[The impact of screening sickle-cell carriers in the general population. A retrospective study in the Paris screening center]. / L'impact du dépistage du trait drépanocytaire en population. Une étude rétrospective au Centre d'information et de dépistage de la drépanocytose (Paris).

BACKGROUND: Since 2006 the CIDD, the Paris information and screening center for sickle-cell disease, provides free assistance for adults who may be at risk of having children with sickle-cell disease. Recently, an increasing number of parents of a silent-carrier newborn detected by systematic neonatal screening are attending the center. We present a retrospective study of the impact of such information and screening on people. METHODS: The study involved 81 silent-carrier men and women aged 18 to 45 years, interviewed using a telephone questionnaire (n=70) or during consultation (n=11) one to three years after screening. RESULTS: The study group represented 12% of individuals attending the center with the same characteristics. In general, the information delivered concerning sickle-cell disease and silent-carriers was well understood although concerns about personal and family history and the correctness of prior knowledge revealed a lack of information input from the environment (media, schools, health professionals). Poorly assimilated information involved three subjects: the difference between trait and disease; the difference between type of hemoglobin and blood group; and Mendelian transmission. The screening result was not a cause of separation among couples and was often passed on to family or friends. Disparities in adherence to prenatal diagnosis and termination of pregnancy were mainly related to different representations of disease severity. CONCLUSION: Joint screening of newborns and their parents is a good measure for adults, who are satisfied with being informed despite the psychological difficulties involved. However the implication for children detected remains a relevant issue because of the persistent perception of the trait as a pseudo-disease and the risk of reification of a biological difference between relatives.

Two new Ggamma chain variants: Hb F-clamart [gamma17(A14)Lys-->Asn] and Hb F-Ouled Rabah [gamma19(B1)Asn-->Lys].

Two new fetal hemoglobin variants affecting the Ggamma chain are reported. Hb F-Clamart was found during investigation of a French newborn who presented with a mild microcytemia. The second variant was found during neonatal screening for hemoglobinopathies of 30,000 babies from a population-at-risk living in the Paris region. It was named Hb F-Ouled Rabah because its structural modification and ethnic distribution is similar to that of Hb D-Ouled Rabah [beta19(B1)Asn-->Lys]. Hb F-Ouled Rabah is clinically silent and occurs at a frequency of ca. 0.1% in newborns originating from Maghreb. Structural characterization of both variants was done by protein chemistry methods, including amino acids analysis and mass spectrometry.

Two hemoglobin variants with an alteration of the oxygen-linked chloride binding: Hb Antananarivo [alpha1(NA1)Val-->Gly] and Hb Barbizon [beta144(HC1)Lys-->Met].

We here report two new, clinically silent, hemoglobin variants in which the structural modification disturbs the oxygen-linked chloride binding. Hb Antananarivo [alpha1(NA1)Val-->Gly] was found during a systematic hematological study in a 24-year-old woman, who originates from Madagascar. Hb Barbizon [beta144 (HC1)Lys-Met] was found in several members of a French family. The oxygen binding properties of Hb Barbizon were similar to those of Hb Antananarivo showing, in vitro, a decreased chloride effect as compared to Hb A. In Hb Barbizon, the replacement of lysine beta144 by a methionine residue decreased from 4 to 2 the excess positive charges in the central cavity, thus leading to a reduction of about half of the chloride effect. For Hb Antananarivo, the mechanism is unclear since there is no difference in the number of positive charges in the central cavity but alterations are likely at the alpha1alpha2 interface.

Three-year follow-up of hydroxyurea treatment in severely ill children with sickle cell disease. The French Study Group on Sickle Cell Disease.

PURPOSE: To observe the safety and efficacy of hydroxyurea (HU), a drug that stimulates fetal hemoglobin (Hb F) production, in previously severely ill children with sickle cell disease. PATIENTS AND METHODS: HU was given in an uncontrolled study to 35 children with sickle cell disease, aged from 3 to 20 years, suffering from frequent painful crises. Mean duration of treatment was 32 months (range: 12-59 months). RESULTS: HU induced an increase in Hb F levels in all children out one; this increase was maximal after 9 months of treatment, was largely sustained thereafter, and was related to HU dose and inversely to patients' age. We also noted an apparent reduction in crisis, which occurred principally after 3 months of therapy and did not seem strictly correlated with the rise in Hb F level. No serious hematopoietic complication was observed. Growth curves and sexual development were not modified. CONCLUSION: Our data support the efficacy of HU in reducing painful events in children with sickle cell disease. Short- and middle-term tolerances are good. Thus, we think that HU can be given to children affected by frequent and severe painful crises. We recommend, however, very cautious use of this drug, because its long-term effects in children are still unknown.

Hb Bruxelles, deletion of Phebeta42, shows a low oxygen affinity and low cooperativity of ligand binding.

Functional studies of partially purified hemoglobin (Hb) Bruxelles, Phebeta42 (CD1) --> 0 indicate a major shift in the allosteric equilibrium toward the deoxy (T state) conformation. While Hb A shows a roughly symmetrical oxygenation curve with maximum cooperativity near half-saturation, Hb Bruxelles shows mainly properties of the low affinity (T state) form. The oxygen equilibrium curves for purified (>80%) Hb Bruxelles show little cooperativity and a P50 (without 2,3-diphosphoglycerate) about twice that of Hb A. The low cooperativity for Hb Bruxelles is partially compensated by an increase in oxygen affinity of the deoxy conformation and a lower 2,3-diphosphoglycerate effect. The beta chains of normal Hb have consecutive phenylalanine residues at positions 41 and 42. DNA sequencing studies of Hb Bruxelles showed a deletion of the codon TTT, which corresponds to residue Phe42. The CO rebinding kinetics after flash photolysis show mainly the slow phase, characteristic of CO binding to the deoxy conformation. In phosphate buffer at pH 7, the slow phase dominates even at low photolysis levels, where the main reaction is ligand binding to the triply liganded form. This indicates a switchover point, from the deoxy to oxy conformation, occurring beyond three ligands for Hb Bruxelles. There are few natural mutants that show a change in the oxygen affinity and cooperativity as large as that observed for Hb Bruxelles.

Priapism following splenectomy in an unstable hemoglobin: hemoglobin Olmsted beta 141 (H19) Leu-->Arg.

We report a case of severe priapism occurring in a patient with an unstable hemoglobin, Hb Olmsted (beta 141 Leu-->Arg) This is a rare hemoglobin variant, which until now has been reported only once. The clinical course of the 12-year-old boy was characterized by severe hemolytic anemia leading to splenectomy and cholecystectomy at the of 3.5 years. The priapism occurred 8 years after splenectomy, during a hemolytic febrile episode and required aspiration of the corpora cavernosa. This report raises the question of the benefit of splenectomy in patients suffering from a chronic hemolytic anemia such as that due to an unstable hemoglobin. This treatment lowers the frequency and the severity of acute hemolytic attacks, but several cases of vascular complications have been reported after splenectomy.

Hb Poitiers [alpha 45(CE3)His-->Asp]: a new hemoglobin variant with a two-fold increase in oxygen affinity.

Hb Poitiers or alpha 45(CE3)His-->Asp was found in a 9-year-old French Caucasian boy. The structural modification concerns a heme contact and is responsible for an increased oxygen affinity and a faster than normal rate of autooxidation.

Hb Saint Nazaire (beta 103[G5]Phe-->Ile): a new example of polycythemia due to a hemoglobin variant with increased oxygen affinity.

Hb Saint Nazaire [beta 103 (G5) Phe-->Ile] was found in four apparently unrelated French families. The five patients carrying this hemoglobin have been detected because of a moderate erythrocytosis. The structural abnormality of Hb Saint Nazaire concerns the same residue as in Hb Heathrow [beta 103 (G5) Phe-->Leu). A comparative functional study between these two variants showed that the increase in oxygen affinity is much lower in Hb Saint Nazaire than in Hb Heathrow. The replacement of phenylalanine G5, which is localized within the heme pocket, by a leucine abolishes several contacts between the heme and the globin and leads to an environment of the heme having some similarities with that observed in myoglobin. In contrast, the replacement of G5 by an isoleucine is likely to introduce less structural modifications.

Structural characterization of abnormal hemoglobins from dried blood specimens in a neonatal screening program.

Blood specimens dried on filter paper are now widely used for neonatal screening of hemoglobinopathies. These samples are perfectly suited for electrophoresis studies and HPLC analysis. They may also be used for DNA analysis. The structural characterization of a hemoglobin variant is also possible using protein chemistry methods. After elution of the hemoglobin from the paper, the different components are fractionated by a microscale preparative isoelectric focusing. The structural modification of the abnormal hemoglobin is then determined through a series of techniques including chain separation, aminoethylation, trypsin digestion, analysis of the peptides and determination of their aminoacid composition. The efficiency of this strategy is demonstrated by the study of an alpha-chain variant (Hb Hasharon) and three beta-chain variants (Hb S, Hb D Punjab, Hb E). Unambiguous identification of the structural abnormality was obtained with samples stored for up to 18 months and with abnormal fractions amounting to only approximately 10% of the total lysate.

New results of hemoglobin variant structure determinations by fast atom bombardment mass spectrometry.

Fast atom bombardment mass spectrometry has already been used for the identification of mutations in abnormal human hemoglobin chains. This paper presents new results obtained with this technique. The methodology used here is compared with more conventional biochemical techniques and automated microsequencing. In every case, a well-chosen combination of peptide-high performance liquid chromatography, mass spectrometry, amino acid analysis, and sequence analysis led rapidly to the identification of the mutant. The high sensitivity of these techniques holds great promise for the analysis of molecular abnormalities in various genetic disorders presently detectable only by the application of a molecular biological approach.

Hb Bruxelles: alpha 2A beta (2)41 or 42(C7 or CD1)Phe deleted.

Hb Bruxelles is a new beta-globin variant producing severe congenital Heinz body anemia. It results from the deletion of one of the two adjacent phenylalanines, beta 41 or beta 42, presumably by frameshift mutagenesis. Its whole blood oxygen affinity is significantly lowered.

Structure-function of Hb Marseille-Long Island [alpha 2 beta 2 N-methionyl-2(NA2) His----Pro].

Suspensions of red cells containing Hb Marseille-Long Island showed decreased oxygen affinity and low interaction with 2,3-diphosphoglycerate. Oxygen equilibrium studies of the purified component confirmed these abnormalities. Oxidation rate measurements of carbonmonoxy-Hb Marseille and carbonmonoxy-Hb A by ferricyanide showed an increased rate for the former, suggesting an increased dissociation constant for carbon monoxide. Nuclear Magnetic Resonance spectra in the high field region revealed small changes in the proximal region of the heme pocket. These results indicated that the mutation causes a perturbation at a distance from the mutation site.

Hb J-Cordoba [alpha 2A beta 2(95)(FG2)Lys----Met]. A new Hb variant found in Argentina.

Hb J-Cordoba [alpha 2A beta 2(95)(FG2)Lys----Met], is one of the few hemoglobin variants discovered in Argentina. The structure and functional abnormalities are described. Hb J-Cordoba exhibits a slightly increased oxygen affinity, low cooperativity, and normal interaction with heterotropic cofactors.

Hb Tunis [alpha 2 beta 2 124 (H2)Pro----Ser], a new beta chain variant identified by HPLC.

During a routine hematological investigation of a child from Tunis, a silent hemoglobin variant was discovered by isoelectric-focusing. This variant was not detectable by conventional electrophoretic methods, had normal stability, expression, and oxygen affinity, and did not produce any clinical symptoms. This new variant beta 124(H2)Pro----Ser was named Hb Tunis.

Hemoglobin Saverne: a new variant with elongated beta chains: structural and functional properties.

A 26-year-old French woman born in Saverne (France) was found to have Heinz body hemolytic anemia. Isoelectrofocusing showed the presence of an abnormal band amounting to 35% of the total hemoglobin concentration, suggesting a beta variant. Structural analysis of the abnormal beta chain showed an elongated C-terminal segment. Histidine 143 is replaced by a proline and the C-terminal sequence is identical to the corresponding segment of Hb Cranston. This new variant, named Hb Saverne, has beta chains composed of 156 amino acid residues. Studies of its functional properties showed that Hb Saverne is an unstable, high affinity variant with low cooperativity.

Further characterization of Hb Henri Mondor or alpha 2 beta 2(26)(B8)Glu----Val.

A second case of Hb Henri Mondor is reported. The subject, homozygous for Hb Henri Mondor, is of Algerian origin. The electrophoretical behavior and structural characterization are given and discussed. Hb Henri Mondor, which is characterized by the replacement of the lysine residue in position beta 26, as is the case for Hb E, has normal functional properties and is normally expressed.