Luisa Ronzoni

Preferences for prenatal tests for Down syndrome: an international comparison of the views of pregnant women and health professionals

Non-invasive prenatal testing is increasingly available worldwide and stakeholder viewpoints are essential to guide implementation. Here we compare the preferences of women and health professionals from nine different countries towards attributes of non-invasive and invasive prenatal tests for Down syndrome. A discrete choice experiment was used to obtain participants’ stated preference for prenatal tests that varied according to four attributes: accuracy, time of test, risk of miscarriage, and type of information. Pregnant women and health professionals were recruited from Canada, Denmark, Iceland, Israel, Italy, the Netherlands, Portugal, Singapore, and the United Kingdom. A total of 2666 women’s and 1245 health professionals’ questionnaires were included in the analysis. Differences in preferences were seen between women and health professionals within and between countries. Overall, women placed greater emphasis on test safety and comprehensive information than health professionals, who emphasised accuracy and early testing. Differences between women’s and health professionals’ preferences are marked between countries. Varied approaches to implementation and service delivery are therefore needed and individual countries should develop guidelines appropriate for their own social and screening contexts.

Modulation of gamma globin genes expression by histone deacetylase inhibitors: an in vitro study

Induction of fetal haemoglobin (HbF) is a promising therapeutic approach for the treatment of β‐thalassaemia and sickle cell disease (SCD). Several pharmacological agents, such as hydroxycarbamide (HC) and butyrates, have been shown to induce the γ‐globin genes (HBG1, HBG2). However, their therapeutic use is limited due to weak efficacy and an inhibitory effect on erythroid differentiation. Thus, more effective agents are needed. The histone deacetylase (HDAC) inhibitors are potential therapeutic haemoglobin (Hb) inducers able to modulate gene expression through pleiotropic mechanisms. We investigated the effects of a HDAC inhibitor, Givinostat (GVS), on erythropoiesis and haemoglobin synthesis and compared it with sodium butyrate and HC. We used an in vitro erythropoiesis model derived from peripheral CD34+ cells of healthy volunteers and SCD donors. GVS effects on erythroid proliferation and differentiation and on Hb synthesis were investigated. We found that GVS at high concentrations delayed erythroid differentiation with no specific effect on HBG1/2 transcription. At a low concentration (1 nmol/l), GVS induced Hb production with no effects on cells proliferation and differentiation. The efficacy of GVS 1 mol/l in Hb induction in vitro was comparable to that of HC and butyrate. Our results support the evaluation of GVS as a new candidate molecule for the treatment of the haemoglobinophathies due to its positive effects on haemoglobin production at low and non‐toxic concentrations.

Interstitial 6q25 microdeletion syndrome: ARID1B is the key gene

Interstitial deletions of the long arm of chromosome 6 are rare. Clinically, these deletions are considered to be part of a unique microdeletion syndrome associated with intellectual disability and speech impairment, typical dysmorphic features, structural anomalies of the brain, microcephaly, and non‐specific multiple organ anomalies. The critical region for the interstitial 6q microdeletion phenotype was mapped to 6q24–6q25, particularly the 6q25.3 region containing the genes ARID1B and ZDHHC14. It has been hypothesized that haploinsufficiency of these genes impairs normal development of the brain and is responsible for the phenotype. This case report describes a girl presenting with typical features of 6q microdeletion syndrome, including global developmental delay, speech impairment, distinct dysmorphic features, dysgenesis of the corpus callosum, common limb anomalies, and hearing loss. Chromosome analysis by array‐CGH revealed a small interstitial 6q deletion spanning approximately 1.1 Mb of DNA and containing only one coding gene, ARID1B. We suggest that ARID1B is the key gene behind 6q microdeletion syndrome, and we discuss its possible role in the phenotypic manifestations.

Growth differentiation factor 15 expression and regulation during erythroid differentiation in non-transfusion dependent thalassemia

In the last two decades the research interest in biochemical risk markers has exploded. Among the new biomarkers examined, GDF15, a cytokine member of the transforming growth factor-β (TGFβ) superfamily, is emerging as a biomarker of potential utility in a variety of diseases (cardiovascular disease, diabetes, chronic kidney disease, acute respiratory distress syndromes, rheumatoid arthritis, and many types of cancer) [1,2]. Under normal conditions, GDF15 is expressed at low levels in all organs (serum levels: 200–1150 pg/mL). Although the exact biological functions of GDF15 are still poorly understood, it has been shown to be involved in regulating inflammatory and apoptotic pathways and its expression is upregulated in many different pathological conditions, including inflammation, cancer, cardiovascular disease, pulmonary disease and renal disease [3]. Furthermore, GDF15 concentrations are strongly elevated in disorders hallmarked by increased ineffective erythropoiesis, such as β thalassemia syndromes (up to 100,000 pg/mL), congenital dyserythropoietic anemias (10,000 pg/mL) and myelodysplastic syndromes (5000 pg/mL) [4]. Here, we focused on thalassemia and ineffective erythropoiesis as possible regulator for GDF15 levels. Non-transfusion dependent thalassemia (NTDT) syndromes are characterized by ineffective erythropoiesis and iron overload; GDF15 has been proposed as a link between these two conditions. There is evidence that ineffective erythropoiesis inhibits expression of hepcidin, a hepatic peptide hormone that regulates iron release into the blood stream from duodenal enterocytes, hepatocytes and macrophages [5]. The molecular mechanisms involved in hepcidin suppression in response to increased erythropoietic activity remain unclear, although it was hypothesized that some soluble proteins secreted fromdeveloping erythroblastsmay play a role; GDF15was suggested as one of such proteins. The mechanisms by which GDF15 synthesis is regulated during erythroid differentiation are not known; it has been proposed that GDF15 itself might be responsive to intracellular iron levels [6]. Moreover, correlation between GDF15 levels and the degree of ineffective erythropoiesis has been never explored. In the current study, we evaluated GDF15 expression and regulation during normal and thalassemic erythroid differentiation in vitro andwe investigated the relationship between GDF15 levels and the degree of ineffective erythropoiesis. CD34 cells obtained, after informed consent, from peripheral blood of healthy volunteers (control group) and NTDT patients were cultured for 14 days with a medium stimulating erythroid differentiation [7]. GDF15 expression was evaluated at mRNA levels by real-time PCR (2^-dCt) at different time points (day 0: erythroid progenitors, day 7: proerythroblasts, and day 14: mature erythroblasts) and at protein levels by Western-blot analysis at day 14 of culture. GDF15 secretion

7p22.1 microduplication syndrome: Refinement of the critical region

7p22.1 microduplication syndrome is mainly characterized by developmental and speech delay, craniofacial dysmorphisms and skeletal abnormalities. The minimal critical region includes two OMIM genes: ACTB and RNF216. Here, we report on a girl carrying the smallest 7p22.1 microduplication detected to date, contributing to the delineation of the clinical phenotype of the 7p22.1 duplication syndrome and to the refinement of the minimal critical region. Our patient shares several major features of the 7p22.1 duplication syndrome, including craniofacial dysmorphisms and speech and motor delay, but she also presents with renal anomalies. Based on present and published dup7p22.1 patients we suggest that renal abnormalities might be an additional feature of the 7p22.1 microduplication syndrome. We also pinpoint the ACTB gene as the key gene affecting the 7p22.1 duplication syndrome phenotype.

Response to “characteristics of 2p15‐p16.1 microdeletion syndrome: review and description of two additional patients”

Dear Editor, We read with great interest the recently published paper by Shimojima et al. (2015), who described two patients with 2p15 microdeletion and reviewed the clinical features of 2p15-p16.1 microdeletion syndrome. They also identified the shortest region of overlap (SRO) as 114 kb containing the USP34 and XPO1 genes, and speculated that these may be responsible for the syndrome’s neurological symptoms, although reports of additional patients with 2p15-p16.1 microdeletion are needed to support this hypothesis. We have a patient with an even smaller 2p15-p16.1 microdeletion than those reported by Shimojima et al. (2015): a 14-year-old male (the second child of a healthy non-consanguineous couple) who weighed 3250 g (25 centile) when he was born at a gestational age of 41 weeks after an uneventful pregnancy. He was hypotonic at birth and experienced developmental delay from early infancy (he started walking at the age of 18 months and spoke his first word at the age of >2 years); when he was 13 years old, he scored 55 on the Wechsler Intelligence Scale for Children-IV (WISC-IV), which is consistent with moderate intellectual disability (ID). Brain magnetic resonance imaging (MRI) revealed a type I Arnold-Chiari malformation. At present, his weight is 84 kg (>97th centile), height 166 cm (50 centile), and OFC 57 cm (90th centile). His facial features include deep-set eyes, partial synophrys, hypoplastic tragi and earlobes, a thin nasal tip, a columella below the alae nasi, and retrognathia (Fig. 1), and he is affected by moderate ID, obstructive respiratory disorder, enuresis and scoliosis. An aCGH analysis made using an Agilent array 180K (Agilent Technologies, Santa Clara, CA, USA), detected a 103 kb microdeletion in 2p15 from 61659957 to 61762873 (the genomic positions refer to build19); the deletion was not detected in either parent, thus indicating a de novo origin. Since the first description of two patients with 2p15-p16.1 microdeletion in 2007 (Rajcan-Separovic et al. 2007), more than 10 patients have been described (Felix et al. 2010; Liu et al. 2011; Fannemel et al. 2014). They all share similar clinical manifestations, including mild to severe developmental delay, growth retardation, microcephaly, distinctive facial features primarily affecting the oral region, and brain anomalies. The symptoms of our patient are compatible with the phenotypic spectrum of 2p15 microdeletion syndrome, whose core traits are a distinctive cranio-facial appearance and ID. He also presents a type I Arnold-Chiari malformation, a structural brain abnormality that has not previously been reported in association with the syndrome. The SRO in patients with 2p15-p16.1 microdeletion syndrome has been identified as a 114 kb region of chr2 that includes the USP34 and XPO1 genes (Shimojima et al. 2015); our patient has the shortest deletion region reported so far: 103 kb completely overlapping the SRO (Fig. 2). In conclusion, this report confirms that the SRO is the critical region for the 2p15-p16.1 microdeletion syndrome, and underlines the role of USP34 and XPO1 as the genes responsible for the syndrome’s clinical features. It also expands the spectrum of brain abnormalities associated with the syndrome.

Is cutis verticis gyrata-intellectual disability syndrome an underdiagnosed condition? A case report and review of 62 cases

Cutis Verticis Gyrata‐Intellectual Disability (CVG‐ID) syndrome is a rare neurocutaneous syndrome characterized by intellectual disability and scalp folds and furrows that are typically absent at birth and are first noticed after puberty. First reported in 1893, the syndrome was mainly identified in subjects living in psychiatric institutions, where it was found to have a prevalence of up to 11.4%. Most patients were reported in the literature during the first half of the 20th century. CVG‐ID is now a less reported and possibly under‐recognized syndrome. Here, we report a patient with CVG‐ID that was diagnosed using the novel approach of magnetic resonance imaging and we conduct a systematic review of all patients reported in the last 60 years, discussing the core clinical features of this syndrome.

2q33.1q34 Deletion in a Girl with Brain Anomalies and Anorectal Malformation

2q33 deletions are considered to constitute a distinct clinical entity (Glass syndrome or 2q33 microdeletion syndrome) with a characteristic phenotype. Most patients have moderate to severe developmental delay, speech delay, a particular behavioural phenotype, feeding problems, growth restriction, a typical facial appearance, thin and sparse hair, tooth abnormalities, and skeletal anomalies. Here, we report on a patient with a 2q33.1q34 deletion spanning 8.3 Mb of genomic DNA. Although her clinical features are very reminiscent of the 2q33 microdeletion syndrome, she also presented with brain and anorectal malformations. Based on the present and published patients with 2q33 deletions, we suggest that the critical region for the Glass syndrome may be larger than initially proposed. Moreover, we suggest that brain abnormalities might be an additional feature of the 2q33 microdeletion syndrome, but that anorectal malformation is likely not a key marker.

Molecular cytogenetic characterization of a 2q35-q37 duplication and a 4q35.1-q35.2 deletion in two cousins: A genotype–phenotype analysis

The 2q3 duplication and 4q3 deletion are two distinct conditions with variable phenotypes including developmental delay, intellectual disability, Pierre Robin sequence (PRS), and cardiovascular, craniofacial, digital and skeletal anomalies. We describe two cousins, a 37‐year‐old man (Patient 1) and a 17‐year‐old girl (Patient 2), with a derivative chromosome leading to a 4q35 deletion–2q35q37 duplication. Conventional karyotype showed in both patients the same rearrangement derived from unbalanced segregation of a parental reciprocal translocation involving the long arms of chromosome 2 and 4. Patient 1s father and Patient 2s mother were identified as the carriers of a balanced translocation t(2;4)(q35;q35). Array‐CGH analysis, performed to characterize the rearrangement, documented in both patients the presence of a 26 Mb duplication of the 2q35‐q37.3 region of chromosome 2 and a 6.3 Mb deletion of the 4q35.1‐q35.2 region of chromosome 4. Both patients showed intellectual disability, minor facial, and digital anomalies, hearing, ocular, and genitourinary abnormalities. The comparison of their features with those of published cases of 2q3 duplication and 4q3 deletion allowed us to further delineate the genotype–phenotype correlation as well as the combined effect of partial 2q duplication and 4q deletion syndromes in adulthood.

Ferroportin expression and regulation in non-transfusion dependent thalassemia

In the last few years there have been major advances in knowledge of the regulation of iron metabolism that have had implications for understanding the pathophysiology of iron overload in some disorders like thalassemias and other iron loading anemias [1]. However, little is known about the relationship among ineffective erythropoiesis, the iron-regulatory genes and the tissue iron distribution in thalassemias [2]. Iron is essential for life and it is involved in numerous metabolic reactions. However, iron in excess is toxic, while iron deficiency leads to anemia; for these reasons iron homeostasis necessitates a tight control of iron uptake, storage, export and appropriate management of intracellular iron distribution. Over the last few years, the main pathways of iron uptake processes have been clarified and the principal membrane proteins involved have been identified, while the mechanisms of the cellular iron exit are still poorly defined [3]. Ferroportin (FPN1 or SLC40A1) is the sole iron exporter in vertebrates known so far. It is expressed in various types of cells that play critical roles in mammalian iron metabolism, such as duodenal enterocytes, macrophages and hepatocytes. FPN1 appears to be regulated according to body iron requirements. Both transcriptional and post-transcriptional mechanisms have been implicated in its regulation, however, the precise regulatory pathways are currently poorly understood. The 5′-UTR of FPN1 mRNA contains an iron responsive element (IRE) that confers a translational regulation by iron regulatory proteins (IRPs) [4]. Cianetti et al. reported for the first time the expression of FPN1 in normal human erythroid cells [5]. He also described the existence of alternative FPN1 transcripts, other than the IREcontaining canonical one, that did not contain the IRE element in their 5′-UTR and did not respond to iron treatments. These transcripts were mainly expressed during the middle steps of in vitro erythroid differentiation, corresponding to the maturation from erythroid progenitors to polychromatophilic erythroblasts. In contrast, IRE-containing FPN1 transcripts were mainly expressed in undifferentiated erythroid progenitors and in mature terminal erythroblasts. It has been speculated that erythroid precursor cells need FPN1 transcripts without IRE to evade translational control by IRP–IRE systems in order to export iron during the critical period when cells are committed to proliferate and differentiate. Once the precursor erythroid cells begin to produce hemoglobin, FPN1 with IRE predominates allowing erythroid cells to limit iron export and synthesize heme [5,6]. Although nowadays more is known about FPN1 expression and regulation, its expression in ineffective erythropoiesis and iron overload conditions is still unknown. Here we focused on non-transfusion