Fragile X Screening by Quantification of FMRP in Dried Blood Spots by a Luminex Immunoassay

The Journal of Molecular Diagnostics, Vol. 15, No. 4, July 2013

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Fragile X Screening by Quantification of FMRP in Dried Blood Spots by a Luminex Immunoassay Giuseppe LaFauci,* Tatyana Adayev,* Richard Kascsak,* Regina Kascsak,* Sarah Nolin,y Pankaj Mehta,z W. Ted Brown,y and Carl Dobkiny From the Departments of Developmental Biochemistry,* Human Genetics,y and Developmental Neurobiology,z New York State Institute for Basic Research in Developmental Disabilities, Staten Island, New York Accepted for publication February 20, 2013. Address correspondence to Giuseppe LaFauci, Ph.D., NYS IBR, 1050 Forest Hill Rd., Staten Island, NY 10314. E-mail: giuseppe.x.lafauci@ opwdd.ny.gov.

Fragile X is the most common inherited cause of intellectual disability and is frequently associated with autism. The syndrome is due to mutations of the FMR1 gene that result in the absence of fragile X mental retardation protein (FMRP). We have developed a rapid, highly sensitive method for quantifying FMRP from dried blood spots and lymphocytes. This assay uses two new antibodies, a bacterially expressed abbreviated FMRP standard, and a Luminex platform to quantify FMRP. The assay readily distinguished between samples from males with fragile X full mutations and samples from normal males. It also differentiated mosaic from nonmosaic full-mutation male samples. This assay, because of its methodology and minimal cost, could be the basis for newborn or population screening. (J Mol Diagn 2013, 15: 508e517; http://dx.doi.org/10.1016/j.jmoldx.2013.02.006)

The fragile X syndrome (FXS) (OMIM 309550) results from the absence of fragile X mental retardation protein (FMRP). This lack of expression is most commonly due to the expansion of a CGG repeat in the 50 -untranslated region of the fragile X mental retardation gene (FMR1) to more than 200 repeats (the full mutation), which leads to hypermethylation of the FMR1 gene promoter and silences transcription.1e5 In very rare cases, the syndrome is due to partial or complete deletion of the FMR1 gene or to point mutations within it.2,6,7 FMR1 alleles are highly polymorphic and are classified by CGG repeat size. Normal FMR1 alleles (6 to 44 repeats) rarely change in repeat number on transmission. Intermediate FMR1 alleles (45 to 54 repeats) may show a low level of instability,8,9 which is influenced by the AGG interruption pattern,10 but the intermediate alleles very rarely change repeat size class. Individuals with premutation alleles (55 to 200 repeats) have normal or somewhat reduced FMRP levels, but have increased FMR1 mRNA11 that is translated with reduced efficiency.12,13 Premutation alleles are highly unstable and may expand to the full mutation in one generation when transmitted by a female. Premutation carrier prevalence in North American populations was estimated at approximately 1 in 151 females and 1 in 468 males in a population-based sample Copyright ª 2013 American Society for Investigative Pathology and the Association for Molecular Pathology. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jmoldx.2013.02.006

of 6747 Wisconsin adults.14 The full-mutation allele, with >200 repeats, has an estimated prevalence of 1 in 3600 to 4000 males and 1 in 4000 to 6000 females (http://www. fragilex.org/fragile-x-associated-disorders/prevalence, last accessed April 25, 2013). Some individuals are mosaic, having both the full mutation and a premutation in blood cells15 (mosaic full mutation). The rate of adaptive skills development is two to four times greater in mosaic cases than in full-mutation cases.16 At present, there is no newborn screening for fragile X in the United States, although pilot projects are underway.16,17 Despite the availability of commercial molecular fragile X diagnostic testing, the average age at which the fragile X syndrome is diagnosed in males has remained unchanged, at approximately 36 months.17,18 Delay in diagnosis prevents Supported by funds from the New York State Office of People with Developmental Disabilities. Disclosures: A nonprovisional patent application (no. 13/493318), “System and Method for Quantifying Fragile X Mental Retardation 1 Protein in Tissue Samples,” was filed on June 11, 2012, with the U.S. Patent & Trademark Office. The owner of the patent is the Research Foundation for Mental Hygiene, Inc., and G.L., R.K., and W.T.B. are the inventors. Portions of this work were presented at the 13th International Fragile X Conference in Miami, Florida (July 25e29, 2012).

FXS Immunoscreening of DBS by Luminex early therapeutic intervention for affected individuals and genetic counseling for their families. Early detection may become even more critical if pharmacological therapies specific for fragile X that are currently in phase 2 or 3 clinical trials19 prove effective. Here, we describe an inexpensive immunoassay based on a Luminex (Austin, TX) platform that detects FMRP in dried blood spots (DBS), as well as in fresh human lymphocytes and other tissue samples. The assay accurately measures FMRP in a DBS sample and can identify males with the full mutation with sensitivity and specificity approaching 100%. This highly accurate test could be the basis for a fragile X test for newborn screening, as well as for population studies of fragile X.

(LabSource, Romeoville, IL). Each disk was placed into a well of low-protein-binding Durapore MultiScreen 96well filter plates (EMD Millipore, Billerica, MA), and protein was eluted with agitation at 4 C overnight in 50 mL of extraction reagent (as above). Eluates were collected by centrifugation into a 96-well catch plate and were used in the Luminex assay. We compared the Luminex results for eluates from 30 randomly chosen 3-mm disks with the 28.0mm2 eluate. The FMRP levels detected in the 3-mm disk eluate were consistently 25% of the FMRP detected in the 28-mm2 eluate (r Z 0.91).

Lymphocyte and Lymphoblastoid Extracts

Blood samples were obtained from individuals being evaluated for fragile X at the New York State Institute for Basic Research in Developmental Disabilities (IBR) or were samples received at the Specialty Clinical Laboratory at IBR for fragile X DNA analysis. Control blood samples were obtained from IBR staff volunteers who were confirmed to be of normal genotype by DNA analysis. This study was approved by the Institutional Review Board of IBR.

Blood samples (6 to 8 mL) were collected in Vacutainer CPT tubes with citrate anticoagulant (BD, Franklin Lakes, NJ), and lymphocytes were isolated within 2 hours of blood collection, according to the manufacturer’s instructions. Cell pellets were stored at 70 C. For protein preparation, pellets were lysed in extraction reagent (as above). After a brief sonication, cell debris was removed by centrifugation at 16,000  g for 15 minutes; the protein concentration in the supernatant was determined using a Pierce BCA protein assay (Thermo Fisher Scientific). Long-term lymphoblastoid cells were collected at 400  g, washed in PBS, and frozen at 70 C. Extracts were prepared as described for lymphocytes.

DBS

Antibodies

Blood was spotted onto ID bloodstain cards BFC180 (WB100014; GE Healthcare, Piscataway, NJ), using a syringe with an 18-gauge needle. Cards were dried overnight and stored in low-gas-permeable plastic bags with desiccant packs, according to DBS guidelines and published protocols.20,21 Moisture, heat, and direct sunlight are detrimental to the stability of DBS.20,22

The mouse monoclonal antibody (mAb) 6B8 was generated by immunizing mice with a human FMRP expressed in Sf9 insect cells infected by a recombinant baculovirus.23 The baculovirus (generously provided by M. Toth) included the entire human FMRP open reading frame, which was in-frame with six copies of a His tag; this baculovirus was used to prepare high-titer viral stocks. Sf9 cells (grown in suspension at 27 C) were infected with the baculovirus and cells were harvested at 72 hours after infection. Recombinant FMRP was purified from lysed cells by nickelenitrilotriacetic acid column chromatography (Ni-NTA purification system; Life TechnologieseInvitrogen, Carlsbad, CA) according to the manufacturer’s instructions. Three male FVB Fmr1tm1Cgr mice were immunized four times at 3-week intervals by subcutaneous injection of 100 mg of recombinant FMRP in TiterMax adjuvant (CytRx, Norcross, GA). Mice received additional injections of 50 mg antigen in PBS for three consecutive days before animal sacrifice and spleen removal. After splenocyte fusion to cells of the NSO myeloma cell line (ATCC, Manassas, VA), cells were processed as described previously to clone hybridomas producing anti-FMRP mAbs.24,25 Several anti-FMRP mAbs were isolated, characterized (LaFauci et al, unpublished data), and purified from ascites fluid by protein G spin column chromatography (Pierce kit 89979; Thermo Fisher Scientific) according to the manufacturer’s instructions. Clone 6B8, used in the present

Materials and Methods Subjects

Elution of FMRP from DBS Three 6.9-mm-diameter disks (37.4 mm2) were cut from each card with a paper punch (MCG503, 1/4 inch; McGill, Marengo, IL) and then were transferred into a microtube. Proteins were eluted in 200 mL of extraction reagent (Pierce M-PER mammalian protein extraction reagent; Thermo Fisher Scientific, Rockford, IL) containing 150 mmol/L NaCl, 10 mg/mL chymostatin, 10 mg/mL antipain, and 1 protease inhibitor cocktail (Complete mini tablets, EDTAfree; Roche Applied Science, Indianapolis, IN) by shaking for 3 hours at room temperature. After a brief centrifugation at 10,000  g, the eluates were decanted by pipette, and 50 mL was used in the assay. This 50 mL corresponds to an eluate from 28.0 mm2 (ie, 25% of three 6.9-mm disks). The assay was reliably performed with eluates from samples as small as a 3-mm disk (7.1 mm2). A 3-mm-diameter disk was cut from each ID card with a Harris Micro-Punch

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LaFauci et al study, recognized full-length human FMRP with high affinity and specificity. Rabbit anti-FMRP polyclonal antibody R477 was obtained by immunizing rabbits with the oligopeptide DDHSRTDNRPRNPREAK, which corresponds to a region of the carboxyl terminus of human FMRP spanning residues 554 to 570. This oligopeptide was conjugated to KLH and injected subcutaneously to two 8-week-old, 5-pound (w2.27 kg) female New Zealand rabbits (Charles River Laboratories International, Wilmington, MA) in Freund’s complete adjuvant, followed by four immunizations at 2- to 3-week intervals. Rabbits were tested for the presence of anti-FMRP antibodies by enzyme-linked immunosorbent assay using 96-well plates coated with 5 mg/mL of oligopeptide conjugated to OVA. One rabbit’s serum had the highest titer (R477). This antibody was purified from serum using a Pierce Melon Gel IgG purification system (Thermo Fisher Scientific) according to the manufacturer’s instructions. Both mAb 6B8 and R477, are available on request. Chemicon antiFMRP mAb 1C3 (MAB2160) and mouse anti-GAPDH (MAB374) were purchased from EMD Millipore. Goat anti-rabbit phycoerythrin-conjugated IgG (P2771MP) was purchased from Life TechnologieseInvitrogen.

Recombinant Fusion Protein for FMRP Quantification A glutathione S-transferase (GST) fusion protein carrying the epitopes of mAb 6B8 and R477 was constructed in two steps. First, a double-stranded oligomer encoding a nine-aminoacid sequence of FMRP (amino acids 344 to 352) that includes the mAb 6B8 epitope was cloned into vector pGEX4T (GE Healthcare) using the BamHI and EcoRI sites. Second, the resulting plasmid was modified to include the R477 epitope by ligating (at EcoRI and XhoI sites) an FMR1 sequence corresponding to amino acids 546 to 605. The latter sequence was obtained by PCR using a cloned FMR1 cDNA and primers 50 -CGGAATTCCGTGGAGGAGGCTTCAA30 and 50 -CCCTCGAGCAGCCGACTACCTTCCACTG-30 (forward and reverse, respectively). Plasmids in bacterial clones that expressed proteins recognized by both antibodies (pGEX-hFMR1-SR7) were isolated and expressed in E. coli strain BL21 by isopropyl b-D-1-thiogalactopyranoside (IPTG) induction. The fusion protein, GST-SR7, was purified by glutathione-Superflow resin (Clontech Laboratories, Mountain View, CA) according to the manufacturer’s instructions. Eluted GST-SR7 was dialyzed against 25 mmol/L Tris-HCl pH 7.4, 150 mmol/L NaCl buffer, concentrated in an Amicon Ultra-15 10K centrifugal filter device (EMD Millipore), aliquoted, lyophilized, and stored at 70 C.

Durapore MultiScreen 96-well filter plates (EMD Millipore). Each well contained a total volume of 100 mL, including 50 mL DBS eluate or cell lysate (3 mg total protein in 50 mL) and 3000 mAb 6B8ecoupled microspheres resuspended in 50 mL assay buffer [PBS pH 7.4 containing 1% bovine serum albumin (Biosource; Life TechnologieseInvitrogen) 0.05% Tween 20, and 0.05% sodium azide]. Plates were incubated in the dark with shaking in a Multi-MicroPlate Genie mixer (Scientific Industries, Bohemia, NY) for 5 hours at room temperature. The supernatant was removed using a vacuum manifold (MultiScreen HTS vacuum manifold kit; EMD Millipore), and the microspheres were washed and incubated with the detecting antibody R477 (1.76 mg/mL in 100 mL assay buffer) at 4 C overnight. Supernatant was aspirated, and the microspheres washed and incubated with 100 mL of 2 mg/mL goat anti-rabbit IgG conjugated to phycoerythrin for 2 hours at room temperature with agitation. Finally, microspheres were resuspended in 100 mL assay buffer and were analyzed (in duplicate) using a Luminex 200 system.

FMRP Concentration Dilutions of GST-SR7 were used to generate a standard curve for each plate using MiraiBio MasterPlex QT quantitative analysis software for protein assay (version 2.5; Hitachi Solutions America, South San Francisco, CA). Median fluorescence intensity was plotted against GST-SR7 concentrations. The amount of FMRP in the DBS was reported as concentration (pmol/L) in the DBS extract. A concentration of 1 pmol/L FMRP in the assay well is equivalent to 5.7 pmol/L in the original blood sample.

Western Blot Analysis Protein samples (15 mg) were analyzed on precast 4% to 15% polyacrylamide Criterion Tris-HCl gels (BioRad Laboratories, Hercules, CA) that were run at 200 mV for 1 hour. Separated proteins were transferred onto 0.22-mm polyvinylidene difluoride membranes (BioRad Laboratories) in transfer buffer (25 mmol/L Tris, 192 mmol/L glycine, pH 8.3) using a semidry electroblotter (OWL HEP-1; Thermo Scientific, Waltham, MA) for 1 hour at 10 V. Membranes were incubated in 5% nonfat dry milk in 0.01 mol/L Tris pH 7.5, 0.137 mol/L NaCl, 0.05% Tween 20 and then with either anti-FMRP antibodies or a mouse anti-GAPDH mAb. After washing, membranes were incubated for 1 hour with the conspecific alkaline phosphataseeconjugated secondary antibodies (Sigma-Aldrich, St. Louis, MO). Proteins were detected with CDP-Star reagent (New England Biolabs, Ipswich, MA) according to the manufacturer’s instructions.

Luminex Assay Procedure The mAb 6B8 was coupled to 5  106 xMAP MicroPlex microspheres (Luminex) according to the manufacturer’s instructions. Assays were prepared in low-protein-binding

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DNA Studies Fragile X analysis of DNA isolated from blood samples was performed by PCR and Southern blot as described

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FXS Immunoscreening of DBS by Luminex previously26e28 or with AmplideX FMR1 PCR (RUO) reagents (Asuragen, Austin, TX) and capillary electrophoresis29 according to the manufacturer’s instructions. DBS DNA was isolated with a DNeasy kit (Qiagen, Valencia, CA) according to the manufacturer’s instructions and was concentrated by precipitation with ethanol.

Statistical Analysis DBSs from blood received more than 3 days after collection were excluded from the analysis because of protein degradation. A cord-blood sample DBS was excluded because of a very high FMRP level and because of the unique nature of this sample. Premutation male data are given in Table 1, but were not included in the analysis because there was only one of these samples. Data were analyzed with either SPSS 11 Statistics (SPSS, Chicago, IL) or SigmaPlot version 11 (Systat Software, San Jose, CA) software.

Results Antibody Characterization To develop a DBS immunoassay, we needed one antibody to capture FMRP and another to detect it within a complex background of other proteins. Preliminary experiments suggested mAb 6B8 and R477 as a candidate pair. The specificity of these antibodies was characterized by Western blot analysis of extracts from normal (male and female), premutation (female), and full-mutation (male) lymphocytes (Figure 1A). Three FMRP bands (68 to 80 kDa) were recognized by the mAb 6B8 with short exposure in normal and premutation samples, whereas no bands were detected in the full-mutation FXS male extract (Figure 1A). This indicated that 6B8 has little if any cross-reactivity with the closely related proteins FXR1P and FXR2P,30 as seen with long exposure (overexposure) (Figure 1A). Bands of the

same size (68 to 80 kDa) were detected by R477 in all extracts except the male full-mutation FXS (Figure 1B). This antibody also detected a few faint bands, especially one at approximately 65 kDa, that were visible on overexposure (Figure 1B), indicating that R477 has weak cross-reactivity to a few other proteins. Comparison with the pattern detected by the commercially available anti-FMRP mAb 1C3 (Figure 1C) suggests that the mAb 6B8 and R477 are both highly specific for FMRP. Thus, mAb 6B8 and R477 both recognize FMRP without having any other targets in common.

Luminex Immunoassay We evaluated the capacity of this antibody pair to capture and detect FMRP in Luminex immunoassays of extracts from normal human lymphoblastoid cell lines. Microspheres were coupled to the mAb 6B8 to capture FMRP, and R477 was used to detect its presence. To evaluate the assay, we used 1.2 to 80 mg of protein extracted from normal and fullmutation male lymphoblastoid cell lines. The level of FMRP in normal cells was proportional to the amount of sample (Figure 1D), and there was a linear (r2 Z 0.98) response up to approximately 40 mg of extract. Only background fluorescence values were detected in wells containing up to 80 mg of male full-mutation extracts. To gauge the effectiveness of the Luminex assay, we analyzed the level of FMRP among blood samples from different normal individuals. Repeated assays of 19 lymphocyte extracts were highly correlated (r Z 0.96), indicating that the assay is reliable (data not shown). In addition, the relative levels of FMRP detected by densitometric quantification of the short-exposure mAb 6B8e stained bands (Figure 1A) very closely matched (within 7%) the relative levels in those samples measured by the Luminex assay.

Table 1 Capture Immunoassay Quantification of FMRP in DBS Extracts Derived from 215 Individuals with Normal, Premutation, and FullMutation Fragile X Genotype Protein concentration (pmol/L) Genotype* Male (n Z 103) Normal Premutation Full mutation Nonmosaic Mosaic Female (n Z 112) Normal Premutation Normal þ premutation Full mutation M normal þ F normal

No.

Mean

Median

SD

Min

Max

95% CI

85 1 17 10 7

25.8 ND 1.7 0.6 3.3

24.8 ND 0.7 0.6 2.9

10.3 ND 1.7 0.3 1.6

8.6 29.0 0.2 0.2 1.8

51.5 29.0 6.6 1.2 6.6

23.6e28.0 ND 0.8e2.6 0.40.7 1.8e4.8

49 59 108 4 134

26.0 23.0 24.3 17.2 25.9

25.3 22.5 23.6 16.7 25.0

8.6 7.0 7.9 2.0 9.6

11.6 9.9 9.9 15.4 8.6

46.3 38.7 20.1 20.1 51.5

23.5e28.4 21.2e24.8 22.8e25.8 14.0e20.5 24.2e27.5

*Genotype determined by PCR and Southern analyses. F, female; M, male; CI, confidence interval; Max, maximum; Min, minimum; ND, not determined.

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LaFauci et al stored as recommended (with desiccant at 22 C or 4 C).20,22 Even in the absence of desiccant, DBSs (n Z 8) retained on average 66% of the original FMRP after 1 year of storage at room temperature.

Quantification of FMRP

The assay demonstrated a broad FMRP distribution in 11 lymphocyte samples from normal individuals; mean fluorescence intensity ranged from 1194 to 2375 (SD, 405.1). A lymphocyte extract from a full-mutation male showed only background fluorescence value (data not shown) and was easily distinguished from normal samples. We found that lymphocyte samples are very sensitive to the length of time between blood draw and lymphocyte isolation, as well as to blood storage conditions, as has also been observed by others.31 Only lymphocyte samples that were isolated within a few hours of blood draw gave dependable results. The requirements for rapid lymphocyte isolation from freshly drawn blood made lymphocyte samples impractical for FMRP screening. Because of these limitations and in view of reports that proteins are stable for at least 6 months in DBS that are stored with desiccant,20 we tried using DBS eluates; we were surprised to find that FMRP was easily detectable in these samples. In an initial experiment, DBS from four normal individuals and three premutation females averaged approximately 100-fold higher than three male full-mutation samples and approximately 10-fold higher than a male mosaic full-mutation sample (data not shown). The level of FMRP detected in DBS also depended on storage conditions. Proteins are stable for at least 6 months when DBS are

For FMRP quantification and to control for technical variations in capture and detection, we constructed an abbreviated FMRP reference protein for inclusion in the assay as a standard. We used a series of GST-fusion proteins that carried discrete regions of FMRP to localize the mAb 6B8 and R477 epitopes (LaFauci et al, unpublished data) and constructed a GST fusion protein, GST-SR7, that included both epitopes (Figure 1E). Purified GST-SR7 at concentrations of 0.5 to 280 pmol/L resulted in a linear response (R2 Z 0.99) in the Luminex assay (Figure 1F). Repeat analyses of GST-SR7 aliquots during 4 months of storage at 70 C were highly correlated (r Z 0.996), which indicated that this standard was stable and did not aggregate during this period. We used a standard curve calculated from dilutions of a known amount of GST-SR7 to measure the amount of FMRP present in DBS samples from 215 individuals with normal, premutation, or full-mutation genotypes (Table 1). FMRP levels are reported as concentration (pmol/L) in the 50-mL extracts used in the assays, which are equivalent to 8.7 mL of whole blood. As with lymphocytes, assays of duplicate extracts of 57 randomly selected DBS were highly correlated (r Z 0.96), indicating that the assay is reliable. In individuals with normal FMR1 alleles, the FMRP level appears to be normally distributed (Figure 2A), with no difference between males and females. The level of FMRP detected in the assay declines with age from infants to preteens; it then appears to level off in teenage years and remains relatively unchanged through adulthood (Figure 2B). In males with a full-mutation allele, the mean FMRP level was 1.7 pmol/L (6% of normal), with a maximum of 6.6 pmol/L (26% of normal) (Table 1). There was no overlap between full-mutation and normal levels (Figure 3A), and the difference between the two groups was highly significant (P < 0.001, U-test). Receiver operating characteristic (ROC) analysis showed that, at a cutoff of 7.59 pmol/L, sensitivity and specificity were both 100% (CI Z 79.41% to 100.0% and 94.72% to 100.0%, respectively). The sensitivity and specificity are biased, because they are based on the data set used to construct the ROC curve rather than on an independent test set and are therefore optimistic. Nonetheless, the analysis does indicate that a cutoff can be chosen that will make false negatives extremely unlikely, without generating an unwieldy number of false positives. The full-mutation male samples included full-mutation mosaic samples, which have a significantly higher level of FMRP (Figure 3B) (P Z 0.001, U-test). The separation between the mosaic and nonmosaic full-mutation samples

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Figure 1 Detection with two antibodies highly specific for FMRP. AeC: Detection of FMRP with short and long exposure. Lane 1, normal male; Lane 2 normal female; Lanes 3 and 4, premutation females; lane 5, full-mutation male. GAPDH is the protein loading control. The arrowheads on the right show positions of MW markers. A: With mAb 6B8, three FMRP bands (marked by bullets between lanes 2 and 3) were detected in all but the fullmutation male extract. B: Similar bands were detected with R477. The asterisk indicates the position of the 65 kDa background band. C: Detection of FMRP with commercially available mAb 1C3. D: Luminex assay detection of FMRP in normal and fragile X lymphoblastoid cell extracts. Linear response of the mAb 6b8eR477 assay to increasing amounts of normal cell extract up to 40 mm (triangles); fragile X full-mutation cell extract (squares) showed background fluorescence values up to 80 mm. E: Schematic of the abbreviated FMRP standard, GST-SR7. This protein was engineered to include the epitopes recognized by the mAb 6B8 and R477. F: The response of the Luminex assay to increasing amounts of GST-SR7 shows linearity from 0 to 280 pmol/L. Mean fluorescence intensity MFI Z 24.497 pmol/L þ 295.33. R2 Z 0.99.

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FXS Immunoscreening of DBS by Luminex assay (ie, mAb 6B8 and R477) are highly specific for FMRP. The absence of other shared target proteins is key to the specificity and sensitivity of the assay. The FMRP levels in the 215 cases matched their fragile X genotypes as determined by Southern blot and PCR. The FMRP levels in

Figure 2 FMRP in DBS from normal individuals. A: Distribution of FMRP concentration in 134 normal male and female DBS extracts. Mean FMRP concentration (by comparison with the GST-SR7 standard) is 25.9  9.7 pmol/L. B: FMRP concentration in DBS by age of donor.

(Figure 3B) indicates that the Luminex assay readily distinguishes between them. The level of FMRP detected in the Luminex assay is consistent with the intensity of the premutation band in the Southern blot analysis of the mosaic full-mutation male (Figure 3C). The sample population included only one premutation male, which is too few to allow comparison of this group with the normal population. The FMRP level was shifted down in females with a fullmutation allele (Figure 4), and their mean (17.2 pmol/L) was significantly different from the mean (26.0 pmol/L) in normal allele females (P Z 0.032, U-test) (Table 1). In females with a premutation allele, the mean FMRP level appeared to be lower than normal, but the difference did not reach significance (P Z 0.09, U-test) (Figure 4).

Discussion The immunoassay described in this report readily identified all 17 male fragile X full-mutation samples among DBSs from 215 individuals with normal, premutation, and fullmutation alleles. The capture and detection antibodies in the

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Figure 3 FMRP in DBS from males. A: FMRP concentration in normal males and fragile X full-mutation (FXS) males. B: FMRP concentration in nonmosaic and mosaic FXS males. C: Southern analysis of mosaic FXS showing premutation alleles. Lane 1, normal allele EagIeEcoRI fragment of 2.8 kb which contains CGG triplet repeat and probe (StB12.3) sequence (right side of schematic at bottom). Lane 2, full-mutation alleles EcoRI fragments of approximately 8.5 kb which contain >200 CGG triplet repeats and are not cleaved by EagI, because of methylation (asterisk). Lane 3, mosaic full-mutation including full-mutation alleles as in lane 2 and also premutation alleles EagIeEcoRI fragments of approximately 3 kb which contain <200 CGG triplet repeats and are cleaved at the EagI site (which is unmethylated in these alleles). Box-plot data (A and B) are expressed as 25th to 75th percentile, median, and maximum and minimum, with outliers shown as circles. ***P  0.001, U-test.

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the control population DBS (n Z 134) exhibited an approximately Gaussian distribution, similar to that reported for platelets.31,32 Sex had no effect on the FMRP level detected (Table 1) (P Z 0.5, U-test). In adults, age had no detectable effect on FMRP level (Figure 2B). In infants and preteens, however, there was a higher level of the protein, which was inversely correlated to age and decreased to adult levels in the teen years (Figure 2B). Because a DBS sample corresponds to a specific volume of blood (w0.3 mL/mm2; ID blood stain card BFC180), the progressive FMRP decrease from infants to teens is probably due the reduction seen in the leukocyte count in children as they age.33,34 In addition to accounting for the decrease in FMRP with age in normal children, this explanation also suggests that one factor influencing the variability of FMRP in normal adults is the leukocyte count, which varies with a variety of factors, including body mass index, hyperlipidemia, smoking, infection, inflammation, stress, hypertension, impaired glucose tolerance, and allergy.35,36 Reduced FMRP has also been reported in brain samples of subjects with autism, schizophrenia, major depression, and bipolar disorder,37,38 although it is not known if this decrease is paralleled in blood. The level of FMRP in male full-mutation individuals (n Z 17) ranged between 0.2 and 6.6 pmol/L; it did not overlap with and was significantly lower than the level in controls (Figure 3A), indicating that the assay can identify full-mutation males with sensitivity and specificity that would be more than adequate for newborn or population screening. Moreover, full-mutation mosaic and nonmosaic males were also well separated, thus allowing the differentiation of individuals with mosaic alleles from those with nonmosaic full-mutation alleles (Figure 3B). The assay detects a level of FMRP in mosaic FXS males that corresponds to the degree of mosaicism seen in Southern analysis (Figure 3C). This suggests that, although there is no overlap in the male DBS sample illustrated in Figure 3A, the true population range of FMRP levels in FXS males may overlap with normal in exceptional cases that have unusual Southern blot patterns.39e41 We estimate

from DNA diagnostic data (644 full-mutation males) that less than 1% of FXS males may show expression in the normal range (S. Nolin and A. Glicksman, personal communication). Although FXS mosaicism (ie, the presence of FMR1 premutation alleles in some somatic cells) is relatively common,42 the presence of mosaicism does not necessarily predict a higher level of adaptive functioning.43 This is presumably due to the marginal amount of FMRP expressed in most mosaics or, in some cases, to differences in the extent of mosaicism in different tissues.44,45 The mean FMRP level detected in full-mutation females differs significantly from that of normal females but, in contrast to males (Figure 4), the range overlaps with normal. Variation in X inactivation is assumed to be the explanation for the broad range of impairment in fullmutation females.46,47 In human females, X inactivation results in a ratio of paternal and maternal X chromosome expression that is highly variable, exceeding 70:30 in 25%, 80:20 in 8%, and 90:10 in 2% of DNA samples from normal females.48 Our assay shows a shift in the distribution of FMRP levels in full-mutation females that is consistent with this variability (Figure 4). The present analysis, however, is based on a limited number of fullmutation females and the true range of FMRP probably extends below the normal level. There is evidence that, in full-mutation females, the inactivation ratio in blood correlates with the level of impairment49 and that, in fullmutation males and females, the level of FMRP correlates with full-scale intelligence quotient.50 This suggests that direct measurement of FMRP in DBS may be a predictor of cognitive status. Premutation females appeared to have a slightly lower than normal level of FMRP, but the difference did not reach significance. Other studies have shown a reduced level of FMRP in premutation carriers, both male and female.12,13 Although they have reduced FMRP, both males and females who carry FMR1 premutation alleles have increased levels of FMR1 mRNA and an increased risk, especially in males, for fragile Xeassociated tremor/ataxia syndrome (FXTAS) and fragile Xeassociated primary ovarian insufficiency (FXPOI) in females.51 Application of the immunoassay to DBS samples greatly expands its potential usefulness. DBSs have been used since the 1960s to preserve both proteins and DNA for detection of metabolic and genetic disorders.52,53 DBS samples require only a few drops of blood on a filter card, which can then be stored and transported at ambient temperature. The Luminex assay described here is a rapid and direct quantitative measurement of FMRP that identifies males with full mutations with virtually 100% specificity and sensitivity. The assay is economical, amenable to highthroughput analysis, and is very likely to be an effective method for screening of newborn infants and other populations. We assayed eluates from 28 mm2 of DBS for the results reported here, but we determined that the 3-mm (7.1

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Figure 4 FMRP in DBS from females. FMRP concentration differed significantly between normal and full-mutation females (*P Z 0.032, U-test). Although the median FMRP value for premutation females was lower than normal, this comparison did not reach significance (P Z 0.09, U-test).

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FXS Immunoscreening of DBS by Luminex mm2) DBS samples commonly used in screenings yield 25% of this amount. Thus, analysis of 3-mm DBS samples will still allow identification of full-mutation males, particularly for samples from newborns, whose protein levels tend to be elevated. Screening for FXS in children with cognitive impairments, developmental delays, and autism is already recommended by the American Academy of Pediatrics,54 but, primarily because effective specific treatment is lacking, it is not currently recommended for newborn screening.16,18,55 This situation is likely to change in the near future, because a number of drugs are currently in phase 2 and 3 trials to test their efficacy and safety as targeted treatments for FXS; these include AFQ056 (Novartis), R04917523 (HofmanneLa Roche), arbaclofen (Seaside Therapeutic), donepezil hydrochloride (Stanford UniversityeNIMH), and minocycline (University of CaliforniaeDavis). It is likely that one or more of the drugs currently being developed or tested will lead to an effective pharmacological treatment for FXS and thus could lead to the addition of FXS to newborn screening panels. This will depend in part on the availability of a test that is appropriate for newborn screening, such as one using the method we have described here. Assays of FMRP in fresh blood samples have been described previously,31,32 but these techniques depend on isolation of lymphocytes or platelets from plasma, which may limit their applicability to large-scale fragile X screening. Methods that analyze the number of FMR1 CGG repeats or the methylation status of FMR1 alleles have been used in DBS screening of high-risk populations or in pilot newborn screening. In the CGG repeat-number assays, DNA extracted from a DBS is amplified by PCR and the products are analyzed by capillary electrophoresis, agarose gel electrophoresis, or mass spectrometry.56e59 For FMR1 methylation analysis, DNA from DBS disks is treated with sodium bisulfite, and screened by real-time methylation-specific PCR.60 These DNA-based methods can accurately identify expanded triplet-repeat alleles by direct sizing or by their methylation status, and may identify premutation carriers and full-mutation females in addition to full-mutation males. These assays may, however, be too complicated or expensive to be used in routine newborn screening. The Luminex assay described here is economical and could readily be converted to a high-throughput application. It assays the level of FMRP directly, and may thus be a better prognostic indicator than DNA-based assays. It readily identifies full-mutation males and may identify fullmutation females who are likely to be impaired, but further studies will be needed to determine whether a low level of FMRP detected in a female is indicative of impairment due to a full mutation. Samples that are positive in this Luminex screen can then be subjected to molecular analysis of DBS DNA. Thus, this assay has the potential to be an extremely effective method for screening populations for full-mutation FXS males.

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Acknowledgment We thank Michael Flory for assistance with statistical analysis and for helpful suggestions.

References 1. Pieretti M, Zhang FP, Fu YH, Warren ST, Oostra BA, Caskey CT, Nelson DL: Absence of expression of the FMR-1 gene in fragile X syndrome. Cell 1991, 66:817e822 2. De Boulle K, Verkerk AJ, Reyniers E, Vits L, Hendrickx J, Van Roy B, Van den Bos F, de Graaff E, Oostra BA, Willems PJ: A point mutation in the FMR-1 gene associated with fragile X mental retardation. Nat Genet 1993, 3:31e35 3. Coffee B, Ikeda M, Budimirovic DB, Hjelm LN, Kaufmann WE, Warren ST: Mosaic FMR1 deletion causes fragile X syndrome and can lead to molecular misdiagnosis: a case report and review of the literature. Am J Med Genet A 2008, 146A:1358e1367 4. Tassone F, Hagerman RJ, Iklé DN, Dyer PN, Lampe M, Willemsen R, Oostra BA, Taylor AK: FMRP expression as a potential prognostic indicator in fragile X syndrome. Am J Med Genet 1999, 84:250e261 5. Devys D, Lutz Y, Rouyer N, Bellocq JP, Mandel JL: The FMR-1 protein is cytoplasmic, most abundant in neurons and appears normal in carriers of a fragile X premutation. Nat Genet 1993, 4: 335e340 6. Gedeon AK, Baker E, Robinson H, Partington MW, Gross B, Manca A, Korn B, Poustka A, Yu S, Sutherland GR, Mulley JC: Fragile X syndrome without CCG amplification has an FMR1 deletion. Nat Genet 1992, 1:341e344 7. Collins SC, Bray SM, Suhl JA, Cutler DJ, Coffee B, Zwick ME, Warren ST: Identification of novel FMR1 variants by massively parallel sequencing in developmentally delayed males. Am J Med Genet A 2010, 152A:2512e2520 8. Lévesque S, Dombrowski C, Morel ML, Rehel R, Côté JS, Bussières J, Morgan K, Rousseau F: Screening and instability of FMR1 alleles in a prospective sample of 24,449 mother-newborn pairs from the general population. Clin Genet 2009, 76:511e523 9. Cronister A, Teicher J, Rohlfs EM, Donnenfeld A, Hallam S: Prevalence and instability of fragile X alleles: implications for offering fragile X prenatal diagnosis. Obstet Gynecol 2008, 111:596e601 10. Nolin SL, Sah S, Glicksman A, Sherman SL, Allen E, BerryKravis E, Tassone F, Yrigollen C, Cronister A, Jodah M, Ersalesi N, Dobkin C, Brown WT, Shroff R, Latham GJ, Hadd AG: Fragile X AGG analysis provides new risk predictions for 45-69 repeat alleles. Am J Med Genet A 2013, 161:771e778 11. Tassone F, Hagerman RJ, Chamberlain WD, Hagerman PJ: Transcription of the FMR1 gene in individuals with fragile X syndrome. Am J Med Genet 2000, 97:195e203 12. Kenneson A, Zhang F, Hagedorn CH, Warren ST: Reduced FMRP and increased FMR1 transcription is proportionally associated with CGG repeat number in intermediate-length and premutation carriers. Hum Mol Genet 2001, 10:1449e1454 13. Primerano B, Tassone F, Hagerman RJ, Hagerman P, Amaldi F, Bagni C: Reduced FMR1 mRNA translation efficiency in fragile X patients with premutations. RNA 2002, 8:1482e1488 14. Seltzer MM, Baker MW, Hong J, Maenner M, Greenberg J, Mandel D: Prevalence of CGG expansions of the FMR1 gene in a US population-based sample. Am J Med Genet B Neuropsychiatr Genet 2012, 159:589e597 15. Rousseau F, Vincent A, Rivella S, Heitz D, Triboli C, Maestrini E, Warren ST, Suthers GK, Goodfellow P, Mandel JL, Toniolo D, Oberle I: Four chromosomal breakpoints and four new probes mark out a 10-cM region encompassing the fragile-X locus (FRAXA). Am J Hum Genet 1991, 48:108e116

515

LaFauci et al 16. Bailey DB Jr, Armstrong FD, Kemper AR, Skinner D, Warren SF: Supporting family adaptation to presymptomatic and “untreatable” conditions in an era of expanded newborn screening. J Pediatr Psychol 2009, 34:648e661 17. Skinner D, Choudhury S, Sideris J, Guarda S, Buansi A, Roche M, Powell C, Bailey DB Jr.: Parents’ decisions to screen newborns for FMR1 gene expansions in a pilot research project. Pediatrics 2011, 127:e1455ee1463 18. Bailey DB Jr.: The blurred distinction between treatable and untreatable conditions in newborn screening. Health Matrix Clevel 2009, 19:141e153 19. Michalon A, Sidorov M, Ballard TM, Ozmen L, Spooren W, Wettstein JG, Jaeschke G, Bear MF, Lindemann L: Chronic pharmacological mGlu5 inhibition corrects fragile X in adult mice. Neuron 2012, 74:49e56 20. Mei JV, Alexander JR, Adam BW, Hannon WH: Use of filter paper for the collection and analysis of human whole blood specimens. J Nutr 2001, 131:1631Se1636S 21. Behets F, Kashamuka M, Pappaioanou M, Green TA, Ryder RW, Batter V, George JR, Hannon WH, Quinn TC: Stability of human immunodeficiency virus type 1 antibodies in whole blood dried on filter paper and stored under various tropical conditions in Kinshasa, Zaire. J Clin Microbiol 1992, 30:1179e1182 22. Adam BW, Hall EM, Sternberg M, Lim TH, Flores SR, O’Brien S, Simms D, Li LX, De Jesus VR, Hannon WH: The stability of markers in dried-blood spots for recommended newborn screening disorders in the United States. Clin Biochem 2011, 44:1445e1450 23. Chen L, Yun SW, Seto J, Liu W, Toth M: The fragile X mental retardation protein binds and regulates a novel class of mRNAs containing U rich target sequences. Neuroscience 2003, 120: 1005e1017 24. Kascsak RJ, Fersko R, Pulgiano D, Rubenstein R, Carp RI: Immunodiagnosis of prion disease. Immunol Invest 1997, 26:259e268 25. Spinner DS, Kascsak RB, Lafauci G, Meeker HC, Ye X, Flory MJ, Kim JI, Schuller-Levis GB, Levis WR, Wisniewski T, Carp RI, Kascsak RJ: CpG oligodeoxynucleotide-enhanced humoral immune response and production of antibodies to prion protein PrPSc in mice immunized with 139A scrapie-associated fibrils. J Leukoc Biol 2007, 81:1374e1385 26. Brown WT: The FRAXE Syndrome: is it time for routine screening? Am J Hum Genet 1996, 58:903e905 27. Nolin SL, Brown WT, Glicksman A, Houck GE Jr, Gargano AD, Sullivan A, Biancalana V, Bröndum-Nielsen K, Hjalgrim H, Holinski-Feder E, Kooy F, Longshore J, Macpherson J, Mandel JL, Matthijs G, Rousseau F, Steinbach P, Väisänen ML, von Koskull H, Sherman SL: Expansion of the fragile X CGG repeat in females with premutation or intermediate alleles. Am J Hum Genet 2003, 72: 454e464 28. Nolin SL, Ding XH, Houck GE, Brown WT, Dobkin C: Fragile X full mutation alleles composed of few alleles: implications for CGG repeat expansion. Am J Med Genet A 2008, 146A:60e65 29. Chen L, Hadd A, Sah S, Filipovic-Sadic S, Krosting J, Sekinger E, Pan R, Hagerman PJ, Stenzel TT, Tassone F, Latham GJ: An information-rich CGG repeat primed PCR that detects the full range of fragile X expanded alleles and minimizes the need for southern blot analysis. J Mol Diagn 2010, 12:589e600 30. Tamanini F, Kirkpatrick LL, Schonkeren J, van Unen L, Bontekoe C, Bakker C, Nelson DL, Galjaard H, Oostra BA, Hoogeveen AT: The fragile X-related proteins FXR1P and FXR2P contain a functional nucleolar-targeting signal equivalent to the HIV-1 regulatory proteins. Hum Mol Genet 2000, 9:1487e1493 31. Iwahashi C, Tassone F, Hagerman RJ, Yasui D, Parrott G, Nguyen D, Mayeur G, Hagerman PJ: A quantitative ELISA assay for the fragile X mental retardation 1 protein. J Mol Diagn 2009, 11:281e289 32. Lessard M, Chouiali A, Drouin R, Sebire G, Corbin F: Quantitative measurement of FMRP in blood platelets as a new screening test for fragile X syndrome. Clin Genet 2012, 82:472e477

516

33. Naseri M: Alterations of peripheral leukocyte count, erythrocyte sedimentation rate, and C-reactive protein in febrile urinary tract infection. Iran J Kidney Dis 2008, 2:137e142 34. Hudspeth M and Symons H: Hematology. The Harriet Lane handbook: A Manual for Pediatric House Officers, ed 16. Edited by VL Gunn, C Nechyba. Philadelphia, Mosby, 2002, pp 294 35. Huang ZS, Chien KL, Yang CY, Tsai KS, Wang CH: Peripheral differential leukocyte counts in humans vary with hyperlipidemia, smoking, and body mass index. Lipids 2001, 36:237e245 36. Karthikeyan VJ, Lip GY: White blood cell count and hypertension. J Hum Hypertens 2006, 20:310e312 37. Fatemi SH, Reutiman TJ, Folsom TD, Rooney RJ, Patel DH, Thuras PD: mRNA and protein levels for GABAAalpha4, alpha5, beta1 and GABABR1 receptors are altered in brains from subjects with autism. J Autism Dev Disord 2010, 40:743e750 38. Fatemi SH, Folsom TD: The role of fragile X mental retardation protein in major mental disorders. Neuropharmacology 2011, 60:1221e1226 39. Wöhrle D, Salat U, Gläser D, Mücke J, Meisel-Stosiek M, Schindler D, Vogel W, Steinbach P: Unusual mutations in high functioning fragile X males: apparent instability of expanded unmethylated CGG repeats. J Med Genet 1998, 35:103e111 40. Smeets HJ, Smits AP, Verheij CE, Theelen JP, Willemsen R, van de Burgt I, Hoogeveen AT, Oosterwijk JC, Oostra BA: Normal phenotype in two brothers with a full FMR1 mutation. Hum Mol Genet 1995, 4:2103e2108 41. Hagerman RJ, Hull CE, Safanda JF, Carpenter I, Staley LW, O’Connor RA, Seydel C, Mazzocco MM, Snow K, Thibodeau SN, Kuhl D, Nelson DL, Caskey T, Taylor AK: High functioning fragile X males: demonstration of an unmethylated fully expanded FMR-1 mutation associated with protein expression. Am J Med Genet 1994, 51:298e308 42. Nolin SL, Glicksman A, Houck GE Jr, Brown WT, Dobkin CS: Mosaicism in fragile X affected males. Am J Med Genet 1994, 51: 509e512 43. Cohen IL, Nolin SL, Sudhalter V, Ding XH, Dobkin CS, Brown WT: Mosaicism for the FMR1 gene influences adaptive skills development in fragile X-affected males. Am J Med Genet 1996, 64:365e369 44. Dobkin CS, Nolin SL, Cohen I, Sudhalter V, Bialer MG, Ding XH, Jenkins EC, Zhong N, Brown WT: Tissue differences in fragile X mosaics: mosaicism in blood cells may differ greatly from skin. Am J Med Genet 1996, 64:296e301 45. Dobkin C, Zhong N, Brown WT: The molecular basis of fragile sites. Am J Hum Genet 1996, 59:478 46. Migeon BR: The role of X inactivation and cellular mosaicism in women’s health and sex-specific diseases. JAMA 2006, 295:1428e1433 47. Hagerman RJ, Hagerman PJ: The fragile X premutation: into the phenotypic fold. Curr Opin Genet Dev 2002, 12:278e283 48. Amos-Landgraf JM, Cottle A, Plenge RM, Friez M, Schwartz CE, Longshore J, Willard HF: X chromosome-inactivation patterns of 1,005 phenotypically unaffected females. Am J Hum Genet 2006, 79: 493e499 49. Reiss AL, Freund LS, Baumgardner TL, Abrams MT, Denckla MB: Contribution of the FMR1 gene mutation to human intellectual dysfunction. Nat Genet 1995, 11:331e334 50. Loesch DZ, Huggins RM, Hagerman RJ: Phenotypic variation and FMRP levels in fragile X. Ment Retard Dev Disabil Res Rev 2004, 10:31e41 51. Willemsen R, Levenga J, Oostra BA: CGG repeat in the FMR1 gene: size matters. Clin Genet 2011, 80:214e225 52. Guthrie R: The origin of newborn screening. Screening 1992, 1:5e15 53. Corran PH, Cook J, Lynch C, Leendertse H, Manjurano A, Griffin J, Cox J, Abeku T, Bousema T, Ghani AC, Drakeley C, Riley E: Dried blood spots as a source of anti-malarial antibodies for epidemiological studies. Malar J 2008, 7:195 54. Moeschler JB, Shevell M, American Academy of Pediatrics Committee on Genetics: Clinical genetic evaluation of the child with mental retardation or developmental delays. Pediatrics 2006, 117:2304e2316

jmd.amjpathol.org

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FXS Immunoscreening of DBS by Luminex 55. Bailey DB Jr, Skinner D, Davis AM, Whitmarsh I, Powell C: Ethical, legal, and social concerns about expanded newborn screening: fragile X syndrome as a prototype for emerging issues. Pediatrics 2008, 121: e693ee704 56. Dodds ED, Tassone F, Hagerman PJ, Lebrilla CB: Polymerase chain reaction, nuclease digestion, and mass spectrometry based assay for the trinucleotide repeat status of the fragile X mental retardation 1 gene. Anal Chem 2009, 81:5533e5540 57. Yuhas J, Walichiewicz P, Pan R, Zhang W, Casillas EM, Hagerman RJ, Tassone F: High-risk fragile x screening in Guatemala: use of a new blood spot polymerase chain reaction technique. Genet Test Mol Biomarkers 2009, 13:855e859

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-

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58. Tassone F, Pan R, Amiri K, Taylor AK, Hagerman PJ: A rapid polymerase chain reaction-based screening method for identification of all expanded alleles of the fragile X (FMR1) gene in newborn and high-risk populations. J Mol Diagn 2008, 10:43e49 59. Fernandez-Carvajal I, Walichiewicz P, Xiaosen X, Pan R, Hagerman PJ, Tassone F: Screening for expanded alleles of the FMR1 gene in blood spots from newborn males in a Spanish population. J Mol Diagn 2009, 11:324e329 60. Coffee B, Keith K, Albizua I, Malone T, Mowrey J, Sherman SL, Warren ST: Incidence of fragile X syndrome by newborn screening for methylated FMR1 DNA. Am J Hum Genet 2009, 85: 503e514

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