25 Years of Newborn Screening in Uruguay

Abstract In the 1960s Guthrie conceived the idea of preventing congenital disease using dried blood spot samples on filter paper to detect them through biochemical tests and then be able to treat environmental factors in time to avoid the devastating effect of the diseases. Uruguay started in 1994 with the detection of congenital hypothyroidism in umbilical cord blood. In 2007 it was extended to Phenylketonuria and Congenital Adrenal Hyperplasia, starting with dried blood spot sample. In 2008, with the incorporation of Mass Spectrometry, a pilot program was started for the detection of aminoacidopathies, beta-oxidation defects and organic acidemias disorders. In the following years, the program expanded to more diseases, reaching a total of 25 disorders that could be detected, 5 of them are investigated on a mandatory basis and others in pilot program. During the 25-year of experience, 974277 umbilical cord blood samples were analyzed and since 2007: 532684 dried blood spot samples. 613 true positive congenital disorders were identified. The coverage has been greater than 98% and the repetition rate for insufficient samples less than 1.9%.

Impact of a timed-release follicle-stimulating hormone treatment from one to three months of age on endocrine and testicular development of prepubertal bulls.

In prepubertal bulls, FSH facilitates testis maturation and a transient proliferation of Sertoli cells. Two experiments examined the effects of exogenous FSH on hormone secretion and testis development in Angus bulls. Exogenous FSH treatment consisted of an intramuscular injection (i.m.) of 30 mg FSH (Folltropin-V) in a 2% hyaluronic acid solution (FSH-HA). In Exp. 1, bulls (50 ± 6.5 d of age) received either FSH-HA ( = 5) or saline (control; = 5) on d 50 and 53.5. Blood samples were collected via jugular venipuncture to assess FSH concentrations every 6 h for 24 h after treatment and every 12 h until 84 h. After each treatment, peripheral FSH concentrations were greater ( < 0.05) in the FSH-HA-treated bulls than in the control bulls 6 h after treatment and tended to be greater ( ≤ 0.08) 12 h after treatment. The FSH concentration from 18 to 84 h after treatment did not differ between treatments. In Exp. 2, bulls were treated with FSH-HA ( = 11) or saline (control; = 11) every 3.5 d from 35 to 91 ± 2 d of age. Blood samples were collected before each treatment to quantify FSH, testosterone, and activin A concentrations. Scrotal circumference (SC) and BW were measured weekly. Bulls were castrated at 93 ± 2 d of age. Seminiferous tubule diameter, testis composition, and the number of Sertoli cells per tubule cross section (GATA-4 positive staining) were determined from fixed and stained histological sections. Follicle-stimulating hormone concentrations within the FSH-HA-treated bulls increased ( < 0.05) on d 70 from prior sampling and remained elevated. The FSH concentration did not differ between treatments from 35 to 66.5 d of age but were greater ( < 0.05) in the FSH-HA-treated bulls than in the control bulls from 70 to 91 d of age. Serum concentration of activin A on d 35, 70, and 91 did not differ between treatments. The FSH-HA and control bulls did not differ ( > 0.1) in BW, SC, testis weight, testis volume, percent of parenchyma composed of tubules, tubule diameter, and concentration of testosterone. The number of Sertoli cells per tubule cross section was greater in the FSH-HA-treated bulls than in the control bulls (33.35 ± 0.9 vs. 28.27 ± 0.9 cells; ˂ 0.05). In summary, the FSH-HA treatment from 35 to 91 d of age resulted in increased endogenous FSH from 70 to 91 d and increased numbers of Sertoli cells at 93 d of age. Exogenous FSH altered endocrine mechanisms regulating endogenous FSH secretion and augmented Sertoli cell proliferation in young bulls, but this effect was apparently not caused by increased activin A concentration in the FSH-HA-treated bulls.

Investigation of mechanisms involved in regulation of progesterone catabolism using an overfed versus underfed ewe-lamb model.

Alterations in progesterone (P4) catabolism due to high feed intake underlie some effects of nutrition on reproduction. Based on previous research, we hypothesized that high feed intake could potentially increase P4 catabolism, likely due to increased liver blood flow. However, there could also be an opposing action due to increased circulating insulin, which has been shown to inhibit hepatic expression of key enzymes involved in P4 catabolism. To test which effect would have the greatest impact on circulating P4 during a 1- and 2 -mo time frame, we used a noncyclic ewe model. The plane of nutrition was controlled, and effects on circulating insulin, P4 catabolism in response to exogenous P4, and steady state mRNA for key hepatic enzymes were evaluated. Twenty-four F Dorper × Santa Inês ewe lambs (5 mo old and approximately 25 kg BW) were used. After 14 d of adaptation, ewes were randomized into 2 groups: ad libitum fed (Ad), with intake of 3.8% DM/kg BW, or restricted feed intake (R), with 2% DM/kg BW, for 8 wk. At wk 4 and 8, ewes received an intravaginal P4 implant to evaluate P4 catabolism. As designed, Ad ewes had greater daily feed intake than R ewes (means of 1.8 [SE 0.03] and 0.6 kg/ewe [SE 0.01]; < 0.001) and greater weekly gain in BW (means of 1.7 [SE 0.12] vs. -0.1 kg/ewe [SE 0.03]; < 0.001). Mean circulating insulin of samples collected from -0.5 to 7 h after the start of feeding was over 5-fold greater in Ad ewes than in R ewes (least squares means of 8.2 [SE 0.93] vs. 1.5 µIU/mL [SE 0.16], respectively, at wk 4 and 12.0 [SE 1.02] vs. 2.2 µIU/mL [SE 0.18], respectively, at wk 8; < 0.001). Although both groups received the same P4 treatment, mean circulating P4 of samples collected from -0.5 to 7 h after feeding was much lower in Ad ewes than in R ewes (least squares means of 3.2 [SE 0.32] vs. 5.5 ng/mL [SE 0.32], respectively, at wk 4 and 2.8 [SE 0.28] vs. 5.2 ng/mL [SE 0.28], respectively, at wk 8; < 0.001) indicating much greater P4 catabolism in ewes with high feed intake. Unexpectedly, there was no effect of diet on hepatic mRNA concentrations for , , , or at wk 4 or 8 in spite of dramatically elevated insulin. Therefore, high energy/feed intake primarily increased P4 catabolism with no evidence for offsetting effects due to insulin-induced changes in hepatic P4 metabolizing enzymes.

p.L18P: a novel IDUA mutation that causes a distinct attenuated phenotype in mucopolysaccharidosis type I patients.

Mucopolysaccharidosis type I is a rare autosomal recessive disorder caused by deficiency of α-l-iduronidase (IDUA) which leads to a wide spectrum of clinical severity. Here, we describe the case of four male patients who present the previously undescribed p.L18P mutation. Patient 1 (p.L18P/p.L18P) presents, despite multiple joint contractures, an attenuated phenotype. Patient 2 (p.L18P/p.W402X) was diagnosed at 4 years of age with bone dysplasia, coarse facies, limited mobility, claw hands and underwent bilateral carpal tunnel surgery at 6 years of age. Patients 3 and 4 (both p.L18P/p.L18P) are brothers. Patient 3 was diagnosed at 4 years of age, when presented claw hands, lower limb and shoulder pain, restricted articular movement and bilateral carpal tunnel syndrome. Patient 4 was diagnosed at 17 months of age when presented lower limb pain at night, respiratory allergy and repeated upper airways infections. Bioinformatics analysis indicates that p.L18P mutation reduces the signal peptide to 25 amino acids and alters its secondary structure. In conclusion, we report a new IDUA variant that alters the structure of the signal peptide, which likely impairs transport to lysosomes. Moreover, it leads to a distinct attenuated phenotype with mainly bone and cartilage symptoms, without visceromegalies, heart disease, or cognitive impairment.

Effect of interval from induction of puberty to initiation of a timed AI protocol on pregnancy rate in Nellore heifers.

Prepubertal Bos indicus heifers (n = 774) were submitted to an E2/P4-based timed artificial insemination (TAI) protocol at three different intervals after induction of their pubertal ovulation by insertion of an intravaginal progesterone (P4) device for 12 days. Heifers were randomly assigned to start the TAI protocol at 10 (group 10; n = 253), 12 (group 12; n = 265), or 14 (group 14; n = 256) days after the P4 device was removed. The TAI protocol consisted of the following: insertion of intravaginal device containing P4 (Controlled internal drug release [CIDR]; previously used twice for 9 days each) + estradiol benzoate (2 mg) on Day 0, CIDR withdrawal + estradiol cypionate (0.5 mg) and PGF2α (12.5 mg) on Day 9, and TAI on Day 11. A subgroup of heifers (n = 472) was evaluated by ultrasound on Days 9 and 11 to evaluate the ovaries and to determine P4 concentrations on Day 9. On Day 9, more (P < 0.05) CLs were present, and follicular diameter was smaller (P < 0.05) for group 10 than for groups 12 and 14 (38.4%, 29.3%, and 23.3% with CL and 9.4 ± 0.1, 9.9 ± 0.1, and 9.8 ± 0.1 mm diameter, respectively), but P4 concentrations did not differ (P > 0.1) between treatments (2.4 ± 0.06 ng/mL). Follicular diameter at TAI (11.08 ± 0.09 mm) and ovulation rate (88.4%) did not differ between treatments (P > 0.1). However, conception and pregnancy rates for all heifers were greater (P < 0.05) in group 12 (50.4% and 45.5%, respectively) than in group 10 (38.2% and 33.7%, respectively), with group 14 intermediate to other treatments (45.6% and 40.6%, respectively). The final pregnancy rate did not differ between treatments (80.9%). In conclusion, a 12-day interval from the end of the puberty induction protocol to the start of the TAI protocol resulted in greater conception and pregnancy rates in prepubertal Nellore heifers.

Progesterone-based strategies to induce ovulation in prepubertal Nellore heifers.

Four experiments were conducted to evaluate hormonal strategies to induce ovulation in Nellore heifers. In experiment 1, heifers (N = 1039) received a controlled internal drug release (CIDR) of fourth use (CIDR-4) on Day -12 or no CIDR (CIDR-0). The CIDR was removed on Day 0 in the CIDR-4 treatment, and estrus detection and AI were performed from Days 1 to 7. On Day 8, heifers not detected in estrus were evaluated for CL presence and received the same treatment again, followed by estrus detection and AI from Days 21 to 27. All heifers in experiments 2 (N = 896), 3 (N = 839), and 4 (N = 948) received the CIDR-4 treatment on Day -12. In experiment 2, heifers were randomly assigned to a control group (no additional treatment) or to receive equine chorionic gonadotropin (eCG; 200 IU eCG im) on Day 0. In experiment 3, heifers received the same treatments as in experiment 2, or a treatment that included eCG and estradiol cypionate (ECP) (eCG+ECP; 200 IU im eCG plus 0.5 mg ECP im) on Day 0. In experiment 4, heifers received the treatments described in experiment 3 or only ECP (0.5 mg) on Day 0. In experiments 2 and 3, estrus detection and AI was performed from Days 1 to 7 and on Day 8, heifers not detected in estrus were evaluated for CL presence. In experiment 4, heifers were evaluated for presence of a CL between Days 10 and 14. In experiment 1 heifers treated with CIDR-4 had greater estrus detection, ovulation induction, and pregnancy rates than in the CIDR-0 group. In experiment 2, heifers treated with eCG had greater estrus detection, ovulation induction, and pregnancy rates in 7 days than heifers in the control group. In experiment 3, heifers treated with eCG+ECP had greater estrus detection, ovulation induction, and pregnancy rates than the control and eCG treatments. In experiment 4, ovulation induction was greater for heifers treated with eCG and eCG+ECP relative to control, but did not differ from the ECP treatment. In conclusion, the use of a CIDR of fourth use for 12 days and the addition of eCG and/or ECP at CIDR removal efficiently induced ovulation and increased pregnancy rates in prepubertal Nellore heifers.

Sistema nacional de pesquisa neonatal en Uruguay / National system of newborn screening in Uruguay

En la década del 60 se gestó la idea de detectar enfermedades prevenibles, modificando los factores ambientales para atenuar el curso natural de la enfermedad. Muchos países en América en la década del 90 comenzaron sus programas, Uruguay entre ellos. Hoy el Sistema Nacional de Pesquisa Neonatal en este país es una realidad. Se detectan de forma obligatoria 4 enfermedades y defectos de la audición. Además está en marcha un programa piloto por Espectrometría de Masa para 20 enfermedades: aminoacidopatías, defectos de la beta oxidación y acidemias orgánicas. Se presentan los algoritmos utilizados y los resultados obtenidos en nuestro país.

In the 60’s, it was conceived the idea of detecting preventable diseases, modifying environmental factors to attenuate the disease natural course. In Latin America, many countries started their programs in the 90’s and Uruguay was one of them. Nowadays, the National Newborn Screening Program is a reality in this country. The detection of four diseases is mandatory as well as hearing defects. There is also an ongoing pilot program using mass spectrometry to detect 20 diseases: aminoacidopathies, beta-oxidation defects and organic acidemias. This work presents the algorithms used and the results obtained in our country.

Splenic marginal zone lymphoma--a clinicopathological study in a series of 16 patients.

Splenic marginal zone lymphoma (SMZL), characterized in the WHO classification of lymphoid tumors, is a rare disorder comprising less than 1% of lymphoid neoplasms; only a few series concerning this entity have been published. Although this type of lymphoma is well defined histologically, its histogenesis remains obscure. Moreover, specific biological markers are still lacking and immunophenotype profile is not specific. These and other reasons, such as the existence of cytogenetic subtypes, have led to some authors to suspect that SMZL constitutes a heterogeneous entity. We have analyzed a series of sixteen SMZL cases from four hospitals in our community, from a clinical, biological and pathological point of view. When compared with those reported in the literature, our findings show three main differences: our patients less frequently showed an intrasinusoidal bone marrow infiltration pattern; the presence of a serum monoclonal component was rarely seen; and CD5-positive SMZL cases appear to be more common than previously thought.

Refractory anemia with ringed sideroblasts associated with thrombocytosis: comparative analysis of marked with non-marked thrombocytosis, and relationship with JAK2 V617F mutational status.

The World Health Organization (WHO) classification of tumors of hematopoietic and lymphoid tissues (2001) defined a provisional entity named refractory anemia with ringed sideroblasts associated to marked thrombocytosis (RARS-MT). Diagnosis of RARS-MT requires more than 15% of ringed sideroblasts in bone marrow aspirate and the existence of a thrombocytosis in blood, with a platelet count above 600 x 10(9)/L. Nevertheless, controversy exists regarding this platelet count "cut-off" value and, when RARS-MT was defined, the JAK2 mutation and its importance in the study of myeloproliferative disorders was unknown. We present the results of a Spanish retrospective multicentric study, which includes 76 cases of RARS with associated thrombocytosis (platelet count above 400 x 10(9)/L) at diagnosis (RARS-T), 36 of them with a platelet count above 600 x 10(9)/L. Our aim was to analyze their clinical, analytical and morphological characteristics, and to establish correlations with the JAK2 mutational status.

Monoclonal antibody fluorescence for routine lymphocyte subpopulation analysis with the Abbott CELL-DYN Sapphire haematology analyser.

Using previously described procedures, this study quantified T-cell, T-cell subset, B-cell and NK-cell populations with the CD-Sapphire haematology analyser in a series of patients with mild to moderate lymphocytosis. Lymphocyte counts ranged from 6.0 to 14.9 x 10(9)/l, with 86/97 being <10.0 x 10(9)/l. Immunophenotyping (CD3/CD19/HLA-DR, CD4/CD8 and CD16/CD56 combinations) was performed using EDTA-anticoagulated blood, automated CD-Sapphire analysis and subsequent software processing. Of 35 samples from younger (<12 years) patients, 22 (63%) had nonspecific lymphocyte changes, 4 (11%) showed specific increases in nonreactive T-Helper or T-Suppressor cells, and five showed a reactive T-cell lymphocytosis. The remaining four were classified as 'Transient/Persistent NK-associated (NKa) Expansion' (n = 3) and specific B-cell lymphocytosis (n = 1). For older patients (n = 59), 15 (25%) had an increase (>1.5 x 10(9)/l) in B-cells, and seven investigated for surface immunoglobulin expression were all found to be clonal. The remaining samples were categorized as 'Transient/Persistent NK-associated (NKa) Expansion' (13/59), Reactive Lymphocytosis (5/59), 'Reactive Lymphocytosis or Transient/Persistent NKa Expansion' (8/59), specific T-Helper cell (n = 8) or T-Suppressor cell (n = 3) lymphocytosis, and 'Lymphocytosis of Undetermined Significance' (n = 7). This study has demonstrated the feasibility of applying limited immunophenotyping protocols to the investigation of patients with abnormal lymphocyte counts in routine haematology. By using commercially purchased liquid monoclonal reagents to determine lymphocyte subpopulation profiles, haematology laboratories can provide more definitive information of potential clinical importance.

Analysis and enumeration of T cells, B cells and NK cells using the monoclonal antibody fluorescence capability of a routine haematology analyser (Cell-Dyn CD4000).

This communication details a method for the quantitative and qualitative analysis of blood T-, B- and NK-cell populations using the Abbott Cell-Dyn CD4000 haematology analyser. A series of 66 ethylenediaminetetraacetic acid (EDTA)-anticoagulated samples with lymphocyte counts between 0.2 and 33.3 x 10(9)/l were selected and analysed with CD3, CD19, Ia and CD56 monoclonal reagents. The flow cytometry reference method utilized a lymphocyte gate defined by optical scatter, with phenotypic analyses referencing to this gate and the absolute lymphocyte count. The CD4000 method analysed all leucocyte events, set primary gates for specific immunophenotypic fractions, and then determined population counts by reference to the white blood cell (WBC) count. Comparisons of CD3+ T-cell and CD19+ B-cell numbers showed high coefficients of correlation (R(2) > 0.95) and agreement (y = 1.01x) between the CD4000 and flow cytometry reference methods. Lower coefficients of correlation were obtained for CD3-CD56+ (R(2) = 0.52) and CD3+CD56+ (R(2) = 0.83) components. No major discrepancies were observed, and the CD4000 procedures additionally provided qualitative insights into the possibility of T-cell activation. The potential to undertake immediate analysis of EDTA-anticoagulated blood samples to determine the nature of abnormal lymphocyte morphology or numbers represents a considerable advance in the capability of haematology laboratories.

Experiencia metodológica en pesquisa neonatal de hiperfenilalaninemias. Instituto de Genética Médica del Hospital Italiano / Newborn screening for hyperphenylalanine. Institute of Medical genetics of Hospital Italiano

La detección neonatal de errores congénitos del metabolismo mediante pesquisa neonatal consiste en la búsqueda sistemática en el recién nacido de aquellas afecciones para las que existe un tratamiento probadamente efectivo ante su instalación precoz. En el Instituto de Genética Médica del Hospital Italiano se realiza, desde noviembre de 1993, la cuantificación de fenilalanina sanguínea en el recién nacido en sangre seca sobre papel de filtro mediante método fluorométrico como test de pesquisa para hiperfenilalaninemias. Los reactivos son preparados en el laboratorio y la exactitud del método es controlada a través de un programa de control de calidad externo por método de referencia. En el presente trabajo se estimó el valor de un punto de corte en función del cual considerar un resultado como presuntamente positivo para nuestra población (n=190), obteniéndose un valor de 2,5 mg/dl de fenilalanina. Se evaluó el método fluorométrico utilizado. El análisis de regresión entre los resultados obtenidos por el método en uso y el de referencia mostró que existe asociación lineal entre estos resultados (n=93; r=0,94; y=0,87x + 0,519) y que aunque ambos métodos no son intercambiables, sí son equivalentes, lo cual otorga confianza al método en uso. Se examinó la estabilidad de la Phe en muestras de sangre recogidas sobre papel de filtro almacenadas a 4°C. El porcentaje del aminoácido recuperado después de 5 años de almacenamiento (83 por ciento a 100 por ciento) y el test estadístico aplicado mostraron que el aminoácido tiene buena estabilidad almacenando las muestras en esas condiciones.

Acute promyelocytic leukemia developing after radiotherapy for prostate cancer in a patient with chronic lymphocytic leukemia.

Chronic lymphocytic leukemia (CLL) is rarely associated with secondary acute myelogenous leukemia (AML) usually due to chemotherapy or radiotherapy. No cases of concomitant CLL and acute promyelocytic leukemia (APL) have been found in the literature. Nevertheless, up to 12% of therapy-related AML cases are classified as APL. Of these latter, most are related to topoisomerase treatment, with a few acute cases occurring after radiotherapy. We report here a patient with an untreated CLL who developed APL 2 years after radiotherapy for prostate carcinoma.

t(2;5) associated with a histiocytic-monocytic neoplasm.

We describe a patient with a neoplasm derived from the histiocytic-monocytic lineage associated with t(2;5) detected by FISH. The patient presented with bone marrow involvement, no organomegaly and subsequently developed a leukaemic picture. The clinical course was aggressive and the patient died four months from diagnosis. Cell morphology, immunophenotype (CD30-, EMA-, Lisozyme+, cy CD68+ and CD45+) and DNA analysis showing germ-line configuration of the Ig/TCR chain genes ruled out the diagnosis of anaplastic large cell lymphoma (ALCL). This unusual case ilustrates that t(2;5) is not exclusive for ALCL but may be found in a few cases of rare neoplasms derived from the histiocytic-monocytic cells.

Citoquímica de la fosfatasa ácida. Consideraciones metodológicas / The citochemistry of acid phosphatase. Methodological considerations

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Uruguay facio-cardio-musculo-skeletal syndrome: a novel X-linked recessive disorder.

We report on three male patients from a single family with a brachyturricephaly, "pugilistic" facial appearance, a muffled voice, cardiomyopathy, muscular hypertrophy, broad hands, wide feet with progressive pes cavus deformities, dislocation of toes, variable congenital hip dislocation, and scoliosis. Three other males in the family, now deceased from cardiac disease, appear to have had the same disorder. The mother of the propositus has milder signs of the syndrome. All affected males are related through the maternal line. These cases represent an apparently previously undescribed X-linked recessive syndrome.

p190 BCR-ABL rearrangement in chronic myeloid leukemia and acute lymphoblastic leukemia.

A minority of chronic myeloid leukemia (CML) cases have breakpoint in the minor cluster region (m-bcr) of the BCR-ABL fusion gene. We report a patient with Ph-positive acute lymphoblastic leukemia and m-bcr breakpoint at diagnosis. The patient was treated with chemotherapy followed by an autologous peripheral blood stem cell transplantation, achieving a clinical and hematological complete remission but with persistence of the Philadelphia chromosome. One year later, she developed leukocytosis with a blood picture consistent with CML. She was treated with hydroxyurea and interferon alpha with no response. This is the second case of m-bcr CML reported presenting with features of lymphoid blast crisis or acute lymphoblastic leukemia.

Signet-ring cells in a Waldenström's Macroglobulinaemia.

A case of signet-ring cell lymphoma affecting bone marrow is reported. The patient was diagnosed as Waldenström's Macroglobulinaemia on the basis of clinical and laboratory features including morphology, immunohistochemistry and gene rearrangement studies. Light microscopy examination showed cells contained large globular inclusions (signet-ring cells) that stained for kappa immunoglobulin light chain by immunohistochemistry. In addition, the neoplastic cells expressed the common leukocyte antigen CD45 and the B cell marker CD19. This to the best of our knowledge is the first report of a patient with Waldenström's Macroglobulinaemia with the presence of vacuolated signet ring- cells in the bone marrow. Differential diagnosis arises with non-haemopoietic tumours and this needs to be based on specific immunostaining. Tumours and this need to be based on specific immunostaining.