Quality of care metrics for patients with inborn errors of metabolism.

Despite recent calls to action and a heavy emphasis on timeliness of care in guidelines for common inborn errors of metabolism, there is a dearth of specific measurable quality metrics for these conditions and little to no electronic decision support for their management. We have developed a novel set of process-oriented metrics based on the aforementioned guidelines that can be calculated from data already contained in most major EHRs, which we believe are responsive to the needs of the metabolism community.

Testing and extending strategies for identifying genetic disease-related encounters in pediatric patients.

PURPOSE: To better understand health care utilization and develop decision support tools, methods for identifying patients with suspected genetic diseases (GDs) are needed. Previous studies had identified inpatient-relevant International Classification of Diseases (ICD) codes that were possibly, probably, or definitely indicative of GDs. We assessed whether these codes identified GD-related inpatient, outpatient, and emergency department encounters among pediatric patients with suspected GDs from a previous study (the North Carolina Clinical Genomic Evaluation by Next-Generation Exome Sequencing [NCGENES] study). METHODS: Using the electronic medical records of 140 pediatric patients from the NCGENES study, we characterized the presence of ICD codes representing possible, probable, or definite GD-related diagnoses across encounter types. In addition, we examined codes from encounters for which initially no GD-related codes had been found and determined whether these codes were indicative of a GD. RESULTS: Among NCGENES patients with visits between 2014 and 2017, 92% of inpatient, 75% of emergency department, and 63% of outpatient encounters included ≥1 GD-related code. Encounters with highly specific (ie, definite) GD codes had fewer low-specificity GD codes than encounters with only low-specificity GD codes. We identified an additional 32 ICD-9 and 56 ICD-10 codes possibly indicative of a GD. CONCLUSION: Code-based strategies can be refined to assess health care utilization among pediatric patients and may contribute to a systematic approach to identify patients with suspected GDs.

Mucopolysaccharidosis Type I Diagnosed by Aortic and Mitral Valve Replacement.

A 32-year-old developmentally delayed man presenting with dyspnea was found to have severe aortic and mitral valve stenosis. After double valve replacement, unique histologic findings prompted a genetics evaluation, ultimately leading to the diagnosis of mucopolysaccharidosis type I, a rare lysosomal storage disorder with high rates of cardiac manifestations. (Level of Difficulty: Advanced.).

Diagnostic utility of exome sequencing in the evaluation of neuromuscular disorders.

OBJECTIVE: To evaluate the diagnostic yield and workflow of genome-scale sequencing in patients with neuromuscular disorders (NMDs). METHODS: We performed exome sequencing in 93 undiagnosed patients with various NMDs for whom a molecular diagnosis was not yet established. Variants on both targeted and broad diagnostic gene lists were identified. Prior diagnostic tests were extracted from the patient's medical record to evaluate the use of exome sequencing in the context of their prior diagnostic workup. RESULTS: The overall diagnostic yield of exome sequencing in our cohort was 12.9%, with one or more pathogenic or likely pathogenic variants identified in a causative gene associated with the patient's disorder. Targeted gene lists had the same diagnostic yield as a broad NMD gene list in patients with clear neuropathy or myopathy phenotypes, but evaluation of a broader set of disease genes was needed for patients with complex NMD phenotypes. Most patients with NMD had undergone prior testing, but only 10/16 (63%) of these procedures, such as muscle biopsy, were informative in pointing to a final molecular diagnosis. CONCLUSIONS: Genome-scale sequencing or analysis of a panel of relevant genes used early in the evaluation of patients with NMDs can provide or clarify a diagnosis and minimize invasive testing in many cases.

Effect of uncertainty in composition and weight measures in control of cheese yield and fat loss in large cheese factories.

Our objective was to develop a computer-based cheese yield, fat recovery, and composition control performance measurement system to provide quantitative performance records for a Cheddar and mozzarella cheese factory. The system can be used to track trends in performance of starter cultures and vats, as well as systematically calculate theoretical yield. Yield equations were built into the spreadsheet to evaluate cheese yield performance and fat losses in a cheese factory. Based on observations in commercial cheese factories, sensitivity analysis was done to demonstrate the sensitivity of cheese factory performance to analytical uncertainty of data used in the evaluation. Analytical uncertainty in the accuracy of milk weight and milk and cheese composition were identified as important factors that influence the ability to manage consistency of cheese quality and profitability. It was demonstrated that an uncertainty of ±0.1% milk fat or milk protein in the vat causes a range of theoretical Cheddar cheese yield from 10.05 to 10.37% and an uncertainty of yield efficiency of ±1.5%. This equates to ±1,451 kg (3,199 lb) of cheese per day in a factory processing 907,185 kg (2 million pounds) of milk per day. The same is true for uncertainty in cheese composition, where the effect of being 0.5% low on moisture or fat is about 484 kg (1,067 lb) of missed revenue opportunity from cheese for the day. Missing the moisture target causes other targets such as fat on a dry basis and salt in moisture to be missed. Similar impacts were demonstrated for mozzarella cheese. In analytical performance evaluations of commercial cheese quality assurance laboratories, we found that analytical uncertainty was typically a bias that was as large as 0.5% on fat and moisture. The effect of having a high bias of 0.5% moisture or fat will produce a missed opportunity of 484 kg of cheese per day for each component. More accurate rapid methods for determination of moisture, fat, and salt contents of cheese in large cheese factories will improve the accuracy of yield performance evaluation and control of consistency of cheese composition and quality.

Effect of ceramic membrane channel diameter on limiting retentate protein concentration during skim milk microfiltration.

Our objective was to determine the effect of retentate flow channel diameter (4 or 6mm) of nongraded permeability 100-nm pore size ceramic membranes operated in nonuniform transmembrane pressure mode on the limiting retentate protein concentration (LRPC) while microfiltering (MF) skim milk at a temperature of 50°C, a flux of 55 kg · m(-2) · h(-1), and an average cross-flow velocity of 7 m · s(-1). At the above conditions, the retentate true protein concentration was incrementally increased from 7 to 11.5%. When temperature, flux, and average cross-flow velocity were controlled, ceramic membrane retentate flow channel diameter did not affect the LRPC. This indicates that LRPC is not a function of the Reynolds number. Computational fluid dynamics data, which indicated that both membranes had similar radial velocity profiles within their retentate flow channels, supported this finding. Membranes with 6-mm flow channels can be operated at a lower pressure decrease from membrane inlet to membrane outlet (ΔP) or at a higher cross-flow velocity, depending on which is controlled, than membranes with 4-mm flow channels. This implies that 6-mm membranes could achieve a higher LRPC than 4-mm membranes at the same ΔP due to an increase in cross-flow velocity. In theory, the higher LRPC of the 6-mm membranes could facilitate 95% serum protein removal in 2 MF stages with diafiltration between stages if no serum protein were rejected by the membrane. At the same flux, retentate protein concentration, and average cross-flow velocity, 4-mm membranes require 21% more energy to remove a given amount of permeate than 6-mm membranes, despite the lower surface area of the 6-mm membranes. Equations to predict skim milk MF retentate viscosity as a function of protein concentration and temperature are provided. Retentate viscosity, retentate recirculation pump frequency required to maintain a given cross-flow velocity at a given retentate viscosity, and retentate protein determination by mid-infrared spectrophotometry were all useful tools for monitoring the retentate protein concentration to ensure a sustainable MF process. Using 6-mm membranes instead of 4-mm membranes would be advantageous for processors who wish to reduce energy costs or maximize the protein concentration of a MF retentate.

The promise and peril of genomic screening in the general population.

PURPOSE: Utilization of sequencing to screen the general population for preventable monogenic conditions is receiving substantial attention because of its potential to decrease morbidity and mortality. However, the selection of which variants to return is a serious implementation challenge. Procedures must be investigated to ensure optimal test characteristics and avoidance of harm from false-positive test results. METHODS: We scanned exome sequences from 478 well-phenotyped individuals for potentially pathogenic variants in 17 genes representing 11 conditions that are among the most medically actionable Mendelian disorders in adults. We developed five variant selection algorithms with increasing sensitivity and measured their specificity in these 17 genes. RESULTS: Variant selection algorithms with increasing sensitivity exhibited decreased specificity, and performance was highly dependent on the genes analyzed. The most sensitive algorithm ranged from 88.8 to 99.6% specificity among the 17 genes. CONCLUSION: For conditions with very low prevalence, small reductions in specificity greatly increase false positives. This inescapable test characteristic governs the predictive value of genomic sequencing in the general population. To address this issue, test performance must be evaluated systematically for each condition so that the false negatives and false positives can be tailored for optimal outcomes, depending on the downstream clinical consequences.Genet Med 18 6, 593-599.

Effect of soluble calcium and lactose on limiting flux and serum protein removal during skim milk microfiltration.

The tendency of calcium to promote microfiltration (MF) membrane fouling is well documented, but the role of lactose has not been studied. Milk protein concentrate that is 85% protein on a dry basis (MPC85) contains less calcium and lactose than skim milk. Our objectives were to determine the effects of skim milk soluble calcium and lactose concentrations on the limiting fluxes (LF) and serum protein (SP) removal factors of 0.1-µm ceramic graded permeability membranes. The MF was fed with 3 different milks: skim milk, liquid MPC85 that had been standardized to the protein content of skim milk with reverse osmosis water (MPC), and liquid MPC85 that had been standardized to the protein and lactose contents of skim milk with reverse osmosis water and lactose monohydrate (MPC+L). Retentate and permeate were continuously recycled to the feed tank. The LF for each feed was determined by increasing flux once per hour from 55 kg·m(-2)·h(-1) until flux did not increase with increasing transmembrane pressure. Temperature, pressure drop across the membrane length, and protein concentration in the retentate recirculation loop were maintained at 50°C, 220 kPa, and 8.77 ± 0.2%, respectively. Experiments were replicated 3 times and the Proc GLM procedure of SAS was used for statistical analysis. An increase in LF between skim milk (91 kg·m(-2)·h(-1)) and MPC+L (124 kg·m(-2)·h(-1)) was associated with a reduction in soluble calcium. The LF of MPC+L was lower than the LF of MPC (137 kg·m(-2)·h(-1)) due to the higher viscosity contributed by lactose. Permeates produced from the MPC and MPC+L contained more protein than the skim milk permeate due to the transfer of caseins from the micelles into the reduced-calcium sera of the MPC and MPC+L. A SP removal factor was calculated by dividing true protein in the permeate by SP in the permeate portion of the feed to describe the ease of SP passage through the membrane. No differences in SP removal factors were detected among the 3 feeds below the LF. As the fluxes approached the LF, SP removal factors decreased due to fouling. Feeding a MF system with MPC instead of skim milk will reduce the required membrane surface area, but the permeate protein composition will be slightly higher in casein content.

Effect of ceramic membrane channel geometry and uniform transmembrane pressure on limiting flux and serum protein removal during skim milk microfiltration.

Our objectives were to determine the effects of a ceramic microfiltration (MF) membrane's retentate flow channel geometry (round or diamond-shaped) and uniform transmembrane pressure (UTP) on limiting flux (LF) and serum protein (SP) removal during skim milk MF at a temperature of 50°C, a retentate protein concentration of 8.5%, and an average cross-flow velocity of 7 m·s(-1). Performance of membranes with round and diamond flow channels was compared in UTP mode. Performance of the membrane with round flow channels was compared with and without UTP. Using UTP with round flow channel MF membranes increased the LF by 5% when compared with not using UTP, but SP removal was not affected by the use of UTP. Using membranes with round channels instead of diamond-shaped channels in UTP mode increased the LF by 24%. This increase was associated with a 25% increase in Reynolds number and can be explained by lower shear at the vertices of the diamond-shaped channel's surface. The SP removal factor of the diamond channel system was higher than the SP removal factor of the round channel system below the LF. However, the diamond channel system passed more casein into the MF permeate than the round channel system. Because only one batch of each membrane was tested in our study, it was not possible to determine if the differences in protein rejection between channel geometries were due to the membrane design or random manufacturing variation. Despite the lower LF of the diamond channel system, the 47% increase in membrane module surface area of the diamond channel system produced a modular permeate removal rate that was at least 19% higher than the round channel system. Consequently, using diamond channel membranes instead of round channel membranes could reduce some of the costs associated with ceramic MF of skim milk if fewer membrane modules could be used to attain the required membrane area.

Look before you leap: genomic screening in obstetrics and gynecology.

There are a number of new genetic tests and a variety of recommendations for obstetrician-gynecologists. In recent years, screening of low-risk pregnant women with noninvasive prenatal testing has been proposed as well as universal BRCA1 and BRCA2 screening of all women regardless of risk status. Both proposed genetic screening tests raise complicated issues relating to predictive value, cost, and consequences after screening to both the health care system as a whole as well as serious potential adverse consequences for the patient. In addition, there are significant barriers relating to clinician education in proper use of these genetic tests as well as logistic issues of performing adequate genetic counseling in a busy general practice. We recommend that pregnant women offered noninvasive prenatal testing be informed of its advantages and disadvantages compared with standard screening with the caveat that positive noninvasive prenatal tests must be confirmed with further, invasive testing. We recommend against population genetic screening of all women for BRCA1 and BRCA2 mutations until there are comprehensive data regarding harms and benefits as well as cost-effectiveness. Finally, we recommend that new educational models for genetics be developed for obstetrics and gynecology residency training so that future health care providers will be prepared for the opportunities and challenges that genetic testing creates.

A novel statistical approach to detect differences in fat and protein test values among mid-infrared spectrophotometers.

Our objective was to develop a statistical approach that could be used to determine whether a handler's fat, protein, or other solids mid-infrared (MIR) spectrophotometer test values were different, on average, from a milk regulatory laboratory's MIR test values when split-sampling test values are not available. To accomplish this objective, the Proc GLM procedure of SAS (SAS Institute Inc., Cary, NC) was used to develop a multiple linear regression model to evaluate 4 mo of MIR producer payment testing data (112 to 167 producers per month) from 2 different MIR instruments. For each of the 4 mo and each of the 2 components (fat or protein), the GLM model was Response=Instrument+Producer+Date+2-Way Interactions+3-Way Interaction. Instrument was significant in determining fat and protein tests for 3 of the 4 mo, and Producer was significant in determining fat and protein tests for all 4 mo. This model was also used to establish fat and protein least significant differences (LSD) between instruments. Fat LSD between instruments ranged from 0.0108 to 0.0144% (α=0.05) for the 4 mo studied, whereas protein LSD between instruments ranged from 0.0046 to 0.0085% (α=0.05). In addition, regression analysis was used to determine the effects of component concentration and date of sampling on fat and protein differences between 2 MIR instruments. This statistical approach could be performed monthly to document a regulatory laboratory's verification that a given handler's instrument has obtained a different test result, on average, from that of the regulatory laboratory's and that an adjustment to producer payment may be required.

Serum protein removal from skim milk with a 3-stage, 3× ceramic Isoflux membrane process at 50°C.

Small pore microfiltration (MF) can be used to remove serum proteins (SP) from skim milk. The process's SP removal efficiency directly influences the technology's economic feasibility. Our objective was to quantify the capacity of 0.14µm ceramic Isoflux MF membranes (TAMI, Nyons, France) to remove SP from skim milk. A 3-stage, 3×, feed-and-bleed MF study with diafiltration in the latter 2 stages was conducted at 50°C using Isoflux membranes to determine cumulative SP removal percentages and SP removal rates at each processing stage. The experiment was replicated 3 times starting with 3 separate lots of raw milk. In contrast to 3× MF theoretical cumulative SP removal percentages of 68, 90, and 97% after 1, 2, and 3 stages, respectively, the 3× Isoflux MF process removed only 39.5, 58.4, and 70.2% of SP after 1, 2, and 3 stages, respectively. Previous research has been published that provides the skim milk SP removal capacities of 3-stage, 3× 0.1µm ceramic Membralox (Pall Corp., Cortland, NY) uniform transmembrane pressure (UTP), 0.1µm ceramic Membralox graded permeability (GP), and 0.3µm polymeric polyvinylidene fluoride spiral-wound (PVDF-SW) MF systems (Parker-Hannifin, Process Advanced Filtration Division, Tell City, IN) at 50°C. No difference in cumulative SP removal percentage after 3 stages was detected between the Isoflux and previously published PVDF-SW values (70.3%), but SP removal was lower than published GP (96.5%) and UTP (98.3%) values. To remove 95% of SP from 1,000kg of skim milk in 12h it would take 7, 3, 3, and 7 stages with 6.86, 1.91, 2.82, and 17.98m(2) of membrane surface area for the Isoflux, GP, UTP, and PVDF-SW systems, respectively. The MF systems requiring more stages would produce additional permeate at lower protein concentrations. The ceramic MF systems requiring more surface area would incur higher capital costs. The authors hypothesize that SP removal with the Isoflux membranes was lower than theoretical for the following reasons: a range of membrane pore sizes existed (i.e., some pores were too small to pass SP), the selective layer modification and reverse flow conditions at the membrane outlet combined to reduce the effective membrane surface area, and the geometric shape of the Isoflux flow channels promoted early fouling of the membrane and rejection of SP by the foulant.

Effect of annatto addition and bleaching treatments on ultrafiltration flux during production of 80% whey protein concentrate and 80% serum protein concentrate.

The goals of this study were to determine if adding annatto color to milk or applying a bleaching process to whey or microfiltration (MF) permeate influenced ultrafiltration (UF) flux, diafiltration (DF) flux, or membrane fouling during production of 80% whey protein concentrate (WPC80) or 80% serum protein concentrate (SPC80). Separated Cheddar cheese whey (18 vats using 900 kg of whole milk each) and MF permeate of skim milk (18 processing runs using 800 kg of skim milk each) were produced to make WPC80 and SPC80, respectively. The 6 treatments, replicated 3 times each, that constituted the 18 processing runs within either whey or MF permeate UF were as follows: (1) no annatto; (2) no annatto+benzoyl peroxide (BPO); (3) no annatto+hydrogen peroxide (H2O2); (4) annatto; (5) annatto+BPO; and (6) annatto+H2O2. Approximately 700 kg of whey or 530 kg of MF permeate from each treatment were heated to 50°C and processed in 2 stages (UF and DF) with the UF system in batch recirculation mode using a polyethersulfone spiral-wound UF membrane with a molecular weight cutoff of 10,000 Da. Addition of annatto color had no effect on UF or DF flux. The processes of bleaching whey or MF permeate with or without added color improved flux during processing. Bleaching with H2O2 usually produced higher flux than bleaching with BPO. Bleaching with BPO increased WPC80 flux to a greater extent than it did SPC80 flux. Though no differences in mean flux were observed for a common bleaching treatment between the WPC80 and SPC80 production processes during the UF stage, mean flux during WPC80 DF was higher than mean flux during SPC80 DF for each bleaching treatment. Water flux values before and after processing were used to calculate a fouling coefficient that demonstrated differences in fouling which were consistent with flux differences among treatments. In both processes, bleaching with H2O2 led to the largest reduction in fouling. No effect of annatto on fouling was observed. The reasons for flux enhancement associated with bleaching treatments are unclear.

Effect of bleaching permeate from microfiltered skim milk on 80% serum protein concentrate.

Whey proteins that have been removed before the cheese-making process are referred to as "native" whey proteins or milk serum proteins. Because serum proteins isolated directly from milk are not exposed to the cheese-making process, they are free from functional or sensory effects arising from this process. Whey proteins used in food and beverage applications are largely derived from annatto-colored Cheddar cheese. Some of the annatto is left in the whey and this color is converted to a colorless compound by bleaching. The effect of bleaching serum proteins on flavor and functionality of spray-dried protein provides a platform to investigate the effect of bleaching free from the confounding effects of cheese manufacture. The objective of this study was to characterize and compare the sensory and functional properties of 80% milk serum protein concentrate (SPC80) produced from bleached and unbleached microfiltration (MF) permeate made from skim milk with and without added annatto color. Colored and uncolored MF permeates were bleached with benzoyl peroxide (BP) or hydrogen peroxide (HP), ultrafiltered, diafiltered, and spray-dried. The SPC80 from unbleached colored and uncolored MF permeates were manufactured as controls. All treatments were manufactured in triplicate. All SPC80 were evaluated by sensory testing, instrumental analyses, functionality, color, and proximate analysis. The HP-bleached SPC80 was higher in lipid oxidation compounds than BP-bleached or unbleached SPC80, specifically hexanal, heptanal, nonanal, decanal, and 2,3-octadienone. The HP treatments were higher in aroma intensity and cardboard and fatty flavors compared with the unbleached and BP-bleached SPC80. The SPC80 bleached with BP had lower concentrations of norbixin compared with SPC80 bleached with HP. Functionality testing demonstrated that HP treatments had more soluble protein after 10min of heating at 90°C and pH 4.6 and pH 7 compared with the no bleach and BP treatments, regardless of additional color. Foams generated from bleached SPC80 were more stable than those from unbleached SPC80, and those bleached with HP were lower in yield stress than other SPC80. Overall, HP bleaching destroyed less norbixin and caused more lipid oxidation and subsequent off-flavors than did BP bleaching. However, the heat stability of SPC80 was enhanced by HP bleaching compared with control treatments or BP bleaching.

A systematic review of the factors affecting accuracy of SUV measurements.

OBJECTIVE: There is growing interest in using PET/CT for evaluating early response to therapy in cancer treatment. Although widely available and convenient to use, standardized uptake value (SUV) measurements can be influenced by a variety of biologic and technologic factors. Many of these factors can be addressed with close attention to detail and appropriate quality control. This article will review factors potentially affecting SUV measurements and provide recommendations on ways to minimize when using serial PET to assess early response to therapy. CONCLUSION: Scanner and reconstruction parameters can significantly affect SUV measurements. When using serial SUV measurements to assess early response to therapy, imaging should be performed on the same scanner using the same image acquisition and reconstruction protocols. In addition, attention to detail is required for accurate determination of the administered radiopharmaceutical dose.

A high-speed multispectral spinning-disk confocal microscope system for fluorescent speckle microscopy of living cells.

Fluorescent speckle microscopy (FSM) uses a small fraction of fluorescently labeled subunits to give macromolecular assemblies such as the cytoskeleton fluorescence image properties that allow quantitative analysis of movement and subunit turnover. We describe a multispectral microscope system to analyze the dynamics of multiple cellular structures labeled with spectrally distinct fluorophores relative to one another over time in living cells. This required a high-resolution, highly sensitive, low-noise, and stable imaging system to visualize the small number of fluorophores making up each fluorescent speckle, a means by which to switch between excitation wavelengths rapidly, and a computer-based system to integrate image acquisition and illumination functions and to allow a convenient interface for viewing multispectral time-lapse data. To reduce out-of-focus fluorescence that degrades speckle contrast, we incorporated the optical sectioning capabilities of a dual-spinning-disk confocal scanner. The real-time, full-field scanning allows the use of a low-noise, fast, high-dynamic-range, and quantum-efficient cooled charge-coupled device (CCD) as a detector as opposed to the more noisy photomultiplier tubes used in laser-scanning confocal systems. For illumination, our system uses a 2.5-W Kr/Ar laser with 100-300mW of power at several convenient wavelengths for excitation of few fluorophores in dim FSM specimens and a four-channel polychromatic acousto-optical modulator fiberoptically coupled to the confocal to allow switching between illumination wavelengths and intensity control in a few microseconds. We present recent applications of this system for imaging the cytoskeleton in migrating tissue cells and neurons.

Dual-wavelength fluorescent speckle microscopy reveals coupling of microtubule and actin movements in migrating cells.

Interactions between microtubules (MTs) and filamentous actin (f-actin) are involved in directed cell locomotion, but are poorly understood. To test the hypothesis that MTs and f-actin associate with one another and affect each other's organization and dynamics, we performed time-lapse dual-wavelength spinning-disk confocal fluorescent speckle microscopy (FSM) of MTs and f-actin in migrating newt lung epithelial cells. F-actin exhibited four zones of dynamic behavior: rapid retrograde flow in the lamellipodium, slow retrograde flow in the lamellum, anterograde flow in the cell body, and no movement in the convergence zone between the lamellum and cell body. Speckle analysis showed that MTs moved at the same trajectory and velocity as f-actin in the cell body and lamellum, but not in the lamellipodium or convergence zone. MTs grew along f-actin bundles, and quiescent MT ends moved in association with f-actin bundles. These results show that the movement and organization of f-actin has a profound effect on the dynamic organization of MTs in migrating cells, and suggest that MTs and f-actin bind to one another in vivo.