Tandem mass spectrometric analysis for amino, organic, and fatty acid disorders in newborn dried blood spots: a two-year summary from the New England Newborn Screening Program.

BACKGROUND: Tandem mass spectrometry (MS/MS) is rapidly being adopted by newborn screening programs to screen dried blood spots for >20 markers of disease in a single assay. Limited information is available for setting the marker cutoffs and for the resulting positive predictive values. METHODS: We screened >160 000 newborns by MS/MS. The markers were extracted from blood spots into a methanol solution with deuterium-labeled internal standards and then were derivatized before analysis by MS/MS. Multiple reaction monitoring of each sample for the markers of interest was accomplished in approximately 1.9 min. Cutoffs for each marker were set at 6-13 SD above the population mean. RESULTS: We identified 22 babies with amino acid disorders (7 phenylketonuria, 11 hyperphenylalaninemia, 1 maple syrup urine disease, 1 hypermethioninemia, 1 arginosuccinate lyase deficiency, and 1 argininemia) and 20 infants with fatty and organic acid disorders (10 medium-chain acyl-CoA dehydrogenase deficiencies, 5 presumptive short-chain acyl-CoA dehydrogenase deficiencies, 2 propionic acidemias, 1 carnitine palmitoyltransferase II deficiency, 1 methylcrotonyl-CoA carboxylase deficiency, and 1 presumptive very-long chain acyl-CoA dehydrogenase deficiency). Approximately 0.3% of all newborns screened were flagged for either amino acid or acylcarnitine markers; approximately one-half of all the flagged infants were from the 5% of newborns who required neonatal intensive care or had birth weights <1500 g. CONCLUSIONS: In screening for 23 metabolic disorders by MS/MS, an mean positive predictive value of 8% can be achieved when using cutoffs for individual markers determined empirically on newborns.

Anonymous testing of newborn infants for HIV antibodies as a basis for estimating prevalence of HIV in childbearing women: the 1991-1994 study in Spain.

During 1991-1994, anonymous screening of newborn infants for maternal antibody to human immunodeficiency virus (HIV) was carried out in three regions of Spain: Valencia, Galicia and Sevilla. The newborn infants whose heel-stick blood eluates were satisfactory for HIV antibody tests were a consecutive series of 104 876, representing 99.3% of all newborn infants undergoing routine metabolic screening and estimated as comprising at least 98% of all births in the three regions. Enzyme immunoassay (EIA) positives were confirmed by immunoblot, yielding 246 confirmations: a rate of 2.3 per 1000. Seropositivity rates ranged from 1.4 per 1000 in Galicia to 2.1 in Sevilla and 3.1 in Valencia, and remained relatively stable in each region during the years of the study. Within socioeconomically defined subgroups of birth hospitals in Valencia and Galicia, all subgroups contained seropositives, even though there was a twofold to fivefold over-representation in the "inner city" public hospitals. To estimate the proportion of HIV-1-seropositive newborn infants who were positive for HIV-1 DNA, polymerase chain reaction (PCR) assays were performed on 165 dried blood spots that had been retained following positive immunoblot assays. Fifteen (9%) were PCR positive, and when this proportion is adjusted for the age-specific sensitivity of the method, it translates into an estimated HIV-1 transmission rate of 24% (range 18-36%). For 94,906 of the 104,876 newborn infants screened, the EIA used could detect antibodies that react with epitopes of HIV-1 and HIV-2. There were 30 newborn infants whose blood eluate was positive by this combined HIV-1/HIV-2 antibody screen and whose secondary screening with monovalent HIV-2 and HIV-1 EIA indicated that the HIV-2 reactivity was above the cut-off whereas the HIV-1 was not. Ranking these 30 results according to absolute HIV-2 reactivity and relative reactivity with respect to HIV-1 indicated that four infants were probable true HIV-2 seropositives and a total of 12 were possible HIV-2 seropositives, a prevalence of the order of 1:10000 to 1:20000 newborn infants. These anonymous population-based serological studies provide "leading-indicator" data to complement traditional AIDS surveillance for epidemiological and planning purposes.

Outcomes management: an interdisciplinary approach to improving patient outcomes.

Outcomes management provides a means for interdisciplinary collaboration in improving patient outcomes. The benefits of an outcomes management program are numerous, including decreasing healthcare costs, decreasing the length of stay, improving clinical outcomes, improving system processes, and fostering outcomes research. The outcomes manager is responsible for the development, implementation, and evaluation of an outcomes management program. One of the functions of an outcomes manager is developing collaborative practice teams to serve as vehicles of change through their analysis of outcomes data and the identification of best practice patterns. Interdisciplinary collaboration is a key component of an outcomes management program. Without an atmosphere os shared responsibility among disciplines for outcomes noted in a patient population, and recognition of individual expertise regarding care, efforts to produce change will move very slowly, if at all, and optimal improvements in care will be forfeited.

Early detection of human immunodeficiency virus on dried blood spot specimens: sensitivity across serial specimens. Women and Infants Transmission Study Group.

OBJECTIVE: To evaluate the use of dried blood spot (DBS) specimens and the early diagnostic value of the polymerase chain reaction (PCR) for detection of the human immunodeficiency virus (HIV) in DBS specimens collected at predefined age intervals from a large cohort of U.S. infants at risk of congenital or perinatal HIV infection. DESIGN: We assayed available DBS specimens (n = 272) obtained during the first 4 months of life from 144 infants (41 infected, 103 uninfected) born to HIV-infected mothers enrolled in the Women and Infants Transmission Study. The DBS PCR results were compared with infant HIV infection status, PCR on liquid blood, and viral culture results. Analyses also included sensitivity and specificity of assay as related to the age of the infant when the specimen was obtained. RESULTS: The DBS specimen PCR results were concordant with results from liquid blood specimens and with results from viral culture. The DBS PCR was highly specific for all age groups. Sensitivity in detecting HIV infection status rapidly increased during the first month of life, from 19% (5/26) by 1 week to 96% (25/26) by 1 month of age. Specimens obtained on the day of birth or the next day were the least likely to have detectable HIV DNA. CONCLUSIONS: The PCR assay of DBS specimens is a reliable tool for the early diagnosis of HIV infection and has important advantage over that of liquid blood DNA PCR and viral culture. These advantages include a lower volume of blood required for testing, increased safety, and ease of storage or transport of specimens. Thus DBS PCR is a useful test for clinical and epidemiologic tracking of infants at risk of HIV infection.

Collaborative practice teams: the infrastructure of outcomes management.

Collaborative practice teams consist of interdisciplinary providers who are charged with the process of implementing and refining an outcomes management program within a targeted population. Collaborative practice teams work under the assumption that clinical quality enhancement through practice standardization decreases care fragmentation, resulting in improved physiologic, psychosocial, and financial outcomes. Collaborative practice team members identify best practice through the implementation and testing of interdisciplinary interventions. Represented on a critical pathway, these practices are evaluated toward achievement of defined population outcomes. In this article, the authors review the process of collaborative practice team formation, expected pitfalls and barriers to effective collaboration, and the work accomplished by a collaborative practice team.

HIV mass screening of infants and mothers: historical, technical, and practical issues.

Screening groups of anonymous infants for HIV antibody, as an index of maternal infection rates, has been a widely used seroepidemiological method since being introduced in 1986 in Massachusetts (USA). One shortcoming has been the applicability only to parturient women, thus necessitating corrections for fertility rates in extrapolation to all women. A second disadvantage has been controversy and confusion about the distinction between anonymous seroprevalence studies and linked testing. However, there have been major advantages such as the "leading indicator" nature of the data obtained. Experience with screening nearly a half million Massachusetts newborns through December 1992 has shown seroprevalence rates stabilizing at 2.4 per 1000, and with consistent 10-fold differences between groups of birth hospitals serving different socio-economically defined populations. In addition to predicting the future of the AIDS epidemic in children, the information provides a reference point for comparing the completeness of targeted identifications of HIV infection in mothers and infants.

Cytomegalovirus immune globulin prophylaxis in liver transplantation. A randomized, double-blind, placebo-controlled trial.

OBJECTIVE: To study the effect of cytomegalovirus immune globulin (CMVIG) on prevention of cytomegalovirus (CMV) disease and its complications in patients receiving liver transplants. DESIGN: Randomized, multicenter, placebo-controlled, double-blind trial. SETTING: Four university-affiliated transplant centers in Boston (Boston Center for Liver Transplantation). PATIENTS: One hundred forty-one liver transplant recipients completed the study. INTERVENTION: CMVIG or placebo (1% albumin) given in a dose of 150 mg/kg body weight within 72 hours of the transplant, then at weeks 2, 4, 6, and 8, and at 100 mg/kg at weeks 12 and 16. MEASUREMENTS: Patients were observed for 1 year after transplantation for the development of CMV infection, disease, pneumonia, as well as for opportunistic fungal infections, graft survival, and mortality. Weekly cultures were taken of urine, buffy coat, and throat wash for CMV for 2 months, then monthly, and at any clinical illness. RESULTS: Using a Cox proportional hazards model, CMVIG was shown to reduce severe CMV-associated disease (multi-organ CMV disease, CMV pneumonia, or invasive fungal disease associated with CMV infection) from 26% to 12% (relative risk, 0.39; 95% CI, 0.17 to 0.89). When we controlled for the use of monoclonal antibodies to T cells (OKT3), CMVIG use was still protective (relative risk, 0.39; CI, 0.17 to 0.90). Rates of CMV disease were reduced from 31% to 19% (relative risk, 0.56; CI, 0.3 to 1.1) in CMVIG recipients although no effect on rates of CMV infection, graft survival, or patient survival at 1 year were shown. When we controlled for the urgency of transplantation and OKT3 use, a reduction in CMV disease (relative risk, 0.22; CI, 0.06 to 0.81) was shown for globulin recipients for all serologic groups except for the highest risk group (the CMV-seropositive donor, CMV-seronegative group). CONCLUSION: CMVIG reduced the rate of severe CMV-associated disease in patients undergoing orthotopic liver transplantation. No effect of CMVIG on CMV donor-positive, recipient-negative liver transplant recipients was shown, suggesting a need for additional prophylactic strategies.

Identifying human immunodeficiency virus infection at birth: application of polymerase chain reaction to Guthrie cards.

Guthrie cards containing dried blood spots from 67 children now known to be infected with human immunodeficiency virus (HIV) and 63 children now classified as having had seroreversion were retrieved from the newborn infant archives from 1986 through 1991 to determine whether the polymerase chain reaction (PCR) could predict the infection at birth. The PCR assays operating at a sensitivity capable of detecting 2 to 10 copies of HIV proviral DNA per microgram were able to detect HIV proviral DNA in 52% (35/67) of the infected neonatal blood specimens. Longer storage times did not decrease PCR positivity rates, an advantage over assays for HIV antibody. Children whose clinical progression has been aggressive had high rates of PCR positivity in neonatal specimens, 50% (7/14) in those with low CD4 cell counts during the first year of life, 71% (10/14) in those with Pneumocystis pneumonia or disseminated cytomegalovirus infection by age 1 year, 62% (18/29) in those with onset of acquired immunodeficiency syndrome by 18 months, and 66% (14/21) in those who died of the disease by 36 months of age. No evidence of HIV proviral DNA was found in any of the 63 specimens from children with seroreversion. We conclude that PCR, using routinely available dried blood spots from neonates, has applications in early diagnosis and in epidemiologic projections going beyond current seroprevalence studies.

Perinatally acquired human immunodeficiency virus infection: extent of clinical recognition in a population-based cohort. Massachusetts Pediatric HIV Surveillance Working Group.

To evaluate factors that may affect the timely diagnosis of children with human immunodeficiency virus (HIV) infection, we compared data derived from two population-based pediatric HIV studies. Data from anonymous newborn HIV serosurveys were used to estimate the number of children born to HIV-seropositive mothers. A statewide active surveillance project determined the number of HIV-exposed children who had been clinically recognized. Of 88,732 Massachusetts newborn specimens tested anonymously for HIV antibodies during a 12-month period (November, 1987, to October, 1988), 223 were positive. As of October, 1991, 78 of these children (35%) had been identified by a statewide network of infectious disease physicians. HIV-exposed children born in inner city hospitals were more likely to have come to medical attention than those born in suburban hospitals (47% vs. 17%). Among the 29 children with confirmed HIV infection (13% of 223), the initial evaluation for HIV occurred at an earlier age among children born in inner city hospitals than among children born in other areas. HIV testing practices that rely heavily on risk assessment may result in delayed diagnosis of HIV infection in children whose mothers are not perceived to be at risk.

Newborn screening for congenital Toxoplasma infection: five years experience in Massachusetts, USA.

Since 1986, all Massachusetts newborn filter paper blood specimens, and some from New Hampshire, have been screened for the presence of IgM antibodies to Toxoplasma gondii using an enzyme-linked IgM capture assay. Among approximately 530,000 infants screened, 40 had serologically confirmed congenital toxoplasma infection, and 4 additional infants had borderline serologies, for an overall identification and treatment rate of 1:12,000. False positive results from the newborn's filter paper specimen occurred in 22 infants (1/24,000); these were clarified by tests for IgM and IgG in serum specimens obtained 2-3 weeks later from the infant and mother. The screening program would have failed to detect 3 infants with severe infection who were diagnosed on clinical grounds prenatally or at birth and lacked IgM. No infants with a later diagnosis of congenital toxoplasmosis that was missed by screening are known to our statewide network of pediatric infectious disease consultants. Follow-up studies are in progress to evaluate more completely the sensitivity of the IgM assay in newborns and the efficacy of treatment.

Polymerase chain reaction in detecting HIV infection among seropositive infants: relation to clinical status and age and to results of other assays.

The polymerase chain reaction (PCR) for human immunodeficiency virus (HIV) was evaluated using coded blood specimens from infants whose clinical status is now known. A micromethod for the efficient isolation of mononuclear cells from small volumes of blood, and definitions of PCR positivity that took into account the number and purity of these mononuclear cells, were established in an attempt to define parameters for quality assurance. Results of HIV culture, p-24 antigen, and HIV-specific IgA obtained on the same specimens were compared to PCR results. PCR had a specificity of 100% among 83 specimens from 50 babies known to be uninfected. Sensitivity among 26 HIV-infected infants older than 3 months was 98% (44 of 45 specimens); the one negative specimen, which had also been culture negative, gave a positive PCR result on the remaining aliquot when tested after decoding. Among infected infants less than 3 months old, which is an age when diagnosis by other assays is most problematic, PCR identified 10 of 10 patients (10 of 11 specimens) including two younger than one month. Viral culture showed the best concordance with PCR; however, in three infants, positive PCR results were observed several months before positive results were observed by viral culture.

Prevalence of HIV infection in childbearing women in the United States. Surveillance using newborn blood samples.

A national, population-based survey was initiated in 1988 to measure the prevalence of human immunodeficiency virus (HIV) infection in women giving birth to infants in the United States. Following standardized procedures, residual dried-blood specimens collected on filter paper for newborn metabolic screening were tested anonymously in state public health laboratories for maternal antibody to HIV. As of September 1990, annual survey data were available from 38 states and the District of Columbia. The highest HIV seroprevalence rates were observed in New York (5.8 per 1000), the District of Columbia (5.5 per 1000), New Jersey (4.9 per 1000), and Florida (4.5 per 1000). Nationwide, an estimated 1.5 per 1000 women giving birth to infants in 1989 were infected with HIV. Assuming a perinatal transmission rate of 30%, we estimate that approximately 1800 newborns acquired HIV infection during one 12-month period. Preventing transmission of HIV infection to women and infants is an urgent public health priority.

KIE: The authors present the initial results from a national population-based survey initiated in 1988 to measure the prevalence of HIV infection in women giving birth in the United States. Residual dried-blood specimens collected for newborn metabolic screening were tested anonymously in state public health laboratories for maternal antibody to HIV. Basing their estimates on survey data from 38 states and the District of Columbia, the authors estimate the incidence of HIV infection in infants. They urge making the prevention of transmission of HIV infection to women and infants an urgent public health priority.

HIV seroprevalence surveys of childbearing women--objectives, methods, and uses of the data.

A seroprevalence survey of human immunodeficiency virus (HIV) among childbearing women is being conducted in 43 States and Territories as one of the family of HIV seroprevalence surveys. This blinded survey, in which serologic test results are not linked to identifiable persons, uses neonatal dried blood specimens on filter paper to test for maternal antibodies to HIV. This survey provides relatively unbiased estimates of prevalence of HIV infection in the population of women delivering live children during given survey periods, by month or quarter of delivery, geographic area, and demographic subgroup. This objective will be met while protecting the integrity and efficient conduct of neonatal screening programs and ensuring patient anonymity. Information from this survey will be used to (a) assess the levels and trends of HIV infection in women and infants, (b) help develop and evaluate prevention programs, and (c) project the number of women and children who will develop HIV infection and the acquired immunodeficiency syndrome (AIDS) and will require health care and social services in the future.

Eastern equine encephalitis in Massachusetts: a report of 16 cases, 1970-1984.

We studied the case records of 16 patients with eastern equine encephalitis (EEE) in Massachusetts from 1970 to 1984 and compared their presentations, courses, and outcomes with the data available from previous epidemics. In recent years, there has been a greater frequency of EEE in adults, whereas in the past it was considered a disease of children. Also, prognosis for a good functional recovery seems to be correlated with age over 40 years, a long prodromal course (5 to 7 days) of constitutional symptoms, and the absence of coma. Previous reports did not mention these significant correlations. We also stress the positive and negative diagnostic correlations, in order to distinguish between EEE and herpes simplex encephalitis.

Seroprevalence of human immunodeficiency virus among childbearing women. Estimation by testing samples of blood from newborns.

Attempts to predict the course of the epidemic of acquired immunodeficiency syndrome (AIDS) have been hampered by the lack of an objective, practical way to estimate the prevalence of infection with the human immunodeficiency virus (HIV) in the general population. Testing for the prevalence of HIV infection in women should be a sensitive means to track the epidemic and to study the potential for perinatal transmission. Antibodies in maternal blood are contained in neonatal blood specimens routinely collected on absorbent paper for other purposes, such as screening for phenylketonuria; we therefore tested for HIV antibody in these specimens. Analysis of batches of individually blinded specimens from selected hospitals protected the anonymity of the mothers and babies and was cost efficient. Using the newborn's blood as an indicator of the mother's serologic status, we concluded that 1 of every 476 women (2.1 per 1000) giving birth in Massachusetts was positive for HIV antibody by immunofluorescence assay or enzyme-linked immunosorbent assay, both confirmed by immunoblot (Western blot) testing. The prevalence of HIV infection varied according to the type and location of the maternity hospitals; rates of seropositivity were highest in inner-city hospitals (8.0 per 1000), lower in mixed urban and suburban hospitals (2.5 per 1000), and lowest in suburban and rural hospitals (0.9 per 1000). This method is useful for collecting data needed to plan and evaluate prevention strategies and to predict the health care resources that will be needed to care for women and children who contract AIDS. Because other states have newborn screening programs similar to the Massachusetts program, this approach can be used for national surveillance of AIDS in women.

Isolated antibody to hepatitis B surface antigen and response to hepatitis B vaccination.

To determine the need for immunization of health workers with antibody to hepatitis B surface antigen (anti-HBs) as their only serologic marker of previous hepatitis B exposure, we studied the level, persistence, and immunologic specificity of isolated anti-HBs in 46 persons identified during screening for hepatitis B vaccine. We rescreened these persons 1 year later, administered a single dose of hepatitis B vaccine, and determined the anti-HBs level at 1, 2, and 8 weeks after vaccination. Isolated anti-HBs levels were low and antibody did not persist; 22 subjects tested had lost detectable anti-HBs within 19 months even though immunologic specificity was shown in vitro in 34. Anamnestic responses suggesting previous exposure and immunity were seen in only 10 subjects; 5 of these subjects had moderate-level, persistent anti-HBs. Although some persons with naturally acquired, isolated anti-HBs may be protected from hepatitis B, the immunologic specificity and protective value of anti-HBs, especially when levels are low, remain questionable.

Absence of antibodies to HTLV-III in health workers after hepatitis B vaccination.

A proportion of the plasma for the triply inactivated, plasma-derived hepatitis B vaccine produced in the United States is obtained from homosexual men. Because homosexual men are a high-risk group for the acquired immunodeficiency syndrome (AIDS), concern has emerged that the vaccine could harbor the AIDS agent. To evaluate this risk, we tested 15-month postvaccination serum samples for antibodies to human T-cell lymphotropic virus type III in 100 health care workers who had received inactivated hepatitis B vaccine lots made from plasma collected between 1977 and 1979 and 100 who had received placebo injections. None of the 200 health workers had serological evidence of human T-cell lymphotropic virus type III infection. These serological findings lend additional support to earlier epidemiologic and immunologic observations suggesting that hepatitis B vaccine does not transmit infection with an AIDS virus.