Fingerprinting of hydroxy propyl methyl cellulose by comprehensive two-dimensional liquid chromatography-mass spectrometry of monomers resulting from acid hydrolysis.

Hydroxypropyl methyl cellulose (HPMC) is a type of cellulose derivative with properties that render it useful in e.g. food, cosmetics, and pharmaceutical industry. The substitution degree and composition of the ß-glucose subunits of HPMC affect its physical and functional properties, but HPMC characterization is challenging due to its high structural heterogeneity, including many isomers. In this study, comprehensive two-dimensional liquid chromatography-mass spectrometry was used to examine substituted glucose monomers originating from complete acid hydrolysis of HPMC. Resolution between the different monomers was achieved using a C18 and cyano column in the first and second LC dimension, respectively. The data analysis process was structured to obtain fingerprints of the monomers of interest. The results revealed that isomers of the respective monomers could be selectively separated based on the position of substituents. The examination of two industrial HPMC products revealed differences in overall monomer composition. While both products contained monomers with a similar degree of substitution, they exhibited distinct regioselectivity.

Characterization of Dye-Loaded Poly(lactic-co-glycolic acid) Nanoparticles by Comprehensive Two-Dimensional Liquid Chromatography Combining Hydrodynamic and Reversed-Phase Liquid Chromatography.

Analytical methods for the assessment of drug-delivery systems (DDSs) are commonly suitable for characterizing individual DDS properties, but do not allow determination of several properties simultaneously. A comprehensive online two-dimensional liquid chromatography (LC × LC) system was developed that is aimed to be capable of characterizing both nanoparticle size and encapsulated cargo over the particle size distribution of a DDS by using one integrated method. Polymeric nanoparticles (NPs) with encapsulated hydrophobic dyes were used as model DDSs. Hydrodynamic chromatography (HDC) was used in the first dimension to separate the intact NPs and to determine the particle size distribution. Fractions from the first dimension were taken comprehensively and disassembled online by the addition of an organic solvent, thereby releasing the encapsulated cargo. Reversed-phase liquid chromatography (RPLC) was used as a second dimension to separate the released dyes. Conditions were optimized to ensure the complete disassembly of the NPs and the dissolution of the dyes during the solvent modulation step. Subsequently, stationary-phase-assisted modulation (SPAM) was applied for trapping and preconcentration of the analytes, thereby minimizing the risk of analyte precipitation or breakthrough. The developed HDC × RPLC method allows for the characterization of encapsulated cargo as a function of intact nanoparticle size and shows potential for the analysis of API stability.

Sample transformation in online separations: how chemical conversion advances analytical technology.

While the advent of modern analytical technology has allowed scientists to determine the complexity of mixtures, it also spurred the demand to understand these sophisticated mixtures better. Chemical transformation can be used to provide insights into properties of complex samples such as degradation pathways or molecular heterogeneity that are otherwise unaccessible. In this article, we explore how sample transformation is exploited across different application fields to empower analytical methods. Transformation mechanisms include molecular-weight reduction, controlled degradation, and derivatization. Both offline and online transformation methods have been explored. The covered studies show that sample transformation facilitates faster reactions (e.g. several hours to minutes), reduces sample complexity, unlocks new sample dimensions (e.g. functional groups), provides correlations between multiple sample dimensions, and improves detectability. The article highlights the state-of-the-art and future prospects, focusing in particular on the characterization of protein and nucleic-acid therapeutics, nanoparticles, synthetic polymers, and small molecules.

Comprehensive two-dimensional gas chromatography- A discussion on recent innovations.

Although comprehensive 2-D GC is an established and often applied analytical method, the field is still highly dynamic thanks to a remarkable number of innovations. In this review, we discuss a number of recent developments in comprehensive 2-D GC technology. A variety of modulation methods are still being actively investigated and many exciting improvements are discussed in this review. We also review interesting developments in detection methods, retention modeling, and data analysis.

Cumulative Neutral Loss Model for Fragment Deconvolution in Electrospray Ionization High-Resolution Mass Spectrometry Data.

Clean high-resolution mass spectra (HRMS) are essential to a successful structural elucidation of an unknown feature during nontarget analysis (NTA) workflows. This is a crucial step, particularly for the spectra generated during data-independent acquisition or during direct infusion experiments. The most commonly available tools only take advantage of the time domain for spectral cleanup. Here, we present an algorithm that combines the time domain and mass domain information to perform spectral deconvolution. The algorithm employs a probability-based cumulative neutral loss (CNL) model for fragment deconvolution. The optimized model, with a mass tolerance of 0.005 Da and a scoreCNL threshold of 0.00, was able to achieve a true positive rate (TPr) of 95.0%, a false discovery rate (FDr) of 20.6%, and a reduction rate of 35.4%. Additionally, the CNL model was extensively tested on real samples containing predominantly pesticides at different concentration levels and with matrix effects. Overall, the model was able to obtain a TPr above 88.8% with FD rates between 33 and 79% and reduction rates between 9 and 45%. Finally, the CNL model was compared with the retention time difference method and peak shape correlation analysis, showing that a combination of correlation analysis and the CNL model was the most effective for fragment deconvolution, obtaining a TPr of 84.7%, an FDr of 54.4%, and a reduction rate of 51.0%.

Computer-driven optimization of complex gradients in comprehensive two-dimensional liquid chromatography.

Method development in comprehensive two-dimensional liquid chromatography (LC × LC) is a complicated endeavor. The dependency between the two dimensions and the possibility of incorporating complex gradient profiles, such as multi-segmented gradients or shifting gradients, renders method development by "trial-and-error" time-consuming and highly dependent on user experience. In this work, an open-source algorithm for the automated and interpretive method development of complex gradients in LC × LC-mass spectrometry (MS) was developed. A workflow was designed to operate within a closed-loop that allowed direct interaction between the LC × LC-MS system and a data-processing computer which ran in an unsupervised and automated fashion. Obtaining accurate retention models in LC × LC is difficult due to the challenges associated with the exact determination of retention times, curve fitting because of the use of gradient elution, and gradient deformation. Thus, retention models were compared in terms of repeatability of determination. Additionally, the design of shifting gradients in the second dimension and the prediction of peak widths were investigated. The algorithm was tested on separations of a tryptic digest of a monoclonal antibody using an objective function that included the sum of resolutions and analysis time as quality descriptors. The algorithm was able to improve the separation relative to a generic starting method using these complex gradient profiles after only four method-development iterations (i.e., sets of chromatographic conditions). Further iterations improved retention time and peak width predictions and thus the accuracy in the separations predicted by the algorithm.

Algorithm for tracking peaks amongst numerous datasets in comprehensive two-dimensional chromatography to enhance data analysis and interpretation.

Analytical data processing often requires the comparison of data, i.e. finding similarities and differences within separations. In this context, a peak-tracking algorithm was developed to compare multiple datasets in one-dimensional (1D) and two-dimensional (2D) chromatography. Two application strategies were investigated: i) data processing where all chromatograms are produced in one sequence and processed simultaneously, and ii) method optimization where chromatograms are produced and processed cumulatively. The first strategy was tested on data from comprehensive 2D liquid chromatography and comprehensive 2D gas chromatography separations of academic and industrial samples of varying compound classes (monoclonal-antibody digest, wine volatiles, polymer granulate headspace, and mayonnaise). Peaks were tracked in up to 29 chromatograms at once, but this could be upscaled when necessary. However, the peak-tracking algorithm performed less accurate for trace analytes, since, peaks that are difficult to detect are also difficult to track. The second strategy was tested with 1D liquid chromatography separations, that were optimized using automated method-development. The strategy for method optimization was quicker to detect peaks that were still poorly separated in earlier chromatograms compared to assigning a target chromatogram, to which all other chromatograms are compared. Rendering it a useful tool for automated method optimization.

Characterization of a high throughput approach for large scale retention measurement in liquid chromatography.

Many contemporary challenges in liquid chromatography-such as the need for "smarter" method development tools, and deeper understanding of chromatographic phenomena-could be addressed more efficiently and effectively with larger volumes of experimental retention data than are available. The paucity of publicly accessible, high-quality measurements needed for the development of retention models and simulation tools has largely been due to the high cost in time and resources associated with traditional retention measurement approaches. Recently we described an approach to improve the throughput of such measurements by using very short columns (typically 5 mm), while maintaining measurement accuracy. In this paper we present a perspective on the characteristics of a dataset containing about 13,000 retention measurements obtained using this approach, and describe a different sample introduction method that is better suited to this application than the approach we used in prior work. The dataset comprises results for 35 different small molecules, nine different stationary phases, and several mobile phase compositions for each analyte/phase combination. During the acquisition of these data, we have interspersed repeated measurements of a small number of compounds for quality control purposes. The data from these measurements not only enable detection of outliers but also assessment of the repeatability and reproducibility of retention measurements over time. For retention factors greater than 1, the mean relative standard deviation (RSD) of replicate (typically n=5) measurements is 0.4%, and the standard deviation of RSDs is 0.4%. Most differences between selectivity values measured six months apart for 15 non-ionogenic compounds were in the range of +/- 1%, indicating good reproducibility. A critically important observation from these analyses is that selectivity defined as retention of a given analyte relative to the retention of a reference compound (kx/kref) is a much more consistent measure of retention over a time span of months compared to the retention factor alone. While this work and dataset also highlight the importance of stationary phase stability over time for achieving reliable retention measurements, we are nevertheless optimistic that this approach will enable the compilation of large databases (>> 10,000 measurements) of retention values over long time periods (years), which can in turn be leveraged to address some of the most important contemporary challenges in liquid chromatography. All the data discussed in the manuscript are provided as Supplemental Information.

Capacitively coupled contactless conductivity detection to account for system-induced gradient deformation in liquid chromatography.

The time required for method development in gradient-elution liquid chromatography (LC) may be reduced by using an empirical modelling approach to describe and predict analyte retention and peak width. However, prediction accuracy is impaired by system-induced gradient deformation, which can be especially prominent for steep gradients. As the deformation is unique to each LC instrument, it needs to be corrected for if retention modelling for optimization and method transfer is to become generally applicable. Such a correction requires knowledge of the actual gradient profile. The latter has been measured using capacitively coupled "contactless" conductivity detection (C4D), featuring a low detection volume (approximately 0.05 µL) and compatibility with very high pressures (80 MPa or more). Several different solvent gradients, from water to acetonitrile, water to methanol, and acetonitrile to tetrahydrofuran, could be measured directly without the addition of a tracer component to the mobile phase, exemplifying the universal nature of the approach. Gradient profiles were found to be unique for each solvent combination, flowrate, and gradient duration. The profiles could be described by convoluting the programmed gradient with a weighted sum of two distribution functions. Knowledge of the exact profiles was used to improve the inter-system transferability of retention models for toluene, anthracene, phenol, emodin, sudan-I and several polystyrene standards.

Hyphenation of liquid chromatography and pyrolysis-flame ionization detection/mass spectrometry for polymer quantification and characterization.

Size-exclusion chromatography (SEC) hyphenated to pyrolysis-gas chromatography (Py-GC) has been demonstrated as a powerful tool in polymer analysis. A main limitation to the wider application of the method are the long second-dimension Py-GC analysis times, resulting in limited first-dimension sampling and/or long overall run times. Therefore, we set out to develop an online hyphenated SEC×Py-MS/FID method, removing the GC separation and allowing for a drastically reduced second-dimension analysis time compared to SEC-Py-GC. The pyrolysis method had a cycle time of 1.31 min, which was facilitated by liquid nitrogen cooling of the programmable temperature vaporizer (PTV) used for pyrolysis. The developed method featured no molar mass discrimination for masses above ±1.3 kDa, rendering it applicable to most commercial polymer systems. The method was demonstrated on multiple samples, including a complex industrial sample, yielding chemical composition heterogeneity and in some cases sequence heterogeneity information over the molar mass distribution.

Principles and potential of solvent gradient size-exclusion chromatography for polymer analysis.

The properties of a polymeric material are influenced by its underlying molecular distributions, including the molecular-weight (MWD), chemical-composition (CCD), and/or block-length (BLD) distributions. Gradient-elution liquid chromatography (LC) is commonly used to determine the CCD. Due to the limited solubility of polymers, samples are often dissolved in strong solvents. Upon injection of the sample, such solvents may lead to broadened or poorly shaped peaks and, in unfavourable cases, to "breakthrough" phenomena, where a part of the sample travels through the column unretained. To remedy this, a technique called size-exclusion-chromatography gradients or gradient size-exclusion chromatography (gSEC) was developed in 2011. In this work, we aim to further explore the potential of gSEC for the analysis of the CCD, also in comparison with conventional gradient-elution reversed-phase LC, which in this work corresponded to gradient-elution reversed-phase liquid chromatography (RPLC). The influence of the mobile-phase composition, the pore size of the stationary-phase particles, and the column temperature were investigated. The separation of five styrene/ethyl acrylate copolymers was studied with one-dimensional RPLC and gSEC. RPLC was shown to lead to a more-accurate CCD in shorter analysis time. The separation of five styrene/methyl methacrylate copolymers was also explored using comprehensive two-dimensional (2D) LC involving gSEC, i.e. SEC × gSEC and SEC × RPLC. In 2D-LC, the use of gSEC was especially advantageous as no breakthrough could occur.

Online hyphenation of size-exclusion chromatography and pyrolysis-gas chromatography for polymer characterization.

An understanding of the composition and molecular heterogeneities of complex industrial polymers forms the basis of gaining control of the physical properties of materials. In the current work we report on the development of an online method to hyphenate liquid polymer chromatography with pyrolysis-GC (Py-GC). The designed workflow included a 10-port valve for fractionation of the first-dimension effluent. Collected fractions were transferred to the Py-GC by means of a second LC pump, a 6-port valve was used to control injection in the Py-GC, allowing the second pump to operate continuously. The optimized large volume injection (LVI) method was capable of analyzing 117 µL of the LC effluent in a 6 min GC separation with a total cycle time of 8.45 min. This resulted in a total run time of 2.1 h while obtaining 15 Py-GC runs over the molar mass separation. The method was demonstrated on various real-life samples including a complex industrial copolymer with a bimodal molar mass distribution. The developed method was used to monitor the relative concentration of 5 different monomers over the molar mass distribution. Furthermore, the molar mass-dependent distribution of a low abundant comonomer (styrene, <1% of total composition) was demonstrated, highlighting the low detection limits and increased resolving power of this approach over e.g. online NMR or IR spectroscopy. The developed method provides a flexible and widely applicable approach to LC-Py-GC hyphenation without having to resort to costly and specialized instrumentation.

Packed modulation loops to reduce band broadening in two-dimensional liquid chromatography.

Modulation interfaces employing sample loops are applied in many hyphenated separations such as two-dimensional liquid chromatography (2D-LC). When the first-dimension effluent in 2D-LC is eluted from the modulation loop, dispersion effects occur due to differences in the laminar flow velocity of the filling and emptying flow. These effects were recently studied by Moussa et al. whom recommended the use of coiled loops to promote radial diffusion and reduce this effect. In the 1980s, Coq et al. investigated the use of packed loops, which also promote radial diffusion, in large volume injection 1D-LC. Unfortunately, this concept was never investigated in the context of 2D-LC modulation. Our work evaluates use of packed loops in 2D-LC modulation and compares them to unpacked coiled and uncoiled modulation loops. The effect of the solvents, loop volume, differences in filling and emptying rates, and loop elution direction on the elution profile was investigated. Statistical moments were used as a pragmatic tool to quantify elution profile characteristics. Decreased dispersion was observed in all cases for the packed loops compared to unpacked loops and unpacked coiled loops. In particular for larger loop volumes the dispersion was reduced significantly. Furthermore, countercurrent elution resulted in narrower elution profiles in all cases compared to concurrent elution. We found that packed modulation loops are of high interested when analytes are not refocussed in the second-dimension separation (e.g. for size-exclusion chromatography). Moreover, our work suggests that the use of packed loops may aid in prevention of loop overfilling.

Closed-loop automatic gradient design for liquid chromatography using Bayesian optimization.

Contemporary complex samples require sophisticated methods for full analysis. This work describes the development of a Bayesian optimization algorithm for automated and unsupervised development of gradient programs. The algorithm was tailored to LC using a Gaussian process model with a novel covariance kernel. To facilitate unsupervised learning, the algorithm was designed to interface directly with the chromatographic system. Single-objective and multi-objective Bayesian optimization strategies were investigated for the separation of two complex (n>18, and n>80) dye mixtures. Both approaches found satisfactory optima in under 35 measurements. The multi-objective strategy was found to be powerful and flexible in terms of exploring the Pareto front. The performance difference between the single-objective and multi-objective strategy was further investigated using a retention modeling example. One additional advantage of the multi-objective approach was that it allows for a trade-off to be made between multiple objectives without prior knowledge. In general, the Bayesian optimization strategy was found to be particularly suitable, but not limited to, cases where retention modelling is not possible, although its scalability might be limited in terms of the number of parameters that can be simultaneously optimized.

Composition mapping of highly substituted cellulose-ether monomers by liquid chromatography-mass spectrometry and probability-based data deconvolution.

Cellulose ethers (CEs) are semi-synthetic polymers produced by derivatization of natural cellulose, yielding highly substituted products such as ethyl hydroxyethyl cellulose (EHEC) or methyl ethyl hydroxyethyl cellulose (MEHEC). CEs are commonly applied as pharmaceutical excipients and thickening agents in paints and drymix mortars. CE properties, such as high viscosity in solution, solubility, and bio-stability are of high interest to achieve required product qualities, which may be strongly affected by the substitution pattern obtained after derivatization. The average and molar degree of substitution often cannot explain functional differences observed among CE batches, and more in-depth analysis is needed. In this work, a new method was developed for the comprehensive mapping of the substitution degree and composition of ß-glucose monomers of CE samples. To this end, CEs were acid-hydrolyzed and then analyzed by gradient reversed-phase liquid chromatography-mass spectrometry (LC-MS) using an acid-stable LC column and time-of-flight (TOF) mass spectrometer. LC-MS provided monomer resolution based on ethylene oxide, hydroxyl, and terminating methyl/ethyl content, allowing the assignment of detailed compositional distributions. An essential further distinction of constitutional isomer distributions was achieved using an in-house developed probability-based deconvolution algorithm. Aided by differential heat maps for visualization and straightforward interpretation of the measured LC-MS data, compositional variation between bio-stable and non-bio-stable CEs could be identified using this new approach. Moreover, it disclosed unexpected methylations in EHEC samples. Overall, the obtained molecular information on relevant CE samples demonstrated the method's potential for the study of CE structure-property relationships.

Incorporating a liquid-core-waveguide cell in recycling liquid chromatography for detailed studies of photodegradation reactions.

In this work, a microfluidic photoreactor was embedded in a recycling liquid-chromatography system. Mixtures were separated on an analytical column and compounds of interest were subsequently introduced into the light-reactor cell. After degradation, the content of the light-reactor cell was reinjected onto the same column to separate the parent compound from its degradation products. A separated degradation product could be re-introduced into the photoreactor and irradiated again. The next generation of degradation products could again be separated on the same analytical column. This recycling procedure proved an excellent tool to elucidate degradation pathways. This was demonstrated using riboflavin, better known as vitamin B2. By degrading it in the first cycle, degradation products were isolated and subjected to a second degradation in the light-reactor cell. This allows pinpointing secondary products and connect these with primary degradation products. Compared to previous work, this configuration is simpler, cheaper, and more user-friendly, while offering the unique possibility to easily connect degradation products to the initial compounds in a mixture.

Improving the accuracy of copolymer sequence length determination by pyrolysis gas chromatography: A comprehensive study.

Many industrial polymers which find application in contemporary materials are copolymers. Copolymers feature multiple distributions, that govern their physical properties, including the sequence distribution. Styrene-acrylate copolymers are an important class of polymers, their monomer sequence is typically determined by 13C NMR which suffers from low sensitivity and spectral resolution. A series of studies have shown that Py-GC can be applied to determine the sequence length of copolymers. The accuracy of the trimer assignments and the appropriate calibration approaches yielding reliable data have however not yet been validated. In the present study we propose a comprehensive workflow to ensure the accuracy of the sequence determination by Py-GC, next to NMR. In-depth analysis of the trimers observed in the Py-GC pyrograms of model styrene-acrylate copolymers was performed and specific MS fragments relating to the trimer sequence were assigned. A comparison of a series of copolymers yielded reliable assignments for the trimer signals. The obtained sequence lengths were in agreement with those calibrated with the benchmark method, 13C NMR. Py-GC was found to consistently underestimate the acrylate sequence length. Py-GC calibration with 13C NMR was thus found to be indispensable for the accurate absolute quantification of the sequence length by Py-GC. The calculated randomness did not vary significantly after NMR calibration, indicating that NMR calibration might not be required in all cases to obtain (relative) information on the sequence of a copolymer.

Chemometric Strategies for Fully Automated Interpretive Method Development in Liquid Chromatography.

The majority of liquid chromatography (LC) methods are still developed in a conventional manner, that is, by analysts who rely on their knowledge and experience to make method development decisions. In this work, a novel, open-source algorithm was developed for automated and interpretive method development of LC(-mass spectrometry) separations ("AutoLC"). A closed-loop workflow was constructed that interacted directly with the LC system and ran unsupervised in an automated fashion. To achieve this, several challenges related to peak tracking, retention modeling, the automated design of candidate gradient profiles, and the simulation of chromatograms were investigated. The algorithm was tested using two newly designed method development strategies. The first utilized retention modeling, whereas the second used a Bayesian-optimization machine learning approach. In both cases, the algorithm could arrive within 4-10 iterations (i.e., sets of method parameters) at an optimum of the objective function, which included resolution and analysis time as measures of performance. Retention modeling was found to be more efficient while depending on peak tracking, whereas Bayesian optimization was more flexible but limited in scalability. We have deliberately designed the algorithm to be modular to facilitate compatibility with previous and future work (e.g., previously published data handling algorithms).

Two-dimensional tools for analyzing polymer microstructure; coupling non-aqueous ion-exchange chromatography to size-exclusion chromatography.

Traditional liquid-chromatographic techniques, such as size-exclusion chromatography, (critical) interaction chromatography, and hydrodynamic chromatography, can all reveal certain aspects of polymers and the underlying distributions. The distribution of incorporated acid groups present in polyacrylates can be determined by non-aqueous ion-exchange chromatography, independent of other distributions present. The microstructural details on how this number of acid groups is incorporated in the polymer remains unknown. A low-molar mass polymer molecule with high acid content and a high-molar mass polymer with a low acid content may have the exact same number of acid groups. To take a next step towards understanding the polymer microstructure of water-borne resins, the distribution of incorporated acid groups over the molar-mass distribution has been investigated. For this purpose, an on-line coupling of non-aqueous ion-exchange chromatography (NAIEX) to size-exclusion chromatography (SEC) was established. Practical considerations regarding the system setup with respect to chromatography modes and column- and valve switching dimensionality are discussed. The orthogonality of NAIEX and SEC is demonstrated. Both liquid chromatography modes may be calibrated using polymer standards, yielding a calibrated separation plane. Cross-sectional data on either the molar mass distribution or the acid group distribution at a certain point of the separation plane is obtained. The value of the designed setup was demonstrated by the detailed characterization of the combined acid-group and molar-mass distribution in polymers with a low acid content, in the order of a few mass-%. Several stages of the emulsion polymerization process could be identified using the combined power of NAIEX and SEC.

Assessing the feasibility of stationary-phase-assisted modulation for two-dimensional liquid-chromatography separations.

Two-dimensional liquid chromatography (2DLC) offers great separation power for complex mixtures. The frequently encountered incompatibility of two orthogonal separation systems, however, makes its application complicated. Active-modulation strategies can reduce such incompatibility issues considerably. Stationary-phase-assisted modulation (SPAM) is the most-common of these techniques, but also the least robust due to the major disadvantage that analytes may elute prematurely. The range of liquid chromatography (LC) applications continues to expand towards ever more complex mixtures. Retention modelling is increasingly indispensable to comprehend and develop LC separations. In this research, a tool was designed to assess the feasibility of applying SPAM in 2DLC. Several parameters were investigated to accurately predict isocratic retention of analytes on trap columns under dilution-flow conditions. Model parameters were derived from scanning-gradient experiments performed on analytical columns. The trap-to-trap repeatability was found to be similar to the prediction error. Dead volumes for the trap columns could not be accurately determined through direct experimentation. Instead, they were extrapolated from dead-volume measurements on analytical columns. Several known retention models were evaluated. Better predictions were found using the quadratic model than with the log-linear ("linear-solvent-strength") model. Steep scanning gradients were found to result in inaccurate predictions. The impact of the dilution flow on the retention of analytes proved less straightforward than anticipated. Under certain conditions dilution with a weaker eluent was found to be counter productive. A tool was developed to quantify the effect of the dilution flow and to predict whether SPAM could be applied in specific situations. For nine different analytes under 36 different sets of conditions and with three different modulation times, the SPAM tool yielded a correct assessment in more than 95% of all cases (less than 5% false positives plus false negatives).