Population-based screening in children for early diagnosis and treatment of familial hypercholesterolemia: design of the VRONI study.

BACKGROUND: Heterozygous familial hypercholesterolemia (FH) represents the most frequent monogenic disorder with an estimated prevalence of 1:250 in the general population. Diagnosis during childhood enables early initiation of preventive measures, reducing the risk of severe consecutive atherosclerotic manifestations. Nevertheless, population-based screening programs for FH are scarce. METHODS: In the VRONI study, children aged 5-14 years in Bavaria are invited to participate in an FH screening program during regular pediatric visits. The screening is based on low-density lipoprotein cholesterol measurements from capillary blood. If exceeding 130 mg/dl (3.34 mmol/l), i.e. the expected 95th percentile in this age group, subsequent molecular genetic analysis for FH is performed. Children with FH pathogenic variants enter a registry and are treated by specialized pediatricians. Furthermore, qualified training centers offer FH-focused training courses to affected families. For first-degree relatives, reverse cascade screening is recommended to identify and treat affected family members. RESULTS: Implementation of VRONI required intensive prearrangements for addressing ethical, educational, data safety, legal and organizational aspects, which will be outlined in this article. Recruitment started in early 2021, within the first months, more than 380 pediatricians screened over 5200 children. Approximately 50 000 children are expected to be enrolled in the VRONI study until 2024. CONCLUSIONS: VRONI aims to test the feasibility of a population-based screening for FH in children in Bavaria, intending to set the stage for a nationwide FH screening infrastructure. Furthermore, we aim to validate genetic variants of unclear significance, detect novel causative mutations and contribute to polygenic risk indices (DRKS00022140; August 2020).

User-centered development of an mHealth app for cardiovascular prevention.

Background: Mobile health (mHealth) apps can be used for cardiovascular disease (CVD) prevention. User-centered design, evidence-based content and user testing can be applied to ensure a high level of usability and adequate app access. Objective: To develop and evaluate an mHealth app (HerzFit) for CVD prevention. Methods: HerzFit´s development included a user-centered design approach and guideline-based content creation based on the identified requirements of the target group. Beta testing and a preliminary usability evaluation of the HerzFit prototype were performed. For evaluation, German versions of the System Usability Scale (SUS) and the mHealth App Usability Questionnaire (GER-MAUQ) as well as free text feedback were applied. Results: User-centered design thinking led to the definition of four personas. Based on their requirements, HerzFit enables users to individually assess, monitor, and optimize their cardiovascular risk profile. Users are also provided with a variety of evidence-based information on CVD and their risk factors. The user interface and system design followed the identified functional requirements. Beta-testers provided feedback on the structure and functionality and rated the usability of HerzFit´s prototype as slightly above average both in SUS and GER-MAUQ rating. Participants positively noted the variety of functions and information presented in HerzFit, while negative feedback mostly concerned wearable synchronization. Conclusions: The present study demonstrates the user-centered development of a guideline-based mHealth app for CVD prevention. Beta-testing and a preliminary usability study were used to further improve the HerzFit app until its official release.

Guideline-Based Cardiovascular Risk Assessment Delivered by an mHealth App: Development Study.

BACKGROUND: Identifying high-risk individuals is crucial for preventing cardiovascular diseases (CVDs). Currently, risk assessment is mostly performed by physicians. Mobile health apps could help decouple the determination of risk from medical resources by allowing unrestricted self-assessment. The respective test results need to be interpretable for laypersons. OBJECTIVE: Together with a patient organization, we aimed to design a digital risk calculator that allows people to individually assess and optimize their CVD risk. The risk calculator was integrated into the mobile health app HerzFit, which provides the respective background information. METHODS: To cover a broad spectrum of individuals for both primary and secondary prevention, we integrated the respective scores (Framingham 10-year CVD, Systematic Coronary Risk Evaluation 2, Systematic Coronary Risk Evaluation 2 in Older Persons, and Secondary Manifestations Of Arterial Disease) into a single risk calculator that was recalibrated for the German population. In primary prevention, an individual's heart age is estimated, which gives the user an easy-to-understand metric for assessing cardiac health. For secondary prevention, the risk of recurrence was assessed. In addition, a comparison of expected to mean and optimal risk levels was determined. The risk calculator is available free of charge. Data safety is ensured by processing the data locally on the users' smartphones. RESULTS: Offering a risk calculator to the general population requires the use of multiple instruments, as each provides only a limited spectrum in terms of age and risk distribution. The integration of 4 internationally recommended scores allows risk calculation in individuals aged 30 to 90 years with and without CVD. Such integration requires recalibration and harmonization to provide consistent and plausible estimates. In the first 14 months after the launch, the HerzFit calculator was downloaded more than 96,000 times, indicating great demand. Public information campaigns proved effective in publicizing the risk calculator and contributed significantly to download numbers. CONCLUSIONS: The HerzFit calculator provides CVD risk assessment for the general population. The public demonstrated great demand for such a risk calculator as it was downloaded up to 10,000 times per month, depending on campaigns creating awareness for the instrument.

Population-based screening in children for early diagnosis and treatment of familial hypercholesterolemia: design of the VRONI study.

Familial hypercholesterolemia (FH) is the most frequent monogenic disorder (prevalence 1:250) in the general population. Early diagnosis during childhood enables pre-emptive treatment, thus reducing the risk of severe atherosclerotic manifestations later in life. Nonetheless, FH screening programs are scarce. VRONI offers all children aged 5-14 years in Bavaria a FH screening in the context of regular pediatric visits. LDL-cholesterol (LDL-C) is measured centrally, followed by genetic analysis for FH if exceeding the age-specific 95th percentile (130 mg/dl, 3.34 mmol/l). Children with FH pathogenic variants are treated by specialized pediatricians and offered a FH-focused training course by a qualified training center. Reverse cascade screening is recommended for all first-degree relatives. VRONI aims to prove the feasibility of a population-based FH screening in children and to lay the foundation for a nationwide screening program.

Finding the needle in the haystack: differentiating "identical" twins in paternity testing and forensics by ultra-deep next generation sequencing.

Monozygotic (MZ) twins are considered being genetically identical, therefore they cannot be differentiated using standard forensic DNA testing. Here we describe how identification of extremely rare mutations by ultra-deep next generation sequencing can solve such cases. We sequenced DNA from sperm samples of two twins and from a blood sample of the child of one twin. Bioinformatics analysis revealed five single nucleotide polymorphisms (SNPs) present in the twin father and the child, but not in the twin uncle. The SNPs were confirmed by classical Sanger sequencing. Our results give experimental evidence for the hypothesis that rare mutations will occur early after the human blastocyst has split into two, the origin of twins, and that such mutations will be carried on into somatic tissue and the germline. The method provides a solution to solve paternity and forensic cases involving monozygotic twins as alleged fathers or originators of DNA traces.

The photophysics of green fluorescent protein: influence of the key amino acids at positions 65, 203, and 222.

The three amino acids S65, T203, and E222 crucially determine the photophysical behavior of wild-type green fluorescent protein. We investigate the impact of four point mutations at these positions and their respective combinations on green fluorescent protein's photophysics using absorption spectroscopy, as well as steady-state and time-resolved fluorescence spectroscopy. Our results highlight the influence of the protein's hydrogen-bonding network on the equilibrium between the different chromophore states and on the efficiency of the excited-state proton transfer. The mutagenic approach allows us to separate different mechanisms responsible for fluorescence quenching, some of which were previously discussed theoretically. Our results will be useful for the development of new strategies for the generation of autofluorescent proteins with specific photophysical properties. One example presented here is a variant exhibiting uncommon blue fluorescence.

Mutagenic stabilization of the photocycle intermediate of green fluorescent protein (GFP).

The optical spectra of the Aequorea victoria green fluorescent protein (GFP) are governed by an equilibrium between three different chromophore states. Mutants that predominantly show either the protonated (A) or the deprotonated (B) form of the chromophore have previously been described. In contrast, the I form, which is formed by rapid excited-state deprotonation of the A form of the chromophore, has only been described as an obligatory photochemical intermediate. We report the design of a new GFP mutant with a stabilized I form. For this purpose, we introduced two isosteric point mutations, Thr203Val and Glu222Gln, that selectively raise the potential energy of both the A and the B form. Knowledge of the absorption spectrum of the I form at room temperature allows the detailed analysis of concentration dependent changes in bulk wild-type(wt)-GFP spectra, as well as the determination of the dimerization constant of GFP. This information expands the use of GFP to that of a spectral probe for protein concentration. We determined energy differences between the chromophore ground states in the monomer and the dimer and reconstructed part of the potential energy surface.

Picosecond time-resolved fluorescence from blue-emitting chromophore variants Y66F and Y66H of the green fluorescent protein.

The origin of the low steady-state fluorescence quantum yield of some blue-emitting variants of the green fluorescent protein (GFP) is investigated in single-site mutants in which the tyrosine residue at position 66 has been replaced by phenylalanine or by histidine. Time-resolved fluorescence measurements reveal excited-state lifetimes of 74 ps (Y66F) and 0.9 ns (Y66H) at room temperature that increase to values close to the radiative limit as the temperature is lowered. These short lifetimes are explained by temperature-dependent internal conversion. The pronounced difference between the room-temperature lifetimes of the two mutants suggests that hydrogen bonding of the distal aromatic ring plays a more important role than tight packing in the fixation of the chromophore.