To tell or not to tell - what to do about p.C282Y heterozygotes identified by HFE screening.

Hereditary hemochromatosis (HH) is a common preventable disorder of iron overload that can result in liver cirrhosis and reduced lifespan. Most HH is due to homozygosity for the HFE p.C282Y substitution. We conducted a study of screening for p.C282Y in high schools where p.C282Y heterozygotes (CY) individuals were informed of their genotype by letter. We studied whether these individuals understood the implications of their genotype, whether this resulted in anxiety or reduced health perception and whether cascade testing was higher in families of CY than wild-type homozygous (CC) individuals. We found 586 of 5757 (1 in 10) screened individuals were CY. One month after receiving their result, 83% correctly answered that they have one copy of p.C282Y. There was no adverse change in anxiety or health perception from prior to screening to 1 month after receiving results. Significantly more family members of CY individuals than CC individuals were informed about HH and had testing for HH. In conclusion, we found that informing CY individuals of their genotype does not increase anxiety and the implications are generally well understood. This leads to cascade testing in a minority of families. CY individuals should be informed of their genetic status when identified by population screening.

Evaluation of a multi-disease carrier screening programme in Ashkenazi Jewish high schools.

A screening programme for Tay Sachs disease (TSD) carrier status was introduced in high schools in Victoria, Australia in 1997, and was expanded to screen for six other genetic conditions common in the Ashkenazi Jewish population in 2008. The aim of this study was to evaluate the current programme and compare it with an evaluation of the programme when screening was offered for TSD alone. All students from Jewish high schools in Melbourne who offered the programme in 2009 were invited to participate in the study. A purpose-designed questionnaire explored the following domains: knowledge (disease and genetics), reasons for screening, anxiety, and predicted negative feelings if found to be a carrier. Two hundred and seventy-three students were offered screening, and 272 (99.6%) completed the questionnaire. Only two students chose not to have screening. Two hundred and seventy-one students were in the penultimate year of high school (99.6%) and 222 were of Ashkenazi Jewish descent (82.5%). The main reasons for choosing screening were the desire to know carrier status and convenience. Knowledge level decreased and negative feelings increased in the current cohort compared to that when screening was offered for TSD alone. We conclude that the current programme is efficient, although increasing the number of conditions resulted in a decrease in knowledge and increase in predicted negative feelings if found to be a carrier of one of the conditions. This has implications for multi-disease screening programmes that will increase in frequency as more conditions can be screened for and costs diminish.

Implementation of ironXS: a study of the acceptability and feasibility of genetic screening for hereditary hemochromatosis in high schools.

Hereditary hemochromatosis (HH), most often due to HFE C282Y homozygosity, is an iron overload disorder that can result in severe morbidity including hepatic cirrhosis. Predisposition to HH is easily diagnosed and morbidity is preventable by maintaining normal body iron and thus calls have been made to introduce community screening. The current study has been designed to assess the acceptability and feasibility of HH screening in high schools. Students (mostly 15-16 years of age) watched a purpose-designed DVD for education about HH. Those with parental consent were then offered cheek-brush screening for C282Y. Students completed a questionnaire prior to screening. The program was offered to 9187 students at 32 schools and 3489 (38%) had screening. Nineteen C282Y homozygotes (1 in 183) and 376 heterozygotes (1 in 9.3) were identified. More than 90% of students answered each of five knowledge questions correctly. Eight homozygotes (42%) had elevated transferrin saturation, but only two (10.5%) had marginally elevated serum ferritin (SF). We have shown that genetic screening for HH can successfully be offered in the high school setting. Ongoing research in this study will answer questions about the impact of high school students learning that they are at risk of HH.

Use of community genetic screening to prevent HFE-associated hereditary haemochromatosis.

HFE-associated hereditary haemochromatosis is a recessive, iron-overload disorder that affects about one in 200 north Europeans and that can be easily prevented. However, genetic screening for this disease is controversial, and so we assessed whether such screening was suitable for communities. Cheek-brush screening for the Cys282Tyr HFE mutation was offered to individuals in the workplace. Outcomes were assessed by questionnaires before and after testing. 11,307 individuals were screened. We recorded no increase in anxiety in individuals who were homozygous for the Cys282Tyr mutation or non-homozygous. Self-reported tiredness before testing was significantly higher in homozygous participants than in non-homozygous participants (chi2 test, p=0.029). Of the 47 homozygous individuals identified, 46 have taken steps to treat or prevent iron accumulation. Population genetic screening for HFE-associated hereditary haemochromatosis can be practicable and acceptable.

Type II phospholipase A2 in human gestational tissues: extractable immuno- and enzymatic activity in fetal membranes.

In this study, we have established the presence of immunoreactive (ir) Type II PLA2 in human amnion and choriodecidua obtained from women at term prior to the onset of labour. The content of irType II PLA2 present in 1 M NaCl extracts of choriodecidua and amnion averaged 3.5 +/- 3.1 and 10.6 +/- 5.2 ng/mg tissue protein (n = 3), respectively. PLA2 enzymatic activity present in the same tissues averaged 1.3 +/- 0.2 and 1.9 +/- 0.7 nmol phosphatidylethanolamine (PE) hydrolysed/mg tissue protein per h (n = 3), respectively. To allow intra-patient comparison of the relative distribution in gestational tissues, irType II PLA2 and PLA2 enzymatic activity was also determined in placenta obtained from the same group of women, and averaged 26.0 +/- 7.0 ng/mg tissue protein and 3.5 +/- 1.0 nmol PE hydrolysed/mg protein per h (n = 3), respectively. As has been previously reported for human placenta, the recovery of Type II PLA2 and PLA2 enzymatic activity from amnion and choriodecidua was increased between 16- and 25-fold when tissues were homogenized in high-ionic strength media (i.e., 10% (w/v) ammonium sulphate or 1 M NaCl) compared with that recovered when tissues were homogenized in low-ionic strength media (i.e., 0.32 M sucrose-20 mM Hepes). The data obtained represent the first quantitative estimates of immunoreactive Type II PLA2 in human amnion and choriodecidua, and support the conclusion that previous analyses of the PLA2 enzymatic activity present in gestational tissues have essentially excluded the contribution made by this PLA2 isozyme to net enzymatic activity. We suggest that this isozyme represents a major component of the PLA2 enzymatic activity present in human gestational tissues at term and that it contributes significantly to the phospholipid metabolism and arachidonic acid release which occurs during late pregnancy and at the time of labour.

Type II phospholipase A2 in human gestational tissues: subcellular distribution of placental immuno- and catalytic activity.

The aims of this study were to determine the subcellular distribution of Type II phospholipase A2 immunoactivity (irPLA2) and in vitro net PLA2 catalytic activity in human term placenta and to establish the efficacy of previously utilised homogenisation procedures with respect to the quantitative recovery of Type II PLA2 immunoreactive and in vitro net PLA2 catalytic activity. Type II PLA2 immunoactivity and PLA2 catalytic activity recovered in 900 x g supernates prepared from placental tissue (n = 3) homogenised in low ionic strength media (sucrose 0.32 M Hepes 20 mM; phosphate-buffered saline or phosphate-buffered saline containing 3 mM EGTA) was less than 10% of that recovered following homogenisation in high ionic strength medium (ammonium sulphate 10%, w/v). The subcellular distribution of Type II PLA2 immunoactivity and PLA2 catalytic activity was established by the differential centrifugation (10,000, 20,000 and 100,000 x g) of placental homogenates (n = 3). Although Type II PLA2 immunoactivity was equally distributed throughout the particulate subcellular fractions examined, PLA2 catalytic activity increased by comparison in 100,000 x g particulate material. This apparent dissociation between irType II PLA2 and catalytic activity may indicate the presence of other types of PLA2 in this fraction. The data obtained in this study indicate that previous studies which have utilised low ionic strength extractions of human gestational tissue to characterise PLA2 catalytic activity and subcellular distribution have largely excluded the contribution made by Type II PLA2. Consequently, much of the available published data on the role of PLA2 in human parturition is inadequate. A reappraisal of this enzyme's contribution to the biochemical events associated with human pregnancy and labour is required.

Gestational- and labour-associated changes in the relative abundance of prostaglandin G/H synthase-1 and -2 mRNA in ovine placenta.

The aim of this study was to establish the gestational- and labour-associated variation in the relative abundance of prostaglandin synthase-1 (PGHS-1) and prostaglandin synthase-2 (PGHS-2) mRNA in ovine placenta (cotyledons). Cotyledons were collected from non-labouring ewes at 40-145 days of gestation (n = 25) and from ewes in active labour (145-147 days, n = 5). The relative abundance of PGHS-1 and PGHS-2 mRNA transcripts was determined by Northern blot analysis and laser densitometry, using a 2.3 kb sheep and a 1.2 kb mouse cDNA probe respectively. Data were expressed as a ratio of PGHS transcript hybridization/18S rRNA hybridization. During pregnancy, the relative abundance of PGHS-2 mRNA increased sevenfold, from 0.19 +/- 0.04 at 40-85 days (n = 5) to 1.39 +/- 0.05 at 140-145 days (n = 4) (P < 0.01). PGHS-1 mRNA relative abundance did not change significantly (P > 0.05) during gestation. Neither PGHS-1 nor PGHS-2 mRNA relative abundance changed significantly in association with labour onset at term (n = 5) when compared with the relative abundance observed at 140-145 days (n = 4) (P > 0.05). The data obtained in this study are consistent with the hypothesis that PGHS-1 is constitutively expressed in ovine placenta during pregnancy and at the time of labour, and that PGHS-2 is induced during the second half of pregnancy.(ABSTRACT TRUNCATED AT 250 WORDS)

Localization of type II phospholipase A2 messenger RNA and immunoactivity in human placenta and fetal membranes.

Although Type II phospholipase A2 (PLA2) immunoactivity has been identified in homogenates of human placenta and fetal membranes, there is a paucity of information concerning the sites of synthesis of this secreted PLA2 isozyme. The aim of this study, therefore, was to establish the cellular localization of Type II PLA2 messenger RNA (mRNA) in human term placental and fetal membranes by in situ hybridization. In addition, the co-localization of immunoreactive Type II PLA2 in gestational tissues was determined, and the effect of labour status and pre-eclampsia on immunolabelling intensity were established. Type II PLA2 mRNA was identified in all tissue sections examined and was localized principally in placental villous vasculature and mesenchymal elements of placenta, chorion and amnion. Within the vasculature, Type II PLA2 mRNA was associated with smooth muscle cells. Immunoreactive Type II PLA2 was identified in the fibroblast and spongy layers of the amnion, the fibroblast and reticular layer of the chorion, and in the mesenchymal core and trophoblasts of placental villi. Immunolabelling staining intensity was greater in placenta and chorion than that observed in amnion, however, staining intensity was unaffected by labour status. Pre-eclampsia was associated with increased immunolabelling for Type II PLA2 in placenta but not fetal membranes. The data obtained clearly established that Type II PLA2 is synthesized by multiple cell types within human gestational tissues and co-localization of Type II PLA2 mRNA and immunoreactive protein has been established. The role of Type II PLA2 in gestational tissue phospholipid metabolism and, in particular, in vascular and mesenchymal elements, has yet to be established. Possible roles for this isozyme may include, the provision of substrate for eicosanoid synthesis, maintaining cell membrane phospholipid asymmetry and prevention of clot formation within the placental vascular bed.

Gestational tissue phospholipase A2 messenger RNA content and the onset of spontaneous labour in the human.

Considerable evidence supports a central role for prostaglandins in the genesis of uterine activity and cervical dilatation at the time of human labour. The first step in prostaglandin synthesis is the liberation of arachidonic acid from glycerophospholipids by phospholipase A2. In this study, we examined the periparturitional gene expression of PLA2 in human placentae and fetal membranes, using a cDNA clone for non-pancreatic PLA2. PLA2 gene expression was found to be significantly increased (P less than 0.05) in placentae obtained after spontaneous-onset labour and normal vaginal delivery as compared with placentae from elective Caesarean section. In both of these groups, PLA2 expression in amnion and chorion was significantly less than that in placenta. The results of this study suggest that placental PLA2 gene expression increases in association with spontaneous-onset of labour in the human. This conclusion is consistent with the finding of increased levels of prostaglandins in gestational tissues, amniotic fluid and blood plasma at the time of labour.

Educational outcomes of a workplace screening program for genetic susceptibility to hemochromatosis.

Education is an essential component of a genetic screening program. Knowledge outcomes were measured after large-scale workplace education and screening for genetic susceptibility to hereditary hemochromatosis. The aim was to assess knowledge of concepts presented, impact of mode of delivery, and knowledge retention. Education in a group setting was delivered via oral or video presentation and knowledge assessed using self-administered questionnaires at baseline, 1 month, and 12 months. Over 60% of 11 679 participants correctly answered all questions at baseline, scoring higher with clinical concepts (disease etiology and treatment) than genetic concepts (penetrance and genetic heterogeneity). Revising the education program significantly increased correct responses for etiology (p < 0.002), whilst modifying the knowledge assessment tool significantly increased correct responses for etiology (p < 0.001) and gene penetrance (p < 0.001). For three of the four concepts assessed, use of video was as effective as oral presentation for knowledge outcomes. A significantly higher proportion of those at increased risk of disease (n = 44) responded correctly at 12 months than did controls (n = 82; p = 0.011 for etiology, p = 0.002 for treatment and p = 0.003 for penetrance). Hence, genetic screening can be successfully offered in a group workplace setting, with participants remembering clinical concepts better than genetic concepts up to 1 year later.

Genetic susceptibility screening in schools: attitudes of the school community towards hereditary haemochromatosis.

Carrier screening to provide reproductive options has been offered to students in the school setting for a number of years; however, genetic susceptibility screening for disease predisposition has not been introduced to the school community. Experience has shown that the success of a population-based programme relies on the community's acceptance. Therefore, we sought to establish the Australian secondary school community's attitudes towards genetic susceptibility screening in schools, with hereditary haemochromatosis as the model condition with an available prevention. School students, aged 15-18 (n = 748), completed a questionnaire immediately before and following an oral educational presentation. Their parents (n = 179) and staff (n = 89) received written information and returned a questionnaire by post. Semi-structured interviews were with Government representatives. Attitudes towards genetic screening in schools and knowledge of genetic and clinical features of haemochromatosis, as well as the likelihood of accepting a genetic susceptibility test for haemochromatosis, were all measured. Participants were positive about genetic screening for disease susceptibility in schools. Their knowledge was high following education with no significant differences between participants of each group. Sixty-eight percent of students would be likely to have the test if it were offered, with parents and staff, indicating that they would like the students to be offered a test, on average. Genetic susceptibility screening in schools is a novel concept. The results of our study indicate that it could be a public health success with the support of the community.

Relative abundance of human placental phospholipase A2 messenger RNA in late pregnancy.

The aim of this study was to determine messenger RNA (mRNA) levels for a specific phospholipase A2 (PLA2) in human placenta during late gestation prior to the onset of labour. The relative abundance of human placental mRNA for a nonpancreatic Group II PLA2 was determined using cDNA clone specific for this PLA2. Twenty seven placentae were collected from women undergoing elective (i.e. before the onset of labour) Caesarean section between 37 and 41 completed weeks gestation. The relative amount of human placental PLA2 mRNA did not change significantly over this period of late pregnancy (p greater than 0.8). Previously, we have demonstrated that placental PLA2 messenger RNA levels are increased in association with spontaneous onset labour at term in the human. The data obtained in this current study are consistent with the conclusion that the regulation of this human placental PLA2 gene is tightly controlled around the time of parturition and that its expression is increased acutely in association with labour.

Prostaglandin G/H synthase-1 messenger RNA relative abundance in human amnion, choriodecidua and placenta before, during and after spontaneous-onset labour at term.

The aim of this study was to determine the relative abundance of prostaglandin G/H synthase-1 (PGHS-1) mRNA in human amnion, choriodecidua and placenta obtained before (n = 5), during (n = 5) and after spontaneous-onset labour and delivery at term (n = 5). PGHS-1 mRNA relative abundance was not affected by labour status (p > 0.1) nor differently expressed between gestational tissues (p > 0.05). These data are consistent with the hypothesis that PGHS-1 is a constitutively expressed isozyme and that an increase in the relative abundance of mRNA encoding this enzyme is not necessary for the labour-associated increase in prostaglandin formation.

Evaluation of a Tay-Sachs disease screening program.

Tay-Sachs Disease (TSD) is an autosomal recessive neurodegenerative disorder. TSD is prevalent in the Ashkenazi Jewish population, and carrier screening programs have been implemented worldwide in these communities. A screening program initiated in 1997 involving the Melbourne Jewish community (Australia) incorporated education, counselling and carrier testing of high-school students aged 15 to 18 years. This study aimed to assess the participation rates, level of knowledge obtained and predicted feelings and attitudes of the students involved. Seven hundred and ten students participated, there was a 67% uptake for testing with a carrier rate of 1 in 28 determined. The level of knowledge of the students following education was high and of relative importance in regard to decision making, as were their feelings and attitudes about genetic testing for carrier status. A significant impediment to test uptake was the need for blood sampling, resulting in a recommendation for the introduction of DNA analysis on cheek brush samples. The evaluation of this program has given a wider scope for further development as well as providing valuable information for the implementation of community screening programs.

LCR-mediated, long-term tissue-specific gene expression within replicating episomal plasmid and cosmid vectors.

Locus control regions (LCRs) are transcriptional regulatory elements, which possess a dominant chromatin remodelling and transcriptional activating capability conferring full physiological levels of expression on a gene linked in cis, when integrated into the host cell genome. Using the human beta-globin LCR (betaLCR) as a model, we show that this class of control element can drive high levels of tissue-specific gene expression in stably transfected cultured cells from within an Epstein-Barr virus-based plasmid REV. Furthermore, a 38-kb betaLCR minilocus-REV cosmid vector was efficiently retained and maintained therapeutic levels of beta-globin transgene expression in the absence of drug selective pressure over a 2-month period of continuous culture equivalent to at least 60 generations. This demonstrates for the first time the feasibility of using REVs for gene therapy of the haemoglobinopathies. Importantly, our results demonstrate that as in the case of integrated transgenes, expression from within REVs is prone to silencing but that the inclusion of the betaLCR prevented this repression of gene function. Therefore, appropriate control elements to provide and maintain tissue-specific gene expression, as well as the episomal status of REVs is a crucial feature in vector design. Our data suggest that LCRs can contribute to this vital function.

Implementation of HaemScreen, a workplace-based genetic screening program for hemochromatosis.

There is debate as to whether community genetic screening for the mutation(s) causing hereditary hemochromatosis (HH) should be implemented, due to issues including disease penetrance, health economic outcomes, and concerns about community acceptance. Hemochromatosis is a common preventable iron overload disease, due in over 90% of cases to C282Y homozygosity in the HFE gene. We are, therefore, piloting C282Y screening to assess understanding of genetic information and screening acceptability in the workplace setting. In this program, HaemScreen, education was by oral or video presentation in a group setting. C282Y status was assessed by polymerase chain reaction (PCR) and melt-curve analysis on DNA obtained by cheek-brush sampling. Of eligible participants, 5.8% (1.5-15.8%) attended information and screening sessions, of whom 97.7% (5571 individuals) chose to be tested. Twenty-two C282Y (1 : 253) homozygotes were identified and offered clinical follow-up. There were 638 heterozygotes (1 : 8.7). The determinants for participation have been analyzed in terms of the principles outlined in the Health Belief Model. Widespread screening for HH is readily accepted in a workplace setting, and a one-to-many education program is effective. The level of participation varies greatly and the advertizing and session logistics should be adapted to the specific features of each workplace.