1
|
Sebaa R, AlMogren M, Alseraty W, Abdel Rahman AM. Untargeted Metabolomics Identifies Biomarkers for MCADD Neonates in Dried Blood Spots. Int J Mol Sci 2023; 24:ijms24119657. [PMID: 37298607 DOI: 10.3390/ijms24119657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 05/02/2023] [Accepted: 05/16/2023] [Indexed: 06/12/2023] Open
Abstract
Medium-chain acyl-CoA dehydrogenase deficiency (MCADD) is the most common inherited mitochondrial metabolic disease of fatty acid β-oxidation, especially in newborns. MCADD is clinically diagnosed using Newborn Bloodspot Screening (NBS) and genetic testing. Still, these methods have limitations, such as false negatives or positives in NBS and the variants of uncertain significance in genetic testing. Thus, complementary diagnostic approaches for MCADD are needed. Recently, untargeted metabolomics has been proposed as a diagnostic approach for inherited metabolic diseases (IMDs) due to its ability to detect a wide range of metabolic alterations. We performed an untargeted metabolic profiling of dried blood spots (DBS) from MCADD newborns (n = 14) and healthy controls (n = 14) to discover potential metabolic biomarkers/pathways associated with MCADD. Extracted metabolites from DBS samples were analyzed using UPLC-QToF-MS for untargeted metabolomics analyses. Multivariate and univariate analyses were used to analyze the metabolomics data, and pathway and biomarker analyses were also performed on the significantly identified endogenous metabolites. The MCADD newborns had 1034 significantly dysregulated metabolites compared to healthy newborns (moderated t-test, no correction, p-value ≤ 0.05, FC 1.5). A total of 23 endogenous metabolites were up-regulated, while 84 endogenous metabolites were down-regulated. Pathway analyses showed phenylalanine, tyrosine, and tryptophan biosynthesis as the most affected pathways. Potential metabolic biomarkers for MCADD were PGP (a21:0/PG/F1alpha) and glutathione, with an area under the curve (AUC) of 0.949 and 0.898, respectively. PGP (a21:0/PG/F1alpha) was the first oxidized lipid in the top 15 biomarker list affected by MCADD. Additionally, glutathione was chosen to indicate oxidative stress events that could happen during fatty acid oxidation defects. Our findings suggest that MCADD newborns may have oxidative stress events as signs of the disease. However, further validations of these biomarkers are needed in future studies to ensure their accuracy and reliability as complementary markers with established MCADD markers for clinical diagnosis.
Collapse
Affiliation(s)
- Rajaa Sebaa
- Department of Medical Laboratories, College of Applied Medical Sciences, University of Shaqra, Al-Dawadmi 17472, Saudi Arabia
| | - Maha AlMogren
- Metabolomics Section, Department of Clinical Genomics, Center for Genomics Medicine, King Faisal Specialist Hospital and Research Centre (KFSHRC), Riyadh 11211, Saudi Arabia
- Department of Biochemistry and Molecular Medicine, College of Medicine, Al Faisal University, Riyadh 11533, Saudi Arabia
| | - Wafaa Alseraty
- Department of Nursing, College of Applied Medical Sciences, University of Shaqra, Al-Dawadmi 17472, Saudi Arabia
| | - Anas M Abdel Rahman
- Metabolomics Section, Department of Clinical Genomics, Center for Genomics Medicine, King Faisal Specialist Hospital and Research Centre (KFSHRC), Riyadh 11211, Saudi Arabia
- Department of Biochemistry and Molecular Medicine, College of Medicine, Al Faisal University, Riyadh 11533, Saudi Arabia
| |
Collapse
|
2
|
Bernhardt I, Glamuzina E, Ryder B, Knoll D, Heather N, De Hora M, Webster D, Wilson C. The risk of classical galactosaemia in newborns with borderline galactose metabolites on newborn screening. JIMD Rep 2023; 64:180-186. [PMID: 36873086 PMCID: PMC9981414 DOI: 10.1002/jmd2.12339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 09/08/2022] [Accepted: 09/09/2022] [Indexed: 11/06/2022] Open
Abstract
Newborn screening (NBS) for classical galactosaemia (CG) facilitates early diagnosis and treatment to prevent life-threatening complications, but remains controversial, and screening protocols vary widely between programmes. False-negatives associated with first-tier screening of total galactose metabolites (TGAL) are infrequently reported; however, newborns with TGAL below the screening threshold have not been systematically studied. Following the diagnosis of CG in two siblings missed by NBS, a retrospective cohort study of infants with TGAL just below the cut-off (1.5 mmol/L blood) was conducted. Children born in New Zealand (NZ) from 2011 to 2019, with TGAL 1.0-1.49 mmol/L on NBS were identified from the national metabolic screening programme (NMSP) database, and clinical coding data and medical records were reviewed. GALT sequencing was performed if CG could not be excluded following review of medical records. 328 infants with TGAL 1.0-1.49 mmol/L on NBS were identified, of whom 35 had ICD-10 codes relevant to CG including vomiting, poor feeding, weight loss, failure to thrive, jaundice, hepatitis, Escherichia coli urinary tract infection, sepsis, intracranial hypertension and death. CG could be excluded in 34/35, due to documentation of clinical improvement with continued dietary galactose intake, or a clear alternative aetiology. GALT sequencing in the remaining individual confirmed Duarte-variant galactosaemia (DG). In conclusion, undiagnosed CG appears to be rare in those with TGAL 1.0-1.49 mmol/L on NBS; however, our recent experience with missed cases is nevertheless concerning. Further work is required to establish the optimum screening strategy, to maximize the early detection of CG without excess false-positives.
Collapse
Affiliation(s)
- Isaac Bernhardt
- National Metabolic Service, Auckland City Hospital and Starship Children's HospitalAucklandNew Zealand
| | - Emma Glamuzina
- National Metabolic Service, Auckland City Hospital and Starship Children's HospitalAucklandNew Zealand
| | - Bryony Ryder
- National Metabolic Service, Auckland City Hospital and Starship Children's HospitalAucklandNew Zealand
| | - Detlef Knoll
- Chemical Pathology (Section New Born Screening), Auckland City HospitalAucklandNew Zealand
| | - Natasha Heather
- Newborn Metabolic Screening Unit, Auckland City HospitalAucklandNew Zealand
| | - Mark De Hora
- Chemical Pathology (Section New Born Screening), Auckland City HospitalAucklandNew Zealand
| | - Dianne Webster
- Newborn Metabolic Screening Unit, Auckland City HospitalAucklandNew Zealand
| | - Callum Wilson
- National Metabolic Service, Auckland City Hospital and Starship Children's HospitalAucklandNew Zealand
| |
Collapse
|
3
|
Katler Q, Stepien KM, Paull N, Patel S, Adams M, Balci MC, Berry GT, Bosch AM, De La O A, Demirbas D, Edman J, Ficicioglu C, Goff M, Hacker S, Knerr I, Lancaster K, Li H, Mendelsohn BA, Nichols B, de Rezende Pinto WBV, Rocha JC, Rubio-Gozalbo ME, Saad-Naguib M, Scholl-Buergi S, Searcy S, de Souza PVS, Wittenauer A, Fridovich-Keil JL. A multinational study of acute and long-term outcomes of Type 1 galactosemia patients who carry the S135L (c.404C > T) variant of GALT. J Inherit Metab Dis 2022; 45:1106-1117. [PMID: 36093991 PMCID: PMC9643640 DOI: 10.1002/jimd.12556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/23/2022] [Accepted: 09/09/2022] [Indexed: 11/08/2022]
Abstract
Patients with galactosemia who carry the S135L (c.404C > T) variant of galactose-1-P uridylyltransferase (GALT), documented to encode low-level residual GALT activity, have been under-represented in most prior studies of outcomes in Type 1 galactosemia. What is known about the acute and long-term outcomes of these patients, therefore, is based on very limited data. Here, we present a study comparing acute and long-term outcomes of 12 patients homozygous for S135L, 25 patients compound heterozygous for S135L, and 105 patients homozygous for two GALT-null (G) alleles. This is the largest cohort of S135L patients characterized to date. Acute disease following milk exposure in the newborn period was common among patients in all 3 comparison groups in our study, as were long-term complications in the domains of speech, cognition, and motor outcomes. In contrast, while at least 80% of both GALT-null and S135L compound heterozygous girls and women showed evidence of an adverse ovarian outcome, prevalence was only 25% among S135L homozygotes. Further, all young women in this study with even one copy of S135L achieved spontaneous menarche; this is true for only about 33% of women with classic galactosemia. Overall, we observed that while most long-term outcomes trended milder among groups of patients with even one copy of S135L, many individual patients, either homozygous or compound heterozygous for S135L, nonetheless experienced long-term outcomes that were not mild. This was true despite detection by newborn screening and both early and life-long dietary restriction of galactose. This information should empower more evidence-based counseling for galactosemia patients with S135L.
Collapse
Affiliation(s)
- Quinton Katler
- Division of Reproductive Endocrinology and Infertility, Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia USA
| | - Karolina M. Stepien
- Adult Inherited Metabolic Diseases Department, Salford Royal Foundation NHS Trust, Salford, Greater Manchester, UK
| | - Nathan Paull
- Department of Human Genetics, Emory University School of Medicine, Atlanta, Georgia USA
| | - Sneh Patel
- Emory College, Emory University, Atlanta, Georgia USA
| | - Michael Adams
- UNC School of Medicine, Division of Pediatric Genetics and Metabolism, Chapel Hill, North Carolina USA
| | - Mehmet Cihan Balci
- Department of Pediatric Metabolic Disease, Istanbul Medical School, Fatihİstanbul, Turkey
| | - Gerard T. Berry
- Division of Genetics and Genomics, Department of Pediatrics, The Manton Center for Orphan Disease Research, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts USA
| | - Annet M. Bosch
- Amsterdam UMC location University of Amsterdam, Emma Children’s Hospital, Department of Pediatrics, Division of Metabolic Diseases, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
| | | | - Didem Demirbas
- Division of Genetics and Genomics, Department of Pediatrics, The Manton Center for Orphan Disease Research, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts USA
| | - Julianna Edman
- Department of Pediatric Genetics, University of Illinois-Chicago, Chicago, Illinois USA
| | - Can Ficicioglu
- The Children’s Hospital of Philadelphia, Division of Human Genetics and Metabolism, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania USA
| | - Melanie Goff
- Division of Genetic and Genomic Medicine, Nationwide Children’s Hospital, Columbus, Ohio USA
| | - Stephanie Hacker
- Department of Human Genetics, University of Miami Miller School of Medicine, Miami, Florida USA
| | - Ina Knerr
- National Centre for Inherited Metabolic Disorders, Temple St. Children’s University Hospital, Dublin, Ireland
| | - Kristen Lancaster
- UNC School of Medicine, Division of Pediatric Genetics and Metabolism, Chapel Hill, North Carolina USA
| | - Hong Li
- Departments of Human Genetics and Pediatrics, Emory University School of Medicine, Atlanta, Georgia USA
| | - Bryce A. Mendelsohn
- Department of Genetics, Oakland Medical Center, Kaiser Permanente, Oakland, California USA
| | - Brandi Nichols
- Department of Clinical Nutrition, Arkansas Children’s Hospital, Little Rock, Arkansas USA
| | | | - Júlio César Rocha
- Nutrition & Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa Reference Centre of Inherited Metabolic Diseases, Centro Hospitalar Universitário de Lisboa Central, and Center for Health Technology and Services Research (CINTESIS), NOVA Medical School, Lisboa, Portugal
| | - M Estela Rubio-Gozalbo
- Department of Pediatrics, Department of Clinical Genetics, GROW-School for Oncology and Reproduction, European Reference Network for Hereditary Metabolic Disorders (MetabERN) member and United for Metabolic Diseases member, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Michael Saad-Naguib
- Department of Human Genetics, University of Miami Miller School of Medicine, Miami, Florida USA
| | | | - Sarah Searcy
- Division of Genetic and Genomic Medicine, Nationwide Children’s Hospital, Columbus, Ohio USA
| | | | - Angela Wittenauer
- Department of Human Genetics, Emory University School of Medicine, Atlanta, Georgia USA
| | | |
Collapse
|
4
|
Lasarev MR, Bialk ER, Allen DB, Held PK. Application of Principal Component Analysis to Newborn Screening for Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2020; 105:5856153. [PMID: 32525982 DOI: 10.1210/clinem/dgaa371] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 06/08/2020] [Indexed: 11/19/2022]
Abstract
PURPOSE Newborn screening laboratories are challenged to develop reporting algorithms that accurately identify babies at increased risk for congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency (21OHD). Screening algorithms typically use cutoff values for a key steroid(s) and include considerations for covariates, such as gestational age or birth weight, but false-positive and false-negative results are still too frequent, preventing accurate assessments. Principal component analysis (PCA) is a statistical method that reduces high-dimensional data to a small number of components, capturing patterns of association that may be relevant to the outcome of interest. To our knowledge, PCA has not been evaluated in the newborn screening setting to determine whether it can improve the positive predictive value of 21OHD screening. METHODS PCA was applied to a data set of 920 newborns with measured concentrations of 5 key steroids that are known to be perturbed in patients with 21OHD. A decision tree for the known outcomes (confirmed 21OHD cases and unaffected individuals) was created with 2 principal components as predictors. The effectiveness of the PCA-derived decision tree was compared with the current algorithm. RESULTS PCA improved the positive predictive value of 21OHD screening from 20.0% to 66.7% in a retrospective study comparing the current algorithm to a tree-based algorithm using PCA-derived variables. The streamlined PCA-derived decision tree, comprising only 3 assessment points, greatly simplified the 21OHD reporting algorithm. CONCLUSIONS This first report of PCA applied to newborn screening for 21OHD demonstrates enhanced detection of affected individuals within the unaffected population.
Collapse
Affiliation(s)
- Michael R Lasarev
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Eric R Bialk
- Wisconsin State Laboratory of Hygiene, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - David B Allen
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Patrice K Held
- Wisconsin State Laboratory of Hygiene, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| |
Collapse
|
5
|
Welsink-Karssies MM, van Weeghel M, Hollak CEM, Elfrink HL, Janssen MCH, Lai K, Langendonk JG, Oussoren E, Ruiter JPN, Treacy EP, de Vries M, Ferdinandusse S, Bosch AM. The Galactose Index measured in fibroblasts of GALT deficient patients distinguishes variant patients detected by newborn screening from patients with classical phenotypes. Mol Genet Metab 2020; 129:171-176. [PMID: 31954591 DOI: 10.1016/j.ymgme.2020.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 01/07/2020] [Accepted: 01/08/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND The high variability in clinical outcome of patients with Classical Galactosemia (CG) is poorly understood and underlines the importance of prognostic biomarkers, which are currently lacking. The aim of this study was to investigate if residual galactose metabolism capacity is associated with clinical and biochemical outcomes in CG patients with varying geno- and phenotypes. METHODS Galactose Metabolite Profiling (GMP) was used to determine residual galactose metabolism in fibroblasts of CG patients. The association between the galactose index (GI) defined as the ratio of the measured metabolites [U13C]Gal-1-P/ [13C6]UDP-galactose, and both intellectual and neurological outcome and galactose-1-phosphate (Gal-1-P) levels was investigated. RESULTS GMP was performed in fibroblasts of 28 patients and 3 control subjects. The GI of the classical phenotype patients (n = 22) was significantly higher than the GI of four variant patients detected by newborn screening (NBS) (p = .002), two homozygous p.Ser135Leu patients (p = .022) and three controls (p = .006). In the classical phenotype patients, 13/18 (72%) had a poor intellectual outcome (IQ < 85) and 6/12 (50%) had a movement disorder. All the NBS detected variant patients (n = 4) had a normal intellectual outcome (IQ ≥ 85) and none of them has a movement disorder. In the classical phenotype patients, there was no significant difference in GI between patients with a poor and normal clinical outcome. The NBS detected variant patients had significantly lower GI levels and thus higher residual galactose metabolism than patients with classical phenotypes. There was a clear correlation between Gal-1-P levels in erythrocytes and the GI (p = .001). CONCLUSIONS The GI was able to distinguish CG patients with varying geno- and phenotypes and correlated with Gal-1-P. The data of the NBS detected variant patients demonstrated that a higher residual galactose metabolism may result in a more favourable clinical outcome. Further research is needed to enable individual prognostication and treatment in all CG patients.
Collapse
Affiliation(s)
- Mendy M Welsink-Karssies
- Department of Pediatrics, Division of Metabolic Disorders, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Michel van Weeghel
- Department of Clinical Chemistry, Laboratory Genetic Metabolic Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Core Facility Metabolomics, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Carla E M Hollak
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Hyung L Elfrink
- Department of Clinical Chemistry, Laboratory Genetic Metabolic Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Core Facility Metabolomics, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Mirian C H Janssen
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Kent Lai
- Department of Pediatrics, Division of Medical Genetics, University of Utah School of Medicine, United States
| | - Janneke G Langendonk
- Department of Internal Medicine, Center for Lysosomal and Metabolic Diseases, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Esmee Oussoren
- Department of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jos P N Ruiter
- Department of Clinical Chemistry, Laboratory Genetic Metabolic Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Eileen P Treacy
- National Centre for Inherited Metabolic Disorders, The Mater Misericordiae University Hospital Dublin, Ireland
| | - Maaike de Vries
- Department of Pediatrics, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Sacha Ferdinandusse
- Department of Clinical Chemistry, Laboratory Genetic Metabolic Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Annet M Bosch
- Department of Pediatrics, Division of Metabolic Disorders, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| |
Collapse
|
6
|
Satekge TM, Kiabilua O, Krause A, Pillay TS. Five years of screening for galactosaemia in South Africa: Pitfalls of using Benedict's test and thin layer chromatography to screen for galactosaemia in a developing country. Clin Chim Acta 2020; 505:73-77. [PMID: 32092319 DOI: 10.1016/j.cca.2020.02.018] [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: 02/02/2020] [Revised: 02/15/2020] [Accepted: 02/17/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND The objective of the study was to investigate the effectiveness of screening for hereditary galactosaemia with Benedict's test and thin layer chromatography (TLC) in a tertiary laboratory from a developing country. METHODS We retrospectively analysed the results of tests done in suspected galactosaemia patients including Benedict's test, thin layer chromatography, GALT activity and DNA analysis. RESULTS 878 paediatric patients were screened with Benedict's test; the age range was 5 days to 19 years. 48% tested positive/trace on the Benedict's test of which 52% of these had galactosuria evident on TLC. 22% of this sample had pathologically low GALT results on follow-up. 8 patients from the screened population were confirmed to have galactosaemia, in addition to 6 more patients diagnosed with galactosaemia without screening tests performed. Median ages at which the diagnoses were made in the screened and non-screened samples were 2 months and 6 months respectively. Confirmatory DNA testing was performed in 2 patients, whom were found to be heterozygous for S135L mutation. CONCLUSION Inadequate performance of Benedict's test and TLC was demonstrated by false positive and false negative results leading us to conclude that screening test results require interpretation with caution.
Collapse
Affiliation(s)
- Tumelo M Satekge
- Department of Chemical Pathology, Faculty of Health Sciences, University of Pretoria and National Health Laboratory Service Tshwane Academic Division, Pretoria, South Africa
| | - Olivia Kiabilua
- Department of Chemical Pathology, Faculty of Health Sciences, University of Pretoria and National Health Laboratory Service Tshwane Academic Division, Pretoria, South Africa
| | - Amanda Krause
- Department of Human Genetics, School of Pathology, University of the Witwatersrand and National Health Laboratory Service, Braamfontein, Johannesburg, South Africa
| | - Tahir S Pillay
- Department of Chemical Pathology, Faculty of Health Sciences, University of Pretoria and National Health Laboratory Service Tshwane Academic Division, Pretoria, South Africa; Division of Chemical Pathology, University of Cape Town, South Africa.
| |
Collapse
|
7
|
Teke Kisa P, Kose M, Unal O, Er E, Hismi BO, Bulbul FS, Kose E, Gunduz M, Canda E, Kucukcongar A, Arslan N. Clinical and molecular characteristics and time of diagnosis of patients with classical galactosemia in an unscreened population in Turkey. J Pediatr Endocrinol Metab 2019; 32:675-681. [PMID: 31194682 DOI: 10.1515/jpem-2018-0457] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 03/30/2019] [Indexed: 12/23/2022]
Abstract
Classical galactosemia is an autosomal recessive inborn error of metabolism caused by biallelic pathogenic variants in the GALT gene. With the benefit of early diagnosis by newborn screening, the acute presentation of galactosemia can be prevented. In this study, we describe the clinical phenotypes, time of diagnosis and GALT genotypes of 76 galactosemia patients from Turkey, where the disease is not yet included in the newborn screening program. The median age at first symptom was 10 days (range 5-20), while the median age at diagnosis was 30 days (range 17-53). Nearly half of the patients (36 patients, 47.4%) were diagnosed later than age 1 month. Fifty-eight individuals were found to have 18 different pathogenic variants in their 116 mutant alleles. In our sample, Q188R variant has the highest frequency with 53%, the other half of the allele frequency of the patients showed 17 different genotypes. Despite presenting with typical clinical manifestations, classical galactosemia patients are diagnosed late in Turkey. Due to the geographical location of our country, different pathogenic GALT variants may be seen in Turkish patients. In the present study, a clear genotype-phenotype correlation could not be established in patients.
Collapse
Affiliation(s)
- Pelin Teke Kisa
- Department of Pediatrics, Division of Pediatric Metabolism and Nutrition, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - Melis Kose
- Division of Pediatric Metabolism and Nutrition, Dr. Behcet Uz Children's Training and Research Hospital, Izmir, Turkey
| | - Ozlem Unal
- Division of Pediatric Metabolism and Nutrition, Ankara Children's Training and Research Hospital, Ankara, Turkey
| | - Esra Er
- Division of Pediatric Metabolism and Nutrition, Ege University Faculty of Medicine, Izmir, Turkey
| | - Burcu Ozturk Hismi
- Division of Pediatric Metabolism and Nutrition, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Fatma Selda Bulbul
- Division of Pediatric Metabolism and Nutrition, Kirikkale University, Kirikkale, Turkey
| | - Engin Kose
- Department of Pediatrics, Division of Pediatric Metabolism and Nutrition, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - Mehmet Gunduz
- Division of Pediatric Metabolism and Nutrition, Ankara Children's Training and Research Hospital, Ankara, Turkey
| | - Ebru Canda
- Division of Pediatric Metabolism and Nutrition, Ege University Faculty of Medicine, Izmir, Turkey
| | - Aynur Kucukcongar
- Division of Pediatric Metabolism and Nutrition, Ankara Children's Training and Research Hospital, Ankara, Turkey
| | - Nur Arslan
- Department of Pediatrics, Division of Pediatric Metabolism and Nutrition, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| |
Collapse
|
8
|
Demirbas D, Huang X, Daesety V, Feenstra S, Haskovic M, Qi W, Gubbels CS, Hecht L, Levy HL, Waisbren SE, Berry GT. The ability of an LC-MS/MS-based erythrocyte GALT enzyme assay to predict the phenotype in subjects with GALT deficiency. Mol Genet Metab 2019; 126:368-376. [PMID: 30718057 DOI: 10.1016/j.ymgme.2019.01.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 01/20/2019] [Accepted: 01/21/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND GALT deficiency is a rare genetic disorder of carbohydrate metabolism. Due to the decreased activity or absence of the enzyme galactose-1-phosphate uridylyltransferase (GALT), cells from affected individuals are unable to metabolize galactose normally. Lactose consumption in the newborn period could potentially lead to a lethal disease process with multi-organ involvement. In contrast to the newborn-stage disease, however, a galactose-restricted diet does not prevent long-term complications such as central nervous system (CNS) dysfunction with speech defects, learning disability and neurological disease in addition to hypergonadotropic hypogonadism or primary ovarian insufficiency (POI) in females. As the literature suggests an association between GALT enzyme activity and the long-term complications, it is of importance to have a highly sensitive assay to quantify the GALT enzyme activity. To that end, we had developed a sensitive and accurate LC-MS/MS method to measure GALT enzyme activity. Its ability to predict outcome is the subject of this report. MATERIALS AND METHODS The GALT enzyme activity in erythrocytes from 160 individuals, in which 135 with classic, clinical variant or biochemical variant galactosemia, was quantified by LC-MS/MS. Individuals with GALT deficiency were evaluated for the long-term complications of speech defects, dysarthria, ataxia, dystonia, tremor, POI, as well as intellectual functioning (full scale IQ). The LC-MS/MS results were compared to a variety of assays: radioactive, [14C]-galactose-1-phosphate, paper chromatography with scintillation counting, enzyme-coupled assays with spectrophotometric or fluorometric readout or high-pressure liquid chromatography with UV detection of UDP-galactose. RESULTS The LC-MS/MS method measured GALT activity as low as 0.2%, whereas other methods showed no detectable activity. Largely due to GALT activities that were over 1%, the LC-MS/MS measurements were not significantly different than values obtained in other laboratories using other methodologies. Severe long-term complications were less frequently noted in subjects with >1% activity. Patients with a p.Q188R/p.Q188R genotype have no residual enzyme activity in erythrocytes. CONCLUSION Our LC-MS/MS assay may be necessary to accurately quantify residual GALT activities below 5%. The data suggest that patients with >1% residual activity are less likely to develop diet-independent long-term complications. However, much larger sample sizes are needed to properly assess the clinical phenotype in patients with residual enzyme activities between 0.1 and 5%.
Collapse
Affiliation(s)
- Didem Demirbas
- Manton Center for Orphan Disease Research, Division of Genetics and Genomics, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Xiaoping Huang
- Manton Center for Orphan Disease Research, Division of Genetics and Genomics, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Vikram Daesety
- Manton Center for Orphan Disease Research, Division of Genetics and Genomics, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Susan Feenstra
- Manton Center for Orphan Disease Research, Division of Genetics and Genomics, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Minela Haskovic
- Manton Center for Orphan Disease Research, Division of Genetics and Genomics, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Wanshu Qi
- Manton Center for Orphan Disease Research, Division of Genetics and Genomics, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Cynthia S Gubbels
- Manton Center for Orphan Disease Research, Division of Genetics and Genomics, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Leah Hecht
- Manton Center for Orphan Disease Research, Division of Genetics and Genomics, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Harvey L Levy
- Manton Center for Orphan Disease Research, Division of Genetics and Genomics, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Susan E Waisbren
- Manton Center for Orphan Disease Research, Division of Genetics and Genomics, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Gerard T Berry
- Manton Center for Orphan Disease Research, Division of Genetics and Genomics, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States.
| |
Collapse
|
9
|
Laboratory diagnosis of galactosemia: a technical standard and guideline of the American College of Medical Genetics and Genomics (ACMG). Genet Med 2017; 20:3-11. [PMID: 29261178 DOI: 10.1038/gim.2017.172] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 08/30/2017] [Indexed: 11/09/2022] Open
Abstract
Disclaimer: These ACMG Standards and Guidelines are developed primarily as an educational resource for clinical laboratory geneticists to help them provide quality clinical laboratory genetic services. Adherence to these Standards and Guidelines is voluntary and does not necessarily assure a successful medical outcome. These Standards and Guidelines should not be considered inclusive of all proper procedures and tests or exclusive of other procedures and tests that are reasonably directed to obtaining the same results. In determining the propriety of any specific procedure or test, the clinical laboratory geneticist should apply his or her own professional judgment to the specific circumstances presented by the individual patient or specimen. Clinical laboratory geneticists are encouraged to document in the patient's record the rationale for the use of a particular procedure or test, whether or not it is in conformance with these Standards and Guidelines. They also are advised to take notice of the date any particular guideline was adopted, and to consider other relevant medical and scientific information that becomes available after that date. It also would be prudent to consider whether intellectual property interests may restrict the performance of certain tests and other procedures.Galactosemias are inherited disorders of galactose metabolism due to deficiency in one of the three enzymes involved in the Leloir pathway: galactose-1-phosphate uridyltransferase, galactokinase, and uridine diphosphate (UDP)-galactose-4'-epimerase. Galactose-1-phosphate uridyltransferase deficiency, or classic galactosemia, is the most frequent and the most severe of the three enzyme deficiencies; it is characterized by failure to thrive, liver failure, susceptibility to sepsis, and death, if untreated. Newborn screening for classic galactosemia has been implemented in all of the United States, while screening for galactokinase deficiency and UDP-galactose-4'-epimerase deficiency is not universal. Early identification and treatment of galactosemia leads to improved outcome. This document reviews the laboratory methods and best practices for the diagnosis of galactosemia.
Collapse
|
10
|
Cocanougher B, Aypar U, McDonald A, Hasadsri L, Bennett MJ, Edward Highsmith W, D'Aco K. Compound heterozygosity with a novel S222N GALT mutation leads to atypical galactosemia with loss of GALT activity in erythrocytes but little evidence of clinical disease. Mol Genet Metab Rep 2015. [PMID: 28649529 PMCID: PMC5471153 DOI: 10.1016/j.ymgmr.2014.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Galactosemia is an inborn error of galactose metabolism caused by mutations in the GALT gene. Though early detection and galactose restriction prevent severe liver disease, affected individuals have persistently elevated biomarkers and often neuro-developmental symptoms. We present a teenage compound heterozygote for a known pathogenic mutation (H132Q) and a novel variant of unknown significance (S222N), with nearly absent erythrocyte GALT enzyme activity but normal biomarkers and only mild anxiety despite diet non-adherence. This case is similar to a previously reported S135L mutation. In this report we investigate the novel S222N variant and critically evaluate a clinically puzzling case.
Collapse
Affiliation(s)
- Benjamin Cocanougher
- University of Rochester School of Medicine and Dentistry, Department of Pediatrics, Division of Genetics, Rochester, NY, USA
| | - Umut Aypar
- Molecular Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Amber McDonald
- Molecular Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Linda Hasadsri
- Molecular Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Michael J Bennett
- Metabolic Disease Laboratory, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Department of Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - W Edward Highsmith
- Molecular Genetics Laboratory, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Kristin D'Aco
- University of Rochester School of Medicine and Dentistry, Department of Pediatrics, Division of Genetics, Rochester, NY, USA
| |
Collapse
|
11
|
Coelho AI, Ramos R, Gaspar A, Costa C, Oliveira A, Diogo L, Garcia P, Paiva S, Martins E, Teles EL, Rodrigues E, Cardoso MT, Ferreira E, Sequeira S, Leite M, Silva MJ, de Almeida IT, Vicente JB, Rivera I. A frequent splicing mutation and novel missense mutations color the updated mutational spectrum of classic galactosemia in Portugal. J Inherit Metab Dis 2014; 37:43-52. [PMID: 23749220 DOI: 10.1007/s10545-013-9623-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 05/16/2013] [Accepted: 05/17/2013] [Indexed: 01/28/2023]
Abstract
Classic galactosemia is an autosomal recessive disorder caused by deficient galactose-1-phosphate uridylyltransferase (GALT) activity. Patients develop symptoms in the neonatal period, which can be ameliorated by dietary restriction of galactose. Many patients develop long-term complications, with a broad range of clinical symptoms whose pathophysiology is poorly understood. The high allelic heterogeneity of GALT gene that characterizes this disorder is thought to play a determinant role in biochemical and clinical phenotypes. We aimed to characterize the mutational spectrum of GALT deficiency in Portugal and to assess potential genotype-phenotype correlations. Direct sequencing of the GALT gene and in silico analyses were employed to evaluate the impact of uncharacterized mutations upon GALT functionality. Molecular characterization of 42 galactosemic Portuguese patients revealed a mutational spectrum comprising 14 nucleotide substitutions: ten missense, two nonsense and two putative splicing mutations. Sixteen different genotypic combinations were detected, half of the patients being p.Q188R homozygotes. Notably, the second most frequent variation is a splicing mutation. In silico predictions complemented by a close-up on the mutations in the protein structure suggest that uncharacterized missense mutations have cumulative point effects on protein stability, oligomeric state, or substrate binding. One splicing mutation is predicted to cause an alternative splicing event. This study reinforces the difficulty in establishing a genotype-phenotype correlation in classic galactosemia, a monogenic disease whose complex pathogenesis and clinical features emphasize the need to expand the knowledge on this "cloudy" disorder.
Collapse
Affiliation(s)
- Ana I Coelho
- Metabolism & Genetics Group, Research Institute for Medicines and Pharmaceutical Sciences (iMed.UL), Faculty of Pharmacy, University of Lisbon, Av. Prof. Gama Pinto, 1643-009, Lisbon, Portugal
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Coss KP, Hawkes CP, Adamczyk B, Stöckmann H, Crushell E, Saldova R, Knerr I, Rubio-Gozalbo ME, Monavari AA, Rudd PM, Treacy EP. N-Glycan Abnormalities in Children with Galactosemia. J Proteome Res 2013; 13:385-94. [DOI: 10.1021/pr4008305] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Karen P. Coss
- University College Dublin (UCD), Clinical Research
Centre, Mater Misericordiae University Hospital, Eccles Street, Dublin, Ireland
| | - Colin P. Hawkes
- National
Centre for Inherited Metabolic Disorders (NCIMD), Children’s University Hospital, Temple Street, Dublin, Ireland
| | - Barbara Adamczyk
- National Institute for Bioprocessing Research and Training (NIBRT), GlycoScience Group, Mount
Merrion, Blackrock, Dublin, Ireland
| | - Henning Stöckmann
- National Institute for Bioprocessing Research and Training (NIBRT), GlycoScience Group, Mount
Merrion, Blackrock, Dublin, Ireland
| | - Ellen Crushell
- National
Centre for Inherited Metabolic Disorders (NCIMD), Children’s University Hospital, Temple Street, Dublin, Ireland
| | - Radka Saldova
- National Institute for Bioprocessing Research and Training (NIBRT), GlycoScience Group, Mount
Merrion, Blackrock, Dublin, Ireland
| | - Ina Knerr
- National
Centre for Inherited Metabolic Disorders (NCIMD), Children’s University Hospital, Temple Street, Dublin, Ireland
| | | | - Ardeshir A. Monavari
- National
Centre for Inherited Metabolic Disorders (NCIMD), Children’s University Hospital, Temple Street, Dublin, Ireland
| | - Pauline M. Rudd
- National Institute for Bioprocessing Research and Training (NIBRT), GlycoScience Group, Mount
Merrion, Blackrock, Dublin, Ireland
| | - Eileen P. Treacy
- National
Centre for Inherited Metabolic Disorders (NCIMD), Children’s University Hospital, Temple Street, Dublin, Ireland
- Trinity College, College Green, Dublin, Ireland
| |
Collapse
|
13
|
Ryan EL, Lynch ME, Taddeo E, Gleason TJ, Epstein MP, Fridovich-Keil JL. Cryptic residual GALT activity is a potential modifier of scholastic outcome in school age children with classic galactosemia. J Inherit Metab Dis 2013; 36:1049-61. [PMID: 23319291 PMCID: PMC3657299 DOI: 10.1007/s10545-012-9575-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Revised: 11/26/2012] [Accepted: 12/04/2012] [Indexed: 11/28/2022]
Abstract
Classic galactosemia is a potentially lethal disorder that results from profound deficiency of galactose-1-phosphate uridylyltransferase (GALT), the second enzyme in the Leloir pathway of galactose metabolism. Although early diagnosis and rigorous dietary restriction of galactose prevent or resolve the potentially lethal acute symptoms, patients are at markedly increased risk of long-term complications including significant cognitive, speech, and behavioral difficulties, among other problems. The mechanisms that underlie these long-term complications remain unclear, as do the factors that modify their severity. Here we explored the scholastic and behavioral outcomes experienced by a cohort of 54 school age children with classic galactosemia. Data collected included survey responses from parents and teachers, school records including standardized test scores, and GALT genotype data used to estimate predicted residual GALT activity based on a yeast expression system. As expected, many but not all of the children in our study demonstrated speech, scholastic, and behavioral difficulties. Perhaps most striking, we found that predicted cryptic residual GALT activity, often below the threshold of detection of clinical assays, appeared to modify scholastic outcome. These data raise the intriguing possibility that cryptic GALT activity might also influence the severity of other long-term complications in classic galactosemia.
Collapse
Affiliation(s)
- Emily L. Ryan
- Graduate Program in Biochemistry, Cell, and Developmental Biology, Emory University, Atlanta, GA, USA
| | | | - Elles Taddeo
- Department of Psychiatry, Emory University School of Medicine
| | - Tyler J. Gleason
- Department of Human Genetics, Emory University School of Medicine
| | | | - Judith L. Fridovich-Keil
- Department of Human Genetics, Emory University School of Medicine
- Correspondence to: Judith L. Fridovich-Keil, Department of Human Genetics, Emory University School of Medicine, Rm. 325.2 Whitehead Bldg., 615 Michael St, Atlanta, GA 30322 TEL 404-727-3924, FAX 404-727-3949,
| |
Collapse
|
14
|
Dunn CT, Skrypek MM, Powers ALR, Laguna TA. The need for vigilance: the case of a false-negative newborn screen for cystic fibrosis. Pediatrics 2011; 128:e446-9. [PMID: 21727111 PMCID: PMC8202520 DOI: 10.1542/peds.2010-0286] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Cystic fibrosis (CF) is the most common life-limiting recessive genetic disorder in the white population. CF is caused by abnormalities in the gene that codes for the cystic fibrosis transmembrane conductance regulator protein (CFTR) and may result in severe chronic lung disease, poor growth, and malnutrition. Physicians often do not consider CF in the differential diagnosis of an infant with failure to thrive in the presence of a negative newborn screening (NBS) result. In Minnesota, newborn infants are screened for CF by immunoreactive trypsinogen (IRT) testing followed by DNA analysis if the IRT screen result is abnormal. All positive NBS results are followed by confirmatory sweat-testing by pilocarpine iontophoresis. We present here the case of a 1-month-old white boy with failure to thrive, chronic diarrhea, and severe malnutrition. Minnesota state CF NBS results were negative at birth (IRT: 43 ng/mL [96% cutoff value: 52 ng/mL]). Clinical symptoms resulted in sweat-testing by Gibson-Cooke pilocarpine iontophoresis at 1 month of age, and the result was positive (102 mmol Cl(-)/L [normal: ≤30 mmol Cl(-)/L]). CFTR mutation analysis confirmed a homozygous f508del genotype, and stool pancreatic elastase testing revealed severe exocrine pancreatic insufficiency. This case represents the first known false-negative result in Minnesota since the initiation of NBS for CF in 2006, which illustrates the importance of considering CF in the evaluation of an infant with failure to thrive and symptoms of malabsorption, regardless of NBS results.
Collapse
Affiliation(s)
- Christina T. Dunn
- Department of Pediatrics, University of Minnesota and University of Minnesota Amplatz Children's Hospital, Minneapolis, Minnesota; and
| | - Mary M. Skrypek
- Department of Pediatrics, University of Minnesota and University of Minnesota Amplatz Children's Hospital, Minneapolis, Minnesota; and
| | - Amy L. R. Powers
- University of Minnesota Medical Center, Fairview and University of Minnesota Cystic Fibrosis Center, Minneapolis, Minnesota
| | - Theresa A. Laguna
- Department of Pediatrics, University of Minnesota and University of Minnesota Amplatz Children's Hospital, Minneapolis, Minnesota; and
| |
Collapse
|
15
|
Coman DJ, Murray DW, Byrne JC, Rudd PM, Bagaglia PM, Doran PD, Treacy EP. Galactosemia, a single gene disorder with epigenetic consequences. Pediatr Res 2010; 67:286-92. [PMID: 19952866 DOI: 10.1203/pdr.0b013e3181cbd542] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Long-term outcomes of classic galactosemia (GAL) remain disappointing. It is unclear if the complications result mainly from prenatal-neonatal toxicity or persistent glycoprotein and glycolipid synthesis abnormalities. We performed gene expression profiling (T transcriptome) to characterize key-altered genes and gene clusters of four patients with GAL with variable outcomes maintained on a galactose-restricted diet, compared with controls. Significant perturbations of multiple cell signaling pathways were observed including mitogen-activated protein kinase (MAPK) signaling, regulation of the actin cytoskeleton, focal adhesion, and ubiquitin mediated proteolysis. A number of genes significantly altered were further investigated in the GAL cohort including SPARC (osteonectin) and S100A8 (S100 calcium-binding protein). The whole serum N-glycan profile and IgG glycosylation status of 10 treated patients with GAL were compared with healthy control serum and IgG using a quantitative high-throughput analytical HPLC platform. Increased levels of agalactosylated and monogalactosylated structures and decreases in certain digalactosylated structures were identified in the patients. The persistent abnormal glycosylation of serum glycoproteins seen with the microarray data indicates persisting metabolic dyshomeostasis and gene dysregulation in "treated" GAL. Strict restriction of dietary galactose is clearly life saving in the neonatal period; long-term severe galactose restriction may contribute to ongoing systemic abnormalities.
Collapse
Affiliation(s)
- David J Coman
- National Centre for Inherited Metabolic Disorders, Children's University Hospital, Dublin 1, Ireland
| | | | | | | | | | | | | |
Collapse
|