Testing the Children: Do Non-Genetic Health-Care Providers Differ in Their Decision to Advise Genetic Presymptomatic Testing on Minors? A Cross-Sectional Study in Five Countries in the European Union

BACKGROUND: Within Europe many guidelines exist regarding the genetic testing of minors. Predictive and presymptomatic genetic testing of minors is recommended for disorders for which medical intervention/preventive measures exist, and for which early detection improves future medical health. AIM: This study, which is part of the larger 5th EU-framework "genetic education" (GenEd) study, aimed to evaluate the self-reported responses of nongenetic health-care providers in five different EU countries (Germany, France, Sweden, the United Kingdom, and the Netherlands) when confronted with a parent requesting presymptomatic testing on a minor child for a treatable disease. METHODS: A cross-sectional study design using postal, structured scenario-based questionnaires that were sent to 8129 general practitioners (GPs) and pediatricians, between July 2004 and October 2004, addressing self-reported management of a genetic case for which early medical intervention during childhood is beneficial, involving a minor. RESULTS: Most practitioners agreed on testing the oldest child, aged 12 years (81.5% for GPs and 87.2% for pediatricians), and not testing the youngest child, aged 6 months (72.6% for GPs and 61.3% for pediatricians). After multivariate adjustment there were statistical differences between countries in recommending a genetic test for the child at the age of 8 years. Pediatricians in France (50%) and Germany (58%) would recommend a test, whereas in the United Kingdom (22%), Sweden (30%), and the Netherlands (32%) they would not. CONCLUSION: Even though presymptomatic genetic testing in minors is recommended for disorders for which medical intervention exists, EU physicians are uncertain at what age starting to do so in young children

BioOK – a Comprehensive System for Analysis and Risk Assessment of Genetically Modified Plants

Gentechnisch veränderte (GV) Pflanzen müssen im Rahmen des Zulassungsverfahrens in der EU auf ihre potentiellen Auswirkungen auf die Umwelt und die mensch­liche oder tierische Gesundheit analysiert werden. Der gegenwärtige Zulassungsprozess ist ein Konglo­merat verschiedenster Analysemethoden und extrem zeit- und kostenaufwendig. Das Anliegen von BioOK als ein multidisziplinäres wissenschaftliches Netzwerk ist die Entwicklung von maßgeschneiderten Ansätzen zur Risikoanalyse von GV Pflanzen auf der Grundlage von Ursache-Wirkungs­hypothesen mit dem Ziel des Aufbaus eines effektiven und qualifizierten Risikobewertungssystems. Die Forschungsaktivitäten von BioOK zielen auf einen Paradigmenwechsel im aktuellen Zulassungsprozess. Sie basieren auf einem modularen System, das alle Aspekte des Risikomanagements umfasst: molekulare Charakterisierung, Inhaltsstoffanalyse, agronomische Eigenschaften, Ziel- und Nichtzielorganismen, Boden und Mikroorganismen, Toxikologie, Allergenität und Überwachung nach Markt­einführung, wobei jeder Modul unterschiedliche Analysemethoden beinhaltet. Die durch BioOK angestrebte Reform des Risikobewertungsprozesses von GV Pflanzen umfasst zwei Phasen: zunächst die Optimierung der Analysemethoden selbst und dann die Etablierung eines Entscheidungsunterstützungssystems (Test Decision System – DSS), basierend auf biologischen Schwankungsbreiten (baselines), Zeigermerkmalen (indicators) und Grenzwerten (thresholds) für jede Analysemethode. BioOK hat in einer ersten Entwicklungsphase bereits optimierte Testmethoden entwickelt: Für die Inhaltsstoffanalyse wurde die Untersuchung auf substantielle Äquivalenz durch GC-MS, LC-MS und HPLC/RI Methoden vereinfacht. Ein neu eingeführtes Analyseschema zur Ermittlung potentieller Effekte von GV Pflanzen auf den Boden kombiniert ein in vitro System zur Beprobung von Rhizodepositaten von Pflanzen, die unter kontrollierten Umweltbedingen gewachsen sind, sowie die entsprechenden Bodentypen und deren Charakterisierung mit offenen und hochsensitiven molekular-chemischen Screening und Fingerprinting-Methoden. Ein neues in vitro System zur Simulation des Transports von Substanzen aus dem Darm ins Blut, das das Risiko der Aufnahme durch Mensch oder Tier zu einem frühen Zeitpunkt misst, wurde entwickelt. Um die Effektivität und Reproduzierbarkeit von Probenahmen an der Pflanze zu erhöhen, wird ein genau definiertes Probenahmeschema entwickelt. Schließlich, in Ergänzung der aktuellen Methodik zur Allgemeinen Überwachung (General Surveillance) von GV Pflanzen im Anbau, wurde eine Herangehensweise zur Abschätzung der Notwendigkeit für ein europaweites fallspezifisches (Case Specific) Monitoring beruhend auf Ursache-Wirkungsszenarien, erarbeitet. Die zweite Phase der BioOK F&E-Arbeiten konzentriert sich auf die Entwicklung eines Entscheidungsunterstützungssystems (Decision Support System, DSS). Dazu wird ein computergestütztes System implementiert, in dem alle standardisierten und validierten Methoden zu einem Entscheidungsbaum mit Knotenpunkten, definiert über biologische Schwankungsbreiten und potentielle Risiken definierenden Grenzwerten für Zeigermerkmale, zusammengeführt sind.    Genetically modified (GM) plants have to be analyzed for their potential impacts on the environment and on human or animal health before authorisation by the EU. The approval process currently refers to a conglomeration of diverse analytical methods and is intensive in time and costs. The intention of BioOK as a multidisciplinary scientific network is the development of tailor-made approaches for GM plants based on a cause-effect hypothesis to obtain an effective and qualified risk assessment system. The research activity of BioOK aims to renew the current approval process. It is based on a modular system covering all aspects of risk assessment: molecular characterisation, compound analysis, agronomic traits, target and non-target organisms, soil and micro organisms, toxicology, allergenicity and post-market monitoring, each module containing several test methods. The renewal of the risk assessment procedure intended by BioOK consists of two phases: first the optimization of test methods and second the establishment of a decision support system (DSS) based on baselines, indicators and thresholds developed for each of the methods. Optimized test methods have been developed mainly during the first phase: For compound analysis methods have been developed to ease the analysis of substantial equivalence of the events by GC-MS, LC-MS and HPLC/RI. A newly introduced testing scheme for the detection of potential effects of GM plants on soil combines an in-vitro system to collect rhizodeposits from plants grown under controlled environmental conditions and the correspon­ding bulk soil, and their characterisation by untargeted and highly sensitive molecular-chemical screening and fingerprinting technique. A novel in vitro system simula­ting the transport of substances from the gut into the blood that detects the risk of incorporation in human or animal at an early time point was developed. In order to increase the effectiveness and reproducibility of the sampling procedure we developed a valid defined sampling scheme. Finally, complementing the actual General Surveillance methodology, an approach for a Europe-wide case specific monitoring referring to cause-effect sce­narios was developed. The second phase concentrates on the development of a Decision Support System (DSS). A computer-based system will implement and merge all standardized methods in a decision tree system following decision rules defined by baseline and thresholds for indicators.   &nbsp

Phenotypic and molecular insights into CASK-related disorders in males

Background: Heterozygous loss-of-function mutations in the X-linked CASK gene cause progressive microcephaly with pontine and cerebellar hypoplasia (MICPCH) and severe intellectual disability (ID) in females. Different CASK mutations have also been reported in males. The associated phenotypes range from nonsyndromic ID to Ohtahara syndrome with cerebellar hypoplasia. However, the phenotypic spectrum in males has not been systematically evaluated to date. Methods: We identified a CASK alteration in 8 novel unrelated male patients by targeted Sanger sequencing, copy number analysis (MLPA and/or FISH) and array CGH. CASK transcripts were investigated by RT-PCR followed by sequencing. Immunoblotting was used to detect CASK protein in patient-derived cells. The clinical phenotype and natural history of the 8 patients and 28 CASK-mutation positive males reported previously were reviewed and correlated with available molecular data. Results: CASK alterations include one nonsense mutation, one 5-bp deletion, one mutation of the start codon, and five partial gene deletions and duplications; seven were de novo, including three somatic mosaicisms, and one was familial. In three subjects, specific mRNA junction fragments indicated in tandem duplication of CASK exons disrupting the integrity of the gene. The 5-bp deletion resulted in multiple aberrant CASK mRNAs. In fibroblasts from patients with a CASK loss-of-function mutation, no CASK protein could be detected. Individuals who are mosaic for a severe CASK mutation or carry a hypomorphic mutation still showed detectable amount of protein. Conclusions: Based on eight novel patients and all CASK-mutation positive males reported previously three phenotypic groups can be distinguished that represent a clinical continuum: (i) MICPCH with severe epileptic encephalopathy caused by hemizygous loss-of-function mutations, (ii) MICPCH associated with inactivating alterations in the mosaic state or a partly penetrant mutation, and (iii) syndromic/nonsyndromic mild to severe ID with or without nystagmus caused by CASK missense and splice mutations that leave the CASK protein intact but likely alter its function or reduce the amount of normal protein. Our findings facilitate focused testing of the CASK gene and interpreting sequence variants identified by next-generation sequencing in cases with a phenotype resembling either of the three groups

a controlled multicenter study with assessment of echocardiographic reference values, and the frequency of dilatation and aneurysm in Marfan syndrome

Background Echocardiographic upper normal limits of both main pulmonary artery (MPA) diameters (MPA-d) and ratio of MPA to aortic root diameter (MPA-r) are not defined in healthy adults. Accordingly, frequency of MPA dilatation based on echocardiography remains to be assessed in adults with Marfan syndrome (MFS). Methods We enrolled 123 normal adults (72 men, 52 women aged 42 ± 14 years) and 98 patients with MFS (42 men, 56 women aged 39 ± 14 years) in a retrospective cross-sectional observational controlled study in four tertiary care centers. We defined outcome measures including upper normal limits of MPA-d and MPA-r as 95 quantile of normal persons, MPA dilatation as diameters > upper normal limits, MPA aneurysm as diameters >4 cm, and indication for surgery as MPA diameters >6 cm. Results MPA diameters revealed normal distribution without correlation to age, sex, body weight, body height, body mass index and body surface area. The upper normal limit was 2.6 cm (95% confidence interval (CI) =2.44-2.76 cm) for MPA-d, and 1.05 (95% CI = .86–1.24) for MPA-r. MPA dilatation presented in 6 normal persons (4.9%) and in 68 MFS patients (69.4%; P < .001), MPA aneurysm presented only in MFS (15 patients; 15.3%; P < .001), and no patient required surgery. Mean MPA-r were increased in MFS (P 1.05 were equally frequent in 7 normal persons (5%) and in 8 MFS patients (10.5%; P = .161). MPA-r related to aortic root diameters (P = .042), reduced left ventricular ejection fraction (P = .006), and increased pulmonary artery systolic pressures (P = .040). No clinical manifestations of MFS and no FBN1 mutation characteristics related to MPA diameters. Conclusions We established 2.6 cm for MPA-d and 1.05 for MPA-r as upper normal limits. MFS exhibits a high prevalence of MPA dilatation and aneurysm. However, patients may require MPA surgery only in scarce circumstances, most likely because formation of marked MPA aneurysm may require LV dysfunction and increased PASP

Points to consider for prioritizing clinical genetic testing services: a European consensus process oriented at accountability for reasonableness.

Given the cost constraints of the European health-care systems, criteria are needed to decide which genetic services to fund from the public budgets, if not all can be covered. To ensure that high-priority services are available equitably within and across the European countries, a shared set of prioritization criteria would be desirable. A decision process following the accountability for reasonableness framework was undertaken, including a multidisciplinary EuroGentest/PPPC-ESHG workshop to develop shared prioritization criteria. Resources are currently too limited to fund all the beneficial genetic testing services available in the next decade. Ethically and economically reflected prioritization criteria are needed. Prioritization should be based on considerations of medical benefit, health need and costs. Medical benefit includes evidence of benefit in terms of clinical benefit, benefit of information for important life decisions, benefit for other people apart from the person tested and the patient-specific likelihood of being affected by the condition tested for. It may be subject to a finite time window. Health need includes the severity of the condition tested for and its progression at the time of testing. Further discussion and better evidence is needed before clearly defined recommendations can be made or a prioritization algorithm proposed. To our knowledge, this is the first time a clinical society has initiated a decision process about health-care prioritization on a European level, following the principles of accountability for reasonableness. We provide points to consider to stimulate this debate across the EU and to serve as a reference for improving patient management

The changing landscape of genetic testing and its impact on clinical and laboratory services and research in Europe

The arrival of new genetic technologies that allow efficient examination of the whole human genome (microarray, next-generation sequencing) will impact upon both laboratories (cytogenetic and molecular genetics in the first instance) and clinical/medical genetic services. The interpretation of analytical results in terms of their clinical relevance and the predicted health status poses a challenge to both laboratory and clinical geneticists, due to the wealth and complexity of the information obtained. There is a need to discuss how to best restructure the genetic services logistically and to determine the clinical utility of genetic testing so that patients can receive appropriate advice and genetic testing. To weigh up the questions and challenges of the new genetic technologies, the European Society of Human Genetics (ESHG) held a series of workshops on 10 June 2010 in Gothenburg. This was part of an ESHG satellite symposium on the 'Changing landscape of genetic testing', co-organized by the ESHG Genetic Services Quality and Public and Professional Policy Committees. The audience consisted of a mix of geneticists, ethicists, social scientists and lawyers. In this paper, we summarize the discussions during the workshops and present some of the identified ways forward to improve and adapt the genetic services so that patients receive accurate and relevant information. This paper covers ethics, clinical utility, primary care, genetic services and the blurring boundaries between healthcare and research

The main pulmonary artery in adults : a controlled multicenter study with assessment of echocardiographic reference values, and the frequency of dilatation and aneurysm in Marfan syndrome

BACKGROUND: Echocardiographic upper normal limits of both main pulmonary artery (MPA) diameters (MPA-d) and ratio of MPA to aortic root diameter (MPA-r) are not defined in healthy adults. Accordingly, frequency of MPA dilatation based on echocardiography remains to be assessed in adults with Marfan syndrome (MFS). METHODS: We enrolled 123 normal adults (72 men, 52 women aged 42 ± 14 years) and 98 patients with MFS (42 men, 56 women aged 39 ± 14 years) in a retrospective cross-sectional observational controlled study in four tertiary care centers. We defined outcome measures including upper normal limits of MPA-d and MPA-r as 95 quantile of normal persons, MPA dilatation as diameters > upper normal limits, MPA aneurysm as diameters >4 cm, and indication for surgery as MPA diameters >6 cm. RESULTS: MPA diameters revealed normal distribution without correlation to age, sex, body weight, body height, body mass index and body surface area. The upper normal limit was 2.6 cm (95% confidence interval (CI) =2.44-2.76 cm) for MPA-d, and 1.05 (95% CI = .86–1.24) for MPA-r. MPA dilatation presented in 6 normal persons (4.9%) and in 68 MFS patients (69.4%; P < .001), MPA aneurysm presented only in MFS (15 patients; 15.3%; P < .001), and no patient required surgery. Mean MPA-r were increased in MFS (P < .001), but ratios >1.05 were equally frequent in 7 normal persons (5%) and in 8 MFS patients (10.5%; P = .161). MPA-r related to aortic root diameters (P = .042), reduced left ventricular ejection fraction (P = .006), and increased pulmonary artery systolic pressures (P = .040). No clinical manifestations of MFS and no FBN1 mutation characteristics related to MPA diameters. CONCLUSIONS: We established 2.6 cm for MPA-d and 1.05 for MPA-r as upper normal limits. MFS exhibits a high prevalence of MPA dilatation and aneurysm. However, patients may require MPA surgery only in scarce circumstances, most likely because formation of marked MPA aneurysm may require LV dysfunction and increased PASP

Twenty-Five Years of Contemplating Genotype-Based Hereditary Hemochromatosis Population Screening

Hereditary hemochromatosis (HH) is a rather frequent, preventable disease because the progressive iron overload affecting many organs can be effectively reduced by phlebotomy. Even before the discovery of the major gene, HFE, in 1996, hemochromatosis was seen as a candidate for population-wide screening programmes. A US Centers of Disease Control and the National Human Genome Research Institute expert panel convened in 1997 to consider genotype-based HH population-wide screening and decided that the scientific evidence available at that time was insufficient and advised against. In spite of a large number of studies performed within the last 25 years, addressing all aspects of HH natural history, health economics, and social acceptability, no professional body worldwide has reverted this decision, and HH remains a life-threatening condition that often goes undetected at a curable stage