Regulating reproductive genetic services: dealing with spiral-shaped processes and techno-scientific imaginaries.

PURPOSE: We have been inquiring into the diffusion process of reproductive genetic services (RGS) and the viability of geneticization in human reproduction. METHOD: A 2-round modified-Delphi survey was applied amongst Israeli and Spanish experts to analyze regulatory attitudes and expectations about the future applications of RGS. We argue that an explanation of RGS diffusion based on a 'technology-push' impulse should be complemented by a 'demandpull' approach, which underscores the importance of regulatory frameworks and demand-inducing policies. The diffusion of RGS is advancing in a 'spiralshaped' process where technology acts as a cause and effect simultaneously, modulating social acceptance and redefining the notions of health and responsibility along the way. RESULTS: We suggest that there is a 'grey-zone' of RGS regulations regarding four procedures: the use of germline genome modification (GGM) for severe monogenic disorders, preimplantation genetic testing (PGT) for detection of chromosomal abnormalities, PGT for multifactorial diseases, and PGT with whole-exome screening. CONCLUSIONS: Although far from the geneticization of human reproduction, our findings suggest that, since techno-scientific imaginaries tend to shape regulations and thus favor the diffusion of RGS, policymakers should pay attention to those procedures by focusing on good practices and equity while providing sound information on potential risks and expected success rates. A broad and inclusive societal debate is critical for overcoming the difficulty of drawing a clear line between medical and non-medical uses of genetic selection and engineering while searching for the right balance between allowing reproductive autonomy and protecting the public interest.

Regulatory responses to assisted reproductive technology: a comparative analysis of Spain and Israel.

PURPOSE: The market of assisted reproductive technologies (ARTs) is rapidly evolving, raising growing ethical and social dilemmas. This paper compares the regulatory responses to technological and market developments in Israel and Spain, both intensive users of ART. We identify strengths and deficiencies in the regulation of ART in these two countries. METHODS: We developed a conceptual framework to classify the factors affecting regulations and priority setting, and applied it using a Delphi survey combined with in-depth interviews. We selected two panels of experts from various fields, trying to simulate the bioethics committees of Israel and Spain. RESULTS: ART is often wrongfully perceived as a solution to age-related infertility. Both panels embraced alternative solutions. The impact of private commercial interest on regulations is resulting in excessive practices such as the repeat of ineffective cycles and the push of sometimes unnecessary treatment add-ons. Our findings show experts dissatisfaction with the regulations of donor-eggs concerning reimbursement and registries in both countries. CONCLUSIONS: The adequacy of ART to solve age-related infertility should be confronted with alternative approaches, with emphasis on the distribution of accurate information. The magnitude of ART markets, particularly the use of donor-eggs, should raise the need for additional societal debate and the reform of regulations. The impact factors analysis leads us to question the current regulatory framework, which could be improved by nominating a non-governmental statutory central regulatory agency in Israel and by reforming the Spanish agency.

Variability of plasma homovanillic acid over 13 months in patients with schizophrenia; relationship with the clinical response and the Wisconsin card sort test.

In the present study we have measured, on a monthly basis, the concentration of plasma homovanillic acid (pHVA) in schizophrenic patients during 13 months of their pharmacological treatment. The average pHVA values of each patient were within the range of 7.30-17.70 ng/ml and the coefficients of variation for each patient (CV %) were within the range of 13-33%. Half of the patients that showed higher pHVA CV% values also showed higher scores on the Brief Psychiatric Rating Scale at the beginning of the study, and improved more after 6 months, when compared to the remaining 50% with lower CV% values. There was no significant relationship between the scores of the Wisconsin Card Sort Test and the concentration or the CV% of the pHVA of each patient. A greater variability in the pHVA may be associated with a greater plasticity of the dopaminergic system and a better clinical response.

Catechol O-methyltransferase and monoamine oxidase A genotypes, and plasma catecholamine metabolites in bipolar and schizophrenic patients.

Metabolites of dopamine and norepinephrine measured in the plasma have long been associated with symptomatic severity and response to treatment in schizophrenic, bipolar and other psychiatric patients. Plasma concentrations of catecholamine metabolites are genetically regulated. The genes encoding enzymes that are involved in the synthesis and degradation of these monoamines are candidate targets for this genetic regulation. We have studied the relationship between the Val158Met polymorphism in catechol O-methyltransferase gene, variable tandem repeat polymorphisms in the monoamine oxidase A gene promoter, and plasma concentrations of 3-methoxy-4-hydroxyphenylglycol, 3,4-dihydroxyphenylacetic acid and homovanillic acid in healthy control subjects as well as in untreated schizophrenic and bipolar patients. We found that the Val158Met substitution in catechol O-methyltransferase gene influences the plasma concentrations of homovanillic and 3,4-dihydroxyphenylacetic acids. Although higher concentrations of plasma homovanillic acid were found in the high-activity ValVal genotype, this mutation did not affect the plasma concentration of 3-methoxy-4-hydroxyphenylglycol. 3,4-dihydroxyphenylacetic acid concentrations were higher in the low-activity MetMet genotype. Interestingly, plasma values 3-methoxy-4-hydroxyphenylglycol were greater in schizophrenic patients and in bipolar patients than in healthy controls. Our results are compatible with the previously reported effect of the Val158Met polymorphism on catechol O-methyltransferase enzymatic activity. Thus, our results suggest that this polymorphism, alone or associated with other polymorphisms, could have an important role in the genetic control of monoamine concentration and its metabolites.

GABA and homovanillic acid in the plasma of Schizophrenic and bipolar I patients.

We have determined the plasma (p) concentration of gamma-aminobutyric acid (GABA) and the dopamine metabolite homovanillic acid (HVA), and the pHVA/pGABA ratio in schizophrenic and bipolar patients. The research was undertaken in a geographic area with an ethnically homogeneous population. The HVA plasma concentrations were significantly elevated in the schizophrenic patients compared to the bipolar patients. The levels of pGABA was significantly lower in the two groups of patients compared to the control group, while the pHVA/pGABA ratio was significantly greater in the both groups of patients compared to the controls. As the levels of pHVA and pGABA are partially under genetic control it is better to compare their concentrations within an homogeneous population. The values of the ratio pHVA/pGABA are compatible with the idea of an abnormal dopamine-GABA interaction in schizophrenic and bipolar patients. The pHVA/pGABA ratio may be a good peripheral marker in psychiatric research.

Plasma homovanillic acid and family history of psychotic disorders in bipolar I patients.

It has been suggested that the family history of psychotic disorders is useful in defining homogeneous groups of bipolar patients. The plasma homovanillic acid (pHVA) concentrations have been related to the effect of antipsychotic treatment in psychotic patients. We have studied the influence of a positive family history of psychotic disorders both on the variation of pHVA levels and on the relation between pHVA concentrations and the clinical response to treatment. Clinical status and pHVA levels were assessed in 58 medication free patients before and after 4 weeks of treatment with olanzapine and lithium. Clinical improvement correlated positively with pHVA levels on the 28th day of treatment only in the patients having first degree relatives with psychotic disorders. The pHVA levels did not decrease after 28 days of treatment. Our results reinforce the idea that a positive family history of psychosis in psychotic bipolar disorders may constitute a good basis for sub-grouping these patients.

Biological correlates of the congruence and incongruence of psychotic symptoms in patients with type 1 bipolar disorder.

UNLABELLED: We examined the catechol-O-methyl transferase (COMT) Val108/158Met genotype in 160 type 1 bipolar patients. We also analyzed the plasma concentrations of homovanillic acid (HVA), 3-methoxy-4-hydroxyphenylethylenglycol (MHPG) and 3,4-dihydroxyphenylacetic acid in 60 of those patients who had been without mood stabilizers or neuroleptic treatment for at least 8 days. RESULTS: Patients with congruent psychotic symptoms presented a higher plasma concentration of HVA than mood incongruent psychotic patients. The Val/Val genotype was associated with higher plasma concentrations of HVA and MHPG. We detected a larger proportion of patients with psychotic symptoms in the Val/Val genotype group, although this did not reach statistical significance. It was found that the distribution of the COMT genotype was not influenced by the congruent/incongruent nature of the psychotic symptoms. LIMITATIONS: The proportion of patients without psychotic symptoms in our sample was low. This fact limits the value of some comparisons. CONCLUSIONS: Congruent and incongruent psychotic patients can be distinguished in terms of the concentration of plasma HVA. Based on the presence or absence of mood incongruent symptoms, the Val108/158Met polymorphism of the COMT gene alone does not appear to be a crucial determinant in the division of psychotic bipolar patients. Nevertheless, COMT polymorphisms may influence some of the characteristics of the patients by their effect on monoamine metabolism.

Inter- and intra-individual variability in the levels of plasma homovanillic acid in schizophrenic patients.

BACKGROUND: Changes in the levels of homovanillic acid in blood plasma (pHVA) may reflect changes which occur in the brain. In healthy individuals, this concentration of pHVA is stable over time. METHODS: Over the course of one month, we studied 98 acute schizophrenic patients who had not been taking any medication but were administered neuroleptics upon hospital admission, together with 23 chronic schizophrenic patients on long-term treatment from whom medication was withdrawn. Blood samples were taken at regular intervals from each individual and the concentration of plasma homovanillic acid was measured. RESULTS: We found relative stable values of pHVA with an intraclass correlation coefficient of 0.363 in acute patients and 0.638 (p<0.0001) in chronic patients, although no differences were found in mean values (13.79 and 14.18 microg/L, respectively) or in the variation range (7.20 to 26.7 microg/L and 6.96 to 29.96 microg/L respectively). The index of individuality was calculated to be 1.36 in acute patients and 0.74 in chronic patients. CONCLUSIONS: Despite the wide range of values in the concentration of pHVA and the presence of pharmacological stimuli, we found a certain reproducibility in the levels of this dopamine metabolite. These findings are consistent with the idea that the dopaminergic activity is characterized by a constitutive value which would be under genetic control. The higher stability observed in chronic patients may reflect a weaker, age-related dopaminergic plasticity; conversely, it may indicate that a lack of plasticity in response to a pharmacological stimulus may be an indicator of poorer prognosis.

Stigma and discrimination towards people with schizophrenia and their family members. A qualitative study with focus groups.

BACKGROUND: There is a scarcity of data regarding the actual stigma and discrimination experienced by schizophrenic patients and their relatives. Those experiences can vary significantly depending on the specific social group involved. We have explored such phenomena in our culture with a qualitative technique. METHODS: We developed a qualitative study with focus groups of clinically stable schizophrenic outpatients (N = 18) and relatives (N = 26). Three groups were performed in each sample. RESULTS: Six categories of stigma and discrimination experiences were extracted from the patients' data: Mental illness vs. Lack of will, Prejudice related to dangerousness, Over-protection-infantilization, Daily social discrimination, Discrimination in health care, Descendants, Avoidance-social isolation. Data from relatives were divided into three sets: discrimination towards the patients witnessed by relatives, discrimination suffered by the relatives themselves and discrimination exerted by the relatives on the patients. CONCLUSIONS: Patients and relatives describe a great variety of stigma and discrimination experiences in all areas of life, including health care. Isolation and avoidance are common reactions to those experiences. Publicizing these stigma and discrimination experiences could help to reduce stigmatizing attitudes in society and result in healthier reactions from patients, favoring a better course of the illness.

Regulation of platelet alpha 2A-adrenoceptors, Gi proteins and receptor kinases in major depression: effects of mirtazapine treatment.

Major depression is associated with the upregulation of alpha(2A)-adrenoceptors in brain tissue and blood platelets. The homologous regulation of these receptors by G-protein-coupled receptor kinases (GRKs) might play a relevant role in the pathogenesis and treatment of depression. This study was designed to assess the status of the complex alpha(2A)-adrenoceptor/Galphai/GRK 2 in the platelets of depressed patients (n=22) before and after treatment with the antidepressant mirtazapine, an antagonist at alpha(2A)-adrenoceptors (30-45 mg/day for up to 6 months). A second series of depressed suicide attempters (n=32) were also investigated to further assess the status of platelet GRK 2 and GRK 6. Platelet alpha(2A)-adrenoceptors and Galphai protein immunoreactivities were increased in depressed patients (49 and 35%) compared with matched controls. In contrast, GRK 2 content was decreased in the two series of depressed patients (27 and 28%). GRK 6 (a GRK with different properties) was found unchanged. In drug-free depressed patients, the severity of depression (behavioral ratings with two different instruments) correlated inversely with the content of platelet GRK 2 (r=-0.46, n=22, p=0.032, and r=-0.55, n=22, p=0.009). After 4-24 weeks of treatment, mirtazapine induced downregulation of platelet alpha(2A)-adrenoceptors (up to 34%) and Galphai proteins (up to 28%), and the upregulation of GRK 2 (up to 30%). The results indicate that major depression is associated with reduced platelet GRK 2, suggesting that a defect of this kinase may contribute to the observed upregulation of alpha(2A)-adrenoceptors. Moreover, treatment with mirtazapine reversed this abnormality and induced downregulation of alpha(2A)-adrenoceptor/Galphai complex. The results support a role of supersensitive alpha(2A)-adrenoceptors in the pathogenesis and treatment of major depression.

Regulation of GRK 2 and 6, beta-arrestin-2 and associated proteins in the prefrontal cortex of drug-free and antidepressant drug-treated subjects with major depression.

G protein-coupled receptor kinases (GRKs) and beta-arrestin-2 play a crucial role in the regulation of neurotransmitter receptors in brain. In this study, GRK 2, GRK 6, beta-arrestin-2 and associated proteins (Gbeta proteins and protein phosphatase (PP)-2A) were quantitated in parallel (immunodensity with specific antibodies) in brains of depressed subjects (drug-free and antidepressant-treated) to investigate the effect of major depression and antidepressant drugs on these receptor regulatory proteins. Specimens of the prefrontal cortex (Brodmann's area 9) were collected from 19 suicide and non-suicide depressed subjects and 13 control subjects. In drug-free (n=9), but not in antidepressant-treated (n=10), depressed subjects an increase in the density of membrane-associated GRK 2 (30%, n=9, P=0.005) was found compared with that in sex-, age-, and PMD-matched controls. Comparison between drug-free and antidepressant-treated depressed subjects showed that GRK 2 was reduced in membrane (39%, n=10, P=0.008) and cytosolic (44%, n=10, P=0.09) preparations after antidepressant drug treatment. In contrast, membrane-associated GRK 6 (drug-free and antidepressant-treated depressed subjects) was found unchanged when compared with that in matched controls. Similarly, the densities of beta-arrestin-2, PP-2A, and Gbeta proteins were not significantly different from those in matched controls. There was a positive correlation between the immunodensities of GRK 2 and beta-arrestin-2 in membrane preparations (r=0.48, n=19, P=0.04), suggesting that both proteins are regulated in a coordinated manner in brains of depressed subjects. The results of this study indicate that major depression is associated with upregulation of brain GRK 2, but not GRK 6, and that antidepressant drug treatment appears to induce downregulation of GRK 2 protein.

Downregulation of neuronal cdk5/p35 in opioid addicts and opiate-treated rats: relation to neurofilament phosphorylation.

Neuronal cyclin-dependent kinase-5 (Cdk5) and its neuron-specific activator p35 play a major role in regulating the cytoskeleton dynamics. Since opioid addiction was associated with hyperphosphorylation of neurofilament (NF) in postmortem human brains, this study was undertaken to assess the status of the cdk5/p35 complex and its relation with NF-H phosphorylation in brains of chronic opioid abusers. Decreased immunodensities of cdk5 (18%) and p35 (26-44%) were found in the prefrontal cortex of opioid addicts compared with matched controls. In the same brains, the densities of p25 (a truncated neurotoxic form of p35), phosphatase PP2Ac and mu-calpain were found unaltered. Acute treatment of rats with morphine (30 mg/kg, 2 h) increased the density of cdk5 (35%), but not that of p35, in the cerebral cortex. In contrast, chronic morphine (10-100 mg/kg for 5 days) induced marked decreases in cdk5 (40%) and p35 (47%) in rat brain. In brains of opioid addicts, the density of phosphorylated NF-H was increased (43%) as well as the ratio of phosphorylated to nonphosphorylated NF-H forms (two-fold). In these brains, phosphorylated NF-H significantly correlated with p35 (r=0.58) but not with cdk5 (r=0.03). The results suggest that opiate addiction is associated with downregulation of cdk5/p35 levels in the brain. This downregulation and the aberrant hyperphosphorylation of NF-H proteins might have important consequences in the development of neural plasticity associated with opiate addiction in humans.

G protein-coupled receptor kinases, beta-arrestin-2 and associated regulatory proteins in the human brain: postmortem changes, effect of age and subcellular distribution.

G protein-coupled receptor kinases (GRKs) and beta-arrestin-2 play a crucial role in the regulation of neurotransmitter receptors in brain. In this study, GRK2, GRK6, beta-arrestin-2 and associated regulatory proteins (Gbeta proteins and protein phosphatase (PP)-2A) were quantitated in human brains (immunodensity with specific antibodies) to assess for postmortem changes (pattern of protein degradation) and to investigate the effect of aging on these regulatory proteins as well as their subcellular distribution (cytosol and membrane fractions). In brain (prefrontal cortex, total homogenate) of healthy subjects (n=14) the immunodensities of GRK2 (r=-0.76), GRK6 (r=-0.64), beta-arrestin-2 (r=-0.57), Gbeta proteins (r=-0.59) and neurofilament (NF)-L (r=-0.64), but not PP-2A, declined markedly with the length of postmortem delay (PMD, 3-81 h). With these linear decay models, the average decreases per 12 h of PMD (from 12 to 72 h) were 7-11% for the various proteins. The immunodensities of GRK2 (r=-0.71), GRK6 (r=-0.61), and beta-arrestin-2 (r=-0.54) in human brain (n=12) also declined with aging (16 to 87 years) and the average decreases per decade (from 20 to 80 years) were 3-5%. In contrast, the immunodensities of PP-2A, Gbeta and NF-L in brain did not correlate significantly with the age of the subject at death (16-87 years). The immunodensities of GRK2/6 and beta-arrestin-2 showed marked individual variations and were strongly reduced after several freeze/thaw cycles. In the prefrontal cortex the subcellular distribution (cytosol/membrane) of the two GRKs differed markedly (GRK2: 60%/40%; GRK6: 5%/95%), and that of beta-arrestin-2 was as expected for a soluble protein (60%/40%). In brains of healthy subjects, the immunodensities of cytosolic GRK2 and beta-arrestin-2 correlated, respectively, with those of membrane-associated GRK2 (r=0.67, P=0.049, n=9) and membrane-associated beta-arrestin-2 (r=0.77, P=0.01, n=9). The results of this study emphasize the importance of examining relevant variables (PMD, age) and potential artifacts (individual variation, freeze-thawing effect) when designing signal transduction studies in neuropsychiatric disorders using the postmortem human brain.

Effects of age, postmortem delay and storage time on receptor-mediated activation of G-proteins in human brain.

The influence of age, postmortem delay and freezing storage period on receptor-mediated G-protein activity was quantified in cortical membranes from 34 healthy subjects. Concentration-response curves of the [(35)S]GTPgammaS binding stimulation by agonists for alpha(2)-adrenoceptors (UK14304), mu-opioid (DAMGO), 5-HT(1A) (8-OH-DPAT), GABA(B) (baclofen) and muscarinic (carbachol) receptors were analyzed. Immunoreactivities of G(alpha)-protein subunits were also determined. Basal binding and UK14304, 8-OH-DPAT, and baclofen potency to stimulate [(35)S]GTPgammaS binding decreased with aging (1-88 years) without changes of efficacy. DAMGO-mediated stimulation increased both in potency and efficacy with aging. A negative correlation between age and immunoreactivity was observed for G(alphai1/2)-, but not for G(alphai3)-, G(alphao)-,and G(alphas)-proteins. Neither [(35)S]GTPgammaS binding nor G(alpha)-proteins changed with the postmortem delay (8-92 h). Basal [(35)S]GTPgammaS binding decreased with the sample storage period (1-85 months). A careful match between cases and controls should be taken into account when designing signal transduction studies in human disorders, specially for variables such as age and storage period.