New names for old disciplines.

Since the completion of the human genome map, genomics, proteomics and pharmacogenomics have become popular headings. In this review some 40 years of development in research and laboratory diagnosis of inborn errors of metabolism are summarized. It is shown that collaborative approaches of clinicians, geneticists, pathologists, biochemists and molecular biologists have contributed significantly to the (prenatal) diagnosis, genetic counselling and prevention of simple gene disorders, and in some instances to successful treatment. DNA technology widens the range to predictive risk testing for multifactorial disorders manifesting in adulthood. This offers new perspectives for potential patients and their close relatives, but also poses new psychosocial and ethical problems. Despite high expectations of new technologies in the development of new medicines for multifactorial disorders, examples of previous studies on the molecular etiology and pathogenesis of monogenic diseases indicate that a long way is ahead of us. Also the treatment of rare disorders and equal access to cure and care in the Third World need great attention.

The fragile X-related proteins FXR1P and FXR2P contain a functional nucleolar-targeting signal equivalent to the HIV-1 regulatory proteins.

Fragile X syndrome is caused by the absence of the fragile X mental-retardation protein (FMRP). FMRP and the fragile X-related proteins 1 and 2 (FXR1P and FXR2P) form a gene family with functional similarities, such as RNA binding, polyribosomal association and nucleocytoplasmic shuttling. In a previous study, we found that FMRP and FXR1P shuttle between cytoplasm and nucleoplasm, while FXR2P shuttles between cytoplasm and nucleolus. The nuclear and nucleolar-targeting properties of these proteins were investigated further. Here, we show that FXR2P contains in its C-terminal part, a stretch of basic amino acids 'RPQRRNRSRRRRFR' that resemble the nucleolar-targeting signal (NoS) of the viral protein Rev. This particular sequence is also present within exon 15 of the FXR1 gene. This exon undergoes alternative splicing and is therefore only present in some of the FXR1P isoforms. We investigated the intracellular distribution of various FXR1P isoforms with (iso-e and iso-f) and without (iso-d) the potential NoS in transfected COS cells treated with the nuclear export inhibitor leptomycin-B. Both iso-e and iso-f showed a nucleolar localization, as observed for FXR2P; iso-d was detected in the nucleo-plasm outside the nucleoli. Further, when a labelled 16-residue synthetic peptide corresponding to the NoS of FXR1P was added to human fibroblast cultures a clear nucleolar signal was observed. Based on these data we argue that the intranuclear distribution of FXR2P and FXR1P isoforms is very likely to be mediated by a similar NoS localized in their C-terminal region. This domain is absent in some FXR1P isoforms as well as in all FMRP isoforms, suggesting functional differences for this family of proteins, possibly related to RNA metabolism in different tissues.

A new gene, encoding an anion transporter, is mutated in sialic acid storage diseases.

Sialic acid storage diseases (SASD, MIM 269920) are autosomal recessive neurodegenerative disorders that may present as a severe infantile form (ISSD) or a slowly progressive adult form, which is prevalent in Finland (Salla disease). The main symptoms are hypotonia, cerebellar ataxia and mental retardation; visceromegaly and coarse features are also present in infantile cases. Progressive cerebellar atrophy and dysmyelination have been documented by magnetic resonance imaging (ref. 4). Enlarged lysosomes are seen on electron microscopic studies and patients excrete large amounts of free sialic acid in urine. A H+/anionic sugar symporter mechanism for sialic acid and glucuronic acid is impaired in lysosomal membranes from Salla and ISSD patients. The locus for Salla disease was assigned to a region of approximately 200 kb on chromosome 6q14-q15 in a linkage study using Finnish families. Salla disease and ISSD were further shown to be allelic disorders. A physical map with P1 and PAC clones was constructed to cover the 200-kb area flanked by the loci D6S280 and D6S1622, providing the basis for precise physical positioning of the gene. Here we describe a new gene, SLC17A5 (also known as AST), encoding a protein (sialin) with a predicted transport function that belongs to a family of anion/cation symporters (ACS). We found a homozygous SLC17A5 mutation (R39C) in five Finnish patients with Salla disease and six different SLC17A5 mutations in six ISSD patients of different ethnic origins. Our observations suggest that mutations in SLC17A5 are the primary cause of lysosomal sialic acid storage diseases.

Oligomerization properties of fragile-X mental-retardation protein (FMRP) and the fragile-X-related proteins FXR1P and FXR2P.

The absence of fragile-X mental-retardation protein (FMRP) results in fragile-X syndrome. Two other fragile-X-related (FXR) proteins have been described, FXR1P and FXR2P, which are both very similar in amino acid sequence to FMRP. Interaction between the three proteins as well as with themselves has been demonstrated. The FXR proteins are believed to play a role in RNA metabolism. To characterize a possible functional role of the interacting proteins the complex formation of the FXR proteins was studied in mammalian cells. Double immunofluorescence analysis in COS cells over-expressing either FMRP ISO12/FXR1P or FMRP ISO12/FXR2P confirmed heterotypic interactions. However, Western-blotting studies on cellular homogenates containing physiological amounts of the three proteins gave different indications. Gel-filtration experiments under physiological as well as EDTA conditions showed that the FXR proteins were in complexes of >600 kDa, as parts of messenger ribonuclear protein (mRNP) particles associated with polyribosomes. Salt treatment shifted FMRP, FXR1P and FXR2P into distinct intermediate complexes, with molecular masses between 200 and 300 kDa. Immunoprecipitations of FMRP as well as FXR1P from the dissociated complexes revealed that the vast majority of the FXR proteins do not form heteromeric complexes. Further analysis by [(35)S]methionine labelling in vivo followed by immunoprecipitation indicated that no proteins other than the FXR proteins were present in these complexes. These results suggest that the FXR proteins form homo-multimers preferentially under physiological conditions in mammalian cells, and might participate in mRNP particles with separate functions.

Noninvasive test for fragile X syndrome, using hair root analysis.

Identification of the FMR1 gene and the repeat-amplification mechanism causing fragile X syndrome led to development of reliable DNA-based diagnostic methods, including Southern blot hybridization and PCR. Both methods are performed on DNA isolated from peripheral blood cells and measure the repeat size in FMR1. Using an immunocytochemical technique on blood smears, we recently developed a novel test for identification of patients with fragile X syndrome. This method, also called "antibody test," uses monoclonal antibodies against the FMR1 gene product (FMRP) and is based on absence of FMRP in patients' cells. Here we describe a new diagnostic test to identify male patients with fragile X syndrome, on the basis of lack of FMRP in their hair roots. Expression of FMRP in hair roots was studied by use of an FMRP-specific antibody test, and the percentage of FMRP-expressing hair roots in controls and in male fragile X patients was determined. Control individuals showed clear expression of FMRP in nearly every hair root, whereas male fragile X patients lacked expression of FMRP in almost all their hair roots. Mentally retarded female patients with a full mutation showed FMRP expression in only some of their hair roots (<55%), and no overlap with normal female controls was observed. The advantages of this test are (1) plucking of hair follicles does no appreciable harm to the mentally retarded patient, (2) hairs can be sent in a simple envelope to a diagnostic center, and (3) the result of the test is available within 5 h of plucking. In addition, this test enabled us to identify two fragile X patients who did not show the full mutation by analysis of DNA isolated from blood cells.

Different targets for the fragile X-related proteins revealed by their distinct nuclear localizations.

Fragile X syndrome is caused by the absence of the fragile X mental retardation protein (FMRP). FMRP and its structural homologues FXR1P and FXR2P form a family of RNA-binding proteins (FXR proteins). The three proteins associate with polyribosomes as cytoplasmic mRNP particles. Here we show that small amounts of FMRP, FXR1P and FXR2P shuttle between cytoplasm and nucleus. Mutant FMRP of a severely affected fragile X patient (FMRPI304N) does not associate with polyribosomes and shuttles more frequently than normal FMRP, indicating that the association with polyribosomes regulates the shuttling process. Using leptomycin B we demonstrate that transport of the FXR proteins out of the nucleus is mediated by the export receptor exportin1. Finally, inactivation of the nuclear export signal in two FXR proteins shows that FMRP shuttles between cytoplasm and nucleoplasm, while FXR2P shuttles between cytoplasm and nucleolus. Therefore, molecular dissection of the shuttling routes used by the FXR proteins suggests that they transport different RNAs.

[The stability of freeze-drying lysosomal enzymes].

OBJECTIVE: Enzyme assays for the diagnosis of lysosomal storage diseases have been underway in China only in a few laboratories, and the specimens for enzyme assay must not be inactivated by environmental factors. To solve the problem, the stability of freeze-drying lysosomal enzymes was tested. METHODS: Three pools for samples were set up: control leucocytes pool and plasma pool(40 individuals in each pool), control fibroblasts pool( 3 cell lines). 4 groups of different dispositions of samples were designed for the pools:(1)pellets or plasma directly stored at -80 degrees C as routine(non-freeze-drying group or N);(2)after freeze-drying, pellets or plasma immediately stored at -80 degrees C (0 week or 0W); (3) after freeze-drying, pellets or plasma stayed at room temperature for 1 week(simulated mail) then stored at -80 degrees C (1 week or 1W);(4) the same with 1W but 3 weeks at room temperature(3 weeks or 3W). Microassay for enzyme activity was employed: 20 enzymes in leucocytes pool, 14 enzymes in fibroblasts pool and 7 in plasma pool. RESULTS: Enzyme activities among 4 groups in each sample pool were compared. Single factor analysis of variance (F test) showed no significance of differences (P>0.05) among 4 groups in leucocytes and fibroblasts pool, but highly significant differences (P<0.01) among 4 groups in plasma pool. "t test" showed no significance of differences (P> 0.05) between N and 3W in leucocytes and also fibroblasts pool, but very significant differences (P<0.01) between N and 3W in plasma pool. CONCLUSION: The results suggest that freeze-drying samples from leucocytes and fibro- blasts can provide a stable resource for enzyme assay and be simple for transportation of the diagnostic samples. Though freeze-drying is not appropriate for the plasma samples, it is still applicable for wide use since only a few kinds of lysosomal enzyme being indicated to use plasma for enzyme assay.

Differential expression of FMR1, FXR1 and FXR2 proteins in human brain and testis.

Lack of expression of the fragile X mental retardation protein (FMRP) results in mental retardation and macroorchidism, seen as the major pathological symptoms in fragile X patients. FMRP is a cytoplasmic RNA-binding protein which cosediments with the 60S ribosomal subunit. Recently, two proteins homologous to FMRP were discovered: FXR1 and FXR2. These novel proteins interact with FMRP and with each other and they are also associated with the 60S ribosomal subunit. Here, we studied the expression pattern of the three proteins in brain and testis by immunohistochemistry. In adult brain, FMR1, FXR1 and FXR2 proteins are coexpressed in the cytoplasm of specific differentiated neurons only. However, we observed a different expression pattern in fetal brain as well as in adult and fetal testis, suggesting independent functions for the three proteins in those tissues during embryonic development and adult life.

Rapid antibody test for prenatal diagnosis of fragile X syndrome on amniotic fluid cells: a new appraisal.

Fragile X syndrome is caused by mutations in the FMR1 gene and is one of the most frequent forms of inherited mental retardation in males. Postnatal and prenatal diagnosis of fragile X syndrome is feasible by direct DNA analysis. A new approach to prenatal diagnosis of fragile X syndrome in amniotic fluid cells is described, using a rapid and simple antibody test on uncultured amniotic fluid cells. The test requires 1 ml of amniotic fluid and the results of this antibody test are available on the same day as the amniocentesis.

Rapid antibody test for diagnosing fragile X syndrome: a validation of the technique.

To date, the identification of patients and carriers of the fragile X syndrome has been carried out by DNA analysis by means of the polymerase chain reaction and Southern blot analysis. This direct DNA analysis allows both the size of the CGG repeat and methylation status of the FMR1 gene to be determined. We have recently presented a rapid antibody test on blood smears based on the presence of FMRP, the protein product of the FMR1 gene, in lymphocytes from normal individuals and the absence of FMRP in lymphocytes from patients. Here, we have tested the diagnostic value of this new technique by studying FMRP expression in 173 blood smears from normal individuals and fragile X patients. The diagnostic power of the antibody test is "perfect" for males, whereas the results are less specific for females.

Gene technology and social acceptance.

About 10% of the human genome has now been mapped and for more than 1000 diseases closely linked DNA polymorphisms or the responsible genes have been identified. These developments have extended the scope of (prenatal) diagnosis and carrier detection which already was possible by biochemical analysis of protein defects in some 400 Mendelian disorders. Together with the study of chromosomal aberrations these activities form the basis for genetic counselling and carrier screening programmes. A brief overview of the activities in clinical genetics will be presented and their importance for the prevention of congenital disorders and for informed decisions of couples at risk will be emphasized. Reproductive decisions are, however very closely related to culture, religion, education and the socioeconomic status of individuals and populations. Up to now genetic services have mainly been developed in wealthy postindustrial countries with a low infant mortality. But even among these countries there are major differences in the implementation of gene technology as will be shown by comparisons of the United States, Europe and Japan. In the developing countries where about 95% of the world's future children will be born there are major hindrances in the development of clinical genetics such as poverty, illiteracy of women, low contraceptive use and a high infant mortality. There are, however, examples of developing countries that give high priority to the application of gene technology such as Cuba and China. While the developing countries are struggling to improve their basic health care, research on gene technology in the western countries proceeds fast. The early identification of a particular gene constitution will show whether a young adult is at higher risk of important diseases such as various forms of cancer, cardiovascular disease, diabetes or psychiatric disorders. The therapeutical, preventive, psychological and some ethical aspects of this new era of predictive medicine will be discussed.

[Clinical genetics in The Netherlands. I. Organization, activities and laboratory diagnosis]. / De klinische genetica in Nederland. I. Organisatie, activiteiten en laboratoriumdiagnostiek.

There are seven centres for clinical genetics in the Netherlands. In 1996, some 63,000 persons (patients and possible carriers of hereditary diseases) were tested. In centres for clinical genetics chromosomal studies, biochemical diagnostics of hereditary metabolic diseases and DNA diagnostics are integrated with genetic counseling and prenatal diagnosis. The borders between the three different forms of laboratory testing for congenital anomalies and hereditary diseases gradually diminish. The variations of the numbers of laboratory examinations, genetic advices and prenatal diagnoses over the last ten years show that there is no correlation between these activities and the method of funding. Owing to the low prevalence of the diseases involved, the total number of DNA diagnoses for monogenic diseases will not increase significantly. However, once genetic risk factors of diseases such as cancer, cardiovascular diseases, diabetes, asthma, rheumatism, some psychiatric disorders and Alzheimer dementia will have been mapped, DNA diagnostics will greatly expand and will have implications in a broad area of medicine.

[Clinical genetics in The Netherlands. II. Genetic counseling and prenatal diagnosis]. / De klinische genetica in Nederland. II. Erfelijkheidsadvisering en prenatale diagnostiek.

The main feature of clinical genetics is the involvement of close relatives in the diagnostics of a hereditary disorder, and the possible consequences of the findings for future generations. Complex genetic counseling is required in cases with different, possibly hereditary disorders or congenital anomalies in the family or by a syndrome with variable risks of recurrence, depending on the exact nature of the disorder; also the difficult, often emotionally charged choices with which counselees are faced demands the expertise of a clinical genetic centre. Results of follow-up studies after genetic counseling show that experience with a handicap or disease in the own environment and the presence of healthy issue are the main determinants for the decision about reproduction of persons with an enhanced genetic risk who request counseling. Because of the great variety in perception of risks and of the severity of a disorder, and because of the marked clinical heterogeneity, rigid legislation should be avoided in the field of prenatal diagnosis. In the future, the training of the clinical geneticist has to be adapted to the rapid progress in human genetics. Increasingly, the clinical geneticist will function in collaboration with other disciplines such as oncology, obstetrics and gynaecology, paediatrics and neurology; in connection with family testing and counseling, there will also be more collaboration with primary health care.

[Future developments in genetic research. I. Technological possibilities]. / Toekomstige ontwikkelingen in het erfelijkheidsonderzoek. I. Technologische mogelijkheden.

The attention in genetic research is shifting from the determination' of (rare) monogenic disorders to identification of genetic risk factors for important diseases at adult age. Mapping of all man's 80,000-100,000 genes will also provide more insight into the gene polymorphisms and mutations that are associated with various types of cancer, certain cardiovascular diseases, diabetes and neurodegenerative disorders, including Alzheimer dementia. Apart from new diagnostic possibilities, the DNA techniques create new prospects for the study of the pathogenesis of diseases and the devising of new strategies for treatment. Examples are familial hypercholesterolaemia, diabetes, breast cancer and colorectal carcinoma.

[Future developments in genetic research. II. Psychological and social aspects]. / Toekomstige ontwikkelingen in het erfelijkheidsonderzoek. II. Psychologische en maatschappelijke aspecten.

Regarding the determination of genetic risk factors for serious diseases, the main question for a patient's young relatives is 'to know or not to know'. The answer depends among other things on the assessment of the severity of the disorder and the magnitude of the risk in relation to the population risk and on the availability of therapeutic or preventive measures. Experience with the requests for and the coping with results of the presymptomatic DNA test for untreatable neurodegenerative chorea of Huntington show that expectations about the effect of predictive DNA studies are often different from reality. A problem of a different nature arises in multifactorial diseases such as mammary or colonic carcinoma, because irrespective of the DNA study it remains uncertain whether or not the disease will occur. Nevertheless more than half of the healthy relatives of a patient with breast cancer requests DNA testing and a large majority of the proven carriers of a BCRAI and BRCA2 mutation chose for bilateral mastectomy and oophorectomy. Many questions about psychosocial consequences of predictive DNA testing remain to be answered: what will be the effect of early medicalization, how will relations be affected and which effect will carriership of genetic risk factors have on behaviour? Dutch legislation provides adequate guarantees against the use by third parties of results of genetic testing. The question remains, however, how future internationalization will work out in this respect. The possibly far-reaching social and psychological consequences of genetic research make some people feel that restraints should be imposed on this research. However, there are more grounds for curiosity and enthusiasm to constantly find new solutions for the new problems.

Association of FMRP with ribosomal precursor particles in the nucleolus.

The fragile X syndrome, one of the most common forms of inherited mental retardation, is caused by an expansion of a polymorphic CGG repeat upstream the coding region of the FMR1 gene. These expansions are associated with hypermethylation of the FMR1 gene, which results in the absence of the gene product, the FMR1 protein (FMRP). The physiological function of FMRP remains to be determined. We studied the ultrastructural localization of FMRP at the electron microscopical level using the immunogold technique. FMRP is associated with ribosomes attached to the endoplasmic reticulum and with ribosomes free in the cytoplasm. In addition, FMRP is found in the nucleus where the protein is associated with the granular component of the nucleolus. The cellular function of FMRP is hypothesized in relation to its subcellular distribution.

Cathepsin A deficiency in galactosialidosis: studies of patients and carriers in 16 families.

Deficiency of lysosomal protective protein/cathepsin A in humans is the primary cause of galactosialidosis, a lysosomal storage disease characterized by combined deficiency of beta-galactosidase and neuraminidase. We have investigated 20 galactosialidosis patients and nine of their obligate heterozygous parents. A group of 12 patients with the early infantile type of the disease exhibited practically complete absence of cathepsin A activity, whereas eight patients with either the late infantile or the juvenile/adult type had 2-5% residual activity. Highest levels (5%) were present in two patients with milder clinical manifestations and later onset of the disease. In most fibroblast strains, beta-galactosidase activity was 10-15% of normal levels, whereas neuraminidase was reduced to less than 4%. Interestingly, a substantial residual activity (10%) of the latter enzyme was detected in the patient with the mildest phenotype and the highest cathepsin A activity. Heterozygous values for cathepsin A were reduced on average to half of normal levels. However, in two cell strains, the activity was far below control range, and in these cases, neuraminidase activity was severely depressed. Finally, we showed that cathepsin A had considerable activity in chorionic villi and amniocytes, but was deficient in amniocytes from a pregnancy with an affected fetus, indicating the relevance of cathepsin A assay for prenatal diagnosis of galactosialidosis.

FMRP is associated to the ribosomes via RNA.

The FMR1 transcript is alternatively spliced and generates different splice variants coding for FMR1 proteins (FMRP) with a predicted molecular mass of 70-80 kDa. FMRP is widely expressed and localized in the cytoplasm. To study a possible interaction with other cellular components, FMRP was isolated and characterized under non-denaturing conditions. Under physiological salt conditions FMRP appears to have a molecular mass of > 600 kDa, indicating a binding to other cellular components. This interaction is disrupted in the presence of high salt concentrations. The dissociation conditions to free FMRP from the complex are similar to the dissociation of FMRP from RNA as shown before. The binding of FMRP from the complex is also disrupted by RNAse treatment. That the association of FMRP to a high molecular weight complex possibly occurs via RNA, is further supported by the observation that the binding of FMRP, containing an lle304Asn substitution, to the high molecular weight complex is reduced. An equal reduced binding of mutated FMRP to RNA in vitro was observed before under the same conditions. The reduced binding of FMRP with the lle304Asn substitution further indicates that the interaction to the complex indeed occurs via FMRP and not via other RNA binding proteins. In a reconstitution experiment where the low molecular mass FMRP (70-80 kDa) is mixed with a reticulocyte lysate (enriched in ribosomes) it was shown that FMRP can associate to ribosomes and that this binding most likely occurs via RNA.