Screening for inborn errors of metabolism using gas chromatography-mass spectrometry

Screening of newborns for inborn errors of metabolism (IEM) in China is both a challenging and undeveloped area for gynecologists and pediatricians. Since 1999, the Capital Institute of Pediatrics has been studied as regards screening for IEM using advanced gas chromatography-mass spectrometry (GC-MS) method in collaboration with the Matsumoto Institute of Life Science (MILS), Japan, and has successfully diagnosed 51 cases of IEM in a total of 393 patients. Galactosemia, phenylketonuria and methylmalonic acidemia were the most frequent disorders among 51 cases of IEM. Treatment by suitable drugs and/or diet therapy was very effective in the most cases.     

Pilot study of gas chromatographic-mass spectrometric screening of newborn urine for inborn errors of metabolism after treatment with urease.

Gas chromatographic-mass spectrometric (GC-MS) techniques for urinary organic acid profiling have been applied to high-risk screening for a wide range of diseases, mainly for inborn errors of metabolism (IEM), rather than to low-risk screening or mass screening. Using a simplified procedure with urease-pretreatment and the GC-MS technique, which allows simultaneous determination of organic acids, amino acids, sugars and sugar acids, we performed a pilot study of the application of this procedure to neonatal urine screening for 22 IEM. Out of 16,246 newborns screened, 11 cases of metabolic disorders were chemically diagnosed: two each of methylmalonic aciduria and glyceroluria, four of cystinuria, and one each of Hartnup disease, citrullinemia and alpha-aminoadipic aciduria/alpha-ketoadipic aciduria. The incidence of IEM was thus one per 1477, which was higher than the one per 3000 obtained in the USA in a study targeting amino acids and acylcarnitines in newborn blood spots by tandem mass spectrometry. Also, 227 cases were found to have transient metabolic abnormalities: 108 cases with neonatal tyrosinuria, 99 cases with neonatal galactosuria, and 20 cases with other transient metabolic disorders. Two hundred and thirty-eight cases out of 16,246 neonates (approximately 1/68) were thus diagnosed using this procedure as having either persistent or transient metabolic abnormalities.     

Detection of antibodies to human immunodeficiency virus (HIV) in eluates from whole blood impregnated filter paper discs

A method for elution of HIV antibodies from whole blood or serum impregnated filter paper discs was developed. The results from testing of 73 eluates in an enzyme linked immunosorbent assay and the immunoblotting test agreed with the results obtained by ordinary serum testing. Significant loss of antibody activity was not observed, neither in the eluates after storage for 1 mth at -20 degrees C nor in the filter paper discs after storage for 3 mths at +4 degrees C. This technique may be useful in facilitating sample collection and transportation, particularly in remote areas of the world.     

Detection of Puumala and Rift Valley Fever virus by quantitative RT-PCR and virus viability tests in samples of blood dried and stored on filter paper

Haemorrhagic fever viruses cause emerging infections worldwide, and blood or serum is the main sample used for diagnosis. However, storage and transportation of such samples from remote areas to regional laboratories may be complicated and expensive. In this study, a novel approach was evaluated for the detection of Puumala hantavirus (PUUV) RNA and Rift Valley fever virus (RVFV) RNA. Whole-blood samples spiked with viable virus particles were tested in parallel with clinical samples from patients with acute haemorrhagic fever with renal syndrome (nephropathia epidemica). Individual blood samples were spotted on filter paper, dried, and used for RNA extraction at later time points. PUUV RNA was detected by RT-PCR after storage at room temperature for up to six weeks. In contrast, only low copy numbers of RVFV RNA were detected after 1-2 days even though viable RVFV was eluted from the dried filter papers after the same time. The use of filter paper to collect and store blood samples for PUUV RNA detection is therefore a simple and reliable procedure. This approach might facilitate sampling and analysis of other RNA viruses from human or animal sources and could be used for field studies in remote areas or in developing countries.     

Comparison of paired whole milk and dried filter paper samples for anti-enterotoxin and anti-rotavirus activities.

Milk specimens, 75 from cows immunized against cholera toxin and 35 from a human population in which enterotoxigenic Escherichia coli and rotaviral infections are endemic, were collected as paired filter paper and frozen whole milk samples. Each pair was tested for antibody activity against heat-labile E. coli and Vibrio cholerae enterotoxins. Additionally, 12 of the 35 paired human milk samples stored as frozen whole milk and dried on filter paper were tested for anti-rotavirus immunoglobulin A. Anti-enterotoxin and anti-rotavirus immunoglobulin A titers in milk dried on filter paper compared favorably with those of their frozen whole milk pairs. Filter paper samples offered considerable advantages for field collection, transportation, and storage over frozen liquid samples.     

Adenoviruses in faeces of children with acute gastroenteritis in Rio de Janeiro, Brazil

Faeces from 746 children less than 5 years old with acute gastroenteritis were screened for the presence of adenovirus particles or antigens by immunoelectron microscopy (IEM) and enzyme immunoassay (EIA). Thirty-five samples were positive by both IEM and EIA, two only by IEM, and two only by EIA, giving a total of 39 (5.2%) samples with positive results. Of these, 25 could be propagated in HEp2 cells and were neutralized by one of the antisera to adenovirus types 1 to 18. The remaining 14 samples could be propagated only in the 293 permanent line of human cells transformed by adenovirus type 5 DNA [Graham et al, 1977] and were not neutralized by antisera to adenovirus types 1 to 31. An EIA carried out by the antibody-capture technique, using antiserum specific for "enteric" adenoviruses [Johansson et al, 1979], gave positive results with all isolates that could be propagated only in 293 cells and with none of those capable of growing in HEp2 cells.     

Diagnosis of rickettsial diseases using samples dried on blotting paper.

The use of filter paper is an inexpensive and convenient method for collecting, storing, and transporting blood samples for serological studies. In addition, samples occupy little space and can be readily transported without refrigeration. Rickettsial diseases often evolve according to an epidemic mode and are now considered reemerging diseases, especially in developing countries, under conditions where fieldwork could be difficult. The suitability of collecting whole-blood specimens on filter paper discs for rickettsial antibody assay was evaluated. Dried blood specimens from 64 individuals with antibodies to Coxiella burnetii, Bartonella quintana, or Rickettsia conorii were tested for rickettsial antibodies by microimmunofluorescence. Although occasional titers were 1 or 2 dilutions lower than those of tested serum samples, no statistically significant differences were observed. Among patients with negative serology, no false positives were found. This study demonstrated that the recovery of antibodies from finger-stick blood dried on filter paper after elution produces results comparable to those obtained by recovering antibodies from serum. Storing paper samples for 1 month at room temperature or at 4 degrees C did not significantly affect the level of antibodies recovered. This report shows the utility of this sample collection method in developing countries where refrigeration is not possible and venipuncture is problematic.     

Diagnosis of Rickettsial Diseases Using Samples Dried on Blotting Paper

The use of filter paper is an inexpensive and convenient method for collecting, storing, and transporting blood samples for serological studies. In addition, samples occupy little space and can be readily transported without refrigeration. Rickettsial diseases often evolve according to an epidemic mode and are now considered reemerging diseases, especially in developing countries, under conditions where fieldwork could be difficult. The suitability of collecting whole-blood specimens on filter paper discs for rickettsial antibody assay was evaluated. Dried blood specimens from 64 individuals with antibodies to Coxiella burnetii, Bartonella quintana, or Rickettsia conorii were tested for rickettsial antibodies by microimmunofluorescence. Although occasional titers were 1 or 2 dilutions lower than those of tested serum samples, no statistically significant differences were observed. Among patients with negative serology, no false positives were found. This study demonstrated that the recovery of antibodies from finger-stick blood dried on filter paper after elution produces results comparable to those obtained by recovering antibodies from serum. Storing paper samples for 1 month at room temperature or at 4°C did not significantly affect the level of antibodies recovered. This report shows the utility of this sample collection method in developing countries where refrigeration is not possible and venipuncture is problematic.     

Electron microscopic diagnosis of viral diseases

Rotaviruses were detected in 58 among 194 children with nonbacterial gastroenteritis whose feces were examined by direct electron microscopy and immune electron microscopy (IEM). Identification of Coxsackie B viruses isolated from patients with infectious-allergic myocarditis by IEM and the neutralization tests gave similar results (Coxsackie B6). Besides, IEM detected the accompanying virus types.     

A comparison of disease and gene frequencies of inborn errors of metabolism among different ethnic groups in the West Midlands, UK.

OBJECTIVE: To assess birth and gene frequencies of specific autosomal recessively inborn errors of metabolism (IEM) within different ethnic groups. DESIGN: Retrospective study in a regional centre for investigation and treatment of IEM. SUBJECTS: All children born within the West Midlands NHS Region, UK, during the decade immediately preceding the 1991 National Census. METHODS: Birth frequencies for individual IEM were calculated separately for the main ethnic groups in the West Midlands using data from the West Midlands Neonatal Screening Programme, the regional register of IEM patients, and population frequencies from the National Census. Gene frequencies were calculated using previously documented observations on parental consanguinity rates and inbreeding coefficients. RESULTS: The overall incidence of recorded IEM was tenfold higher among Pakistanis compared to white children (1:318 v 1:3760), whereas only one AfroCaribbean child was identified (incidence 1:16 887). Tyrosinaemia type 1, cystinosis, mucopolysaccharidosis type 1, non-ketotic hyperglycinaemia, and hyperchylomicronaemia all occurred more frequently among Pakistanis. An increased gene frequency was only confirmed for tyrosinaemia. The incidence of phenylketonuria was similar in Pakistani and white children (1:14 452 v 1:12 611), but the gene frequency was significantly lower in Pakistanis (1:713 v 1:112). These results illustrate the interplay between gene frequency and parental consanguinity in determining disease frequencies in different populations, and indicate anticipated disease frequencies in the absence of consanguineous marriage. These figures have implications for the organisation of services for management of inborn errors, for genetic counselling, and for the assessment of gene flow in world populations.     

The participation of minorities in published pediatric research

OBJECTIVES: There is extensive documentation that minority adults are underrepresented in medical research, but there are scant data regarding minority children and their parents. DESIGN: All full-length articles published in three general pediatric journals between July 2002 through June 2003 were collected and reviewed. Articles were excluded if they did not include at least one U.S. researcher, all subjects enrolled at U.S. institutions, parents or children as subjects, some prospective data collection, or between eight and 10,000 subjects. Corresponding authors were surveyed to clarify race/ethnicity data, language barriers and how race/ethnicity data were collected. RESULTS: Two-hundred-twenty-eight articles qualified for further analysis. Black children and parents and Asian/Pacific Islander parents were overrepresented, and Hispanic children and parents were underrepresented compared to the Census data. Most researchers collected race/ethnicity data by having subjects self-report. Most studies did not have translation available, although most Hispanic and Asian/Pacific Islander subjects were enrolled in studies in which translation was available. CONCLUSION: Our data show that Hispanic and Asian/Pacific Islander research subjects are more likely to participate in pediatric research when translation is available. If the goal is to ensure access to pediatric research for all ethnic populations, then more research needs to accommodate non-English-speaking participants.     

Detection of adenovirus types 40 and 41 in stool specimens by immune electron microscopy

An immune electron microscope (IEM) test was developed that allowed the direct detection of adenovirus type 40 (ad 40) or ad 41 in stools specimens. The polyclonal rabbit antisera used differentiated ad 40 and 41 from other ad serotypes but not from each other. The method was evaluated in a 13 month prospective study of stools from children with gastroenteritis. Seventy-two specimens found to contain ad by conventional electron microscope screening were retested by IEM. Results were typically obtained within 2 hr and showed that 55 (76%) viruses typed as ad 40/41. No ads were recovered from conventional virus isolation attempts on these specimens. Additionally, 39 of these 55 viruses were tested by restriction endonuclease analysis (REA) after growth in 293 cells, and results showed that all produced digest patterns typical of ad 40 (seven cases) or ad 41 (32 cases). Twenty-four percent (17/72) of viruses could not be typed by IEM; 9/17 (53%) yielded ads [ad 1 (1), ad 2 (4), ad 5 (1), ad 6 (1), ad 7 (2)] in routine culture, whereas REA identified the other eight as ad 2 (6), ad 1 (1), and ad 41 (1). The concordance between IEM and the reference methods was therefore 100% specificity and 97.5% sensitivity. The method described allows the clinically useful diagnosis of ad 40/41 infection to be rapidly made and will be a particularly useful technique in laboratories screening faeces by electron microscopy.     

Prevalence of antibody to human calicivirus in general population of northern Japan

Serum specimens from children and adults living in Saporo, Japan, were tested for antibody against human calicivirus by immune electron microscopy (IEM), using virus-rich faecal extracts as the source of antigen. Of 83 serum specimens tested, 49 (59%) were positive for calicivirus antibody. Age-related prevalence of antibody to calicivirus was as follows: 23% (3/13) in the 0-5-month-old group, 30% (6/20) in the 6-23-month-old group, 65% (13/20) in the 2-5-year-old group, and 90% in school children (18/20) and adults (9/10). As for IEM antibody ratings scored from 0 to 4, almost all positive sera from older infants and preschool children scored 3 to 4. Antibody scores were rather more scattered in school children. The results indicated that caliciviral infection is prevalent in younger children in this part of Japan.     

Comparison of direct electron microscopy, immune electron microscopy, and rotavirus enzyme-linked immunosorbent assay for detection of gastroenteritis viruses in children.

An approximate 10% suspension in water of the first available stool sample from 411 infants and young children with acute gastroenteritis was examined by electron microscopy (EM) after 2 min of negative staining. This procedure enabled the detection of 88% of the 199 rotavirus infections, all of the 22 adenovirus infections, and 47% of the 15 approximately 27-nm virus infections ultimately detected by a combination of techniques, including immune electron microscopy (IEM) and rotavirus enzyme-linked immunosorbent assay (ELISA). Of the 204 infections detected by direct EM of stools, 76% were detected within 2 min of viewing, and 94% were detected within 6 min of viewing. Type 1 and type 2 rotavirus particles were visualized with approximately equal efficiency, although type 2 rotavirus infections were more common. Rectal swab preparations were clearly inferior to stool preparations for the detection of virus infection by direct EM. IEM examination was required for efficient visualization of viruses in rectal swab specimens. ELISA was the most sensitive method for the detection of rotaviruses; with this method, all infections in which rotavirus particles were visualized by EM or IEM were detected. However, 73% of the 1,834 specimens which were presumptively positive for rotavirus by conventional indirect ELISA proved to be falsely positive on the basis of EM, IEM, blocking ELISA, confirmatory ELISA, or a combination of these methods. False-positive rotavirus ELISA reactions apparently were eliminated when fecal specimens were tested in a modified confirmatory ELISA with a lower dilution of rotavirus-negative (pre-immunization) than rotavirus-positive (post-immunization) capture antibody from the same animal.     

Simple, sensitive, and specific detection of human immunodeficiency virus type 1 subtype B DNA in dried blood samples for diagnosis in infants in the field

The detection of virus is used to diagnose human immunodeficiency virus type 1 (HIV-1) infection in infants due to the persistence of maternal antibodies for a year or more. An HIV-1 DNA PCR assay with simple specimen collection and processing was developed and evaluated. Whole blood was collected on filter paper that lysed cells and bound the DNA, eliminating specimen centrifugation and extraction procedures. The DNA remained bound to the filter paper during PCR amplification. Assays of copy number standards showed reproducible detection of 5 to 10 copies of HIV-1 in 5 microl of whole blood. The sensitivity of the assay did not decrease after storage of the standards on filter paper for 3 months at room temperature or after incubation at 37 or 45 degrees C for 20 h. The primers used for nested PCR of the HIV-1 pol gene amplified templates from a reference panel of multiple HIV-1 subtypes but did not amplify a subtype A or a subtype C virus from children living in Seattle. The assay had a sensitivity of 98.4% and a specificity of 98.3% for testing of 122 specimens from 35 HIV-1-infected and 16 uninfected children and 43 seronegative adults living in Washington. The assay had a sensitivity of 99% and a specificity of 100% for testing of 102 HIV-1-positive (as determined by enzyme immunoassay) Peruvian women and 6 seropositive and 34 seronegative infants. This assay, with adsorption of whole blood to filter paper and no specimen processing, provides a practical, economical, sensitive, and specific method for the diagnosis of HIV-1 subtype B infection in infants.     

The occurrence of calicivirus in infants with acute gastroenteritis.

Calicivirus was detected in 8 (1.2%) of 647 hospitalized patients during a survey of acute gastroenteritis in infants and young children, conducted between December 1974 and September 1977. Morphologically calicivirus was approximately 30 nm in diameter with an easily recognizable staining "star of David" configuration. Its buoyant density in cesium chloride was 1.38-1.40 gm/ml. The serologic response to calicivirus by immune electron microscopy (IEM) was demonstrated only in paired sera from patients who shed the virus in their stools. The results suggest that calicivirus might be a cause of acute gastroenteritis in infants and young children.     

Oyster-associated gastroenteritis in Australia: the detection of Norwalk virus and its antibody by immune electron microscopy and radioimmunoassay

Following widespread outbreaks of oyster-associated gastroenteritis in Australia during 1978 in which Norwalk virus was implicated as the causative agent, collaborative studies were undertaken between laboratories in Australia and the United States to confirm the etiology. Immune electron microscopy (IEM) techniques were used in Australia and radioimmunoassay (RIA) methods in the United States. Norwalk virus was detected by IEM in seven of 15 faecal samples, and four were positive by RIA. A much better correlation was found with antibody determinations. Both methods demonstrated significant increases in antibody to Norwalk virus in 22 of 30 sets (73%) of "acute" and "convalescent" sera, confirming that Norwalk virus was responsible for the majority of cases. It is significant that the RIA serology was determined using Norwalk antigen originating in the United States and the IEM serology was determined using 27--30-nm particles originating in Australia.     

Epidemiology of food allergy: what's new? A critical appraisal of recent population-based studies

PURPOSE OF REVIEW: To appraise critically recent unselected population-based studies to establish the "true" prevalence or incidence of subjective and objective food allergy, and of food sensitization. RECENT FINDINGS: Five recent studies in children (< 10 years), and one in adults (60-97 years) were identified. Three studies in children (UK and Denmark) applied thorough diagnostic assessments, confirming the overestimation of parent-perceived food allergy compared with objectively assessed diagnosis. A further study in 9-year-old children (UK) found that subjectively assessed food-related wheeze was five times as common in children of south Asian ethnicity than in white children, all born in the same region. A study from Thailand suggested that the prevalence of subjectively and objectively assessed food allergy in preschool children was lower than in western countries. A Hungarian study specifically examined food allergy in the elderly, a population until now neglected by food allergy researchers. SUMMARY: Based also on food challenge tests, valid estimates of the prevalence of food allergy in children up to 6 years were obtained in studies from the UK, Denmark, and Thailand. Two methodologically weaker studies highlighted issues, such as ethnic differences in food allergy and a high proportion of sensitization to food allergens in the elderly that urgently need further evaluation.     

Long-term storage at tropical temperature of dried-blood filter papers for detection and genotyping of RNA and DNA viruses by direct PCR

In tropical countries the diagnosis of viral infections of humans or animals is often hampered by the lack of suitable clinical material and the necessity to maintain a cold chain for sample preservation up to the laboratory. This study describes the use of filter papers for rapid sample collection, and the molecular detection and genotyping of viruses when stored over long periods at elevated temperatures. Infected blood was collected on filter papers, dried and stored at different temperatures (22, 32 and 37 degrees C) for various periods (up to 9 months). Two animal viruses, African swine fever, a large double-stranded DNA virus and Peste des Petits Ruminants, a negative single-stranded RNA virus, were used to validate the method. Filter papers with dried blood containing virus or control plasmid DNA were cut in small 5mm(2) pieces and added directly to the PCR tube for conventional PCR. Nucleic acid from both viruses could still be detected after 3 months at 32 degrees C. Moreover, the DNA virus could be detected at least 9 months after conservation at 37 degrees C. PCR products obtained from the filter papers were sequenced and phylogenetic analysis carried out. The results were consistent with published sequences, demonstrating that this method can be used for virus genotyping.