Offering fragile X syndrome carrier screening: a prospective mixed-methods observational study comparing carrier screening of pregnant and non-pregnant women in the general population

INTRODUCTION

Fragile X syndrome (FXS) is the leading cause of inherited intellectual and developmental disability. Policy development relating to carrier screening programmes for FXS requires input from large studies examining not only test uptake but also psychosocial aspects. This study will compare carrier screening in pregnant and non-pregnant populations, examining informed decision-making, psychosocial issues and health economics.

METHODS AND ANALYSIS

Pregnant and non-pregnant women are being recruited from general practices and obstetric services. Women receive study information either in person or through clinic mail outs. Women are provided pretest counselling by a genetic counsellor and make a decision about testing in their own time. Data are being collected from two questionnaires: one completed at the time of making the decision about testing and the second 1 month later. Additional data are gathered through qualitative interviews conducted at several time points with a subset of participating women, including all women with a positive test result, and with staff from recruiting clinics. A minimum sample size of 500 women/group has been calculated to give us 88% power to detect a 10% difference in test uptake and 87% power to detect a 10% difference in informed choice between the pregnant and non-pregnant groups. Questionnaire data will be analysed using descriptive statistics and multivariate logistic regression models. Interview data will be thematically analysed. Willingness-to-pay and cost effectiveness analyses will also be performed. Recruitment started in July 2009 and data collection will be completed by December 2013.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Universities of Melbourne and Western Australia and by recruiting clinics, where required. Results will be reported in peer-reviewed publications, conference presentations and through a website http://www.fragilexscreening.net.au. The results of this study will make a significant contribution to discussions about the wider introduction of population carrier screening for FXS.

Pulsed rotating supersonic source for merged molecular beams

We describe a pulsed rotating supersonic beam source, evolved from an ancestral device [M. Gupta and D. Herschbach, J. Phys. Chem. A 105, 1626 (2001)]. The beam emerges from a nozzle near the tip of a hollow rotor which can be spun at high-speed to shift the molecular velocity distribution downward or upward over a wide range. Here we consider mostly the slowing mode. Introducing a pulsed gas inlet system, cryocooling, and a shutter gate eliminated the main handicap of the original device in which continuous gas flow imposed high background pressure. The new version provides intense pulses, of duration 0.1-0.6 ms (depending on rotor speed) and containing ∼10(12) molecules at lab speeds as low as 35 m/s and ∼10(15) molecules at 400 m∕s. Beams of any molecule available as a gas can be slowed (or speeded); e.g., we have produced slow and fast beams of rare gases, O(2), Cl(2), NO(2), NH(3), and SF(6). For collision experiments, the ability to scan the beam speed by merely adjusting the rotor is especially advantageous when using two merged beams. By closely matching the beam speeds, very low relative collision energies can be attained without making either beam very slow.

Detection of cryptic pathogenic copy number variations and constitutional loss of heterozygosity using high resolution SNP microarray analysis in 117 patients referred for cytogenetic analysis and impact on clinical practice

BACKGROUND

Microarray genome analysis is realising its promise for improving detection of genetic abnormalities in individuals with mental retardation and congenital abnormality. Copy number variations (CNVs) are now readily detectable using a variety of platforms and a major challenge is the distinction of pathogenic from ubiquitous, benign polymorphic CNVs. The aim of this study was to investigate replacement of time consuming, locus specific testing for specific microdeletion and microduplication syndromes with microarray analysis, which theoretically should detect all known syndromes with CNV aetiologies as well as new ones.

METHODS

Genome wide copy number analysis was performed on 117 patients using Affymetrix 250K microarrays.

RESULTS

434 CNVs (195 losses and 239 gains) were found, including 18 pathogenic CNVs and 9 identified as "potentially pathogenic". Almost all pathogenic CNVs were larger than 500 kb, significantly larger than the median size of all CNVs detected. Segmental regions of loss of heterozygosity larger than 5 Mb were found in 5 patients.

CONCLUSIONS

Genome microarray analysis has improved diagnostic success in this group of patients. Several examples of recently discovered "new syndromes" were found suggesting they are more common than previously suspected and collectively are likely to be a major cause of mental retardation. The findings have several implications for clinical practice. The study revealed the potential to make genetic diagnoses that were not evident in the clinical presentation, with implications for pretest counselling and the consent process. The importance of contributing novel CNVs to high quality databases for genotype-phenotype analysis and review of guidelines for selection of individuals for microarray analysis is emphasised.

Autosomal dominant Klippel-Feil anomaly with cleft palate

Klippel-Feil anomaly is characterized by the fusion of two or more cervical vertebrae. Most cases are sporadic but dominant and recessive inheritance are well described. Associated anomalies such as a cleft palate are common. We describe a unique family with autosomal dominantly inherited Klippel-Feil anomaly in six individuals associated with a cleft palate in four. One patient, a child, has a cleft palate only but may develop radiological cervical fusion with time, as documented in two other family members.

Acidic and basic fibroblast growth factor mRNA and protein in mouse mammary glands

Previous studies suggest that members of the fibroblast growth factor (FGF) family are mitogenic to mammary epithelium. In order to determine expression of acidic and basic FGF (aFGF and bFGF) during mammary development, mice were euthanized as virgins, early pregnant, mid-pregnant, late-pregnant, or during early lactation. Mammary expression of both aFGF and bFGF mRNA increased through pregnancy. Acidic FGF mRNA continued to increase during early lactation, but basic FGF message level decreased drastically during early lactation. Western blots probed with anti-aFGF showed four immunoreactive bands approx 30, 48, 52, and 55-kDa in size. The 30-, 48-, and 55-kDa bands for aFGF were expressed at low levels during virgin and early pregnant stages but were more prominent during the later stages. The 52-kDa band was high during the virgin and early pregnant stages and low in mid-pregnancy through early lactation. Blots probed with anti-bFGF showed two bands approx 30 and 50 kDa in size. Both bands increased through early-pregnancy, but during late-pregnancy there was a decrease in immunoreactive protein levels, which remained low during early lactation. Experiments to determine where FGF mRNAs are produced in the mammary gland suggest that both FGFs may be produced in the stroma, leading to the hypothesis that aFGF and bFGF are stromally produced growth factors and probably act on the epithelial component of the gland in a paracrine fashion.

Hormonal regulation of acidic and basic fibroblast growth factor production and expression in mouse mammary gland

Based on previous results showing developmental regulation of aFGF and bFGF, we evaluated the effect of various hormones on aFGF and bFGF mRNA levels, in mammary gland. Northern blots indicated that estrogen alone increased aFGF but had no effect on bFGF messenger RNA level. Progesterone alone increased aFGF and bFGF mRNA levels. Estrogen and progesterone together increased aFGF mRNA level in mammary gland, but the increase was no greater than that caused by either hormone alone. However, the combination of estrogen and progesterone had no effect on bFGF message level. PRL or GH, when administered with estrogen and progesterone, increased aFGF, but did not have any effect on bFGF message level. However, when PRL and GH were administered together with estrogen and progesterone, they increased bFGF messenger RNA level. Ovarian steroid withdrawal increased aFGF, but did not have any effect on bFGF mRNA accumulation. PRL alone (in the absence of estrogen and progesterone) decreased aFGF, whereas it had no effect on bFGF message level. Hydrocortisone alone decreased aFGF, but increased bFGF mRNA level. However, PRL and hydrocortisone increased aFGF, but did not have any significant effect on bFGF message level. In the overall model, during growth of the mammary gland, ovarian steroids cause an increase in aFGF mRNA. During lactogenesis, ovarian steroid withdrawal causes an increase in aFGF messenger RNA levels. Lactogenic hormones together cause a further increase in aFGF message levels.

A cluster of sulfatase genes on Xp22.3: mutations in chondrodysplasia punctata (CDPX) and implications for warfarin embryopathy

X-linked recessive chondrodysplasia punctata (CDPX) is a congenital defect of bone and cartilage development characterized by aberrant bone mineralization, severe underdevelopment of nasal cartilage, and distal phalangeal hypoplasia. A virtually identical phenotype is observed in the warfarin embryopathy, which is due to the teratogenic effects of coumarin derivatives during pregnancy. We have cloned the genomic region within Xp22.3 where the CDPX gene has been assigned and isolated three adjacent genes showing highly significant homology to the sulfatase gene family. Point mutations in one of these genes were identified in five patients with CDPX. Expression of this gene in COS cells resulted in a heat-labile arylsulfatase activity that is inhibited by warfarin. A deficiency of a heat-labile arylsulfatase activity was demonstrated in patients with deletions spanning the CDPX region. These data indicate that CDPX is caused by an inherited deficiency of a novel sulfatase and suggest that warfarin embryopathy might involve drug-induced inhibition of the same enzyme.

Charting infant distress: an aid to defining colic

The value of a 24-hour distress diary, previously validated against a voice-activated audiotape record, was investigated in 30 infants with colic and 30 control infants. The infants with colic had significantly more distress behavior (300.0 minutes vs 102.5 minutes; p < 0.001), although overlap of duration of distress was noted. On the basis of a clinical definition of colic--total distress lasting 180 minutes in a 24-hour period--the diary had a sensitivity of 77% and a specificity of 87%. The sensitivity of the chart was confirmed in a separate study of another 90 infants with colic.

Evidence that Rieger syndrome maps to 4q25 or 4q27

We report a baby with the features of Rieger syndrome and a de novo interstitial deletion of 4q which includes band 4q26 and an adjoining GTL light band, either q25 or q27. Rieger syndrome is provisionally mapped to 4q23----q27 but band 4q26 has been excluded as a possible site, suggesting that Rieger syndrome must map to a band, either 4q25 or 4q27, adjoining 4q26.

Duplications of the X chromosome in males: evidence that most parts of the X chromosome can be active in two copies

We have analysed two duplications of the X chromosome in male patients using chromosome replication and DNA methylation patterns as determinants of the functional status of the duplicated segments. In both cases, the large duplicated regions, Xq12-q22 and Xq26.3-qter, were not inactivated. A review of previously reported male cases revealed that these duplications were also not subject to inactivation. Taken together, the examined duplications cover almost the entire X chromosome except the pericentromeric region and Xq25-26. Thus, most regions of the X chromosome can be present in two functional copies without lethal consequences.

Glyceryl ethers in peroxisomal disease

1-O-Alkyl and 1-O-alk-1-enyl (plasmalogens) glyceryl ether lipid levels were measured in post-mortem brain and/or liver biopsies from 7 patients with ultrastructural and biochemical evidence of a defect in peroxisomal biogenesis and/or enzymological evidence of a disturbance in ether lipid synthesis. Near normal levels of both species of glyceryl ether lipids were found in neonatal adrenoleukodystrophy and infantile Refsum's disease but marked deficiencies were found in Zellweger's syndrome and rhizomelic chondrodysplasia punctata, the latter manifesting the most profound reduction in ether lipid levels. These observations suggest that little ether lipid biosynthesis occurs in vivo in rhizomelic chondrodysplasia punctata or Zellweger's syndrome. However, in some phenotypes with apparently gross reductions in peroxisomal numbers, e.g. neonatal adrenoleukodystrophy and infantile Refsom's disease, there is significant ether lipid synthesis in liver and brain.

Unusual X chromosome inactivation in a mentally retarded girl with an interstitial deletion Xq27: implications for the fragile X syndrome

A de novo interstitial deletion (X)(q27.1q27.3), between the loci DXS 105 and F8, has been found in a mentally retarded female. The deleted X chromosome is preferentially early replicating in fibroblasts, B cells and T cells, suggesting that the missing region plays a role in inactivation of the X chromosome. None of the available DNA probes except DXS 98 maps to the deleted region of about 10,000 kb. The locus FRAXA is either included in the deletion, or located close to the distal break point.

Linkage heterogeneity between X-linked retinitis pigmentosa and a map of 10 RFLP loci

In nine families in which X-linked retinitis pigmentosa (XLRP) is segregating, the lod scores of XLRP in a map of 10 RFLP loci were obtained by multipoint linkage analysis. The XLRP locus was located telomeric to DXS7 in seven of the families and centromeric to DXS7 in two of the families. Under the hypothesis of two XLRP loci, a heterogeneity (admixture) test was performed, providing significant evidence of heterogeneity in XLRP (P less than .01). No correlation was detected between the clinical manifestations of XLRP and the two different disease loci.

Non-allelic mutations in X-linked retinitis pigmentosa

Using RFLP studies, the disease locus in two X-linked retinitis pigmentosa families was found to be centromeric to DXS7 in one family and telomeric to DXS7 in another, suggesting non-allelic heterogeneity.

Rhizomelic chondrodysplasia punctata: clinical, pathologic, and biochemical findings in two patients

The clinical, pathologic, and biochemical features of rhizomelic chondrodysplasia punctata are described in two patients. Although both patients had clinical and radiologic similarities, one patient survived for only 13 days and the other is still alive at 8 years. The most prominent pathologic feature was the marked degenerative change in the chondrocytes from resting cartilage. Fibroblast alkyldihydroxyacetone phosphate synthase activity was markedly reduced in both patients (approximately 10% of control mean); in contrast, dihydroxyacetone phosphate acyltransferase activity was only moderately reduced (50% of control mean). Alkyl and alk-l-enyl ether (plasmalogens) levels were very low in brain and liver. The accumulation of phytanic acid observed in plasma or liver was paralleled by a reduced ability of the patients' fibroblasts to oxidize phytanic acid. Our data indicate that the genetic defect in rhizomelic chondrodysplasia punctata results in abnormalities in two apparently unrelated pathways (i.e., phytanic acid oxidation and ether lipid biosynthesis.

Investigation of the twinning rate in families with the fragile X syndrome

An excess of twins in families with the Martin-Bell or fra(X) syndrome was noted previously in one family study [Fryns, 1986]. We tried to confirm this observation in a second large sample of families from a different population. We calculated the number of twin births among the total number of live births of known obligate carriers found in fra(X) families ascertained in New South Wales, Australia. We only included births of known sex and excluded triplets. There were 5 male pairs, 3 female pairs and 9 unlike sex pairs of twins born among 752 live births. Thus the twining rate was 1/44 per live birth. We compared this rate to that found in two different types of individuals: 1) the rate of 1/96 which was obtained from the 1985 vital statistics for New South Wales, and 2) the rate 1/75 obtained from a sample of live births of obligate carriers with hemophilia A. The increase in twinning among heterozygotes with the fra(X) was highly significant when compared to the census data (p less than 0.001). However, it was not significantly different from that in the hemophilia data (p less than 0.05) which were collected in the same way as in the fra(X) families.

Variable distributions of serum creatine kinase reference values. Relationship to exercise activity

Although the effect of exercise on serum creatine kinase (CK: EC 2.7.3.2) activity is well known, no standard protocol for blood collection conditions has been developed. Variable frequency distributions of CK activities have been reported for reference range samples from different laboratories and have been attributed to laboratory differences. In this study the frequency distributions of creatine kinase activities (CK: EC 2.7.3.2) in serum samples obtained from the same groups of volunteers varied from a normal Gaussian distribution, to skewed distributions, on different occasions. In one collection extremely high CK values followed the performance of an eccentric exercise step test 5-8 days previously. In 2 students serum CK activities had not returned to resting values 12 and 15 days later. Peak serum CK values occurred within 24 h of other types of exercise. Serum CK frequency distributions in blood samples obtained from a group of nurses was skewed, whereas the distribution in mothers of school children was Gaussian. When repeat samples were obtained from the nurses after instruction to avoid exercise, the distribution became Gaussian. In view of the increasing levels of physical activity in the community, a standard protocol for serum CK analysis is required, in which exercise activity over the previous three weeks should be documented. Test subjects should be counselled to avoid unusual eccentric exercise and sampling should include 3 tests at least 1 week apart.

Fronto-ethmoidal meningoencephaloceles: morphology and treatment

Twenty-five cases of fronto-ethmoidal meningoencephaloceles have been studied. The relationship to other sincipital meningoencephaloceles is explored. In all cases the exit holes from the anterior cranial fossa are at the site of the foramen caecum. The facial component of the defect determines the sub-classification: naso-frontal, naso-ethmoidal and naso-orbital. The cranio-facial deformity may consist of hypertelorism, orbital dystopia, elongation of the face and dental malocclusion. These reflect the distorting influence of the extruded intracranial contents on facial growth. Early removal of the meningoencephalocele by the cranio-facial route is recommended to allow normal growth forces to be re-established. In older patients with established deformities translocation of the orbits may be necessary.