Exam 2 Flashcards
Series of blood tests performed on a neonate with the goal of early identification and treatment of disease
newborn screening
newborn screening consists of
- Individual tests for specific diseases (PKU)
- Tandem mass spec
- Genetic probes
- Hearing screen
- Pulse oximetry screening
Galactosemia screening was adopted in all 50 states when
mid 1970’s
Features of any Screening Test (6)
- High sensitivity
- Disease with severity which would warrant early detection
- Cheap, easy and fast
- Definitive test is available
- Early detection can change the course of the illness
- Treatment available- historically a requirement, now contorversial
the probability that a person who truly has a disease will have a positive test. This is a “true positive”
sensitivity
Screening tests should have a very high _____ rate, though it means sacrificing ____
high sensitivity rate
specificity
the probability that a person who really does not have the disease will have a negative test. This is a “true negative.”
specificity
true positive
sensitivity
true negative
specificity
a person who tests as negative but who is actually positive
false negative
a person who tests as positive but who is actually negative
false positive
the likelihood that a person has the disease given a positive test result
positive predictive value
the likelihood that a person does not have the disease given a negative test result
negative predictive value
who mandates and gives states time to comply as states have particularities
HHS
what are the screening requirements for CO
initial and second test screening (second test around 1-2 weeks of age)
**some diseases show up later and can be missed at birth screening like thyroidism
tests currently being screened in CO (9)
- Phenylketonuria*
- Congenital Hypothyroidism*
- Hemoglobinopathies*
- Galactosemia
- Cystic Fibrosis
- Biotinidase Deficiency
- Congenital Adrenal hyperplasia*
- B.A.E.R. (hearing test)
- TANDEM Mass spect
what tests use dried blood spot sample
- PKU
- Hypothyroidism
- Sickle cell disease
First and classic congenital disease identified by newborn screen
PKU
a disorder of amino acid metabolism where branched chain AA are not broken down appropriately caused by an enzyme deficiency
PKU
sx include:
- neurodevelopmental problems:
- Developmental delay to severe cognitive impairment
- Seizures
- Autism
- Hyperactivity
- Aggressive behavior
- Hair and skin changes incl. hypopigmentation (from lack of melanin)
PKU
How is PKU treated?
-restricted diet- elimination of certain amino acids**Children of mom off diet during pregnancy at risk for congenital heart disease
Most common true positive test
and most common test to be missed on 1st screening and picked up on second screening
hypothyroidism
when do you check for hypothyroidism
Check as close to or after 24 hours bc there is a TSH spike immediately after birth which can alter results
if mom is on TH what can happen to the babys results
get false positive
Untreated, causes “cretinism”
hypothyroidism
sx include:
- “cretinism”
- Cognitive impairment
- growth and neurologic abnormalities,
- fatigue,
- skin changes,
- coarse hair
- large tongue
hypothyroidism
how is hypothyroidism treated
Thyroid hormone for life
*normal IQ, good health
sx include: Painful crises Aplastic crises Predisposition to infection Tendency toward infarction Bony changes associated with high blood cell turnover
sickle cell disease
caused by ectopic thyroid gland (migrated wrong)
hypothyroidism
commonly causes bone marrow to shunt down or infarct of the spleen
sickle cell disease
sickle cell is screen by screening for what conditions
Hemoglobinopathies Screen
diagnostic/confirmatory test and screening test for sickle cell disease
screening: isoelectric focusing
diagnostic/confirmatory: hemoglobic electrophoresis
treatment of sickle cell
- Early immunization against “encapsulated organisms,” pneumococcus and H.flu
- Penicillin prophylaxis
- Early treatment of crises
- Attention toward hydration
- Avoid triggers such as infection, hypoxia (such as altitude)
- Genetic counseling of parents
- Pain meds
Disorder of membrane transport of ions, specifically sodium and chloride (usually genetic mutation)
cystic fibrosis
sx include:
1. Chronic lung disease
(secretions can’t be cleared and act as plugs)
2. Chronic infection
3. Malabsorption/ malnutrition
(secretions are thick and block pancreatic function)
CF
treatment of CF
- C.F. is managed, not cured
- Antibiotics, preventive and therapeutic
- Bronchodilators
- Exogenous pancreatic enzymes
- Attention to nutrition
how do you screen for CF
- Screen measures immunoreactive trypsinogen
- Definitive test is sweat chloride
- Genetic testing for specific mutation
an analytic instrument that separates and determines the quantity of ions in a sample based on mass-to-charge ratios
TANDEM Mass Spectrometry
*difficult to determine normal ranges
TANDEM Mass Spectrometry is used to detect primarily what kind of disorders
- organic metabolism
- AA metabolism
- FA metabolism
How do you screen for Medium chain Acyl-CoA dehydrogenase deficiency
MASS spect
Times of stress and fasting, will cause hypoglycemia and shock
M.C.A.D
treatment of M.C.A.D.
Treatment is to avoid fasting & dehydration and administer carnitine
(might need IV hydration)
Most debilitating human lymphoid deficiency disease
severe combined immune deficiency (SCID)
impairs the differentiation of both T and B lymphocytes
SCID
Infants are highly susceptible to recurring infections of viruses, fungi and bacteria
SCID
how is SCID inherited
X-linkedor autosomal recessive control
how is SCID tested for
genetic probe
confirmatory test- gentic marker
how do you treate SCID
bone marrow transplant
hemoglobin is a tetramer of 4 beta strands
Bart’s hemoglobin
normal adult hemoglobin has what
Hbg A, has 2 alpha and 2 beta strands
testing for bart’s hemoglobin
- genetic probe
2. confirmatory test- hemoglobin electrophoresis
One gene missing
silent carrier
2 missing genes
Alpha-thal trait
*usually do well clinically
3 missing genes
alpha-thal major
sx include:
hydrops fetalis
incompatible with life because of inability to carry oxygen to tissues leading to high output congestive heart failure, hepatosplenomegaly, and end organ failure.
Demise occurs in utero or short after birth usually.
alpha-thal major
distribution of Alpha-thalassemia
along the malaria belt
*same as sickle cell disease
the 2ndmost frequently observed autosomal recessive lethal disorder
spinal muscular atrophy (SMA)
types of SMA
type 1- lethal in first year
type 2
type 3- may live into adulthood
how do you screen for SMA
preparation of genomic DNA , a “calibrated short-amplicon genotyping”, and high-resolution melt profiling
high prevalence in Navajos
SCID
when does the 1st newborn screening take place
24-48 hrs after birth bc you need several feedings first
ex. galactosemia
when does the 2nd newborn screening take place
8-14 days
How is the dried blood test administered?
- Blood is drawn from baby’s heel and allowed to dry on filter paper
- Sent to Colorado Dept. of Public Health and Environment where individual tests are run
- Results sent to hospital, PCP, specialty follow-up clinics and definitive tests arranged with families
secondary causes of congential hearing loss
irreversible and permanent impairments in:
speech, language, and cognitive abilities
how do you test for congenital hearing loss
BAER
Brainstem auditory evoked response measures brainwave response to broadband click
*non-invasive
*most accurate a 2 weeks but do it at birth when newborns are captive
The first non-blood test screen
BAER hearing screening
how do you screen for CCHD
pulse oximetry
heart disease comprises those lesions that require intervention within 1st month of life
cirtical heart disease
pulse ox helps screen for these CHDs
- Tetralogy of Fallot
- Transposition of Arteries
- Truncus Arteriosis
- Tricuspid Atresia
- TAPVR
- Pulmonic Stenosis
- Hypoplastic Left Heart
- Coarctation of the Aorta
where do you place the pulse ox probe on the baby
Place probe on right hand (preductal) and one foot (postductal)
Room air saturation less than ____% requires further workup
95%
what is the definitive test for CCHD
echo
Approximately ____ % of all newborns have a major malformation diagnosable at birth
2%
What is the most common cause of infant mortality in the US
Malformations
groups of anomalies occurring together with a common cause
syndrome
groups of anomalies occurring together more often than chance alone would allow but cause is unknown
associations
one primary defect causes the next, which causes the next
sequence
presents with:
- Small chin causes tongue to be pushed up and back (glossoptosis)
- Position of tongue prevents normal closure of palate, causing cleft palate
Pierre Robin Sequence
*cause is unknown
PIerre Robin Sequence results in
Results in obstruction of airway and feeding difficulties
*tends to improve as mandible grows in the first year of life
complete or partial absence or abnormal formation of a structure caused by environmental or genetic factors which interfere with development
malformation
a body part which was forming normally but was acted upon by environment to be distorted. Most often, musculoskeletal and fixable
deformation
a body part was forming normally when an event occurs that changes it dramatically and irreversibly– often amniotic bands or vascular accident
disruption
the inner membrane of the sac which contains the fetus
amnion
example of a disruption
amion acting as a tourniquets causing amputations
Club foot, properly known as “talipes equinovarus” is an example of what
deformation
Caused by in utero positioning and restriction of movement
Can not be passively moved back to normal anatomic position
club food deformation
when is the most common ttime for a malformation to occur
period of organogenesis
weeks 3-8
an example of a malformation
CHD
Physical exam findings that occur in less than 4% of population but have no major intrinsic medical significance
Minor malformation
most minor malformations are found where
face or hands (70%)
ex. syndactyly
___% of neonates have 1 minor anomaly
___% of neonates have 1 major anomaly
15-20% minor
3% major
Single, uninterrupted horizontal crease on palm
Previously called “simian crease”
transverse palmar crease
transverse palmar crease occurs in __% of babes with down syndrome and ___% of chinese
45% of down syndome babes
16% of chinese -considered a normal variant
- occur in preauricular region from tragus to corner of mouth
- Can be associated with hearing loss if bilateral- hearing screen
ear tags
*Not associated with renal disease
examples of major malformations
omphalocele
CHD
____ % of all malformations occur as isolated malformation: i.e., not as part of a syndrome
70%
Multiple malformations are usually due to what etiology
Chromosomal : 14.7%
Single gene: 2.5%
Teratogen: 0.4%
types of chromsomal disorders
- Abnormalities of number- eg. Trisomy v. triploidy
2. Abnormalities of structure- eg. Deletions or duplications of portions of chromosome
a subset of genetics in which we look at the turning on or off of specific genes
genomics
Explains how normal tissues vary from organ to organ
Also explains how teratogens can effect the expression of an individual’s genetic makeup
genomic defect
2 techniques used for prenatal diagnosis of genetic defects and what they can be used for
2 techniques:
- Amniocentesis
- Chorionic villus sampling
Can be used for:
- Biochemical screening
- Genetic screening (karyotype and FISH probe)
Under ultrasound guidance, a spinal needle is inserted through the maternal abdominal wall and uterine wall, into a pocket of amniotic fluid
r
amniocentesis
risks of amniocentesis
- fetal loss
- damage to fetal structures
- leakage of amniotic fluid
*risk is greater in 1st trimester than second
amniotic fluid contains
cells from skin and kidney
- and then cultured, karyotyped, or FISH technique
how is amniotic fluid made/cycled
amnion makes fluid, baby swallows it and then “urinates” it back into the amniotic sac
Needle biopsies a portion of the chorion
Approach may be trans-vaginal or trans-abdominal, depending upon location of the placenta
Chorionic Villus Sampling
when is Chorionic Villus Sampling best performed
11-13 weeks
risks of Chorionic Villus Sampling
2-3% risk of fetal loss
Why make the diagnosis of a syndrome in a neonate?
- External signs give clues to serious, internal malformations
- Enables provider to help family plan early interventions for expected issues
- Genetic counseling; incl. likelihood of recurrence
- Helps family to deal with uncertainty (prognosis, prediction of potential future problems, community support)
Visual inspection of chromosomes and their banding (ID’s all types of specific abnormalities)
karyotyping
indications for karyotyping (5)
- Confirmation of a known syndrome
- Infants with multiple congenital anomalies
- Child with developmental delays and morphologic changes
- Ambiguous genitalia
- Still born infant with malformation
advantage of karyotyping
- Can see structure of chromosomes.
2. Human genome project has enabled us to make more diagnoses based on karyotype
disadvantage of karyotyping
- needs to grow in tissue culture, therefore takes about a week to get results
DNA probe + label
Hybridize with sample cells
Fluorescent detector
FISH Probe
Fluorescent In Situ Hybridization
disadvantage of FISH
Asks a specific question; ie. You have to have the disorder in mind when selecting which probe to use.