The positive predictive value of screening significantly increased from 1.71% to 11.1% (X2 test, p < 0.0001). LCMSMS analysis of 17OHP as a second-tier test significantly improves screening specificity for CAH due to 21-hydroxylase deficiency in New Zealand.
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Affiliation(s)
- Mark R de Hora
- Newborn Screening, Specialist Chemical Pathology, LabPlus, Auckland City Hospital, Auckland 1023, New Zealand; (N.L.H.); (T.P.); (L.G.B.); (D.W.)
| | - Natasha L Heather
- Newborn Screening, Specialist Chemical Pathology, LabPlus, Auckland City Hospital, Auckland 1023, New Zealand; (N.L.H.); (T.P.); (L.G.B.); (D.W.)
| | - Tejal Patel
- Newborn Screening, Specialist Chemical Pathology, LabPlus, Auckland City Hospital, Auckland 1023, New Zealand; (N.L.H.); (T.P.); (L.G.B.); (D.W.)
| | - Lauren G Bresnahan
- Newborn Screening, Specialist Chemical Pathology, LabPlus, Auckland City Hospital, Auckland 1023, New Zealand; (N.L.H.); (T.P.); (L.G.B.); (D.W.)
| | - Dianne Webster
- Newborn Screening, Specialist Chemical Pathology, LabPlus, Auckland City Hospital, Auckland 1023, New Zealand; (N.L.H.); (T.P.); (L.G.B.); (D.W.)
| | - Paul L Hofman
- Clinical Research Unit, Liggins Institute, University of Auckland, Auckland 1010, New Zealand;
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49
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Two-Tiered Newborn Screening with Post-Analytical Tools for Pompe Disease and Mucopolysaccharidosis Type I Results in Performance Improvement and Future Direction. Int J Neonatal Screen 2020; 6:2. [PMID: 32064362 PMCID: PMC7021244 DOI: 10.3390/ijns6010002] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We conducted a pilot newborn screening (NBS) study for Pompe disease (PD) and mucopolysaccharidosis type I (MPS I) in the multiethnic population of Georgia. We screened 59,332 infants using a two-tier strategy of flow injection tandem mass spectrometry (FIA-MSMS) enzyme assays. The first tier of testing was a 2-plex assay measuring PD and MPS I enzyme activity, followed by a second-tier test with additional enzymes to improve specificity. Interpretation of results was performed using post-analytical tools created using Collaborative Laboratory Integrated Reports (CLIR). We identified a single case of infantile onset PD, two cases of late onset PD, and one pseudodeficiency. The positive predictive value (PPV) for PD screening during the study was 66.7%. No cases of MPS I were identified during the study period, but there were 2 confirmed cases of pseudodeficiency and 6 cases lost to follow up. The two-tier screening strategy was successful in reducing false positive results and allowed for the identification and early treatment of a case of infantile PD but the frequency of pseudodeficiency in MPS I is problematic. Molecular testing is required and should be covered by the screening program to avoid delays in case resolution.
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50
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Peck DS, Lacey JM, White AL, Pino G, Studinski AL, Fisher R, Ahmad A, Spencer L, Viall S, Shallow N, Siemon A, Hamm JA, Murray BK, Jones KL, Gavrilov D, Oglesbee D, Raymond K, Matern D, Rinaldo P, Tortorelli S. Incorporation of Second-Tier Biomarker Testing Improves the Specificity of Newborn Screening for Mucopolysaccharidosis Type I. Int J Neonatal Screen 2020; 6:10. [PMID: 33073008 PMCID: PMC7422968 DOI: 10.3390/ijns6010010] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 02/05/2020] [Indexed: 11/17/2022] Open
Abstract
Enzyme-based newborn screening for Mucopolysaccharidosis type I (MPS I) has a high false-positive rate due to the prevalence of pseudodeficiency alleles, often resulting in unnecessary and costly follow up. The glycosaminoglycans (GAGs), dermatan sulfate (DS) and heparan sulfate (HS) are both substrates for α-l-iduronidase (IDUA). These GAGs are elevated in patients with MPS I and have been shown to be promising biomarkers for both primary and second-tier testing. Since February 2016, we have measured DS and HS in 1213 specimens submitted on infants at risk for MPS I based on newborn screening. Molecular correlation was available for 157 of the tested cases. Samples from infants with MPS I confirmed by IDUA molecular analysis all had significantly elevated levels of DS and HS compared to those with confirmed pseudodeficiency and/or heterozygosity. Analysis of our testing population and correlation with molecular results identified few discrepant outcomes and uncovered no evidence of false-negative cases. We have demonstrated that blood spot GAGs analysis accurately discriminates between patients with confirmed MPS I and false-positive cases due to pseudodeficiency or heterozygosity and increases the specificity of newborn screening for MPS I.
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Affiliation(s)
- Dawn S Peck
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (J.M.L.); (A.L.W.); (G.P.); (A.L.S.); (D.G.); (D.O.); (K.R.); (D.M.); (P.R.)
| | - Jean M Lacey
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (J.M.L.); (A.L.W.); (G.P.); (A.L.S.); (D.G.); (D.O.); (K.R.); (D.M.); (P.R.)
| | - Amy L White
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (J.M.L.); (A.L.W.); (G.P.); (A.L.S.); (D.G.); (D.O.); (K.R.); (D.M.); (P.R.)
| | - Gisele Pino
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (J.M.L.); (A.L.W.); (G.P.); (A.L.S.); (D.G.); (D.O.); (K.R.); (D.M.); (P.R.)
| | - April L Studinski
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (J.M.L.); (A.L.W.); (G.P.); (A.L.S.); (D.G.); (D.O.); (K.R.); (D.M.); (P.R.)
| | - Rachel Fisher
- Division of Pediatric Genetics, Metabolism and Genomic Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI 48109, USA; (R.F.); (A.A.)
| | - Ayesha Ahmad
- Division of Pediatric Genetics, Metabolism and Genomic Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI 48109, USA; (R.F.); (A.A.)
| | - Linda Spencer
- Division of Genetic, Genomic and Metabolic Disorders, Children's Hospital of Michigan, Detroit, MI 48201, USA;
| | - Sarah Viall
- Rare Disease Institute, Children's National Health System, Washington, DC 20010, USA;
| | - Natalie Shallow
- Division of Medical Genetics and Genomic Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN 37232, USA;
| | - Amy Siemon
- Division of Genetic and Genomic Medicine, Nationwide Children's Hospital, Columbus, OH 43205, USA;
| | - J Austin Hamm
- Pediatric Genetics, East Tennessee Children's Hospital, Knoxville, TN 37916, USA;
| | - Brianna K Murray
- Division of Medical Genetics and Metabolism, Children's Hospital of the King's Daughters, Norfolk, VA 23507, USA; (B.K.M.); (K.L.J.)
| | - Kelly L Jones
- Division of Medical Genetics and Metabolism, Children's Hospital of the King's Daughters, Norfolk, VA 23507, USA; (B.K.M.); (K.L.J.)
| | - Dimitar Gavrilov
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (J.M.L.); (A.L.W.); (G.P.); (A.L.S.); (D.G.); (D.O.); (K.R.); (D.M.); (P.R.)
| | - Devin Oglesbee
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (J.M.L.); (A.L.W.); (G.P.); (A.L.S.); (D.G.); (D.O.); (K.R.); (D.M.); (P.R.)
| | - Kimiyo Raymond
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (J.M.L.); (A.L.W.); (G.P.); (A.L.S.); (D.G.); (D.O.); (K.R.); (D.M.); (P.R.)
| | - Dietrich Matern
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (J.M.L.); (A.L.W.); (G.P.); (A.L.S.); (D.G.); (D.O.); (K.R.); (D.M.); (P.R.)
| | - Piero Rinaldo
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (J.M.L.); (A.L.W.); (G.P.); (A.L.S.); (D.G.); (D.O.); (K.R.); (D.M.); (P.R.)
| | - Silvia Tortorelli
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA; (J.M.L.); (A.L.W.); (G.P.); (A.L.S.); (D.G.); (D.O.); (K.R.); (D.M.); (P.R.)
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