Congenital adrenal hyperplasia (CAH) is an autosomal recessive disease that causes a disorder of steroidogenesis in the adrenal cortex. This disease is a part of a panel of diseases searched in preclinical nationwide neonatal screening. The methodology is based on measuring the concentration of 17-hydroxyprogesterone (17-OHP) in a dried blood spot using fluorescence immunoassay (FIA). However, this determination is not entirely specific and generates a high rate of false positive results (up to 4.3 %). In this diploma thesis the LC-MS / MS method was developed. This method measures selected steroid hormones involved in cortisol metabolism with respect to the diagnosis of CAH disease. The method was validated and applied to clinical samples, it identified CAH patients from negative controls and significantly reduced the false positivity of neonatal screening results. Compared to the FIA results, the LC-MS / MS method reduced false positivity up to 50 % by evaluating the concentration of 17-OHP. Moreover, by extending the diagnostic algorithm with other measured markers, the reduction was enhanced up to 98%. The developed method is also applicable for the measurement of serum and plasma samples, respectively, and has become a part of the confirmation tests for suspected CAH screening findings. Key...

Parents do not always receive accurate, timely and comprehensive information regarding a positive newborn screening from their infants’ primary care providers. The dissertation outlines the investigation of this problem. The methodology of the study is discussed including the survey of parents and primary care providers using the past system, the development of a web portal with a focus on plain language and action focused handouts. Without a simple to understand parent handout the newborn screening process is more stressful to families. Review of the literature is detailed including newborn screening, patient education, health literacy, Internet usage, online health education, design of patient education websites and the evaluative process of learning tools. Surveys informed the content of the web-based patient portal for both parents and PCP. Abbreviated parental stress scores did not identify elevated stress in parents during the initial PCP visit when the NBS results and plan of care were discussed. Evaluation of the planned web portal was permanently delayed related to change in statewide policies; thus, a standalone website was developed using Agency for Health Care Research and Quality’s patient education material tool for understandability and actionability of both patient handouts and web portals. Physician actionable NBS handouts were also developed. Formative evaluation using experts’ input, one-to-one trials and small group trials of the handouts for the site were completed with minor revisions made to the portal. The formative evaluation using the simple survey tool would have provided any additional portal changes required. Strengths of the study to include survey response rates, rigor of the comments by both parents and PCPs as well as constructive feedback from NBS experts are highlighted. The weakness is the lack of having a final participant group identified or available related to local NBS policies. Recommendations for future research are highlighted as well as discussion of changes in federal policy that will now allow further NBS research without the limitations once imposed.

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Inborn errors of metabolism (IEM) cause significant morbidity and mortality when left untreated. Urine organic acid (UOA) analysis is often a first-line investigation when an IEM is suspected. UOAs are usually qualitatively analyzed via the current gold standard, GC-EI-MS (Gas Chromatography-Electron Impact-Mass Spectroscopy). The Agilent 7890 GC in tandem with the Waters’ Xevo TQ-S MS contains an easily interchangeable LC-ESI (liquid chromatography-electrospray Ionization) and GC-APCI (Atmospheric Pressure Chemical Ionization) instrument set-up, while maintaining accuracy and sensitivity in both LC and GC applications. Utilizing this novel GC-APCI instrument, this project aims to develop and validate a new UOA method for clinical use. Furthermore, utilizing the machine’s MRM mode would increase sensitivities thus allowing for hopefully quantitative analysis. Chemical standards and patient urine samples were extracted via a liquid-liquid ether extraction and derivatized with BSTFA for proper GC elution. Results were compared on the current gold standard GC-EI-MS instrument and the new GC-APCI-MS instrument. Initial instrument suitability and method setup was then optimized. Source moisture levels were modified to explore the wet proton transfer and the dry charge transfer mechanism using [M+H]+ and [M+*]+ ion peak ratios, respectively. Elution times and APCI ion mass spectra profiles of UOA metabolites of interest were identified from full scan mode in preparation for MRM mode analysis. Exploration into the wet and dry mode settings of the APCI source determined that the former induced via methanol had greater peak areas and signal-to-noise ratios. Suitable MRMs were determined for clinically relevant organic acids from which a quantitative assay was developed for methyl malonic acid and several other compounds. The Waters’ Xevo TQ-S micro with Agilent 7890 GC demonstrated promising GC-APCI-MS detection of urine organic acids. With clear avenues for future work, the APCI technique hints at great benefits for biochemical genetic laboratories. / Thesis / Master of Science (MSc) / Inborn errors of metabolism (IEM) are a class of genetic diseases that when left untreated, cause reduced quality of life and sometimes death in newborns. Urine organic acid (UOA) analysis is used for detection using an instrument called GC-EI-MS (Gas Chromatography Electron Impact Mass Spectroscopy). This project explores how a new instrument, the Agilent 7890 GC and the Waters’ Xevo TQ-S MS, can detect these genetic diseases using a technique called APCI (Atmospheric Pressure Chemical Ionization) while still being accurate and sensitive. UOAs are isolated from urine and run through the new machine. When compared to the currently used technique, results were promising but further optimization is needed. Using the new machine, various UOA compounds that were elevated and/or decreased in newborns with genetics diseases were identified and quantified. With clear avenues for future work, the APCI technique can greatly improve newborn diagnosis of IEMs.

Ein neuartiger Ansatz für die Immunphänotypisierung wird vorgestellt. Die Durchflusszytometrie (FACS) ist die übliche Methode für die Charaketrisierung des Immunsystems. Jedoch ist die Verfügbarkeit von frischem Vollblut, sowie ein schnelle Probenlogistik Vorraussetzung für die Analyse. Als potentialle Alternative werden epigentische qPCR Assays vorgestellt. Für die Quantifizierung von B- und NK-Zellen wurden epigenetische qPCR Systeme etabliert. Anhand eines erweiterten epigenetischen Markerpanels wurde die klinische Anwendung in drei Kohorten getestet: a) 41 Patienten mit primären Immundefizienzen (PID); b) 19 Neugeborene mit und ohne PID und c) 28 Patienten nach einer Stammzelltransplantation (SZT). In Kohorte a) und c) konnte die Äquivalenz der Ergebnisse mit FACS bestätigt werden. Diskrepanzen bei der regulatorischen T-Zell Quantifizierung in einzelnen PID Patienten wurde festgestellt, welche durch Mutationen verursacht wurden, die die Integrität der analysierten Proteine beeinflussen. Zudem konnte die Anwendung der epigentischen Quantifizierung in Trockenblutkarten von Neugeborenen gezeigt werden. Dies würde die Anwendung auch im Neugeborenen-Screening für die Erkennung von PIDs ermöglichen. Für die Anwendung in der SZT konnte gezeigt werden, dass das epigenetische System eine frühe Analyse der Immunrekonstitution ermöglicht, welche eine prädiktive Aussage über das Überleben der Patienten erlaubt. Patienten, welche eine Immunantwort der Lymphozyten gegen eine Virusinfektion bereits am Tag 26 nach Transplantation aufwiesen, hatten eine signifikant höhere Überlebenschance als Patienten ohne Immunantwort. Zusammengefassend zeigen die Daten, dass die epigenetische Systeme für klinische Anwendungen eine zuverlässige Methode darstellt. Die Aussagekraft der Daten ist aufgrund der Studiengröße noch limitiert, und komplizierte klinische Szenarien erschweren die Evaluierung. Deshalb sind weitere Studien erforderlich, um das gezeigte Potenzial zu validieren. / A novel approach for immunophenotyping for clinical applications is presented here. Flow cytometry is currently a common method to characterize the immune system but requiring fresh whole blood and good sample logistics which is not always available. To overcome this limitations, epigenetic qPCR assays are introduced as potential alternative. New epigenetic qPCR systems to quantiy B and NK cells have been established. Using an extended epigenetic marker panel, clinical applications were tested in three patient cohorts: a) 41 patients with different primary immunodeficiencies (PID); b) 19 newborns with and without PID and c) 28 patients after stem cell transplantation (SCT). In cohort a) and c) the equivalence of the epigenetic quantification with flow cytometry was confirmed. However, discrepancies between both methods for regulatory T-cell quantification were found in individual PID patients caused by disease-associated mutations affecting the integrity of the respective protein. Furthermore, the epigenetic quantification using dried blood spots from newborns was demonstrated. This would allow the implementation of epigenetic immunophenotyping in neonatal screening for the detection of congenital immunodeficiencies. For the application in SCT, it was shown that the epigenetic system allows an early analysis of immune reconstitution, which may allow a prediction of the patients' overall survival. Patients who showed an immune response of lymphocytes against viral infections at day 26 after transplantation had a significantly higher survival rate. In summary, the available data show that epigenetic immunophenotyping is a reliable analytical method for various clinical applications. The significance of the data is still limited due to the size of the study and complicated clinical scenarios make the evaluation of individual measurements difficult. Therefore, further extensive investigations are needed to clinically validate the demonstrated potential.

Neonatal screening (NBS) was initiated in Europe during the 1960s with the screening for phenylketonuria. The panel of screened disorders (“conditions”) then gradually expanded, with a boost in the late 1990s with the introduction of tandem mass spectrometry (MS/MS), making it possible to screen for 40–50 conditions using a single blood spot. The most recent additions to screening programmes (screening for cystic fibrosis, severe combined immunodeficiency and spinal muscular atrophy) were assisted by or realised through the introduction of molecular technologies. For this survey, we collected data from 51 European countries. We report the developments between 2010 and 2020 and highlight the achievements reached with the progress made in this period. We also identify areas where further progress can be made, mainly by exchanging knowledge and learning from experiences in neighbouring countries. Between 2010 and 2020, most NBS programmes in geographical Europe matured considerably, both in terms of methodology (modernised) and with regard to the panel of conditions screened (expanded). These developments indicate that more collaboration in Europe through European organisations is gaining momentum. We can only accomplish the timely detection of newborn infants potentially suffering from one of the many rare diseases and take appropriate action by working together.

The development of new high throughput technologies able to multiplex disease biomarkers as well as advances in medical treatments has lead to the recent expansion of the newborn screening panel to include DNA-based targets. Four rare disorders; deletion 22q11.2 syndrome and Spinal Muscular Atrophy (SMA), Severe Combined Immunodeficiency (SCID) and Congenital Cytomegalovirus (CMV), are potential candidates for inclusion to the newborn screening panel within the next few years. The major focus of this study was to determine whether 5’-hydrolysis assays developed for the four distinct disorders with specific detection needs and analytical ranges could be combined on the OpenArray system and in multiplexed qPCR reactions. SNP detection of homozygous SMN1 deletions in SMA, CNV detection in the 22q11.2 critical region, and quantification of the SCID biomarker, T-cell receptor excision circles (TRECs) and CMV were all required for disease confirmation. SMA and 22q11.2 gene deletions were accurately detected using the OpenArray system, a first for the technology. The medium density deletion 22q11.2 multiplex successfully identified deletion carriers having either the larger 3 Mb deletion or the smaller 1.5 Mb deletions. Both TREC and CMV targets were detected but with a decrease in sensitivity when compared to their singleplex counterparts. Lastly, copy number detection of the TBX1 was performed when multiplexed with the TREC assay, without a decrease in detection limit of either assay. Here, we provide proof of principal that qPCR multiplexing technologies are amenable to implementation with a newborn screening laboratory.