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Identification of point mutations in Turkish DMD/BMD families using multiplex-single stranded conformation analysis (SSCA).

Small mutations are the cause of the disease in one third of cases of Duchenne and Becker muscular dystrophy (DMD/BMD). The identification of point mutations in the dystrophin gene is considered to be very important, because it may provide new insights into the function of dystrophin and direct information for genetic counselling. In this study, we have screened 18 deletion-prone exons (25.5% of the coding region) of the dystrophin gene by using a modified non-isotopic multiplex single-stranded conformation analysis (SSCA). Mutations responsible for the disease phenotype could be identified in five out of 56 unrelated DMD/BMD patients without detectable deletions. Two of these mutations, 980-981delCC and 719G > C, are novel mutations which have not been described previously. Four of the five mutations, including 980-981delCC detected in this study are found to be nonsense or frameshift mutations leading to the synthesis of a truncated dystrophin protein. The missense mutation, 719G > C, causing the substitution of highly conserved alanine residue at 171 with proline in the actin binding domain of the dystrophin, is associated with a BMD phenotype. This study also revealed the presence of six polymorphisms in Turkish DMD/BMD patients.

Amino Acid Sequence↗

Aetiology of intellectual disability--the Finnish classification: development of a method to incorporate WHO ICD-10 coding.

The present authors made an attempt to ease the diagnostic work of physicians who have patients with intellectual disability by creating an aetiological classification system based on the time and mechanism of injury to the central nervous system (CNS). The current paper presents the work-up needed for understanding at least the timing of the causative factor/factors. The timing principle opens a direct course to family counselling. This method has been very well accepted during its 18 years of use in Finland, and therefore, it was felt that it would be helpful to organize the relevant ICD-10 diagnoses according to the timing principle. This method has been published as a manual. An image of a tree became the obvious metaphor for this system. The genetic category forms the main root and stem, from which multiple branched roots and limbs emerge. The individual diagnoses appear as root nodules and leaves. The system is flexible, making it possible to add new branches for groups of diagnoses when improved diagnostic methods create these options (e.g. microdeletions). The aetiological diagnoses change accordingly. Over the course of further development, new incidents damaging the CNS may affect the functional level of an individual and require additional diagnoses. It is a constant challenge for physicians to keep the diagnoses of their patients up to date. The image of the tree helps professionals to think in terms of timing, and thus, makes family counselling easier. It is also helpful in the education of medical professionals.

Central Nervous System↗

Drive for thinness and fear of fat: separate yet related constructs?

The terms drive for thinness and fear of fat are consistently used in the literature to describe eating disorders in their clinical and sub-clinical forms, yet distinct definitions of each are not provided. Although similar on first examination, these terms may represent two distinct constructs in the motivational factors of persons at risk for developing eating disorders. The following article presents the notion that drive for thinness and fear of fat are separate yet related constructs, perhaps representing approach and avoidance mechanisms in persons at risk. The implications for counseling and practice and directions for further research are provided.

Journal Article↗

Characterization of a germline mosaicism in families with Lowe syndrome, and identification of seven novel mutations in the OCRL1 gene.

The oculocerebrorenal syndrome of Lowe (OCRL) is an X-linked disorder characterized by major abnormalities of eyes, nervous system, and kidneys. Mutations in the OCRL1 gene have been associated with the disease. OCRL1 encodes a phosphatidylinositol 4, 5-biphosphate (PtdIns[4,5]P2) 5-phosphatase. We have examined the OCRL1 gene in eight unrelated patients with OCRL and have found seven new mutations and one recurrent in-frame deletion. Among the new mutations, two nonsense mutations (R317X and E558X) and three other frameshift mutations caused premature termination of the protein. A missense mutation, R483G, was located in the highly conserved PtdIns(4,5)P2 5-phosphatase domain. Finally, one frameshift mutation, 2799delC, modifies the C-terminal part of OCRL1, with an extension of six amino acids. Altogether, 70% of missense mutations are located in exon 15, and 52% of all mutations cluster in exons 11-15. We also identified two new microsatellite markers for the OCRL1 locus, and we detected a germline mosaicism in one family. This observation has direct implications for genetic counseling of Lowe syndrome families.

Amino Acid Sequence↗

Advance directives and the elderly: a study of intervention strategies to increase use.

This study tested the efficacy of educational interventions to increase the use of advance directives among the elderly. Three types of educational materials, various community-dwelling populations of older people (n = 293), and offers of free legal assistance were examined. Interventions increased use slightly, not dramatically, especially with the group receiving a moderate level of materials plus an invitation to a meeting. Knowledge and use were also associated with race and education levels. The most common reason given for nonuse was deferring to others and putting it off.

Advance Directives↗

Sampling genotypes on complex pedigrees with phenotypic constraints: the origin of the B allele among the Polar Eskimos.

Exact probability calculations are often infeasible on large complex pedigrees. Conditional independences, however, occurring as a natural consequence of Mendelian inheritance of genetic traits, define a locally dependent Markov random field on the state space of all genotypic configurations on the pedigree. The underlying Markov chain is irreducible for most traits determined by a diallelic locus. For a given pedigree and a known genetic model, the Gibbs sampler can be used to obtain good estimates of the posterior distribution of genotypes given the observed data. The areas of pedigree analysis to which such an approach would be most directly relevant include genetic counselling and selective animal breeding, together with questions about ancestral genotypes and the ancestral paths of rare alleles. The method is illustrated by tracing the ancestral paths of a rare allele in a simple diallelic system on a highly complex Eskimo pedigree.

ABO Blood-Group System↗

Evaluation of a nurse-based hypertension management program: screening, management, and outcomes.

This article reports the experience of patients with elevated blood pressure scheduled to be seen in a nurse-based hypertension management program in a large multispecialty group practice. The hypertension management program is a screening and follow-up program designed to improve the measurement and management of patients' blood pressure with standardized protocols. The cohort for this study of the effectiveness of the hypertension management program consisted of 200 patients with elevated blood pressure (140 referred directly for management and counseling, 60 entered through screening). At entry, only 17% of the patients had blood pressure within controlled limits (< 140/90 mm Hg). One year after entry in the management phase of the program, systolic pressure had decreased an average of 6.20 mm Hg (P < 0.01), and 44% of patients had blood pressure within controlled limits (P < 0.001). These results suggest that the use of standardized screening techniques using multiple measurements helps to ensure that patients will not be unnecessarily treated. Furthermore, patients who entered the program successfully lowered their blood pressure and maintained the reduction over time.

Blood Pressure↗

Recombinant DNA technology and its diagnostic applications.

As yet recombinant DNA technology does not appear to have widespread diagnostic application in pathology. However, it does have a useful role to play in specific circumstances in at least three main areas: a it can provide precise diagnostic information about genetic diseases, allowing appropriate counselling, and indicating future directions for research on therapeutic intervention, e.g. gene therapy; b micro-organisms can be identified more sensitively and specifically, in fresh or fixed tissue samples, and their genomes can be analysed in fine detail, providing information relevant to the aetiology, epidemiology and pathogenesis of many diseases; c in tumour pathology the main application so far has been to resolve diagnostic problems associated with leukaemias and lymphomas, when other diagnostic procedures have been inconclusive. Specific chromosomal translocations, involving recognized genes, are particularly amenable to diagnosis by these means. Diagnostic applications to solid tumours are yet to be identified, although significant insights into tumorigenesis have been obtained, and these may ultimately lead to the development of useful markers for prognostic and therapeutic purposes.

Base Sequence↗

Hemidesmosomal variants of epidermolysis bullosa. Mutations in the alpha6beta4 integrin and the 180-kD bullous pemphigoid antigen/type XVII collagen genes.

Epidermolysis bullosa (EB), a heterogeneous group of genodermatoses, is characterized by fragility and blistering of the skin, associated with characteristic extracutaneous manifestations. Based on clinical severity, constellation of the phenotypic manifestations, and the level of tissue separation within the cutaneous basement membrane zone, EB has been divided into distinct subcategories. Traditionally, these include the simplex, junctional and dystrophic variants of EB. Recent attention has been drawn to variants of EB demonstrating tissue separation at the level of hemidesmosomes, ultrastructurally recognizable adhesion complexes within the cutaneous basement membrane zone. Clinically, these hemidesmosomal variants manifest either as generalized atrophic benign epidermolysis bullosa (GABEB), EB with pyloric atresia, or EB with late-onset muscular dystrophy. Elucidation of basement membrane zone components by molecular cloning and development of mutation detection strategies have revealed that the hemidesmosomal variants of EB result from mutations in the genes encoding the subunit polypeptides of the 180-kD bullous pemphigoid antigen/type XVII collagen, the alpha6beta4 integrin, or plectin, respectively. Collectively, these data add to the understanding of the molecular complexity of the cutaneous basement membrane zone in EB, as attested by the fact that mutations in 10 different genes can underlie different variants of EB. Elucidation of mutations in different forms of EB has direct application to genetic counseling and DNA-based prenatal testing in families with EB.

Animals↗

Pastoral counseling: an alternative path in mental health.

Claims that a strong professional identity is key to offering a healing presence and that pastoral counselors can use their dis-ease with conflicting paradigms and wave-trends in mental health care and the wider culture to maintain a professional identity rooted in the history of pastoral care and their respective theological and psychological world-views. Identifies these wave-trends as the defensive use of language, the medicalization of normal human experience, the lack of interest in developmental perspectives on human life, and the overlooking and denial or internal mental processes of persons. Introduces the concept of pastoral counseling as cultural critique and points out implications of this for the direction of the profession of pastoral counseling.

Clergy↗

Cerebral degenerations producing dementia: importance of neuropathologic confirmation of clinical diagnoses.

Dementia is a major public health concern with our increasing elderly population and currently affects more than three million Americans at an annual cost of $50 billion. The marked overlap in symptomatology between Alzheimer's disease and other primary parenchymal degenerations makes antemortem diagnosis based on clinical assessment tentative at best, with error rates of 25% commonly reported. Accurate diagnosis is of vital importance in order to improve our understanding of these illnesses, evaluate potential therapies, and provide appropriate genetic counseling to family members. Direct neuropathologic examination at autopsy is currently the only reliable method for assuring accurate diagnosis, and should be undertaken in all demented patients. To illustrate the importance of these principles, we present three patients who were clinically diagnosed with Alzheimer's disease, and subsequently found to have other dementing illnesses by careful postmortem neuropathologic examination.

Adult↗

Physician-assisted suicide: the role of mental health professionals.

A review of the literature was conducted to better understand the (potential) role of mental health professionals in physician-assisted suicide. Numerous studies indicate that depression is one of the most commonly encountered psychiatric illnesses in primary care settings. Yet, depression consistently goes undetected and undiagnosed by nonpsychiatrically trained primary care physicians. Noting the well-studied link between depression and suicide, it is necessary to question giving sole responsibility of assisting patients in making end-of-life treatment decisions to these physicians. Unfortunately, the use of mental health consultation by these physicians is not a common occurrence. Greater involvement of mental health professionals in this emerging and debated area is advocated. Beyond describing mental health professionals' role in the assessment of patient competency or decision making capacity, other areas of potential involvement are described. A discussion of ethical principles relevant to this area follows, along with comments on the training necessary to adequately serve patient needs.

Advance Care Planning↗

Assessment of workflow redesign in community pharmacy.

OBJECTIVE: To assess the effect that workflow enhancements have on dispensing responsibilities and pharmacist-patient interaction in the community pharmacy setting. DESIGN: Pre-post comparison. Pre-assessment data were obtained from a multisite observational study. SETTING: Pharmacy within a regional pharmacy chain. STUDY PARTICIPANTS: 3 pharmacists and 110 patients. INTERVENTION: The pharmacy was physically remodeled to enable workflow changes, including defining dispensing responsibilities with an emphasis on patient counseling, providing an additional 6 feet of counter space, upgrading technology, installing a third computer, implementing tools to augment the filling process, and requesting that cashiers rephrase the offer to counsel to encourage patient acceptance. Patients and pharmacists were surveyed about the experiences and beliefs, and pharmacy activities were observed directly. MAIN OUTCOME MEASURES: Patient counseling and prescription dispensing. activities. RESULTS: The number of pharmacists who perceived that they had adequate time to counsel patients increased as a result of the intervention (0 of 3 responding pharmacists before the intervention, compared with 2 of 2 afterward). Patient satisfaction scores both before and after the intervention were predominantly favorable and did not differ significantly. The most relevant change in dispensing activities was pharmacist involvement with data entry into the computer, which decreased from 61% to 10%. Oral counseling offers to patients increased significantly, from 5% to 85%, but counseling rates remained low throughout the study and were not measurably affected by workload. CONCLUSION: Workflow redesign has positively affected the dispensing activities at the study site. Technicians took more responsibility for dispensing tasks. Given the drastic increase in counseling offers but lack of effect on counseling rates, patient behavior and expectations with regard to counseling likely need to change to further improve dynamics in the community pharmacy.

Architectural Accessibility↗

Effect of a pharmaceutical care program on vascular risk factors in type 2 diabetes: the Fremantle Diabetes Study.

OBJECTIVE: To examine the effect of a 12-month pharmaceutical care (PC) program on vascular risk in type 2 diabetes. RESEARCH DESIGN AND METHODS: We recruited 198 community-based patients randomized to PC or usual care. PC patients had face-to-face goal-directed medication and lifestyle counseling at baseline and at 6 and 12 months plus 6-weekly telephone assessments and provision of other educational material. Clinical, biochemical, and medication-related data were sent regularly to each patient's physician(s). The main outcome measure was change in HbA(1c). A diabetes-specific risk engine was used to estimate changes in 10-year coronary heart disease (CHD) and stroke risk in patients without a history of cardiovascular disease. RESULTS: At total of 180 patients (91%) completed the study. Mean (95% CI) reductions were greater in PC case subjects (n = 92) than control subjects (n = 88) for HbA(1c) (-0.5% [95% CI -0.7 to -0.3] vs. 0 [-0.2 to 0.2]) and systolic (-14 mmHg [-19 to -9] vs. -7 [-11 to -2]) and diastolic (-5 mmHg [-8 to -3] vs. -2 [-4 to 1]) blood pressure (P < or = 0.043). The improvement in HbA(1c) persisted after adjustment for baseline value and demographic and treatment-specific variables. The median (interquartile range) 10-year estimated risk of a first CHD event decreased in the PC case subjects (25.1% [15.6-36.2] to 20.3 [14.6-30.2]; n = 42, P = 0.002) but not in the control subjects (26.1% [17.2-39.4] vs. 26.4 [16.7-38.0]; n = 52, P = 0.17). CONCLUSIONS: A 12-month PC program in type 2 diabetes reduced glycemia and blood pressure. Pharmacist involvement contributed to improvement in HbA(1c) independently of pharmacotherapeutic changes. PC could prove a valuable component of community-based multidisciplinary diabetes care.

Administration, Oral↗

Reflections on the treatment process by nonabstinent alcoholics.

This study reports on the subjective evaluations of treatment by 162 patients who had been treated and discharged with staff approval at Hazelden Rehabilitation Center. At 2 years following treatment, these patients were asked to comment on what they considered the most important aspects of their treatment experience. Four principal groupings of comments emerged as being most important: (1) Formal Hazelden activities, i.e., lectures, counseling; (2) Inner-directed learning, i.e., understanding, insight; (3) Informal Hazelden activities, i.e., personal friendships, fellowship; and (4) General learning, i.e., effect of alcohol on mind and body. The implications of these findings are discussed in terms of the utility of evaluating treatment effectiveness through the subjective judgments of the treated patients.

Adolescent↗

The CTDP1 Founder Variant in CCFDN: Insights into Pathogenesis, Phenotypic Spectrum and Therapeutic Approaches.

Congenital Cataracts, Facial Dysmorphism, and Neuropathy (CCFDN) syndrome is a rare autosomal recessive disorder predominantly found among Vlax Roma populations, caused by a deep intronic founder variant in the CTDP1 gene. This review synthesizes recent advances in understanding the molecular mechanisms of CTDP1 dysfunction, highlighting its central role in transcriptional regulation, RNA splicing, DNA repair, and genome integrity. The unique splicing defect caused by the founder disease-causing variant in the Roma population results in a multisystem phenotype with early-onset neuropathy, congenital cataracts, and characteristic facial dysmorphism. Beyond its genetic homogeneity, CCFDN displays variable clinical severity and presents diagnostic challenges due to overlapping syndromic features. We discuss the emerging therapeutic landscape, focusing on antisense oligonucleotides, small molecule modulators, gene replacement, and genome or transcriptome editing strategies, while emphasizing the challenges in targeted delivery and efficacy. Ongoing insights into CTDP1's broader biological functions and population genetics inform new directions for diagnosis, genetic counselling, and the development of effective therapies for this severe yet underrecognized disorder.

Humans↗

Preventive health care in the elderly population: a guide for practicing physicians.

Preventive medicine provides important benefits to all persons, including older adults; however, these benefits may be seen more clearly in younger adults than in older persons. Smoking cessation, proper nutrition, exercise, and immunizations are important regardless of age. The prevalence of illness increases as we age; at the same time, life expectancy decreases. All physicians and patients should consider the potential benefits of screening and treatment vs conservative management. We discuss lifestyle recommendations such as smoking cessation, exercise, and good nutrition, as well as the role of screening for cardiovascular disease, cancer, and sensory and other disorders. These recommendations are derived from evidence-based guidelines when available; issues not associated with established guidelines are discussed on the basis of best current thinking.

Advance Directives↗

Genetics: uphold the rights of all clients to informed decision-making and voluntary action.

This article discusses the rights of patients in relation to types of genetic tests and the broader implications for families. Use and misuse of genetic information is considered, including scenarios and points to consider. The use of a non-directive approach in genetic counselling is emphasised and multifactorial disorders, prenatal diagnosis and learning disabilities are discussed.

Genetic Counseling↗