Classic Congenital Adrenal Hyperplasia due to 21-Hydroxylase-Deficiency: 13 Years of Neonatal Screening and Follow-up in Bavaria.

BACKGROUND: 21-Hydroxylase deficient (21-OHD) classic congenital adrenal hyperplasia (CAH) is a potentially lethal inherited endocrine disorder. It is included in many neonatal screening programs to prevent morbidity and mortality from salt-wasting and to reduce long-term health problems. This paper presents a population-based evaluation of CAH screening quality and outcome in Bavaria between 1999 and 2011 including long-term follow-up of patients. METHODS: Screening process quality, clinical complications during the neonatal period, treatment and development of patients up to the age of 4 years were analysed. RESULTS: Among 1 420 102 screened infants, 114 cases of 21-OHD classic CAH were detected (prevalence 1:12 457). Mean age at start of treatment was 7 days. However, in 29 cases (25.4%), age at start of treatment was 12 days or more. The frequency of neonatal salt-wasting increased with age at start of treatment, but all neonatal salt-wasting episodes and crises were managed successfully. Up to the age of 4 years, developmental assessment of the CAH cohort yielded normal results. DISCUSSION: Epidemiological and screening effectiveness results are in keeping with other publications. For the most part, screening process times were compliant with guidelines. The Bavarian CAH screening and tracking system proved successful, but there were process delays and complications which might have been avoidable. The outcome supports the benefits of CAH screening, but further research is necessary to increase CAH screening effectiveness and to evaluate long-term effects.

Positive effect of a simplified diet on blood phenylalanine control in different phenylketonuria variants, characterized by newborn BH4 loading test and PAH analysis.

Until today, the mainstay of phenylketonuria (PKU) treatment is a phenylalanine (Phe)-restricted diet. Strict dietary treatment decreases flexibility and autonomy and still has a major impact on patients and their families. Compliance is often poor, particularly in adolescence. The aim of this study was to investigate the effect of the intake of fruits and vegetables containing Phe less than 100 mg/100g ('simplified diet'), as recommended by WHO for all individuals, instead of classical totally restricted diet on the course and treatment control of the disease in a well-characterized PKU cohort (n=80). All individual blood Phe measurements of each patient (1992-2009) were statistically analyzed before and after diet switch. Epidemiological data, age at diagnosis, PAH mutations, BH(4) responsiveness, as well as Phe control measurements and detailed diet information were tabulated in a local database. 62.5% had BH4 loading test and 40% had PAH analysis; 50/80 switched from classical to simplified diet, including 26 classical PKU, 13 moderate PKU, 7 mild PKU and 4 mild hyperphenylalaninemia (HPA). Median Phe levels on a simplified diet did not differ significantly to the median Phe levels on classical diet in all disease groups. Our results indicate that a simplified diet has no negative effect on blood Phe control in patients with hyperphenylalaninemia, independent of severity of the phenotype or the age at diet switch, over the period of 3 years. Thus, a simpler approach to dietary treatment of PKU available to all HPA patients is more likely to be accepted and adhered by patients and might also increase quality of life.

Dissection of biochemical borderline phenotypes in carriers and genetic variants of medium-chain acyl-CoA dehyrogenase deficiency: implications for newborn screening [corrected].

Medium-chain acyl-CoA dehydrogenase deficiency (MCADD) represents a potentially fatal fatty acid beta-oxidation disorder. Newborn screening (NBS) by tandem mass spectrometry (MS/MS) has been implemented worldwide, but is associated with unresolved questions regarding population heterogeneity, burden on healthy carriers, cut-off policies, false-positive and negative rates. In a retrospective case-control study, 333 NBS samples showing borderline acylcarnitine patterns but not reaching recall criteria were genotyped for the two most common mutations (c.985A>G/c.199C>T) and compared with genotypes and acylcarnitines of 333 controls, 68 false-positives, and 34 patients. c.985A>G was more frequently identified in the study group and false-positives compared to controls (1:4.3/1:2.3 vs. 1:42), whereas c.199C>T was found more frequently only within the false-positives (1:23). Biochemical criteria were devised to differentiate homozygous (c.985A>G), compound heterozygous (c.985A>G/c.199C>T), and heterozygous individuals. Four false-negatives were identified because our initial algorithm required an elevation of octanoylcarnitine (C(8)) and three secondary markers in the initial and follow-up sample. The new approach allowed a reduction of false-positives (by defining high cut-offs: 1.4 micromol/l for C(8); 7 for C(8)/C(12)) and false-negatives (by sequencing the ACADM gene of few suspicious samples). Our validation strategy is able to differentiate healthy carriers from patients doubling the positive predictive value (42-->88%) and to target NBS to MCADD-subsets with potentially higher risk of adverse outcome. It remains controversial, if NBS programs should aim at identifying all subsets of all diseases included. Because the natural course of milder variants cannot be assessed by observational studies, our strategy could serve as a general model for evaluation of MS/MS-based NBS.

Diagnosis of glutathione synthetase deficiency in newborn screening.

Glutathione synthetase (GSS) deficiency is a rare disorder of glutathione metabolism with varying clinical severity. Patients may present with haemolytic anaemia alone or together with acidosis and central nervous system impairment. Diagnosis is made by clinical presentation and detection of elevated concentrations of 5-oxoproline in urine and low GSS activity in erythrocytes or cultured skin fibroblasts. Diagnosis can be confirmed by mutational analysis. Treatment consists of the correction of acidosis, blood transfusion, and supplementation with antioxidants. The most important determinants for outcome and survival in patients with GSS deficiency are early diagnosis and early initiation of treatment. The case of a newborn with GSS deficiency diagnosed by tandem mass spectrometry (MS/MS)-based newborn screening is described. After onset of clinical symptoms on the 2nd day of life, expanded newborn screening revealed normal results for all disorders included in the German screening programme; however, selective MS/MS screening revealed a >10-fold elevation of 5-oxoproline in dried blood, leading to the presumptive diagnosis of GSS deficiency by the 5th day of life. Diagnosis was later confirmed by detection of markedly reduced glutathione concentration in erythrocytes and mutational analysis of the GSS gene. Presently, GSS deficiency is not included in newborn screening programmes in Europe. As outcome depends significantly on early start of treatment, routine inclusion of this disorder in newborn screening panels should be considered.

Establishing New Cut-Off Limits for Galactose 1-Phosphate-Uridyltransferase Deficiency for the Dutch Newborn Screening Programme.

Newborn screening for classical galactosemia in the Netherlands is performed by five laboratories and is based on the measurement of galactose 1-phosphate-uridyltransferase (GALT) activity and total galactose (TGAL) in heel prick blood spots. Unexpected problems with the GALT assay posed a challenge to switch to a new assay. The aim of this study was to make an analytical and clinical evaluation of GALT assays to replace the current assay and to establish new cut-off values (COVs).First, the manual assay from PerkinElmer (NG-1100) and the GSP assay were compared by analyzing 626 anonymous heel prick samples in parallel. Secondly, a manual GSP method was evaluated and 2,052 samples were compared with the automated GSP assay. Finally, a clinical evaluation was performed by collecting data from 93 referred newborns.No satisfactory correlation was observed between GALT activity measured with the manual NG-1100 assay and the automated GSP assay. An acceptable correlation was found between the manual and automated GSP assay. Intra- and inter-assay variation of the automated GSP were 1.8-10.0% and 3.1-13.9%, respectively. Evaluation of clinical data demonstrated that adjusting the COVs for GALT to 2.0 U/dl and TGAL to 1,100 µmol/l improved specificity of screening for classical galactosemia.An assay designed for automated processing to measure GALT activity in heel prick samples works equally well when processed manually. We therefore adopted both methods in the Dutch screening laboratories. As a result of this evaluation new COVs for GALT and TGAL have been introduced and are valid from July 2015.

Maple syrup urine disease: favourable effect of early diagnosis by newborn screening on the neonatal course of the disease.

BACKGROUND: In the rare autosomal recessive disorder maple syrup urine disease (MSUD) the accumulation of the branched-chain amino acids and their metabolic products results in acute and chronic brain dysfunction. Since 2002, MSUD has been part of the extended newborn screening programme in Germany and Austria. Early diagnosis and intervention during the presymptomatic or early symptomatic period should improve the outcome of the patients, which would make the case for screening for MSUD. AIM: The aim of the study was to evaluate the clinical course and alterations of marker metabolites during the first weeks of life in 10 patients with classical MSUD detected by newborn screening (NBS) in comparison with the 10 youngest German patients diagnosed clinically. METHOD: Laboratory data as well as information on clinical course and management during the neonatal period were obtained retrospectively. RESULTS: Patients detected in NBS presented with lower plasma leucine concentrations at confirmation of diagnosis and less severe clinical symptoms. Lowering of leucine to below a critical threshold of 1000 micromol/L was achieved earlier than in patients diagnosed on clinical grounds. CONCLUSION: After diagnosis in screening, treatment can be initiated before the occurrence of severe metabolic decompensation. However, a favourable effect can only be achieved with immediate transfer of the neonate to a metabolic centre for adequate treatment in case of a positive screening result.

Hematological abnormalities and cholestatic liver disease in two patients with mevalonate kinase deficiency.

We describe two patients with mevalonate kinase deficiency and prominent hematologic abnormalities and cholestatic liver disease. Patient R.B. was not anemic at birth, but developed petechiae and cutaneous extramedullary hematopoiesis, hepatosplenomegaly, leukocytosis, and recurrent febrile events without positive bacterial or viral cultures. Patient N.M. manifested minor anomalies, hepatosplenomegaly, anemia, thrombocytopenia, recurrent febrile crises, and facial rashes. Mevalonic aciduria was found by urinary organic acid analysis, and mevalonate kinase deficiency was documented in both. The clinical spectrum of normocytic hypoplastic anemia, leukocytosis, thrombocytopenia, and abnormal blood cell forms led to diagnoses of congenital infection, myelodysplastic syndromes, or chronic leukemia in these patients before recognition of mevalonate kinase deficiency. Mevalonate kinase deficiency represents a single-gene abnormality that may be associated with significant hematologic findings. Recognition of the variability of this disorder with some patients manifesting only mild neurologic findings, yet significant hepatosplenomegaly, normocytic anemia, thrombocytopenia, and leukocytosis is important for all specialists who need to be aware of this organic aciduria.

Comparison of four different phenylalanine determination methods.

The ISOLAB NCS phenylalanine determination kit has not been widely applied for neonatal screening and patient follow up in Europe until now. This method, based on fluorescence enhancement of a phenylalanine-ninhydrin reaction product by the dipeptide L-leucyl-L-alanine, was compared with three other procedures: (1) The Quantase kit (Shield Diagnostics) for enzymatic determination of phenylalanine, (2) the standard amino acid analysis by means of ion exchange chromatography, and (3) the Guthrie Test as a bacterial inhibition assay (BIA). Only authentic samples from PKU patients were evaluated: once with the NCS kit and at least once with one of the three other methods. There was good agreement between the results obtained by the NCS kit using dried blood specimens and either of the other three methods, as well as between the NCS kit using plasma samples and the Quantase kit and ion exchange chromatography. Plasma sample measurement by NCS proved advantageous because of the option of measuring each microtiter plate twice by resetting the calibrators, i.e. special standards for plasma samples could be used on the same plate. We conclude that this method should prove time saving and cost effective when both neonatal screening and patient follow up are carried out in the same laboratory.

How different constituents of human plasma and low density lipoprotein determine plasma oxidizability by copper.

Lipoprotein oxidation induced in vitro in whole plasma is expected to represent a more relevant model of the lipoprotein oxidation in the arterial wall than the in vitro oxidation of single isolated lipoproteins, e.g. low density lipoprotein (LDL). However, it remains unclear, how lipoprotein oxidation occurring in plasma is related to chemical composition and properties of the latter as well as to those of individual plasma lipoproteins. The present study was undertaken to characterize, how different constituents of human plasma contribute to the oxidizability of plasma lipoproteins oxidized directly in plasma samples. Oxidizability of plasma lipoproteins was assessed as oxidizability of whole heparin plasma and was measured spectrophotometrically as an increase in absorbance at 234 nm. To relate plasma oxidizability to its chemical composition and properties, plasma hydrophilic and lipophilic antioxidants, fatty acids, total lipids and TRAP were measured. To relate plasma oxidizability to the properties of individual lipoproteins, chemical composition and oxidizability were evaluated for LDL. We found that the oxidation kinetics of heparin plasma (diluted 150-fold and oxidized by 50 microM Cu2+) was characterized by three consecutive phases similar to the lag-, propagation and decomposition phases of LDL oxidation. Plasma oxidizability measured as different characteristics of these phases correlated negatively with plasma initial SH-groups, albumin, ascorbate, bilirubin, alpha-tocopherol, ubiquinol-10, free cholesterol, monounsaturated and saturated fatty acid content and positively with plasma initial total cholesterol, cholesterol ester and polyunsaturated fatty acid content. Plasma oxidizability measured as a rate of conjugated diene accumulation after different periods of oxidation correlated negatively with plasma initial albumin, urate, alpha-carotene and beta-carotene content. A positive correlation between oxidizabilities of whole plasma and LDL (isolated from the same plasma samples and oxidized by 14 mol Cu2+/mol LDL) was found. These data show that the oxidizability of plasma samples is critically determined by their chemical composition. They also suggest that the plasma oxidizability measured as an increase in absorbance at 234 nm may be used as a practical measure of the oxidizability of plasma lipoproteins.

Regional blood flow to the lymph node during the immune response.

In 62 New Zealand white rabbits the regional blood flow to the popliteal lymph node was determined using the microsphere distribution and the Rb86C1 indicator methods. In 20 animals local immune response was induced with typhoid O antigen and in 7 with bovine serum albumin. The regional blood flow of the popliteal lymph node was 0.57 ml/gm/min. During the immune response the blood flow and weight changes were strictly proportional. The lymph node has the capacity to maintain its blood flow, even following significant enlargement.

Cellular radiation effects and hyperthermia cell cycle kinetics of radiation sensitive mutants of Saccharomyces cerevisiae after X-irradiation and hyperthermia.

Radiosensitive mutants rad2, rad9, and rad51 of Saccharomyces cerevisiae were X-irradiated with 120 Gy or 60 Gy, heated at 50 degrees C for 30 min or treated with a combination of both and incubated in nutrient medium at 30 degrees C. Cell number, percentage of budding cells, and cell cycle progression were determined in 45-min intervals. Cell cycle kinetics were investigated by flow cytofluorometry. Hyperthermia leads mainly to a lengthening of G1, whereas X-rays arrest cells of the rad2 and rad9 mutant in G2 and the rad51--mutant additionaly in a state with DNA contents above G2. Cell division delay is influenced by oxygen in all strains but to a lesser extent in the rad2 mutant. The effect of the combined treatment appears to be merely additive in the rad2 and rad9 mutant while the rad51 mutant is sensitized to X-irradiation by hyperthermia. No selective action of hyperthermia on hypoxic cells was found.

Cell cycle parameters in radiation sensitive strains of Saccharomyces cerevisiae.

Cell cycle parameters in different radiation-sensitive strains of diploid yeast were determined by flow cytofluorometry. The cell generation time was increased in homozygous rad2 and rad51 mutants but was not significantly different from the wild type in rad9 and rad6 mutants. All mutants had a longer G1-phase than the wild type. A lengthened S-phase was found in rad2 cells. Rad51 mutants displayed a considerably longer duration of G2.

Purification and properties of an alpha-methylacyl-CoA racemase from rat liver.

The (R)- and (S)-isomers of alpha-methyl-branched fatty acids were shown to be rapidly interconverted as coenzyme A thioesters, by an alpha-methylacyl-CoA racemase. The enzyme was purified some 5600-fold from rat liver, to apparent homogeneity. It is a monomer of 45 kDa with an isolectric point of pH 6.1 and is optimally active between pH 6 and pH 7. It acts only on coenzyme A thioesters, not on free fatty acids, and accepts as substrates a wide range of alpha-methylacyl-CoAs, including pristanoyl-CoA and trihydroxycoprostanoyl-CoA (an intermediate in bile acid synthesis), but neither 3-methyl-branched nor linear-chain acyl-CoAs. The racemase catalyzes a rapid exchange of the H atom in the alpha-position of the fatty acid against a proton from water, indicating that the mechanism involves abstraction of a proton. Based on this observation, a very sensitive and convenient radiometric assay, with 2-methyl[2-(3)H]acyl-CoAs as substrates, was developed. The enzyme was inactivated by micromolar concentrations of Hg2+ and to a lesser extent by Cu2+ but not by iodoacetamide and only slightly by N-ethylmaleimide and thimerosal.

Purification and characterization of an alpha-methylacyl-CoA racemase from human liver.

A specific racemase for alpha-methylacyl-CoAs, which had previously been studied in rat liver [W. Schmitz, R. Fingerhut, E. Conzelmann (1994) Eur. J. Biochem. 222, 313-323], has now been demonstrated also in human tissues. The human enzyme cross-reacts with a polyclonal antiserum against the rat liver racemase. The racemase was purified from human liver some 3600-fold. It is a monomer of 47 kDa with an isolectric point of pH 6.1 and is optimally active between pH 7-8. It acts only on coenzyme A thioesters, not on free fatty acids, and accepts as substrates a wide range of alpha-methylacyl-CoAs, including pristanoyl-CoA and trihydroxycoprostanoyl-CoA (an intermediate in bile acid synthesis), but neither 3-methyl-branched nor linear-chain acyl-CoAs. A clear difference in subcellular localization of the enzyme was found between humans and rats: the rat enzyme co-distributed exclusively with mitochondrial marker enzymes whereas in human cells, only 10-30% of the activity was found in mitochondria, the bulk activity was located in peroxisomes. Cells from patients with general deficiency of peroxisome assembly (Zellweger syndrome) showed strongly reduced racemase activity, with only the mitochondrial share being present while the peroxisomal form was absent.

Cellular radiation effects and hyperthermia: cytokinetic investigations with stationary phase yeast cells.

Wild type diploid yeast, Saccharomyces cerevisiae strain 211, was subjected to 250 kV X-rays or 50 degrees C heat treatment for 30 min or to a combination of both. X-ray exposure took place either in air or in nitrogen. Cell number, percentage of budding cells and cell cycle progression was followed for up to 12 h post irradiation. The distribution of cell cycle stages was determined by flow cytofluorometry. All treatments cause a retardation of cell division rate. Hyperthermia leads mainly to a lengthening of G1, whereas X-rays arrest the cells reversibly in G2. The effect of the combined treatment appears to be merely additive. No. selective action of hyperthermia on hypoxic cells was found.

Degradation of gangliosides by the lysosomal sialidase requires an activator protein.

Lysosomal sialidase, which was formerly believed to degrade only water-soluble substrates but not glycolipids, cleaves ganglioside substrates II3NeuNAc-LacCer, IV3NeuNAc, II3NeuNAc-GgOse4Cer, IV3 NeuNAc, II3(NeuNAc)2-GgOse4Cer when these are dispersed either with an appropriate detergent (taurodeoxycholate) or with the sulfatide activator protein, a physiologic lipid solubilizer required for the lysosomal hydrolysis of other glycolipids by water-soluble hydrolases. In the presence of the activator protein, time and protein dependence were linear within wide limits, while the detergent rapidly inactivated the enzyme. The disialo group of the b-series gangliosides was only poorly attacked by the enzyme when the lipids were dispersed with the activator protein, whereas in the presence of the detergent, they were hydrolyzed as fast as terminal sialic acid residues. With the appropriate assay method, significant ganglioside sialidase activity could be demonstrated in the secondary lysosome fraction of normal skin fibroblasts but not of sialidosis fibroblasts. Our results support the notion that there is only one lysosomal sialidase, which degrades both the water-soluble and the membrane-bound sialyl glycoconjugates.

Secondary respiratory chain defect in a boy with long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency: possible diagnostic pitfalls.

UNLABELLED: We report on a boy who suffered from microcephaly, growth retardation, cardiomyopathy and hepatic dysfunction. When he had his first febrile infection at the age of 3 months he showed metabolic decompensation. Laboratory parameters and clinical features were compatible with a beta-oxidation defect or a respiratory chain disorder. Measurement of beta-oxidation enzymes showed long-chain 3-hydroxyacyl CoA dehydrogenase (LCHAD) deficiency; determination of respiratory chain complex activities revealed complete absence of complex I, II, III and IV activities in skeletal muscle and reduced activities of complexes II and IV in cultured fibroblasts, with secondary dysregulation of ATP synthase. The patient was found to be homozygous for the MTP:G1528 C mutation (LCHAD-deficiency). CONCLUSION: This patient had LCHAD deficiency as his primary metabolic disorder, leading to secondary inhibition of respiratory chain enzymes by 'toxic' metabolites.

Impaired degradation of phytanic acid in cells from patients with mitochondriopathies: evidence for the involvement of ETF and the respiratory chain in phytanic acid alpha-oxidation.

Phytanic acid alpha-oxidation was studied in cultures of skin fibroblasts and myoblasts from patients with various defects of the respiratory chain in order to obtain information on the subcellular site and the mechanism of this pathway. In fibroblasts from patients with complex IV (cytochrome c oxidase) deficiency or glutaricaciduria type II, phytanic acid alpha-oxidation was reduced to 14% of normal, whereas in myoblasts from patients with complex I (NADH-Q reductase) deficiency, it was normal. Apparently, at least one step of phytanic acid alpha-oxidation occurs in mitochondria and in this process electrons are transferred to the respiratory chain via the electron-transfer flavoprotein (ETF).

Homocysteic and homocysteine sulphinic acid exhibit excitotoxicity in organotypic cultures from rat brain.

UNLABELLED: The excitotoxic action of homocysteine and related sulphur-containing metabolites was investigated in organotpyic cultures derived from rat brain cortex and hippocampus by inhibition experiments using antagonists selective for different glutamate receptor subtypes. In addition the direct interaction of these metabolites with glutamate receptors expressed in frog oocytes was tested by conventional two electrode voltage clamp techniques. CONCLUSION: Neurodegeneration and epilepsy observed in homocystinuria may be mediated by L-homocysteic and L-homocysteine sulphinic acid. Both metabolites exhibit excitotoxic potency by interaction with different glutamate receptor subtypes.

[Model project for updating neonatal screening in Bavaria: concept and initial results]. / Modellprojekt zur Neuordnung des Neugeborenen-Screenings in Bayern: Konzeption und erste Ergebnisse.

The newborn screening programme in Bavaria was confronted with several problems. Number of disorders and process quality no longer complied with screening guidelines. Mixed financing, distributed between the state (PKU, galactosaemia) and health insurances (hypothyroidism) had promoted an increasing dissipation of the system. Notified participation rates had dropped to < 80%. Increasing need for a second screening due to early discharge was an additional challenge. To overcome these problems, and considering the availability of improved screening methodology (tandem mass spectrometry) the programme was reorganised. The project, which started on Jan 1, 1999, is based on a cooperation model between laboratory (logistics, analysis), universities (treatment, scientific evaluation), and public health services (coordination, tracking). Time of blood sampling was predated to the third day of life. Screening was extended to biotinidase deficiency, congenital adrenal hyperplasia (CAH) and by introduction of tandem mass spectrometry for screening of many other disorders (besides PKU). Insurances now finance complete laboratory analysis which was transferred to the private sector. To enable all newborn to participate, the names of screened children are matched against birth lists by public health services on a regional basis. Recalls and conspicuous results are consistently followed up until disorders are either excluded or confirmed. Two clinical hotlines were established in the children's hospitals of the universities in Munich (Southern Bavaria) and in Erlangen (Northern Bavaria). Written consent is required for participation in the programme. Participation in the new programme could be continually increased; coverage is > 95% since April. In several cases screening was made up for not tested children by contacting their parents. Omitted screening was mostly due to misunderstandings regarding testing responsibility or lost samples. Altogether 52 cases of disorder were found in the 87,000 newborn screened until August 1999. Hence, the detection rate of children affected by inborn errors of metabolism was about twice as high than before changes. Among the newly screened diseases CAH was detected most often (11 cases). In 22 cases diagnosis was based on the use of tandem mass spectrometry. Among these (besides PKU, 9 cases) MCAD deficiency (6 cases) was detected most frequently. Whereas recall rates of most disorders were < 0.1%, screening for CAH still revealed a high recall rate, particularly in premature births. Second screening due to early discharge (< 48 h) was required in 1.3%. About 20% of pending recalls required contacting birth hospitals, doctors, midwives or parents. So far all affected children could be brought to treatment in time.