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Int. J. Neonatal Screen., Volume 5, Issue 1 (March 2019)

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Open AccessReview Thalassemias: An Overview
Int. J. Neonatal Screen. 2019, 5(1), 16; https://doi.org/10.3390/ijns5010016
Received: 2 November 2018 / Revised: 12 March 2019 / Accepted: 18 March 2019 / Published: 20 March 2019
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Abstract
Thalassemia syndromes are among the most serious and common genetic conditions. They are indigenous in a wide but specific geographical area. However, through migration they are spreading across regions not previously affected. Thalassemias are caused by mutations in the α (HBA1/HBA2) [...] Read more.
Thalassemia syndromes are among the most serious and common genetic conditions. They are indigenous in a wide but specific geographical area. However, through migration they are spreading across regions not previously affected. Thalassemias are caused by mutations in the α (HBA1/HBA2) and β globin (HBB) genes and are usually inherited in an autosomal recessive manner. The corresponding proteins form the adult hemoglobin molecule (HbA) which is a heterotetramer of two α and two β globin chains. Thalassemia-causing mutations lead to an imbalanced globin chain production and consecutively to impaired erythropoiesis. The severity of the disease is largely determined by the degree of chain imbalance. In the worst case, survival is dependent on regular blood transfusions, which in turn cause transfusional iron overload and secondary multi-organ damage due to iron toxicity. A vigorous monitoring and treatment regime is required, even for the milder syndromes. Thalassemias are a major public health issue in many populations which many health authorities fail to address. Even though comprehensive care has resulted in long-term survival and good quality of life, poor access to essential components of management results in complications which increase the cost of treatment and lead to poor outcomes. These requirements are not recognized by measures such as the Global Burden of Disease project, which ranks thalassemia very low in terms of disability-adjusted life years (DALYs), and fails to consider that it ranks highly in the one to four-year-old age group, making it an important contributor to under-5 mortality. Thalassemia does not fulfil the criteria to be accepted as a target disease for neonatal screening. Nevertheless, depending on the screening methodology, severe cases of thalassemia will be detected in most neonatal screening programs for sickle cell disease. This is very valuable because: (1) it helps to prepare the affected families for having a sick child and (2) it is an important measure of secondary prevention. Full article
Open AccessReview Newborn Screening for Sickle Cell Disease in Europe
Int. J. Neonatal Screen. 2019, 5(1), 15; https://doi.org/10.3390/ijns5010015
Received: 30 December 2018 / Revised: 3 February 2019 / Accepted: 6 February 2019 / Published: 12 February 2019
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Abstract
The history of newborn screening (NBS) for sickle cell disease (SCD) in Europe goes back almost 40 years. However, most European countries have not established it to date. The European screening map is surprisingly heterogenous. The first countries to introduce sickle cell screening [...] Read more.
The history of newborn screening (NBS) for sickle cell disease (SCD) in Europe goes back almost 40 years. However, most European countries have not established it to date. The European screening map is surprisingly heterogenous. The first countries to introduce sickle cell screening on a national scale were France and England. The French West Indies started to screen their newborns for SCD as early as 1983/84. To this day, all countries of the United Kingdom of Great Britain and Northern Ireland have added SCD as a target disease to their NBS programs. The Netherlands, Spain and Malta also have national programs. Belgium screens regionally in the Brussels and Liège regions, Ireland has been running a pilot for many years that has become quasi-official. However, the Belgian and Irish programs are not publicly funded. Italy and Germany have completed several pilot studies but are still in the preparatory phase of national NBS programs for SCD, although both countries have well-established concepts for metabolic and endocrine disorders. This article will give a brief overview of the situation in Europe and put a focus on the programs of the two pioneers of the continent, England and France. Full article
Open AccessEditorial Pulse Oximetry Screening for Critical Congenital Heart Defects: A Life-Saving Test for All Newborn Babies
Int. J. Neonatal Screen. 2019, 5(1), 14; https://doi.org/10.3390/ijns5010014
Received: 31 January 2019 / Accepted: 11 February 2019 / Published: 12 February 2019
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Abstract
Congenital heart defects (CHD) are the commonest congenital malformations and remain a major cause of neonatal mortality and morbidity in the developed world [...] Full article
(This article belongs to the Special Issue Neonatal Screening for Critical Congenital Heart Defects)
Open AccessArticle Analyzing Patterns in NewSTEPs Site Review Recommendations: Practical Applications for Newborn Screening Programs
Int. J. Neonatal Screen. 2019, 5(1), 13; https://doi.org/10.3390/ijns5010013
Received: 20 December 2018 / Revised: 23 January 2019 / Accepted: 2 February 2019 / Published: 12 February 2019
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Abstract
The Newborn Screening Technical assistance and Evaluation Program (NewSTEPs) conducts non-regulatory site reviews of state newborn screening programs in the US with the goal of providing comprehensive reports and recommendations to support quality improvements within the system. A detailed coding and qualitative analysis [...] Read more.
The Newborn Screening Technical assistance and Evaluation Program (NewSTEPs) conducts non-regulatory site reviews of state newborn screening programs in the US with the goal of providing comprehensive reports and recommendations to support quality improvements within the system. A detailed coding and qualitative analysis of data extracted from reports of seven programs visited between 2012 and 2017, of thirteen pre-site visit surveys completed by state newborn screening programs, and of information from interviews conducted with three site review experts revealed four common themes that exist across states within the national newborn screening system. These themes include opportunities to implement improvements in: (1) communications inside and outside of the state newborn screening program, (2) education, (3) information technology, and (4) operations. The cross-cutting recommendations provided by NewSTEPs within the comprehensive site review reports may prove valuable for all state programs to consider and to incorporate as quality improvement measures in the absence of a full site review. The analysis of the site review process and recommendations identified important opportunities for improvement, many of which were previously unknown to be common across programs, and also provided affirmation of known challenges. Full article
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Open AccessReview Improving Screening Programmes for Sickle Cell Disorders and Other Haemoglobinopathies in Europe: The Role of Patient Organisations
Int. J. Neonatal Screen. 2019, 5(1), 12; https://doi.org/10.3390/ijns5010012
Received: 31 December 2018 / Revised: 24 January 2019 / Accepted: 25 January 2019 / Published: 29 January 2019
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Abstract
This discussion paper has been written to show the unique contribution and added value that Patient Organisations can give to the development and improvement of newborn screening programmes for sickle cell disorder (SCD) and other haemoglobinopathies in Europe. As an example, the action [...] Read more.
This discussion paper has been written to show the unique contribution and added value that Patient Organisations can give to the development and improvement of newborn screening programmes for sickle cell disorder (SCD) and other haemoglobinopathies in Europe. As an example, the action of the Sickle Cell Society (SCS) in partnership with statutory organisations in the U.K., such as the National Health Service (NHS) Sickle Cell and Thalassaemia Screening Programme (NHS SCT SP), will be described. Full article
Open AccessReview The Neonatal Screening Program in Brazil, Focus on Sickle Cell Disease (SCD)
Int. J. Neonatal Screen. 2019, 5(1), 11; https://doi.org/10.3390/ijns5010011
Received: 28 September 2018 / Revised: 21 January 2019 / Accepted: 23 January 2019 / Published: 26 January 2019
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Abstract
Since 2001, the Brazilian Ministry of Health has been coordinating a National Neonatal Screening Program (NNSP) that now covers all the 26 states and the Federal District of the Brazilian Republic and targets six diseases including sickle cell disease (SCD) and other hemoglobinopathies. [...] Read more.
Since 2001, the Brazilian Ministry of Health has been coordinating a National Neonatal Screening Program (NNSP) that now covers all the 26 states and the Federal District of the Brazilian Republic and targets six diseases including sickle cell disease (SCD) and other hemoglobinopathies. In 2005, the program coverage reached 80% of the total live births. Since then, it has oscillated between 80% and 84% globally with disparities from one state to another (>95% in São Paulo State). The Ministry of Health has also published several Guidelines for clinical follow-up and treatment for the diseases comprised by the neonatal screening program. The main challenge was, and still is, to organize the public health network (SUS), from diagnosis and basic care to reference centers in order to provide comprehensive care for patients diagnosed by neonatal screening, especially for SCD patients. Considerable gains have already been achieved, including the implementation of a network within SUS and the addition of scientific and technological progress to treatment protocols. The goals for the care of SCD patients are the intensification of information provided to health care professionals and patients, measures to prevent complications, and care and health promotion, considering these patients in a global and integrated way, to reduce mortality and enhance their quality of life. Full article
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Open AccessProject Report Building a Newborn Screening Information Management System from Theory to Practice
Int. J. Neonatal Screen. 2019, 5(1), 9; https://doi.org/10.3390/ijns5010009
Received: 6 December 2018 / Revised: 8 January 2019 / Accepted: 22 January 2019 / Published: 23 January 2019
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Abstract
Information Management Systems are the central process management and communication hub for many newborn screening programs. In late 2014, Newborn Screening Ontario (NSO) undertook an end to end assessment of its information management needs which resulted in a project to develop a flexible [...] Read more.
Information Management Systems are the central process management and communication hub for many newborn screening programs. In late 2014, Newborn Screening Ontario (NSO) undertook an end to end assessment of its information management needs which resulted in a project to develop a flexible IS Information Systems (IS) ecosystem and related process changes. This enabled NSO to better manage its current and future work-flows and communication needs. An idealized vision of a Screening Information Management System (SIMS) was developed that was refined into enterprise and functional architectures. This was followed by the development of technical specifications, user requirements and procurement. In undertaking a holistic full product lifecycle redesign approach, a number of change management challenges were faced by NSO across the entire program. Strong leadership support and full program engagement are key for overall project success. It is anticipated that improvements in program flexibility and the ability to innovate will outweigh the efforts and costs. Full article
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Open AccessArticle A Multicentre Pilot Study of a Two-Tier Newborn Sickle Cell Disease Screening Procedure with a First Tier Based on a Fully Automated MALDI-TOF MS Platform
Int. J. Neonatal Screen. 2019, 5(1), 10; https://doi.org/10.3390/ijns5010010
Received: 4 December 2018 / Revised: 19 January 2019 / Accepted: 21 January 2019 / Published: 23 January 2019
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Abstract
The reference methods used for sickle cell disease (SCD) screening usually include two analytical steps: a first tier for differentiating haemoglobin S (HbS) heterozygotes, HbS homozygotes and β-thalassemia from other samples, and a confirmatory second tier. Here, we evaluated a first-tier approach based [...] Read more.
The reference methods used for sickle cell disease (SCD) screening usually include two analytical steps: a first tier for differentiating haemoglobin S (HbS) heterozygotes, HbS homozygotes and β-thalassemia from other samples, and a confirmatory second tier. Here, we evaluated a first-tier approach based on a fully automated matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) platform with automated sample processing, a laboratory information management system and NeoSickle® software for automatic data interpretation. A total of 6701 samples (with high proportions of phenotypes homozygous (FS) or heterozygous (FAS) for the inherited genes for sickle haemoglobin and samples from premature newborns) were screened. The NeoSickle® software correctly classified 98.8% of the samples. This specific blood sample collection was enriched in qualified difficult samples (premature newborns, FAS samples, late and very late samples, etc.). In this study, the sensitivity of FS sample detection was found to be 100% on the Lille MS facility and 99% on the Dijon MS facility, and the specificity of FS sample detection was found to be 100% on both MS facilities. The MALDI-MS platform appears to be a robust solution for first-tier use to detect the HbS variant: it is reproducible and sensitive, it has the power to analyze 600–1000 samples per day and it can reduce the unit cost of testing thanks to maximal automation, minimal intervention by the medical team and good overall practicability. The MALDI-MS approach meets today’s criteria for the large-scale, cost-effective screening of newborns, children and adults. Full article
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Open AccessArticle Knowledge about Neonatal Screening among Postpartum Women and Complexity Level of Birthing Facilities
Int. J. Neonatal Screen. 2019, 5(1), 8; https://doi.org/10.3390/ijns5010008
Received: 12 December 2018 / Revised: 6 January 2019 / Accepted: 20 January 2019 / Published: 22 January 2019
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Abstract
Background: To ascertain the degree of knowledge of postpartum women about important aspects related to the neonatal screening process and whether differences of opinion exist between those who deliver in low-complexity versus high-complexity health facilities (low-risk versus high-risk pregnancies, respectively). Methods: This was [...] Read more.
Background: To ascertain the degree of knowledge of postpartum women about important aspects related to the neonatal screening process and whether differences of opinion exist between those who deliver in low-complexity versus high-complexity health facilities (low-risk versus high-risk pregnancies, respectively). Methods: This was a prospective, cross-sectional, questionnaire-based study. The sample consisted of postpartum women recruited from 2013 to 2015 at public maternity hospitals in the city of Niterói, Brazil. Participants were divided into two groups and completed a questionnaire consisting of Likert-scored items. Continuous variables were analyzed with the Mann-Whitney test, and categorical variables, with Fisher’s test. A confirmatory factor analysis of participants’ answers was performed. Results: Of 188 women enrolled, 54 (28.7%) had incomplete elementary education; 119 (62.2%) had attended more than six antenatal care visits. The mean age was 25.57 years. Nearly all women (n = 179, 95.2%) were roomed-in with their infants. Knowledge of neonatal screening was very similar in the high-complexity and low-complexity groups. Divergences were limited to items regarding the risks of neonatal screening. Conclusions: The degree of knowledge among postpartum women was similar among high- and low-complexity facilities. Those who attended high-complexity facilities had longer hospital stays and greater adherence to ethical issues regarding neonatal screening. Full article
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Open AccessReview Newborn and Infant Hearing Screening Facing Globally Growing Numbers of People Suffering from Disabling Hearing Loss
Int. J. Neonatal Screen. 2019, 5(1), 7; https://doi.org/10.3390/ijns5010007
Received: 15 September 2018 / Revised: 2 December 2018 / Accepted: 9 January 2019 / Published: 18 January 2019
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Abstract
Recent prevalence estimates indicate that in 2015 almost half a billion people—about 6.8% of the world’s population—had disabling hearing loss and that prevalence numbers will further increase. The World Health Organization (WHO) currently estimates that at least 34 million children under the age [...] Read more.
Recent prevalence estimates indicate that in 2015 almost half a billion people—about 6.8% of the world’s population—had disabling hearing loss and that prevalence numbers will further increase. The World Health Organization (WHO) currently estimates that at least 34 million children under the age of 15 have disabling hearing loss. Based on a 2012 WHO report, approximately 7.5 million of these children were under the age of 5 years. This review article focuses on the importance of high-quality newborn and infant hearing screening (NIHS) programs as one strategy to ameliorate disabling hearing loss as a global health problem. Two WHO resolutions regarding the prevention of deafness and hearing loss have been adopted urging member states to implement screening programs for early identification of ear diseases and hearing loss in babies and young children. The effectiveness of these programs depends on factors such as governmental mandates and guidance; presence of a national committee with involvement of professionals, industries, and stakeholders; central oversight of hearing screening; clear definition of target parameters; presence of tracking systems with bi-directional data transfer from screening devices to screening centers; accessibility of pediatric audiological services and rehabilitation programs; using telemedicine where connectivity is available; and the opportunity for case discussions in professional excellence circles with boards of experts. There is a lack of such programs in middle- and low-income countries, but even in high-income countries there is potential for improvement. Facing the still growing burden of disabling hearing loss around the world, there is a need to invest in national, high-quality NIHS programs. Full article
(This article belongs to the Special Issue Newborn Hearing Screening)
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Open AccessEditorial Acknowledgement to Reviewers of International Journal of Neonatal Screening in 2018
Int. J. Neonatal Screen. 2019, 5(1), 6; https://doi.org/10.3390/ijns5010006
Published: 9 January 2019
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Abstract
Rigorous peer-review is the corner-stone of high-quality academic publishing[...] Full article
Open AccessArticle Newborn Screening for Sickle Cell Disease in the Caribbean: An Update of the Present Situation and of the Disease Prevalence
Int. J. Neonatal Screen. 2019, 5(1), 5; https://doi.org/10.3390/ijns5010005
Received: 13 November 2018 / Revised: 7 December 2018 / Accepted: 1 January 2019 / Published: 8 January 2019
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Abstract
The region surrounding the Caribbean Sea is predominantly composed of island nations for its Eastern part and the American continental coast on its Western part. A large proportion of the population, particularly in the Caribbean islands, traces its ancestry to Africa as a [...] Read more.
The region surrounding the Caribbean Sea is predominantly composed of island nations for its Eastern part and the American continental coast on its Western part. A large proportion of the population, particularly in the Caribbean islands, traces its ancestry to Africa as a consequence of the Atlantic slave trade during the XVI–XVIII centuries. As a result, sickle cell disease has been largely introduced in the region. Some Caribbean countries and/or territories, such as Jamaica and the French territories, initiated newborn screening (NBS) programs for sickle cell disease more than 20 years ago. They have demonstrated the major beneficial impact on mortality and morbidity resulting from early childhood care. However, similar programs have not been implemented in much of the region. This paper presents an update of the existing NBS programs and the prevalence of sickle cell disease in the Caribbean. It demonstrates the impact of the Caribbean Network of Researchers on Sickle Cell Disease and Thalassemia (CAREST) on the extension of these programs. The presented data illustrate the importance of advocacy in convincing policy makers of the feasibility and benefit of NBS for sickle cell disease when coupled to early care. Full article
Open AccessArticle Are ABO Blood Groups or Rh Antigen Perinatal Factors Affecting the Pass Rate of Transient Otoacoustic Emissions Screening Tests in Healthy Newborns during the First 48 h of Life?
Int. J. Neonatal Screen. 2019, 5(1), 4; https://doi.org/10.3390/ijns5010004
Received: 6 August 2018 / Revised: 21 December 2018 / Accepted: 27 December 2018 / Published: 4 January 2019
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Abstract
Most hospitals recommend performing neonatal hearing screening. Transient evoked otoacoustic emission (TEOAE) tests represent an ideal technique for conducting this process. Previous studies have related the influence of ABO blood group and Rhesus antigens (Rh) on the susceptibility to various pathologies. However, available [...] Read more.
Most hospitals recommend performing neonatal hearing screening. Transient evoked otoacoustic emission (TEOAE) tests represent an ideal technique for conducting this process. Previous studies have related the influence of ABO blood group and Rhesus antigens (Rh) on the susceptibility to various pathologies. However, available data about the potential relationship between ABO blood groups, Rh, and TEOAE pass rates are sparse. Recently, several authors concluded that O blood group and Rh+ are possible influential factors of TEOAE pass rates. Significantly different TEOAE amplitude response between the four main ABO blood groups were observed among normal-hearing individuals. Moreover, ABO blood groups were discussed as a possible influential factor for the development of noise-induced hearing loss later in life. The aim of this study was to investigate the relationship between ABO blood groups, Rh, and the first TEOAE pass rates in healthy newborns. Data were retrospectively collected from healthy newborns at the maternity ward of F. Borja hospital in Gandia (Spain). Rh and ABO were compared with the results of TEOAE performed within the first 48 h of life. Results: the study group included 2765 newborns. No significant correlation between ABO blood group or Rh and TEOAE pass rates was observed in comparative tables. Conclusion: ABO blood group and Rhesus antigens do not appear to have a significant impact on the pass rate of TEOAE screening in healthy newborns. Full article
(This article belongs to the Special Issue Newborn Hearing Screening)
Open AccessArticle National Survey Assessment of the United States’ Pediatric Residents’ Knowledge, Attitudes, and Practices Regarding Newborn Screening
Int. J. Neonatal Screen. 2019, 5(1), 3; https://doi.org/10.3390/ijns5010003
Received: 22 October 2018 / Revised: 18 December 2018 / Accepted: 27 December 2018 / Published: 31 December 2018
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Abstract
A pediatrician’s approach to newborn screening (NBS) impacts patient care. Some physicians have reported not being well prepared to inform families about a positive NBS and recommend further follow-up. The knowledge and approach of categorical pediatric residents (RES) in the United States regarding [...] Read more.
A pediatrician’s approach to newborn screening (NBS) impacts patient care. Some physicians have reported not being well prepared to inform families about a positive NBS and recommend further follow-up. The knowledge and approach of categorical pediatric residents (RES) in the United States regarding NBS is not known. They were anonymously surveyed via listserv maintained by American Academy of Pediatrics. A total of 655 responses were analyzed. The mean composite knowledge score (CKS) was 17.7 (SD 1.8), out of maximum 21. Training level (p = 0.001) and completing NICU rotation (p < 0.001) predicted higher CKS. Most RES agreed that NBS is useful and pediatricians play an important role in the NBS process, however, only 62% were comfortable with counseling. Higher level RES were more likely to follow NBS results in clinic (p = 0.0027) and know the contact agency for results (p < 0.001). Most RES wanted more NBS training during residency and were not aware of clinical algorithms like ACTion sheets developed by American College of Medical Genetics. We concluded that although RES have sufficient knowledge about NBS, there is a need for earlier RES education on available tools for NBS to enhance their comfort level and improve practices such as educating parents about the NBS process. Full article
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Open AccessArticle Evaluation of Technical Issues in a Pilot Multicenter Newborn Screening Program for Sickle Cell Disease
Int. J. Neonatal Screen. 2019, 5(1), 2; https://doi.org/10.3390/ijns5010002
Received: 30 October 2018 / Revised: 18 December 2018 / Accepted: 19 December 2018 / Published: 21 December 2018
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Abstract
A multicenter pilot program for universal newborn screening of Sickle cell disease (SCD) was conducted in two centres of Northern Italy (Padova and Monza). High Performance Liquid Chromatography (HPLC) was performed as the first test on samples collected on Guthrie cards and molecular [...] Read more.
A multicenter pilot program for universal newborn screening of Sickle cell disease (SCD) was conducted in two centres of Northern Italy (Padova and Monza). High Performance Liquid Chromatography (HPLC) was performed as the first test on samples collected on Guthrie cards and molecular analysis of the β-globin gene (HBB) was the confirmatory test performed on the HPLC-positive or indeterminate samples. 5466 samples of newborns were evaluated. Of these, 5439/5466 were submitted to HPLC analysis and the molecular analysis always confirmed in all the alteration detected in HPLC (62/5439 newborns); 4/5439 (0.07%) were SCD affected, 37/5439 (0.68%) were HbAS carriers and 21/5439 (0.40%) showed other hemoglobinopathies. Stored dried blood spots were adequate for HPLC and β-globin gene molecular analysis. Samples were suitable for analysis until sixteen months old. A cut-off of A1 percentage, in order to avoid false negative or unnecessary confirmation tests, was identified. Our experience showed that several technical issues need to be addressed and resolved while developing a multicenter NBS program for SCD in a country where there is no national neonatal screening (NBS) program for SCD and NBS programs occur on a regional basis. Full article
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Open AccessReview Newborn Screening for Lysosomal Storage Disorders: Methodologies for Measurement of Enzymatic Activities in Dried Blood Spots
Int. J. Neonatal Screen. 2019, 5(1), 1; https://doi.org/10.3390/ijns5010001
Received: 26 November 2018 / Accepted: 19 December 2018 / Published: 21 December 2018
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Abstract
All worldwide newborn screening (NBS) for lysosomal storage diseases (LSDs) is performed as a first-tier test by measurement of lysosomal enzymatic activities in dried blood spots (DBS). The currently two available methodologies used for measurement of enzymatic activities are tandem mass spectrometry (MS/MS) [...] Read more.
All worldwide newborn screening (NBS) for lysosomal storage diseases (LSDs) is performed as a first-tier test by measurement of lysosomal enzymatic activities in dried blood spots (DBS). The currently two available methodologies used for measurement of enzymatic activities are tandem mass spectrometry (MS/MS) and digital microfluidics fluorimetry (DMF-F). In this chapter we summarize the workflows for the two platforms. Neither platform is fully automated, but the relative ease of workflow will be dependent upon the specific operation of each newborn screening laboratory on a case-by-case basis. We provide the screen positive rate (the number of below cutoff newborns per 100,000 newborns) from all NBS laboratories worldwide carrying out MS/MS-based NBS of one or more LSDs. The analytical precision of the MS/MS method is higher than that for DMF-F as shown by analysis of a common set of quality control DBS by the Centers for Disease Control and Prevention (CDC). Both the MS/MS and DMF-F platforms enable multiplexing of the LSD enzymes. An advantage of MS/MS over DMF-F is the ability to include assays of enzymatic activities and biomarkers for which no fluorimetric methods exist. Advantages of DMF-F over MS/MS are: (1) simple to use technology with same-day turn-around time for the lysosomal enzymes with the fastest rates compared to MS/MS requiring overnight analytical runs.; (2) the DMF-F instrumentation, because of its simplicity, requires less maintenance than the MS/MS platform. Full article
(This article belongs to the Special Issue Newborn Screening for Lysosomal Storage Disorders)
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Int. J. Neonatal Screen. EISSN 2409-515X Published by MDPI AG, Basel, Switzerland RSS E-Mail Table of Contents Alert
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