In this webinar Dr. Bertrand Rochat of Faculté de Biologie et de Médecine of the Centre Hospitalier Universitraire Vaudois (CHUV) at Lausanne discusses the paradigm shift to high resolution mass spectrometry (HRMS) in clinical research for quantitative analyses (sensitivity, selectivity, etc.). Quantifications in high resolution full scan or MS/MS mode will be compared with triple quadrupole MS. He will present Quan/Qual analysis with a study on the fate of an anti-cancer agent in human: with over 40 metabolites being identified and quantified; as well as metabolomics data underscoring the versatility of high resolution Orbitrap MS.
Porella : features, morphology, anatomy, reproduction etc.
High Resolution Mass Spectrometry in Clinical Research: from Targeted Quantification to Metabolomics
1. View from Lausanne, Switzerland
High Resolution Mass Spectrometry :
from Targeted Quantification to Metabolomics
2.
3.
4. A.
QQQ-‐MS
C.
TOF-‐MS
D.
Orbitrap-‐MS
Q
Q
/
IT
Q
CC
CC
CC
d
d
p
O
t
F
r
FT
Q
/
IT
B.
IT-‐MS
d
SRM
Quan
t
t
PS
Qual
+
Quan
FS
or
PS
Qual
(Quan)
FS
or
PS
Qual
(Quan)
2010
…
Q:
quadrupole;
CC:
colision
cell;
d:
detector;
IT:
ion
trap;
p:
pusher;
(TO)F:
(Time-‐Of-‐)
flight;
r:
reflectron;
t:
trap;
O:
orbitrap;
FT:
Fourrier
transform
scanning
fragmentaKon
isolaKon
MS
technology
and
affilia7on
5. Q
Q
/
IT
Q
CC
CC
CC
d
d
p
O
t
F
r
FT
Q
/
IT
d
SRM
Quan
t
t
PS
Qual
+
Quan
FS
or
PS
Qual
+
Quan
FS
or
PS
Qual
+
Quan
2010
…
scanning
fragmentaKon
isolaKon
A.
QQQ-‐MS
C.
TOF-‐MS
B.
IT-‐MS
MS
technology
and
affilia7on
D.
Orbitrap-‐MS
6. Q
Q
/
IT
Q
CC
CC
CC
d
d
p
O
t
F
r
FT
Q
/
IT
scanning
d
Low
resoluKon
Slow
scanning
speed
fragmentaKon
isolaKon
t
t
2010
…
Low
resoluKon
Fast
scanning
speed
High
resoluKon
Fast
scanning
speed
High
resoluKon
Fast
scanning
speed
A.
QQQ-‐MS
C.
TOF-‐MS
B.
IT-‐MS
MS
technology
and
affilia7on
D.
Orbitrap-‐MS
7. Q
Q
/
IT
Q
CC
CC
CC
d
d
p
O
t
F
r
FT
Q
/
IT
scanning
d
Low
resoluKon
Slow
scanning
speed
fragmentaKon
isolaKon
t
t
2010
Low
resoluKon
Fast
scanning
speed
High
resoluKon
Fast
scanning
speed
High
resoluKon
Fast
scanning
speed
A.
QQQ-‐MS
C.
TOF-‐MS
B.
IT-‐MS
MS
technology
and
affilia7on
Selec7vity
UHPLC
+
global
D.
Orbitrap-‐MS
Selec7vity
UHPLC
+
global
…
8. intensity
mass/charge
ra7o
7me
LC
-‐
high
resolu7on
MS
:
full
scan
acquisi7on
SelecKvity
is
based
on
the
ResoluKon
and
Mass
Accuracy
gradient
9. mass/charge
raKo
(m/z)
intensity
intensity
mass/charge
ra7o
7me
gradient
LC
-‐
high
resolu7on
MS
:
full
scan
acquisi7on
SelecKvity
is
based
on
the
ResoluKon
and
Mass
Accuracy
16. 0
50
100
Time [min]
NL: 5.18E6
m/z= 494.26383-494.26877
F: FTMS + p ESI Full lock
ms [200.00-1000.00] MS
ICIS 150123_TKIs_18
Abondance
0 2 4 6 8 10 12 14
Key
HRMS
parameters
:
o
ResoluKon
o
Mass
Accuracy
o
Mass
ExtracKon
Window
intensity
mass/charge
ra7o
7me
±
5
ppm
17. QQQ-‐MS
Ion
transi7on
chromatogram
intensity
7me
HRMS
Extracted
ion
chromatogram
intensity
7me
m/z
494.3
→
394.1
collision
energy
=
32eV
m/z
307.1
→
238.1
collision
energy
=
25eV
m/z
494.2663
±
10ppm
m/z
307.1113
±
10ppm
18. intensity
7me
QQQ-‐MS
Ion
transi7on
chromatogram
intensity
7me
intensity
7me
HRMS
intensity
7me
HR
full
scan
acquisi7on
«
all
»
ions
are
detected
Ion
transi7on
acquisi7on
m/z
m/z
m/z
494.3
→
394.1
collision
energy
=
32eV
m/z
307.1
→
238.1
collision
energy
=
25eV
m/z
494.2663
+/-‐
10ppm
m/z
307.1113
+/-‐
10ppm
one
ion
Extracted
ion
chromatogram
19. intensity
7me
QQQ-‐MS
Ion
transi7on
chromatogram
intensity
7me
intensity
7me
HRMS
intensity
time
HR
full
scan
acquisi7on
«
all
»
ions
are
detected
Ion
transi7on
acquisi7on
Selec7on
of
the
molecules
to
be
determined
prior
the
analysis
m/z
m/z
m/z
494.3
→
394.1
collision
energy
=
32eV
m/z
307.1
→
238.1
collision
energy
=
25eV
m/z
494.2663
+/-‐
10ppm
m/z
307.1113
+/-‐
10ppm
Selec7on
of
the
molecules
to
be
determined
ajer
the
acquisi7on
one
ion
Extracted
ion
chromatogram
20. intensity
7me
QQQ-‐MS
Ion
transi7on
chromatogram
intensity
7me
HRMS
HR
full
scan
acquisi7on
«
all
»
ions
are
detected
Ion
transi7on
acquisi7on
Selec7on
of
the
molecules
to
be
determined
prior
the
analysis
m/z
m/z
Selec7on
of
the
molecules
to
be
determined
ajer
the
acquisi7on
one
ion
Extracted
ion
chromatogram
Retrospec7ve
data
mining
…
21. Goal
QQQ-‐MS
HRMS
Quan
Qual
Untarget.
omics
Quan
Qual
Target.
omics
Quan/Quan
Target.
omics
Untarget.
omics
Quan
/
Qual
Evaluate
in
depth
if
a
new
paradigm
is
possible
New
MS
Gold
Standard
?
22. Targeted
+
Produc7ve
Research
+
Discovery
QQQ
HRMS
MS
Technology
Type
of
Analysis
Future
in
a
clinical
LC-‐MS
analyses
?
23. Targeted
+
Produc7ve
+
Research
+
Discovery
MS
Technology
Type
of
Analysis
HRMS
HRMS
Future
in
a
clinical
LC-‐MS
analyses
?
24. MS
Technology
Type
of
Analysis
HRMS
HRMS
Future
in
a
clinical
LC-‐MS
analyses
?
TDM*
+
Diagnos7cs*
+
Pep7de
analysis
/
pep7domics
+
Targeted
/
untargeted
Metabolomics
HR-‐full
scan
HR-‐SIM
HR-‐SRM=PRM
HR-‐DDA/DIA
*
aher
needed
regulatory
approvals
obtained
25.
26. Criteria to evaluate the Exactive Plus® and Q-Exactive Focus®
HRMS in Quantitative Analyses
1. detection selectivity in HR full scan
2. accuracy and precision of mass determination
3. LOD, dynamic range and linearity of calibration curves
4. level accuracy of UNK samples in comparison to the
quantification performed with our TQ-MS analyses
5. ease of use and bottleneck in the workflow
For
research
use
only.
Not
for
use
in
diagnosKc
procedures.
27. Molecules
determined
by
Q-‐Exac+ve
Focus®
and
Exac+ve
Plus
MS®
in
our
biological
samples
AnKfungal
drugs
Immunosupressive
drugs
AnKcancer
drugs
Steroids
Vitamine
D
Amino
acids
Hepcidin
etc.
► m/z
ranging
from
76
(glycine)
to
2,800
(hepcidin)
Sample
type
and
sample
prep.
o Human
plasma,
serum
etc…
o protein
precipitaKon,
SPE
and
Liquid
Solid
ExtracKon,
alone
or
in
combinaKon
LC
condi7ons
o usual
LC-‐MS
mobile
phases,
1D-‐LC
or
column
switching
o C18,
CN
or
HILIC
and
UHPLC
or
HPLC
staKonary
phases
o 2.1mm
inner
diameter,
30-‐100mm
length
Sojwares
o Xcalibur,
TraceFinder,
Sieve,
Progenesis
QI
and
some
others
For
research
use
only.
Not
for
use
in
diagnosKc
procedures.
28. Criteria to evaluate the Exactive Plus® and Q-Exactive Focus®
HRMS in Quan analyses
1. detection selectivity in HR full scan
2. accuracy and precision of mass determination
3. dynamic range and linearity of calibration curves
4. level accuracy of UNK samples in comparison to the
quantification performed with our TQ-MS analyses
5. ease of use and bottleneck in the workflow
29. Seleted
ReacKon
monitoring
Ion
transiKons
=
High
ResoluKon
accurate
mass
determinaKon,
HRAM
Full
scan
with
extracted
ion
chromatograms
Comparison
between
SRM
on
QQQ-‐MS
and
HR-‐Full
Scan
on
HRMS
m/z
fong190_021 #331 RT: 2.48 AV: 1 NL: 3.64E4
T: FTMS {1;1} + p ESI Full ms [100.00-2000.00]
198.98 199.00 199.02 199.04 199.06 199.08 199.10 199.12 199.14 199.16 199.18 199.20 199.22 199.24 199.26
m/z
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
RelativeAbundance
199.16942199.08702
m/z
Orbitrap
Time
of
Flight
(TOF)
eV
XIC
Extracted
Ion
Chromatogram
30. How
much
Resolu7on
is
needed
in
HR
-‐
full
scan
to
have
selec7ve
detec7ons
?
31. Dunand
M
et
al.,
Clin
Biochem.
2014.
Furlong
M
et
al.,
Rapid
Commun.
Mass
Spectrom.,
2010.
Kumar
P
et
al.,
Meat
Sci.
2014.
Kaufmann
A
et
al.,
Anal.
Chim.
Acta.
2010.
Van
der
Heej
E
et
al.,
J
Am
Soc
Mass
Spectrom.
2009.
Interference
in
SRM
detec7ons
that
are
resolved
by
HR-‐FS
detec7on
m/z
≥
50
ppm
Not
a
selec+vity
problem
if
:
•
R
≥
25,000
and
•
MEW
≤
50
ppm
32. Dunand
M
et
al.,
Clin
Biochem.
2014.
*
considering
in-‐source
and
CE
fragmentaKons
according
to
Kuwayama,
K
et
al.
J
Anal
Toxicol,
2009
HMMA
(4-‐hydroxy-‐3-‐methoxymethamphetamine)*
C10
[13]CH14O2
+
=
166.09436
Normetanephrine
C9H12NO2
=
166.08626
HMMA
RT
1.63
Normetanephrine
RT
1.68
HMMA
RT
3.64
Normetanephrine
RT
3.88
=
49
ppm
HMMA
SRM
=
161.1
134.1
Normetanephrine
SRM
=
161.1
134.1
demands
LC
separa7on
Interference
in
SRM
detec7ons
that
are
resolved
by
HR-‐FS
detec7on
m/z
≥
50
ppm
Not
a
selec+vity
problem
if
:
•
R
≥
25,000
and
•
MEW
≤
50
ppm
33. Isomers
and
enan7omers
with
HR-‐FS
detec7on
LC
separa7on
or
MS/MS
(=
PRM
from
HR-‐product
scan)
For
research
use
only.
Not
for
use
in
diagnos7c
procedures.
34. 0 2 4 6 8 10 12 14
Time [min]
0
50
100
0
50
100
0
50
100
0
50
100
0
50
100
RT: 8.72
AA: 26,265,139
RT: 6.50
AA: 11,618,438
RT: 12.47
AA: 11,297,376
RT: 7.98
AA: 269,780
RT: 6.36
AA: 17,816,895
RT: 9.43
AA: 19,972,935
NL: 7.97E6
m/z= 399.21710-399.22110
F: FTMS + p ESI Full lock
ms [200.00-1000.00] MS
ICIS 150123_TKIs_18
NL: 3.54E6
m/z= 465.09127-465.09593
F: FTMS + p ESI Full lock
ms [200.00-1000.00] MS
ICIS 150123_TKIs_18
NL: 8.73E4
m/z= 488.16028-488.16516
F: FTMS + p ESI Full lock
ms [200.00-1000.00] MS
ICIS 150123_TKIs_18
NL: 5.18E6
m/z= 494.26383-494.26877
F: FTMS + p ESI Full lock
ms [200.00-1000.00] MS
ICIS 150123_TKIs_18
NL: 5.42E6
m/z= 530.18790-530.19320
F: FTMS + p ESI Full lock
ms [200.00-1000.00] MS
ICIS 150123_TKIs_18
Z&E - sunitinib
sorafenib
dasatinib
imatinib
nilotinib
RelativeAbundance
Detec7on
selec7vity
in
HR
full
scan
LC - Q-Exactive Focus® chromatograms in plasma extracts
For
research
use
only.
Not
for
use
in
diagnos7c
procedures.
35. RelativeAbundance
1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0
Time [min]
Fluconazole
Itraconazole
Posaconazole
Voriconazole
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Time [min]
RelativeAbundance
0
50
100
0
50
100
0
50
100
0
50
100
Ciclosporine A
Everolimus
Sirolimus
Tacrolimus
0
50
100
0
50
100
0
50
100
0
50
100
LC - Exactive® - MS chromatograms of LLOQ extracted serum and plasma
samples
Detec7on
selec7vity
in
HR
full
scan
For
research
use
only.
Not
for
use
in
diagnos7c
procedures.
36. 3-epi-25-OH-Vit-D3
25-OH-Vit-D3
0 1 2 3 4 5 6 7 8 9 10 11 12
0
50
100
0
50
100
0
50
100
0
50
100
0
50
100
6.64
6.29
7.65
IS : D3-25-OH-Vit-D3
25-OH-Vit-D2
IS : D6-3-epi-25-OH-Vit-D3
24,25-OH-Vit-D3
Time [min]
LC - Exactive Plus® MS chromatograms of ULOQ extracted plasma samples
Detec7on
selec7vity
in
HR
full
scan
For
research
use
only.
Not
for
use
in
diagnos7c
procedures.
37. Testosterone
quan7fied
in
HR-‐full
scan
or
PRM
(MS/MS)
acquisi7on
Rela7ve
Abundance
2.6
2.8
3.0
3.2
3.4
3.6
3.8
4.0
4.2
4.4
Time
[min]
0
20
40
60
60
80
100
HR-‐full
scan
m/z
200
–
400
XIC:
m/z
289.21621
MEW=
5
ppm
PRM
(MS/MS)
m/z
289.2
50
–
315;
CE
=
28
XIC:
m/z
97.06512
+
109.06505
MEW
=
5
ppm
RT:
3.40
Area:
1,587
RT:
3.41
Area:
13,714
0.00 0.05 0.10 0.15 0.20 0.25
0
20,000
40,000
60,000
80,000
LC-MS
peak area
Levels [ng/mL]
HR-‐full
scan
PRM
LOD
Precision
(N=3)
<
11%
Accuracy
(N=3)
<
18%
Precision
(N=6)
<
16%
Accuracy
(N=6)
<
6%
HRFS
PRM
A
B
0.125
pg
on
column
(LOD)
Rochat
et
al.,
in
prep.
LC - Q-Exactive Focus® chromatogram (pure standard)
For
research
use
only.
Not
for
use
in
diagnos7c
procedures.
38. 0 50 100 150 200 250
0
500
1,000
1,500
2,000
2,500
3,000
PeakArea(x10-3)
0 50 100 150 200 250
0
200
400
600
800
1,000
1,200
1,400
Levels [ng/mL]
Y = a+b*X+c*X^2
W: 1/X
R^2 = 0.9998
Y = a+b*X+c*X^2
W: 1/X
R^2 = 0.9998
0 1 2 3 4 5
0 1 2 3 4 5
LOD
LOD
Data Independant Acquisition (*)
HR-Full Scan Acquisition
PeakArea(x10-3)
0
20
40
60
80
100
RelativeAbundance
HR-full scan
RT 7.98
Height: 424; Area: 1,435
m/z= 488.1630; MEW = ± 10 ppm
H-ESI+; Probe= 300°C
R: 70,000 at m/z= 200
m/z 200 to 1,000; profile
6 7 8 9 10
LOD: 1 pg of dasatinib on column
6 7 8 9 10
Time [min]
0
20
40
60
80
100
RelativeAbundance
DIA, precusor isol. m/z 455-505
RT: 7.97
Height: 140; Area: 441
m/z product = 401.0938 ; MEW = ± 10 ppm
ESI +; Probe= 300°C
@hcd 35eV
R: 35,000 at m/z= 200
scan m/z 50 to 505; profile
Dasa7nib
quan7fied
in
HR-‐full
scan
or
DIA*
(MS/MS)
acquisi7on
HR-Full Scan Acquisition
Data Independant Acquisition (*)
Calibration in extracted plasma samples
Rochat
et
al.,
in
prep.
For
research
use
only.
Not
for
use
in
diagnos7c
procedures.
39. Criteria to evaluate the Exactive Plus® and Q-Exactive Focus®
HRMS in Quan analyses
1. detection selectivity in HR full scan
2. accuracy and precision of mass determination
3. dynamic range and linearity of calibration curves
4. level accuracy of UNK samples in comparison to the
quantification performed with our TQ-MS analyses
5. ease of use and bottleneck in the workflow
40. 0
2
4
6
8
10
12
14
16
18
Time
[min]
0
50
100
0
50
100
0
50
100
0
50
100
AA:
1,911,620
AA:
493,891
AA:
1,081,491
AA:
1,427,138
AA:
1,417,255
A:
MEW
=
±
10
ppm
Z&E
suni7nib
sorafenib
nilo7nib
ima7nib
0
2
4
6
8
10
12
14
16
18
Time
[min]
0
50
100
0
50
100
0
50
100
0
50
100
B:
MEW
=
±
100
ppm
AA:
3,646,352
AA:
1,941,726
AA:
513,581
AA:
1,081,491
AA:
1,444,592
AA:
1,462,899
AA:
266,080
false
posi7ve
detec7on
0
2
4
6
8
10
12
14
16
18
Time
[min]
0
50
100
0
50
100
0
50
100
0
50
100
AA:
418,102
AA:
284,678
AA:
1,394,647
AA:
1,379,635
C:
MEW
=
±
0.8
ppm
false
nega7ve
detec7on
False
detec7ons
of
analytes
in
HRMS
analysis
high
background
peak
area
=
20%
new
peak
As
the
result
of
a
mass
shij
with
a
too
narrow
MEW
For
research
use
only.
Not
for
use
in
diagnos7c
procedures.
41. Mass
Accuracy
(MA)
over
7me
or
concentra7ons
Mass
Accuracy
[ppm]
-‐6
-‐4
-‐2
0
2
4
6
#1
0
4
8
Time
[h]
0
4
8
0
3
6
9
12
4
8
0
#2
#3
#4
5
10
15
20
0
#6
Intra-‐assay
(MA
over
Kme)
N
=
140
N
=
30
N
=
36
N
=
24
N
=
29
5
10
15
20
0
#5
N
=
60
-‐6
-‐4
-‐2
0
2
4
6
1
10
100
1,000
10,000
Calibra7on
(MA
over
levels)
Levels
[ng/mL]
etravirin
2.5
to
10,000
ng/mL
Q-‐Exac7ve
Focus®
(lock
mass
calibraKon
from
0
–
0.15min
with
a
contaminant
ion)
Rochat
et
al.,
in
prep.
For
research
use
only.
Not
for
use
in
diagnos7c
procedures.
42. -6
-4
-2
0
2
4
6
0 2 4 6 8 10 12 140 6 12 18 24 30
-6
-4
-2
0
2
4
6
0 6 12 18 24
-6
-4
-2
0
2
4
6
MA[ppm]
-6
-4
-2
0
2
4
6
0 3 6 9 12 0 6 12 18 24
-6
-4
-2
0
2
4
6
-6
-4
-2
0
2
4
6
0 3 6 9 12
Time [h]
MA[ppm]MA[ppm]
A
B
C
Intra-Assay (MA over time) Calibration (MA over amounts)
0 1 10 100 1,000 10,000
-6
-4
-2
0
2
4
6
Level [ng/mL]
-4
0
4
8
12
16
1 10 100 1,000
*
* *
*
-8
sunitinib
centralite
* overload
1 10 100 1,000 10,000
-6
-4
-2
0
2
4
6 aconitine
echimidine
-6
-4
-2
0
2
4
6
0 5 10 15 20
-6
-4
-2
0
2
4
6
0 3 6 129
-6
-4
-2
0
2
4
6
0 2 4 86
Q
ExacKve
(no
lock
mass)
Q-‐TOF#1
(no
lock
mass)
Q-‐TOF#2
(with
lock
mass)
Mass Accuracy (MA) over time or concentrations
Rochat
et
al.,
in
prep.
For
research
use
only.
Not
for
use
in
diagnos7c
procedures.
43. Suni7nib
spiked
from
0.0125
to
5,000
ng/mL
in
plasma
extract
(PP)
LC-‐HRMS
analysis
(full
scan,
0-‐0.15min
lock
mass
recalib.;
QE
®);
XIC
at
m/z
=
399.2191;
MEW
=
5
ppm
m/zTime [min]
RelativeAbundance
LOD: 0.0125 ng/mL
ULOQ: 5,000 ng/mL
Mass accuracy
- 2.1 ppm
Mass accuracy
- 0.2 ppm
-4
-2
0
2
4
0 1 100 10'000
Sunitinib levels [ng/mL]
MassAccuracy[pm]SunitinibPeakArea
0 1,000 2,000 3,000 4,000 5,000
0 1 2 3 4 5
Sunitinib levels [ng/mL]
5,000 ng/mL
0.0125 ng/mL
(*) Q Exactive Focus®
Mass
Devia7on
in
Calibra7on
Curves
44. Criteria to evaluate the Exactive Plus® and Q-Exactive Focus®
HRMS in Quan analyses
1. detection selectivity in HR full scan
2. accuracy and precision of mass determination
3. LOD, dynamic range and linearity of calibration curves
4. level accuracy of UNK samples in comparison to the
quantification performed with our TQ-MS analyses
5. ease of use and bottleneck in the workflow
45. µg/L
Sirolimus
0 10 20 30 40 50
AreaRatio
Ciclosporine A
0 100 200 300 400 500 600 700 800 900
µg/L
AreaRatio
LC-ESI QQQ-MS (SRM) LC-ESI Exactive-MS (HR-full scan)
Dasatinib
0 100 200 300 400 500
µg/L
AreaRatio
Imatinib
0 2000 4000 6000 8000 10000
µg/L
AreaRatio
Fluconazole
0 10 20 30 40 50
µg/L
AreaRatio
Posaconazole
0 2 4 6 8 10
µg/LAreaRatio
Calibration Curves of LC-HRMS and LC-QQQ-MS
Henry
H
et
al.,
RCMS,
2012
For
research
use
only.
Not
for
use
in
diagnos7c
procedures.
46. Sunitinib: dynamic range of calibrants from 0.0125 to 5,000 ng/mL
with A) QQQ-MS, SRM and B) HRFS full scan*
0.0 0.1 0.2 0.3 0.4 0.5
0
50
100 LC-ESI+ - QQQ-MS; SRM
Area: 181,505
0.0125ng/mL
25 pg on column
m/z 399.2 282.1
centroid
8.3 8.5 8.7 8.9 9.1 9.3
Time [min]
0
50
100
RelativeAbundance
LC-ESI+ - HR full scan
Area: 15,121
0.0125ng/mL
25 pg on column
m/z 399.2191; MEW= 10ppm
m/z 200 to 1,000
R: 70,000 at mz 200
profile
RelativeAbundance
0 1 2 3 4 5
Levels [ng/mL]
A
B
0 1,000 3,000 5,000
AreaArea
0.0 0.1 0.2 0.3 0.4 0.58.3 8.5 8.7 8.9 9.1 9.3 0 1 2 3 4 5 0 1,000 3,000 5,000
(*) Q Exactive Focus®
47. Limit Of Detection and Upper Limit Of Quantification in plasma
extracts analysed by LC-QQQ-MS and LC-HRMS*
QQQ-MS- SRM HRMS*- full scan
TKI LOD ULOQ ULOQ / LOD LOD ULOQ ULOQ / LOD
imatinib 0.013 250 20,000 0.050 5,000 100,000
dasatinib 1.000 5,000 5,000 0.500 5,000 10,000
sunitinib 0.013 250 20,000 0.013 5,000 400,000
nilotinib 0.013 500 40,000 0.013 2,500 200,000
sorafenib 0.100 500 4,000 0.250 2,500 10,000
PI
raltegravir 0.100 2500 25,000 0.100 2500 25,000
darunavir 0.100 2500 25,000 0.100 2500 25,000
ritonavir 0.100 2500 25,000 0.100 2500 25,000
etravirin 0.250 2500 10,000 0.100 5000 50,000
Conclusion:
LOD:
QQQ-‐MS
=
HRMS*
Dynamic
range
:
HRMS*
>
QQQ-‐MS
(*)
Q
ExacKve
Focus®
MS
()
TSQ
Quantum
Ultra
®
MS
For
research
use
only.
Not
for
use
in
diagnos7c
procedures.
48. Criteria to evaluate the Exactive Plus® and Q-Exactive Focus®
HRMS in Quan analyses
1. detection selectivity in HR full scan
2. accuracy and precision of mass determination
3. dynamic range and linearity of calibration curves
4. level accuracy of UNK samples in comparison to the
quantification performed with our TQ-MS analyses
5. ease of use and bottleneck in the workflow
49. 4.5
5
5.5
6
6.5
7
7.5
8
8.5
9
4.5 5.5 6.5 7.5 8.5
HRMS
(HR-FS)
Passing & Bablok (I) fit
1.09 + 0.79x
Everolimus
Identity
2
4
6
8
10
12
14
2 4 6 8 10 12 14
Identity
Passing & Bablok (I) fit
-1.93 + 1.18x
Tacrolimus
HRMS
(HR-FS)
2
4
6
8
10
12
14
16
2 4 6 8 10 12 14 16
-0.21 + 1.04x
HRMS
(HR-FS)
Sirolimus
Passing & Bablok (I) fit
Identity
0
50
100
150
200
250
0 50 100 150 200 250
-5.11 + 0.97x
HRMS
(HR-FS)
TQ-MS (SRM)
Ciclosporine A
Passing & Bablok (I) fit
Identity
TQ-MS (SRM) TQ-MS (SRM)
TQ-MS (SRM)
Passing & Bablok Fit of immunosupressive drugs in serum:
SRM versus HR-FS acquisition (N=100)
Henry
H
et
al.,
RCMS,
2012
For
research
use
only.
Not
for
use
in
diagnos7c
procedures.
50. 0
500
1,000
1,500
2,000
2,500
3,000
0 500 1,000 1,500 2,000 2,500 3,000
HRMS
[ng/ml]
TQ-MS
[ng/ml]
Passing & Bablok Fit of imatinib in plasma:
SRM versus HR-FS acquisition (N=17)
Identity
Passing & Bablok (I) fit
1.0851x 1 78.412
R2 = 0.9808
Exactive Plus MS
Exactive MS
For
research
use
only.
Not
for
use
in
diagnos7c
procedures.
51. Passing & Bablok Fit of 25-OH-vitamin D3 in plasma :
SRM versus HR-FS acquisition (N=100)
25-OH-vitamin D3 [µg/L]
determined by LC-Triple Quadrupole MS
25-OH-vitaminD3[µg/L]
determined
by
LC-‐Exac7ve
plus
MS
N
=
662
clinical
samples
Bruce
S
et
al.,
RCMS
2013
For
research
use
only.
Not
for
use
in
diagnos7c
procedures.
52. Criteria to evaluate the Exactive Plus® and Q-Exactive Focus®
HRMS in Quan analyses
1. detection selectivity in HR full scan
2. accuracy and precision of mass determination
3. dynamic range and linearity of calibration curves
4. level accuracy of UNK samples in comparison to the
quantification performed with our TQ-MS analyses
5. ease of use and bottleneck in the workflow
53.
Resolu7on
Size
[Mo]□
at
m/z
=
200
profile
◊
centroid◊◊
HRMS*
FS
70,000
160
54
5x
PRM
(MS/MS)
35,000
12
8
QQQ-‐MS●
SRM
<
5,000
-‐
5
* : Q Exactive Focus® MS
(□)
Mo:
megaoctets
for
about
a
20
min
analyKcal
run
(◊)
p:
profile
acquisiKon
mode
(◊◊)
c:
centroid
acquisiKon
mode
● : TSQ Quantum Ultra® MS
User-‐friendlyness
of
HRMS*
:
(no
CE
tuning,
troubleshooKng
in
full
scan)
File
Size
:
OK
and
variable
54.
55. Quan
/
Qual
Monitoring
of
Tamoxifen
Extended
to
40
Metabolites
in
Human
Plasma
using
LC-‐HRMS
Tamoxifen (TAM) : Facts
50,000 women treated for breast cancer in the USA in 2005
rare but life-threatening events.
For
research
use
only.
Not
for
use
in
diagnos7c
procedures.
56. Rochat B. Clin Pharmacokinet. 2005.
Fate of Tamoxifen
a long history of drug metabolism studies
57. absolute quantification
o Plasma levels in donors: QQQ = HRMS
o LLOQ comparable (2x lower with HR-full scan than SRM *)
Quan
/
Qual
analysis
•
Tamoxifen
•
N-‐desmethyl-‐Tamoxifen
•
4-‐OH-‐Tamoxifen
•
Endoxifen
(*)
ExacKve
Plus® HRMS
versus
TSQ
Quantum
Ultra ®
MS
For
research
use
only.
Not
for
use
in
diagnos7c
procedures.
58. LC-SRM-QQQ-MS 22 Tamoxifen metabolites determined in donor plasma
Most comprehensive analysis in plasma with QQQ-MS
Mürdter TE et al. Clin Pharmacol Ther. 2011
Teunissen SF et al., Pharm Biomed Anal. 2011
Demethylation
Hydroxylation
Glucuronidation
For
research
use
only.
Not
for
use
in
diagnos7c
procedures.
59. Extracted Ion Chromatograms (XIC) based on 50 predicted biotransformations
Correlations between Tamoxifen and metabolite plasma levels
Mass Defect Filtering
Quan
/
Qual
analysis
Tamoxifen metabolite identification
For
research
use
only.
Not
for
use
in
diagnos7c
procedures.
61. Tamoxifen
m/z 372.23219
UNK-554
m/z = 554.23846
0 1 2 3 4 5 6 7 8 9 10
Time [min]
0
20
40
60
80
100
RelativeAbundance
(%)
0
20
40
60
80
100
RelativeAbundance
(%)
7.91
7.40
5.07
5.38
RT: 3.63
6.22
Intensity
3.6 x108
Intensity
1. 8 x106
E-TAM
Z-TAM
Extracted Ion Chromatograms (XIC): unpredicted metabolite
Dahmane
et
al,
Anal
Bioanal
Chem.
2014
For
research
use
only.
Not
for
use
in
diagnos7c
procedures.
62. R² = 0.305
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
2.0
0.00 5.00 10.00 15.00
Z-endoxifen
TAM
Endoxifen
R² = 0.570
0.00
0.05
0.10
0.15
0.20
0.25
0.00 5.00 10.00 15.00
UNK-554
TAM
UNK at m/z 554
Correlations between Tamoxifen and metabolite plasma levels
Metabolite/ IS
Peak area ratios
Dahmane
et
al,
Anal
Bioanal
Chem.
2014
For
research
use
only.
Not
for
use
in
diagnos7c
procedures.
63. Correlations between Tamoxifen and metabolite plasma levels
Metabolite/ IS
Peak area ratios
R² = 0.463
0.00
0.05
0.10
0.15
0.20
0.25
0.000 5.00 10.00 15.00
R² = 0.346
0.00
0.05
0.10
0.15
0.20
0.25
0.00 5.00 10.00 15.00
R² = 0.968
0.00
0.01
0.02
0.03
0.04
0.05
0.00 5.00 0.000 15.00
TAM-dihydrodiol
TAM-COOH
TAM-desat
TAM
TAM
TAM
R² = 0.897
0
2
4
6
8
10
12
14
16
18
20
0.00 5.00 10.00 15.00
N-demethyl-TAM
TAM
For
research
use
only.
Not
for
use
in
diagnos7c
procedures.
64. Fine isotopic distribution at A+2
for 2 possible compositions
of UNK at m/z 554
556.220 556.230 556.240 556.250 556.260
m/z
Proposal #1 with sulfur : A = [C37H34ON2S]+
FTMS + p ESI Full ms [200-600]
0
10
100
m/z meas = 556.24525
A + 2
AM-XIC from HR-FS acquisitions (N=10 scans; Resolution = 85,000 at m/z = 556)
20
30
40
50
60
70
80
90
RelativeAbundance(%)
0
10
20
30
40
50
60
70
80
90
100
RelativeAbundance(%)
m/z theor. = 556.24270
Proposal # 2 : no sulfur: A = [C30H36O9N]+
m/z theor. = 556.24517
A + 2 = C28
13C2H36O9N
A + 2 = C30H36O8
18ON
A + 2 = [C37H34ON2
34S]+
A + 2 = [C35
13C2H34ON2S]+
0
10
20
30
40
50
60
70
80
90
100
RelativeAbundance(%)
m/z theor. = 556.24535
m/z theor. = 556.23443
Rmin : 100,0000
Rmin : 450,0000
theore7cal
theore7cal
measured
A
monoisotopic
A+1
A+2
m/z
65. Fine isotopic distribution at A+2
for 2 possible compositions
of UNK at m/z 554
556.220 556.230 556.240 556.250 556.260 556.270
m/z
Proposal #1 with sulfur : A = [C37H34ON2S]+
FTMS + p ESI Full ms [200-600]
0
10
100
m/z meas = 556.24525
A + 2
AM-XIC from HR-FS acquisitions (N=10 scans; Resolution = 85,000 at m/z = 556)
20
30
40
50
60
70
80
90
RelativeAbundance(%)
0
10
20
30
40
50
60
70
80
90
100
RelativeAbundance(%)
m/z theor. = 556.24270
Proposal # 2 : no sulfur: A = [C30H36O9N]+
m/z theor. = 556.24517
A + 2 = C28
13C2H36O9N
A + 2 = C30H36O8
18ON
A + 2 = [C37H34ON2
34S]+
A + 2 = [C35
13C2H34ON2S]+
0
10
20
30
40
50
60
70
80
90
100
RelativeAbundance(%)
m/z theor. = 556.24535
m/z theor. = 556.23443
Rmin : 100,0000
Rmin : 450,0000
theore7cal
theore7cal
measured
N 2H
O H
O
O
OH
OH
OH
O H
m/z 554.23846 = C30H36O9N +
O H
O
6th generation metabolite :
didemethyl-triOH-TAM-glucoside
66. Fine isotopic distribution of putative
TAM-O-sulfate metabolite at A+2
A = 100%; A+1 = 28% and A+2 = 5%
C26H30NO5
34S
100%
13C2C24H30NO5
32S
84 %
C26H29NO5S +H : A+2
470.16 470.17 470.18 470.19 470.20 470.21 470.22
m/z
0
10
20
30
40
50
60
70
80
90
100
RelativeAbundance 470.17972
470.19063
470.18817
470.18666
470.19355
Rmin = 88,000
theoretical
100%
60%
HR-Full ms [200-600]; R:140K
470.16 470.17 470.18 470.19 470.20 470.21 470.22
m/z
0
10
20
30
40
50
60
70
80
90
100
RelativeAbundance
470.17984
470.19054
Rmeas. = 105,000
measured
C26H29NO5S
O
N
H+
HO3S
O
67. 0.01
0.10
1.00
10.00
100.00
0 1 2 3 4 5 6 7
Number of biotransformation steps
(metabolite generation)
TAM N-demethyl-TAM
Relative levels of Tamoxifen metabolite
versus
metabolite generation
Phase I enzymes
Phase II enzymes
Tamoxifen metabolites in % of
Tamoxifen in relative levels
(mean peak area ratios; N = 8 to 20 patients)
For
research
use
only.
Not
for
use
in
diagnos7c
procedures.
68.
69. Life
Brick
Biome
Discipline
Informa7on
genes
genome
genomics
genotype/-‐ing
proteins
proteome
proteomics
proteotype/-‐ing
metabolites
metabolome
metabolomics
metabotype/-‐ing
(*)
(*)
Metabolic
phenotype
The
main
bricks
of
life
70. 2011-‐2013
:
#
of
Swiss
Na7onal
Fund
granted
projects
containing
the
following
K-‐Words
0
20
40
60
80
100
120
140
160
180
genome proteome metabolome
-ome
-omics
Similar
results
were
presented
by
David
Wishart
at
the
10th
Interna7onal
Conference
of
the
Metabolomics
Society
(2014):
Metabolomics
represents
8%,
2%
and
14%
of
the
budget
allocated
to
genomics
in
Australia,
Canada
and
USA,
resp.
4%
of
genomics
#
of
granted
projects
71. Systems
Biology
Gonzalez FJ et al.
Gene
Environment
the“final”
measurable
picture
:
a
job
for
HRMS
Mosaicism
72. What
informa2on
can
we
obtain
from
a
human
plasma
with
LC-‐HRMS
analysis
and
how
?
A
biomedical
percep7on:
Could
hundreds
of
metabolites
give
us
a
more
global
informaKon
about
person’s
status
?
73. Time
(0-‐25
min.)
m/z
(60
–
200)
Metabolites
LC-‐HRMS
analysis
with
a
2D
Gel
representa7on
Unknown
(features)
Un-‐targeted
metabolomics
Inden7fied
Targeted
metabolomics
Defini7on
:
For
research
use
only.
Not
for
use
in
diagnos7c
procedures.
77. Our
partner
for
Untargeted
metabolomics
and
biomarker
discovery
untargeted
metabolomics
78. Alignment
Peak
picking
Deconvolu7on
HR
full
scan
data
import
Verifica7on
Metabolite
ID
&
review
Compound
Sta7s7cs
Metabolomics
Informa7c
Workflow
79. Metabolite
#
14,012
Untargeted
Metabolomics:
Prostate
Cancer
Biomarker
Discovery
with
untargeted
metabolomics
in
human
serum
Prostate
Cancer
Hyperplasia
Control
Overall
N
>
300
samples
For
research
use
only.
Not
for
use
in
diagnosKc
procedures.
80. MCI
+
MCI
-‐
Untargeted
Metabolomics:
Alzheimer
disease
Biomarker
Discovery
with
untargeted
metabolomics
in
human
serum
ALZ+
Control
1
Control
2
Control
3
Control
4
ALZ+
:
alzheimer
paKents
MCI+
:
paKents
with
mild
cogniKve
impairement
Overall
N
>
300
samples
For
research
use
only.
Not
for
use
in
diagnosKc
procedures.
81. Targeted
metabolomics
red
blood
cell
storage
in
SAGM*
soluKon
Michel
Prudent1,
Bertrand
Rochat2,
Laure
Marvin1,2,
Frédéric
Stauber1,
Jean-‐Daniel
Tissot1,
Niels
Lion1
(*)
saline-‐adenine-‐glucose-‐mannitol
1
2
Targeted
metabolomics
Our
Partner
82. Targeted
metabolomics
using
LC-‐HRMS
analysis
• DeterminaKon
of
hydrophilic
metabolites
(Zic-‐Hilic
column).
• Untargeted
LC-‐MS
acquisiKon
(full
scan)
but
targeted
data
treatment.
• 71
idenKfied
metabolites
showed
significant
variaKons
over
storage
Kme.
• PCA
exhibits
disKnct
groups
related
to
in
vitro
aging.
Abundance
of
GSH
in
func2on
of
storage
2me
in
10
donors
For
research
use
only.
Not
for
use
in
diagnos7c
procedures.
84. So{as
PE
and
Vernec
A.,
Bioanalysis,
2012
Metabolite
#1
/
Metabolite
#2
ra7o
7me
1
10
2
5
From
Athlete’s
biological
passport
to
personalized
medicine
Targeted
metabolomics
(precise
rela7ve
quan7fica7on
of
known
compounds)
100’s
to
1,000’s
of
metabolites
for
personalized
biological
passports
Popula7on
reference
value
Personal
reference
value
85. So{as
PE
and
Vernec
A.,
Bioanalysis,
2012
Metabolite
#1
/
Metabolite
#2
ra7o
Longitudinal
survey
7me
1
10
From
Athlete’s
biological
passport
to
personal
medicine
More
in
depth
medical
inves7ga7ons
86. Summary
of
our
3-‐4
years
LC-‐HRMS
analyses
with
Exac+ve
Plus®
MS
and
Q
Exac+ve
Focus® MS
For
research
use
only.
Not
for
use
in
diagnos7c
procedures.
87.
88.
89.
90.
91.
92. HRMS
:
the
new
gold
standard
in
LC-‐MS
analyzis.
S7ll
some
doubts
?
HRMS
«
nega7ve
»
points
• Lack of guidelines for quantitative HRMS analysis GLP compatible even if new guidance could be edited
93. HRMS
:
the
new
gold
standard
in
LC-‐MS
analyzis.
S7ll
some
doubts
?
HRMS
«
nega7ve
»
points
• Lack of guidelines for quantitative HRMS analysis GLP compatible even if new guidance could be edited
• Comparison of quantitative performance with QQQ-MS still needed already many comparisons
94. HRMS
:
the
new
gold
standard
in
LC-‐MS
analyzis.
S7ll
some
doubts
?
HRMS
«
nega7ve
»
points
• Lack of guidelines for quantitative HRMS analysis GLP compatible even if new guidance could be edited
• Comparison of quantitative performance with QQQ-MS still needed already many comparisons
• Higher costs to purchase HRMS than QQQ-MS not anymore
95. HRMS
:
the
new
gold
standard
in
LC-‐MS
analyzis.
S7ll
some
doubts
?
HRMS
«
nega7ve
»
points
• Lack of guidelines for quantitative HRMS analysis GLP compatible even if new guidance could be edited
• Comparison of quantitative performance with QQQ-MS still needed already many comparisons
• Higher costs to purchase HRMS than QQQ-MS not anymore
• "Activation energy" to develop quantitative HRMS analysis not difficult
96. HRMS
:
the
new
gold
standard
in
LC-‐MS
analyzis.
S7ll
some
doubts
?
HRMS
«
nega7ve
»
points
• Lack of guidelines for quantitative HRMS analysis GLP compatible even if new guidance could be edited
• Comparison of quantitative performance with QQQ-MS still needed already many comparisons
• Higher costs to purchase HRMS than QQQ-MS not anymore
• "Activation energy" to develop quantitative HRMS analysis not difficult
• No polarity switching in an analytical run True for Q-TOF. False for Orbitrap(R) (but true in very fast LC)
97. HRMS
:
the
new
gold
standard
in
LC-‐MS
analyzis.
S7ll
some
doubts
?
HRMS
«
nega7ve
»
points
• Lack of guidelines for quantitative HRMS analysis GLP compatible even if new guidance could be edited
• Comparison of quantitative performance with QQQ-MS still needed already many comparisons
• Higher costs to purchase HRMS than QQQ-MS not anymore
• "Activation energy" to develop quantitative HRMS analysis not difficult
• No polarity switching in an analytical run True for Q-TOF. False for orbitrap (but true in very fast LC)
• Huge data file (2 to 30x bigger than SRM with QQQ-MS) not difficult to handle (except for metabolomics).
98. HRMS
:
the
new
gold
standard
in
LC-‐MS
analyzis.
S7ll
some
doubts
?
HRMS
«
nega7ve
»
points
• Lack of guidelines for quantitative HRMS analysis GLP compatible even if new guidance could be edited
• Comparison of quantitative performance with QQQ-MS still needed already many comparisons
• Higher costs to purchase HRMS than QQQ-MS not anymore
• "Activation energy" to develop quantitative HRMS analysis not difficult
• No polarity switching in an analytical run True for Q-TOF. False for orbitrap (but true in very fast LC)
• Huge data file (2 to 30x bigger than SRM with QQQ-MS) not difficult to handle (except for metabolomics).
• Useless data it is useful ! e.g. : troubleshooting with full scan; Quan/Qual, (un)targeted metabolomics
99. HRMS
:
the
new
gold
standard
in
LC-‐MS
analyzis.
S7ll
some
doubts
?
HRMS
«
nega7ve
»
points
• Lack of guidelines for quantitative HRMS analysis GLP compatible even if new guidance could be edited
• Comparison of quantitative performance with QQQ-MS still needed already many comparisons
• Higher costs to purchase HRMS than QQQ-MS not anymore
• "Activation energy" to develop quantitative HRMS analysis not difficult
• No polarity switching in an analytical run True for Q-TOF. False for orbitrap (but true in very fast LC)
• Huge data file (2 to 30x bigger than SRM with QQQ-MS) not difficult to handle (except for metabolomics).
• Useless data it is useful ! e.g. : troubleshooting with full scan; Quan/Qual, (un)targeted metabolomics
• Risk of false negative and false positive peak detection easy to cope with; less interference than SRM
100. HRMS
:
the
new
gold
standard
in
LC-‐MS
analyzis.
S7ll
some
doubts
?
HRMS
«
nega7ve
»
points
• Lack of guidelines for quantitative HRMS analysis GLP compatible even if new guidance could be edited
• Comparison of quantitative performance with QQQ-MS still needed already many comparisons
• Higher costs to purchase HRMS than QQQ-MS not anymore
• "Activation energy" to develop quantitative HRMS analysis not difficult
• No polarity switching in an analytical run True for Q-TOF. False for orbitrap (but true in very fast LC)
• Huge data file (2 to 30x bigger than SRM with QQQ-MS) not difficult to handle (except for metabolomics).
• Useless data it is useful ! e.g. : troubleshooting with full scan; Quan/Qual, (un)targeted metabolomics
• Risk of false negative and false positive peak detection easy to cope with; less interference than SRM
• My cheap Single-Quad performs well for what I need OK
101. HRMS
:
the
new
gold
standard
in
LC-‐MS
analyzis.
S7ll
some
doubts
?
HRMS
«
nega7ve
»
points
• Lack of guidelines for quantitative HRMS analysis GLP compatible even if new guidance could be edited
• Comparison of quantitative performance with QQQ-MS still needed already many comparisons
• Higher costs to purchase HRMS than QQQ-MS not anymore
• "Activation energy" to develop quantitative HRMS analysis not difficult
• No polarity switching in an analytical run True for Q-TOF. False for orbitrap (but true in very fast LC)
• Huge data file (2 to 30x bigger than SRM with QQQ-MS) not difficult to handle (except for metabolomics).
• Useless data it is useful ! e.g. : troubleshooting with full scan; Quan/Qual, (un)targeted metabolomics
• Risk of false negative and false positive peak detection easy to cope with; less interference than SRM
• My cheap Single-Quad performs well for what I need OK
• My QQQ-MS is 20X more sensitive than the HRMS systems I have tested OK (possible even not the rule)
102. HRMS
:
the
new
gold
standard
in
LC-‐MS
analyzis.
S7ll
some
doubts
?
HRMS
«
nega7ve
»
points
• Lack of guidelines for quantitative HRMS analysis GLP compatible even if new guidance could be edited
• Comparison of quantitative performance with QQQ-MS still needed already many comparisons
• Higher costs to purchase HRMS than QQQ-MS not anymore
• "Activation energy" to develop quantitative HRMS analysis not difficult
• No polarity switching in an analytical run True for Q-TOF. False for orbitrap (but true in very fast LC)
• Huge data file (2 to 30x bigger than SRM with QQQ-MS) not difficult to handle (except for metabolomics).
• Useless data it is useful ! e.g. : troubleshooting with full scan; Quan/Qual, (un)targeted metabolomics
• Risk of false negative and false positive peak detection easy to cope with; less interference than SRM
• My cheap Single-Quad performs well for what I need OK
• My QQQ-MS is 20X more sensitive than the HRMS systems I have tested OK (possible even not the rule)
• Conservatism See next slides
103. I
have
no
+me
to
change
the
system
It
is
perfect
as
it
is
I
am
not
leRng
a
junior
take
my
posi+on
I
just
realized
I
don’t
care
I
just
re+red
and
started
philosophy
classes
HRMS
:
the
new
gold
standard
in
LC-‐MS
analysis.
S7ll
some
doubts
??
104. •
Ask
bioanalysts
that
perform
LC-‐HRMS
analyses
•
Send
your
samples
to
demo
labs
Quan targeted quantification
Qual biomarker id., fate of drugs and metabolites
Quan/Qual both Quan and Qual combined
Relative Quan metabolite phenotyping: metabolome and exposome
HRMS QQQ-MS
LOD
=
( > or < )
For
research
use
only.
Not
for
use
in
diagnos7c
procedures.