Team-based home blood pressure monitoring for blood pressure equity a protocol for a stepped wedge cluster randomized trial

BACKGROUND

Home Blood Pressure Monitoring (HBPM) that includes a team with a clinical pharmacist is an evidence-based intervention that improves blood pressure (BP). Yet, strategies for promoting its adoption in primary care are lacking. We developed potentially feasible and sustainable implementation strategies to improve hypertension control and BP equity.

METHODS

We assessed barriers and facilitators to HBPM and iteratively adapted implementation strategies through key informative interviews and guidance from a multistakeholder stakeholder team involving investigators, clinicians, and practice administration.

RESULTS

Strategies include: 1) pro-active outreach to patients; 2) provision of BP devices; 3) deployment of automated bidirectional texting to support patients through education messages for patients to transmit their readings to the clinical team; 3) a hypertension visit note template; 4) monthly audit and feedback reports on progress to the team; and 5) training to the patients and teams. We will use a stepped wedge randomized trial to assess RE-AIM outcomes. These are defined as follows Reach: the proportion of eligible patients who agree to participate in the BP texting; Effectiveness: the proportion of eligible patients with their last BP reading <140/90 (six months); Adoption: the proportion of patients invited to the BP texting; Implementation: patients who text their BP reading ≥10 of days per month; and Maintenance: sustained BP control post-intervention (twelve months). We will also examine RE-AIM metrics stratified by race and ethnicity.

CONCLUSIONS

Findings will inform the impact of strategies for the adoption of team-based HPBM and the impact of the intervention on hypertension control and equity.

REGISTRATION DETAILS

www.

CLINICALTRIALS

gov Identifier: NCT05488795.

Predictors of referrals and depression outcomes among obstetrics and gynecology patients with positive depression screens

INTRODUCTION

Little is known about the care provided following positive depression screens in obstetrics and gynecology (Ob/Gyn) patients.

METHOD

This study evaluated documented care plans and outcomes for 445 Ob/Gyn patients with positive depression screens between January 2018 and December 2020. Logistic regression models were estimated to identify predictors of changes in documented care plans and to test if a documented plan was associated with a reduction in depression severity in 6 months.

RESULTS

The sample consisted of 445 patients who were on average 35.5 (SD = 12.8) years; 206 (46.3%) were White and 178 (40.0%) were Black. A total of 64 (14.4%) had a depression care plan documenting antidepressant initiation or change and/or psychotherapy referral. Relative to those aged 18-29, patients 40 or older had approximately 60% lower odds of a documented care plan change (OR = 0.394; p < .05). Relative to those seen by nurses, patients seen by physicians had approximately 70% lower odds of having treatment change (OR = 0.282; p < .05). Patients with a depression care plan documented had approximately 2.7 times higher odds of achieving 50% or more reduction in their Patient Health Questionnaire-9 depression severity score than those without a documented plan (OR = 2.685; p = .009).

DISCUSSION

While most patients did not experience an initiation or change in their depression care plan on the same day as their positive screen, those patients with a plan documented showed significantly more improvement than those who did not. Standardized recommendations may improve depression outcomes among patients with positive depression screens. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Addressing Sexual Harassment and Gender Bias: Mandatory Modules Are Not Enough

BACKGROUND AND OBJECTIVES

Despite decades of new policy guidelines and mandatory training modules, sexual harassment (SH) and gender bias (GB) continue in academic medicine. The hierarchical structure of medical training makes it challenging to act when one experiences or witnesses SH or GB. Most trainings designed to address SH and GB are driven by external mandates and do not utilize current educational techniques. Our goal was to design training that is in-person, active, and directed toward skills development.

METHODS

Our academic family medicine (FM) department began by surveying our faculty and residents about their lived experiences of SH and GB. We used these data, incorporating principles of adult learning, to deliver voluntary, experiential, interactive workshops throughout 2019. The workshops took place during faculty development meetings and an annual retreat. We used interactive techniques that included case-based and Theater of the Oppressed formats.

OUTCOMES

Eighty percent of faculty and residents participated in at least one of our voluntary training sessions. In April of 2020, we administered a retrospective, pre/postsurvey on confidence in recognizing, responding to, and reporting SH and GB. We found significant improvements in all domains surveyed; many participants reported using the skills in the 6 months prior to completing the surveys.

CONCLUSION

We demonstrated that voluntary, interactive training sessions using the recommendations of the National Academies of Science Engineering and Medicine Report on the Sexual Harassment of Women improve participants' reported confidence in recognizing, responding to, and reporting SH and GB in one academic FM department. This training intervention is practical and can be disseminated and implemented in many settings.

Integrated Behavioral Health in Primary Care for Adults with Complex Childhood Onset Medical and Developmental Diagnoses

Increased life expectancy for individuals with complex pediatric-onset conditions means most of this population survive into adulthood. While this is great news for individuals and their families, the traditional adult medical model must adapt to extend the care provided by specialty pediatric practices to primary care. In this paper, we introduce a model of integrated behavioral health (IBH) in a primary care practice for adults with childhood onset medical and developmental conditions. Our discussion includes the role of IBH providers (i.e., psychologists, psychiatrists, and social workers) as members of the integrated team, patient engagement and response to treatment, and innovative ways we strive to meet patient needs. Our review of electronic health records of patients seen at the UR Medicine Complex Care Center suggest that IBH is feasible and highly utilized, with 216 patients (40%) having had contact with an IBH provider on the team at least once. We discuss the challenges of meeting the longer-term needs of this complex patient population and our directions for future growth including creating peer and caregiver support networks, expanding services offered, and continued collaboration with community partners.

Sexual Harassment and Gender Bias in Family Medicine: Divergent Experiences of Men and Women

Background and Objectives: Awareness of sexual harassment (SH), gender bias (GB), and gender discrimination (GD) has spread throughout popular culture and has been highlighted at universities across the United States. More nuanced data is needed to inform policies that address these issues. However, there are currently limited qualitative studies examining the nature of SH, GB, and GD in academic medicine, particularly family medicine. Methods: In 2018, we conducted a series of gender-specific focus groups with faculty and residents in a department of family medicine (DFM) to understand their experiences with and responses to SH, GB, and GD. The focus groups were transcribed verbatim. We used immersion-crystallization and an adapted SH Experiences model to review the transcripts and identify patterns or themes during the immersion process. Results: Participants identified the potential for patients, colleagues, faculty, and themselves as perpetrators and victims of SH, GB, and GD. Results suggested that GB was often implicit. SH was experienced verbally and physically. Women participants, especially, reported that both SH and GB occurred frequently and had lasting psychological effects. Gender, age, and position (faculty vs trainee) moderated SH and GB experiences. The effects seemed to be mediated by moral distress. Conclusions: This study emphasizes the importance of recognizing differences in experiences across gender, age, and position of SH, GB, and GD in academic family medicine. Our findings can be leveraged to develop antiharassment policies and set cultural expectations.

"Am I Making More of It Than I Should?": Reporting and Responding to Sexual Harassment

BACKGROUND AND OBJECTIVES

Health professionals may face sexual harassment from patients, faculty, and colleagues. Medicine's hierarchy deters response to sexual harassment. Current evidence consists largely of quantitative data regarding the frequency and types of sexual harassment. More information is needed about the nature of the experience and how or why professionals choose to report or respond.

METHODS

We developed and administered a semistructured interview guide to elicit family medicine faculty and residents' experiences with sexual harassment and gender bias. Facilitators led a series of focus groups divided by faculty (N=28) and residents (N=24). We ensured voluntary consent and groups were audiotaped, transcribed and deidentified. We coded the transcripts using immersion-crystallization theory to identify emergent themes.

RESULTS

Sexual harassment from patients and colleagues was described as witnessed or personally experienced by faculty and resident participants in 100% of the focus groups. Respondents identified the presence of mentors, clear reporting process and follow-up, history of good organizational response to reporting, and education and training as facilitators to reporting sexual harassment. Barriers to reporting included fear of retaliation, lack of trust of the system to respond, lack of clarity about "what counts," and confusion with the reporting process.

CONCLUSIONS

It is important to capitalize on facilitators to reporting sexual harassment, starting with acknowledging the frequency of sexual harassment and gender discrimination. Addressing barriers to responding through education and training for our learners and faculty is critical. Clarifying the reporting process, having clear expectations for behavior, and a continuum of responses may help increase the frequency of reporting.

Does severe bleeding in HHT patients respond to intravenous bevacizumab? Review of the literature and case series

BACKGROUND

Hereditary Haemorrhagic Telangiectasia (HHT) is an autosomal dominant genetic disorder, with a wide variety of clinical manifestations due to the presence of multiple arteriovenous manifestations. Severe bleeding from the gastrointestinal (GI) tract and/or epistaxis presents a significant problem in a subgroup of patients and systemic bevacizumab, an angiogenesis inhibitor, has been suggested to benefit these patients.

OBJECTIVE

To perform a review of the literature concerning the efficacy of systemic bevacizumab in treatment of bleeding from the nose or GI tract in patients with HHT, including patients from our own HHT-center.

METHODS

A literature review was performed using the guideline &quot;Preferred Reporting Items for systematic Reviews and MetaAnalysis statement&quot; (PRISMA).

RESULTS

After careful selection, we finally analysed the results of eight case series and 33 case reports. Among 195 patients 171 (88%) had reduced bleeding after bevacizumab.

CONCLUSIONS

Based on the literature review and data from our own case series, systemic bevacizumab is very promising as treatment for HHT patients with severe epistaxis and/or GI-bleeding. However, care should be taken using bevacizumab, a potent angiogenesis inhibitor; long-term side effects have not been studied in this population. A randomized controlled study is warranted to support the results in HHT patients.

Building the plane in the air…but also before and after it takes flight: considerations for training and workforce preparedness in integrated behavioural health

Collaborative approaches to healthcare that integrate behavioural and biomedical interventions are more likely to enhance patient outcomes as well as provider satisfaction with care delivery than siloed approaches to care. The recognition for specific and targeted training for these models is growing among all health professions, although many in the field have not received systematized, interprofessional, and competency-based training that adequately prepared them for the work of integration. This article reviews some of the fundamental principles of biopsychosocially-oriented, team-based approaches to care that integrate behavioural and biomedical perspectives and delineates the need for targeted training efforts. It describes which specific elements must be addressed within it in order to promote effective integration, and highlights the array of options for training currently in existence. This review provides an overview of current models of training offered in the US, and concludes with a discussion of the challenges and barriers that may render training either ineffective or difficult to achieve.

Validation of semiautomatic scoring of REM sleep without atonia in patients with RBD

OBJECTIVE/BACKGROUND

To evaluate REM sleep without atonia (RSWA) in REM sleep behavior disorder (RBD) several automatic algorithms have been developed. We aimed to validate our algorithm (Mayer et al., 2008) in order to assess the following: (1). capability of the algorithm to differentiate between RBD, night terror (NT), somnambulism (SW), Restless legs syndrome (RLS), and obstructive sleep apnea (OSA), (2). the cut-off values for short (SMI) and long muscle activity (LMI), (3). which muscles qualify best for differential diagnosis, and (4). the comparability of RSWA and registered movements between automatic and visual analysis of videometry.

PATIENTS/METHODS

RSWA was automatically scored according to Mayer et al., 2008 in polysomnographies of 20 RBD, 10 SW/NT, 10 RLS and 10 OSA patients. Receiver operating characteristic (ROC) curves were used to determine the sensitivity and specificity of SMI and LMI. Independent samples were calculated with t-tests. Boxplots were used for group comparison. The comparison between motor events by manual scoring and automatic analysis were performed with "Visual Basic for Applications" (VBA) for every hundredth second.

RESULTS

Our method discriminates RBD from SW/NT, OSA and RLS with a sensitivity of 72.5% and a specificity of 86.7%. Automatic scoring identifies more movements than visual video scoring. Mentalis muscle discriminates the sleep disorders best, followed by FDS, which was only recorded in SW/NT. Cut-off values for RSWA are comparable to those found by other groups.

CONCLUSION

The semi-automatic RSWA scoring method is capable to confirm RBD and to discriminate it with moderate sensitivity from other sleep disorders.

Ehr

Presents the 55-word story "Ehr." (PsycINFO Database Record

Acute hypoxia induces upregulation of microRNA-210 expression in glioblastoma spheroids

AIM

Tumor hypoxia and presence of tumor stem cells are related to therapeutic resistance and tumorigenicity in glioblastomas. The aim of the present study was therefore to identify microRNAs deregulated in acute hypoxia and to identify possible associated changes in stem cell markers.

MATERIALS & METHODS

Glioblastoma spheroid cultures were grown in either 2 or 21% oxygen. Subsequently, miRNA profiling was performed and expression of ten stem cell markers was examined.

RESULTS

MiRNA-210 was significantly upregulated in hypoxia in patient-derived spheroids. The stem cell markers displayed a complex regulatory pattern.

CONCLUSION

MiRNA-210 appears to be upregulated in hypoxia in immature glioblastoma cells. This miRNA may represent a therapeutic target although it is not clear from the results whether this miRNA may be related to specific cancer stem cell functions.

Integrating care when the end is near: ethical dilemmas in end-of-life care

An integrated and collaborative team provides the best clinical care of patients and families during end-of-life moments. Behavioral Health Clinicians (BHCs) bring a skill set for facilitating team interactions, attending to group process, as well as making space for the patient or family voice in the care, often with more time available for these roles. Through a case scenario, this article explores the relevant existing codes of ethics and professional conduct for professionals practicing in integrated care settings as they pertain to end-of-life transitions and care. Most notably, potential ethical issues pertaining to patient autonomy, scope of practice, confidentiality, multiple relationships, and record keeping all come to play during end-of-life care when practicing in an integrated primary care setting. Gaps in the existing codes are discussed and recommendations for providing ethically informed patient- and family-centered end-of-life care are suggested.

Developing an outcome-based assessment for family therapy training: the Rochester Objective Structured Clinical Evaluation (ROSCE)

This paper addresses a growing need for cost-effective, outcome-based assessment in family therapy training. We describe the ROSCE, a structured, evidence-informed, learner-centered approach to the assessment of clinical skills developed at the University of Rochester Medical Center. The ROSCE emphasizes direct observation of trainees demonstrating clinical competencies. The format integrates both formative and summative assessment methods. It can readily be adapted to a wide variety of educational and training settings.

Pediatric cataract, myopic astigmatism, familial exudative vitreoretinopathy and primary open-angle glaucoma co-segregating in a family

PURPOSE

To describe an Australian pedigree of European descent with a variable autosomal dominant phenotype of: pediatric cortical cataract (CC), asymmetric myopia with astigmatism, familial exudative vitreoretinopathy (FEVR), and primary open-angle glaucoma (POAG).

METHODS

Probands with CC, FEVR, and POAG were enrolled in three independent genetic eye studies in Tasmania. Genealogy confirmed these individuals were closely related and subsequent examination revealed 11 other family members with some or all of the associated disorders.

RESULTS

Twelve individuals had CC thought to be of childhood onset, with one child demonstrating progressive lenticular opacification. One individual had severe retinal detachment while five others had dragged retinal vessels. Seven individuals had POAG. Seven individuals had myopia in at least one eye ≤-3 Diopters. DNA testing excluded mutations in myocilin, trabecular meshwork inducible glucocorticoid response (MYOC) and tetraspanin 12 (TSPAN12). Haplotype analysis excluded frizzled family receptor 4 (FZD4) and low density lipoprotein receptor-related protein 5 (LRP5), but only partly excluded EVR3. Multipoint linkage analysis revealed multiple chromosomal single-nucleotide polymorphisms (SNPs) of interest, but no statistically significant focal localization.

CONCLUSIONS

This unusual clustering of ophthalmic diseases suggests a possible single genetic cause for an apparently new cataract syndrome. This family's clinical ocular features may reflect the interplay between retinal disease with lenticular changes and axial length in the development of myopia and glaucoma.

Advanced life support versus basic life support in the pre-hospital setting: a meta-analysis

BACKGROUND

The scientific evidence of a beneficial effect of ALS in pre-hospital treatment in trauma patients or patients with any acute illness is scarce. The objective of this systematic review of controlled studies was to examine whether ALS, as opposed to BLS, increases patient survival in pre-hospital treatment and if so, to identify the patient groups that gain benefit.

METHODS

A systematic review of studies published in the databases Medline (PubMed), EMBASE, Cochrane Library and Scopus up to July 31st, 2010. Controlled studies comparing survival after the pre-hospital ALS treatment versus BLS treatment in trauma patients or patients with cardiac arrest were included.

RESULTS

We identified 1081 studies of which 18 met our inclusion criteria. In nine of 18 studies including 16,857 trauma patients in the intervention group, ALS care did not increase survival compared to BLS treatment (pooled OR 0.892, 95% CI, 0.775-1.026). In nine of 18 studies including 7659 patients with cardiac arrest in the intervention group, ALS care increased survival compared to BLS treatment (OR 1.468, 95% CI, 1.257-1.715). Most subgroup analyses revealed no significant interactions, but data from six trials, where ALS was provided by physicians, increases the probability of survival at hospital discharge even more (OR 2.047, 95% CI 1.593-2.631).

CONCLUSION

Implementation of ALS care to non-traumatic cardiac arrest patients can increase survival and further research is unlikely to change our confidence in the estimate of the effect. On the contrary, in trauma patients our meta-analysis revealed that ALS care is not associated with increased survival. However, only few controlled studies of sufficient quality and strength examining survival with pre-hospital ALS treatment exist.

Identification of a novel locus for a USH3 like syndrome combined with congenital cataract

Usher syndrome (USH) is the most common genetic disease that causes both deafness and blindness. USH is divided into three types, USH1, USH2 and USH3, depending on the age of onset, the course of the disease, and on the degree of vestibular dysfunction. By homozygosity mapping of a consanguineous Danish family of Dutch descent, we have identified a novel locus for a rare USH3-like syndrome. The affected family members have a unique association of retinitis pigmentosa, progressive hearing impairment, vestibular dysfunction, and congenital cataract. The phenotype is similar, but not identical to that of USH3 patients, as congenital cataract has not been reported for USH3. By homozygosity mapping, we identified a 7.3 Mb locus on chromosome 15q22.2-23 with a maximum multipoint LOD score of 2.0. The locus partially overlaps with the USH1 locus, USH1H, a novel unnamed USH2 locus, and the non-syndromic deafness locus DFNB48.

Baron Dominique-Jean Larrey (1766-1842): founder of military surgery and trauma care

Dominique-Jean Larrey was a distinguished surgeon in chief of Napoleon's army and a faithful servant of the Empire. His surgical skills and inventions, his absolute attachment and devotion to his profession, his humanitarian spirit and courage entitled him as one of history's greatest military surgeons.

Mutations in PCDH21 cause autosomal recessive cone-rod dystrophy

Background

Cone-rod dystrophy is a retinal dystrophy with early loss of cone photoreceptors and a parallel or subsequent loss of rod photoreceptors. It may be syndromic, but most forms are non-syndromic with autosomal dominant, autosomal recessive or X-linked recessive inheritance.

Methods and results

We identified a small consanguineous family with six patients with cone-rod dystrophy from the Faroe Islands. Homozygosity mapping revealed a single homozygous locus of 4.2 Mb on chromosome 10q23.1–q23.2, encompassing 11 genes. All patients were homozygous for a 1-bp duplication in PCDH21, c.524dupA, which results in a frameshift and a premature stop codon (p.Q175QfsX47).

Conclusion

To our knowledge, this is the first report of mutations in PCDH21 as a cause of human disease. PCDH21 is highly expressed in the retinal photoreceptor cells. It encodes protocadherin 21, which belongs to the cadherin superfamily of large cell surface proteins characterised by a variable number of extracellular cadherin domains. A PCDH21 knockout mouse model has previously shown loss of photoreceptor cells and abnormal cone and rod function, similar to the findings in the patients.

The role of parent-adolescent attachment in the glycemic control of adolescents with Type 1 diabetes: a pilot study

This pilot study explored the associations between parent and adolescent reports of adolescent attachment and glycemic control in adolescents with Type 1 diabetes. We hypothesized that more secure attachment would correlate with more optimal diabetes control. Thirty-one families completed written self-report questionnaires about adolescent attachment, demographic data, and diabetes control. Adolescents and parents reported on their perceptions of adolescents' attachment to mothers and fathers. Mean HbA1c for the sample was 7.6% (SD = 1.14). Mothers' perceptions of adolescents' attachment were significantly correlated with adolescents' hemoglobin A1c (r = -.42, p = .022), indicating that maternal perceptions of more secure attachment was associated with better glycemic control. Neither fathers' perceptions nor adolescents' reports of attachment was significantly correlated with glycemic control. Attachment appears to be associated with glycemic control in this population though the mechanisms are unclear. Mothers' perceptions of attachment had the strongest associations with control, not adolescent reports. Further research is needed to understand the mechanisms through which parent reports of adolescent attachment are associated with glycemic control.

A syndrome with retinitis pigmentosa, progressive hearing impairment, vestibular dysfunction, and congenital cataract

A family with an unusual association of retinitis pigmentosa, progressive and severe hearing impairment, vestibular dysfunction, and congenital zonular cataract is described. The disease had a rather uniform appearance in five affected individuals. Parental consanguinity was documented in all cases and a common ancestor born in 1702 was identified. Consequently, autosomal recessive inheritance seems to be the most likely mode of transmission. This disorder possibly represents a new clinical entity among combined retinal dystrophy and hearing impairment syndromes.

Prenatal diagnosis of choroideremia

With the mapping of the locus CHM for choroideremia and the subsequent cloning of the gene, reliable carrier and prenatal diagnosis has become a possibility. We discuss our experience with prenatal diagnosis of choroideremia, an X-linked choroidoretinal dystrophy leading to blindness in otherwise healthy males. In the period 1987-1995, five prenatal diagnoses have been performed by either indirect linkage analysis or by detection of the disease-causing mutation, reflecting the impact of molecular biology in clinical genetic practice.

Visual impairment due to retinopathy of prematurity in Nordic children

The registers of visually impaired children in Denmark, Finland, Iceland and Norway have been compiled into a common database by a Nordic study group of ophthalmologists, NORDSYN. The database contains information on 2527 children aged 0-17 years. The total number of children with visual impairment due to retinopathy of prematurity (ROP) is 247. ROP is the 3rd most common single diagnosis in the database. The age-specific national prevalence of registration (N/100 000) of visual impairment due to ROP varies from 12 in Denmark to 5 in Finland and Norway and 4 in Iceland. The differences can partly be explained by varying efficiency of registration. The age-distribution indicates that visual impairment due to ROP is not decreasing. Of the 247 children 175 had a visual acuity less than 1/60 and 58 had one or more additional impairments. Incidence studies on visual impairment in Nordic children are being prepared.

A novel founder BBS1 mutation explains a unique high prevalence of Bardet-Biedl syndrome in the Faroe Islands

BACKGROUND/AIM

Bardet-Biedl syndrome is a multiorgan disease presenting with retinitis pigmentosa leading to blindness. The aim of the study was to investigate the genetic background of Bardet-Biedl syndrome in the Faroe Island. It was hypothesised that a common genetic background for the syndrome would be found.

METHODS

Patients were identified from the files of the Retinitis Pigmentosa Register at the National Eye Clinic, Denmark. The diagnosis of Bardet-Biedl syndrome was verified from medical files. Mutational screening of BBS1, BBS2, BBS4, MKKS and BBS10 was done by denaturing high-performance liquid chromatography.

RESULTS

Out of 13 prevalent cases in the Faroe Islands, 10 patients from nine families were included. A novel splice site mutation in BBS1, c.1091+3G>C, was identified, and this was predicted to affect protein function by skipping 16 amino acids. Nine patients were homozygous for this mutation, while one patient was compound heterozygous with a recurrent BBS1 mutation, p.Met390Arg. The patients presented with severe ophthalmic phenotypes, while the systemic manifestations of the disease were apparently milder.

CONCLUSION

A novel BBS1 mutation was identified, most probably a founder mutation, further confirming the Faroe Islands as a genetic isolate. The phenotypic expression of the Faroese patients suggests that different mutations in BBS1 affect various organs differently.

Toxic encephalopathy and noise-induced hearing loss

In several laboratory animal studies, it has been documented that the hearing, vision, and brain can be injured due to exposure to organic solvents. This finding formed the background for a pilot study (n=16) aimed at identifying new ways of qualifying diagnostics, treatment, and rehabilitation of patients suffering from brain injury due to exposure to organic solvents, also referred to as toxic encephalopathy. Diagnosing toxic encephalopathy is complicated because the symptoms of this type of diffuse brain injury are non-specific. So, it was initially hypothesised that some of the difficulties involved in diagnosing toxic encephalopathy could be minimized by extending the diagnostic procedure. Apart from clinical interviewing and neuropsychological testing, the diagnosis should include the examination of hearing and vision. This will help in achieving new measures that could improve in diagnosing toxic encephalopathy with more certainty. On the basis of ranking, only one patient in the pilot study was considered to have a normal neuropsychological test profile, which was defined as a test profile without any marked deviations when compared with a normal population. A total of 10 patients were considered to have "discrete problems." These patients had a test profile showing either a few strikingly negative results or an array of results slightly below the expected level when compared with a normal population. A total of four patients were considered to suffer from "moderate problems" and one patient from "severe problems." The patients with "moderate problems" and "severe problems" showed consistent negative results and an unambiguous negative test profile. However, the overall results of all neuropsychological examinations performed revealed a dispersed picture. Quite remarkably, all the 13 patients who had their hearing examined showed a loss of hearing, 7 patients complained about tinnitus, and all patients had a history of exposure to both noise and organic solvents, which had not been observed at the initial examination, but seemed to have serious implications for their prognosis and future life.

Distinct CDH3 mutations cause ectodermal dysplasia, ectrodactyly, macular dystrophy (EEM syndrome)

BACKGROUND

EEM syndrome is the rare association of ectodermal dysplasia, ectrodactyly, and macular dystrophy.

METHODS

We here demonstrate through molecular analysis that EEM is caused by distinct homozygous CDH3 mutations in two previously published families.

RESULTS

In family 1, a missense mutation (c.965A-->T) causes a change of amino acid 322 from asparagine to isoleucine; this amino acid is located in a highly conserved motif likely to affect Ca2+ binding affecting specificity of the cell-cell binding function. In family 2, a homozygous frameshift deletion (c.829delG) introduces a truncated fusion protein with a premature stop codon at amino acid residue 295, expected to cause a non-functional protein lacking both its intracellular and membrane spanning domains and its extracellular cadherin repeats 3-5. Our mouse in situ expression data demonstrate that Cdh3 is expressed in the apical ectodermal ridge from E10.5 to E12.5, and later in the interdigital mesenchyme, a pattern compatible with the EEM phenotype. Furthermore, we discuss possible explanations for the phenotypic differences between EEM and congenital hypotrichosis with juvenile macular dystrophy (HJMD), which is also caused by CDH3 mutations.

CONCLUSIONS

In summary, we have ascertained a third gene associated with ectrodactyly and have demonstrated a hitherto unrecognised role of CDH3 in shaping the human hand.

Autosomal dominant optic atrophy associated with hearing impairment and impaired glucose regulation caused by a missense mutation in the WFS1 gene

Autosomal dominant optic atrophy (ADOA) is genetically heterogeneous, with OPA1 on 3q28 being the most prevalently mutated gene. Additional loci are OPA3, OPA4, and OPA5, located at 19q13.2, 18q12.2, and 22q12.1-q13.1, respectively. Mutations in the WFS1 gene, at 4p16.3, are associated with either optic atrophy (OA) as part of the autosomal recessive Wolfram syndrome or with autosomal dominant progressive low frequency sensorineural hearing loss (LFSNHL) without any ophthalmological abnormalities. Linkage and sequence mutation analyses of the ADOA candidate genes OPA1, OPA3, OPA4, and OPA5, including the genes WFS1, GJB2, and GJB6 associated with recessive inherited OA or dominant LFSNHL, were performed. We identified one novel WFS1 missense mutation E864K, c.2590G-->A in exon 8 that co-segregates with ADOA combined with hearing impairment and impaired glucose regulation. This is the first example of autosomal dominant optic atrophy and hearing loss associated with a WFS1 mutation, supporting the notion that mutations in WFS1 as well as in OPA1 may lead to ADOA combined with impaired hearing.

Burnout among mental health professionals: special considerations for the marriage and family therapist

Burnout is a syndrome consisting of physical and emotional exhaustion resulting from negative self-concept, negative job attitudes, and loss of concern for clients. This research study explores potential predictors and prevalence of burnout among marriage and family therapists (MFTs). It evaluates the Maslach Burnout Inventory (MBI) to establish its applicability to MFTs. Our sample of 116 Clinical Members of the American Association for Marriage and Family Therapy responded to a mailed questionnaire including demographic information and the MBI. Overall, our sample reported low-to-moderate ranges of burnout. Differences were noted in degrees of burnout across job settings. Predictors of clinician burnout include hours worked per week and job setting. Factor analysis indicates that the MBI is an appropriate assessment tool for measuring burnout among MFTs. Implications for clinical practice are discussed.

Caregiver physical and mental health predicts reactions to caregiving

Self-reported health and reactions to providing care to older adults with cognitive or physical impairments were examined. Health status was examined on a single occasion in 177 persons (aged 63-94 years) referred to programs within a comprehensive set of geriatric care services and the 133 family members involved in their care (ages 31-96 years). The five-scale Caregiver Reaction Assessment (CRA) was administered to the family members. Reliability analyses revealed that the CRA had good internal consistency. Being older was related to experiencing greater health problems in the caregiver role. Greater health problems from providing care were reported by caregivers in worse physical health and also when the care recipient had more physical pain. Caregivers who reported fewer health problems attributed to caregiving reported better mental health and less depressive symptomatology. Caregivers with health problems may be at increased risk of suffering from stress from caregiving.

Delineation of an interstitial 9q22 deletion in basal cell nevus syndrome

Basal cell nevus syndrome (Gorlin syndrome) is an autosomal dominant disorder characterized by the presence of multiple basal cell carcinomas (BCC), odontogenic keratocysts, palmoplantar pits, and calcification in the falx cerebri caused by mutational inactivation of the PTCH gene. In few cases, the syndrome is due to a microdeletion at 9q22. Using high-resolution chromosome analysis we have identified a patient with the karyotype, 46,XY,del(9)(q21.3q31) de novo. He had typical clinical features consistent with basal cell nevus syndrome, but also additional features likely to be caused by loss of additional chromosomal material in this region. The deletion breakpoints were characterized with fluorescence in situ hybridization (FISH) analysis using BAC clones. The 15 Mb long deletion includes 87 RefSeq genes including PTCH. Hemizygosity of one or more genes might contribute to the additional symptoms observed in this patient.

An unusual retinal vascular morphology in connection with a novel AIPL1 mutation in Leber's congenital amaurosis

AIMS

To report a case of an unusual retinal vascular morphology in connection with a novel AIPL1 mutation in a patient with Leber's congenital amaurosis (LCA).

METHODS

A patient with LCA and no light perception from birth had both eyes enucleated at the age of 22 years because of excruciating pain. Mutation analysis was performed on known LCA genes. The eyes were processed for casts of the vascular tree, routine histopathology, and electron microscopy.

RESULTS

A novel H82Y (244C-->T) mutation and a H90D (286G-->C) polymorphism were detected in exon 2 of the AIPL1 gene. Both the cast and the histopathological examination showed dilated retinal vessels, mainly venules, primarily localised in the posterior pole. In the mid-peripheral retina the density of capillaries on the arteriolar side of the microcirculatory units was significantly decreased. The vascular system was seen to gradually attenuate towards the retinal periphery, and to stop at a zone located approximately 4 mm from the ora serrata along the whole circumference. In this zone pigmented aggregates characteristic of retinitis pigmentosa were seen to ensheath the retinal vessels. The photoreceptors were almost totally absent and retinal gliosis was present. A decreased number of ganglion cells and an increased vacuolisation of the nerve fibre layer were observed. The retinal pigment cells and Bruch's membrane appeared normal in all regions.

CONCLUSION

An unusual retinal vascular morphology in an LCA patient is presented and possible pathogenic mechanisms of the findings are discussed.

A frameshift mutation in exon 28 of the OPA1 gene explains the high prevalence of dominant optic atrophy in the Danish population: evidence for a founder effect

Dominant optic atrophy (DOA) is a hereditary optic neuropathy characterised by decreased visual acuity, colour vision deficits, centro-coecal scotoma and optic nerve pallor. The gene OPA1, encoding a dynamin-related GTPase, has recently been identified within the genetic linkage interval for the major locus for DOA on chromosome 3q28 and shown to harbour genetic aberrations segregating with disease in DOA families. The prevalence of the disorder in Denmark is reported to be the highest of any geographical location, suggestive of a founder effect. In order to establish the genetic basis of disease in a sample of 33 apparently unrelated Danish families, we screened DNA from affected members for OPA1 gene mutations by heteroduplex analysis and direct sequencing. A novel identical mutation in exon 28 (2826delT) was associated with DOA in 14 pedigrees and led to a frameshift and abnormal OPA1 protein -COOH terminus. Haplotype analysis of a region of approximately 1 Mb flanking the OPA1 gene using eight polymorphic markers revealed a common haplotype shared by all 14 patients; this haplotype was markedly over-represented compared with ethnically matched controls. Statistical analysis confirmed significant linkage disequilibrium with DOA over approximately 600 kb encompassing the disease mutation. We have therefore demonstrated that the relatively high frequency of DOA in Denmark is attributable to a founder mutation responsible for approximately 42% of the examined families and suggest that presymptomatic screening for the (2826delT) mutation may facilitate diagnosis and genetic counselling in a significant proportion of DOA patients of Danish ancestry.

An mtDNA mutation, 14453G-->A, in the NADH dehydrogenase subunit 6 associated with severe MELAS syndrome

We report a novel point mutation in the gene for the mitochondrially encoded ND6 subunit of the NADH:ubiquinone oxidoreductase (complex I of the respiratory chain) in a patient with MELAS syndrome. The mutation causes a change from alanine to valine in the most conserved region of the ND6 subunit. The patient was heteroplasmic for the mutation in both muscle and blood, but the mutation was not detected in the patient's mother. A marked reduction of complex I activity was found in the patient's muscular tissue. This is the first report of a mutation in the ND6 subunit causing MELAS. Our data confirm the genetic heterogeneity in mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes syndrome, and confirms that MELAS can be caused by mutation in polypeptide-coding mtDNA genes.

Rapid quality control for testing the radiochemical purity of 99Tc(m)-tetrofosmin

We describe a new thin-layer chromatography (TLC) method to evaluate the radiochemical purity of 99Tc(m)-tetrofosmin without the drawbacks of toxicity, solvent ratios and time requirement associated with the standard TLC method. The new method uses miniaturized instant TLC plates impregnated with silica gel (ITLCTM/SG, 2.5 x 10 cm) for the stationary phase and 2-butanone for the mobile phase. The standard TLC method was performed with ITLCTM/SG plates (5 x 20 cm) and dichloromethane/acetone (65:35, v/v). Thirty five preparations were analysed by both methods with a storage phosphor imaging system to determine the percentages of hydrolyzed-reduced 99Tc(m) compound (99Tc(m)O2), 99Tc(m)-tetrofosmin and free 99Tc(m)-pertechnetate (99Tc(m)O4(-)). Using the miniaturized TLC method, 99Tc(m)-tetrofosmin had a mean Rf value of 0.55 (standard deviation, 0.05), while 99Tc(m)O4(-) migrated with the solvent front (Rf=1) and 99Tc(m)O2 remained at the origin of the strips (Rf=0). No significant difference was found between miniaturized and standard TLC methods for the radiochemical purity of 99Tc(m)-tetrofosmin using the Wilcoxon matched-pair signed-rank test (P=0.82). Furthermore, the two methods showed a good correlation as measured by the Spearman rank coefficient (r=0.89) and were in perfect agreement, with a kappa index of +1, for a cut-point between positive and negative set at 90%. In conclusion, the results indicate that the miniaturized TLC method is effective for the routine evaluation of the radiochemical purity of 99Tc(m)-tetrofosmin, without some of the drawbacks of the standard method.

Multisystem disorder associated with a missense mutation in the mitochondrial cytochrome b gene

Mitochondrial cytochrome b mutations have been reported to have a homogenous phenotype of pure exercise intolerance. We describe a novel mutation in the cytochrome b gene of mitochondrial DNA (A15579G) associated with a selective decrease of muscle complex III activity in a patient who, besides severe exercise intolerance, also has multisystem manifestations (deafness, mental retardation, retinitis pigmentosa, cataract, growth retardation, epilepsy). The point mutation is heteroplasmic in muscle (88%) and leukocytes (15%), and changes a highly conserved tyrosine to cysteine at amino acid position 278.

Population-based risk estimates of Wilms tumor in sporadic aniridia. A comprehensive mutation screening procedure of PAX6 identifies 80% of mutations in aniridia

Aniridia is a severe eye disease characterized by iris hypoplasia; both sporadic cases and familial cases with an autosomal dominant inheritance exist. Mutations in the PAX6 gene have been shown to be the genetic cause of the disease. Some of the sporadic cases are caused by large chromosomal deletions, some of which also include the Wilms tumor gene (WAGR syndrome), resulting in an increased risk of developing Wilms tumor. Based on the unique registration of both cancer and aniridia cases in Denmark, we have made the most accurate risk estimate to date for Wilms tumor in sporadic aniridia. We have found that patients with sporadic aniridia have a relative risk of 67 (confidence interval: 8.1-241) of developing Wilms tumor. Among patients investigated for mutations, Wilms tumor developed in only two patients out of 5 with the Wilms tumor gene (WT1) deleted. None of the patients with smaller chromosomal deletions or intragenic mutations were found to develop Wilms tumor. Our observations suggest a smaller risk for Wilms tumor than previous estimates, and that tumor development requires deletion of WT1. We report a strategy for the mutational analysis of aniridia cases resulting in the detection of mutations in 68% of sporadic cases and 89% of familial cases. We also report four novel mutations in PAX6, and furthermore, we have discovered a new alternatively spliced form of PAX6.

A common ancestral origin of the frequent and widespread 2299delG USH2A mutation

Usher syndrome type IIa is an autosomal recessive disorder characterized by mild-to-severe hearing loss and progressive visual loss due to retinitis pigmentosa. The mutation that most commonly causes Usher syndrome type IIa is a 1-bp deletion, described as "2299delG," in the USH2A gene. The mutation has been identified in several patients from northern and southern Europe and from North America, and it has been found in single patients from South America, South Africa, and China. Various studies have reported a range of frequencies (.16-.44) among patients with Usher syndrome, depending on the geographic origin of the patients. The 2299delG mutation may be the one that most frequently causes retinitis pigmentosa in humans. Given the high frequencies and the wide geographic distribution of the mutation, it was of interest to determine whether the mutation resulted from an ancestral mutational event or represented a mutational hotspot in the USH2A gene. Haplotype analysis was performed on DNA samples from 116 unrelated patients with Usher syndrome type IIa; the patients were from 14 countries and represented 148 2299delG alleles. On the basis of six single-nucleotide polymorphisms within the USH2A gene, 12 core haplotypes were observed in a panel of normal chromosomes. However, in our analysis, only one core haplotype was found to be associated with the 2299delG mutation. The data indicate that the widespread geographic distribution of the 2299delG mutation is the result of an ancestral mutation that has spread throughout Europe and into the New World as a result of migration.

Prediction of major coronary events by coronary risk profile and silent myocardial ischaemia: prospective follow-up study of primary prevention in 72 diabetic patients

The aim of this study was to examine the predictive value of coronary risk profile (CRP) for major coronary events in patients screened for silent myocardial ischemia (SMI). We studied 72 diabetic patients, aged 41 to 65 years, recruited consecutively at the Poitiers diabetes clinic. All patients had at least one cardiovascular risk factor associated with diabetes mellitus (type 1 diabetes duration > or =15 years, dyslipidaemia, smoking, hypertension, micro/macro-albuminuria). A structured questionnaire, physical examination and resting electrocardiogram provided no evidence of coronary heart disease. SMI was defined as positive exercise electrocardiogram and/or dipyridamole thallium myocardial scintigraphy. CRP was estimated using the Framingham equation adapted to the French population. We defined a high CRP value as annual CRP > or =1.5%. Major coronary events (MCE) were defined as myocardial infarction, ischaemic heart failure, unstable angina or sudden death. Twenty-one patients with type 1, and 51 with type 2 diabetes were followed up for 39+/-12 months: 30 women and 42 men, aged 55+/-7 years with diabetes duration of 16 +/- 11 years (mean +/- SD). SMI was detected in 8 patients. Major coronary events occurred in 8 patients, 2 of whom had SMI. High CRP was found in 18 patients, 3 of whom had MCE. CRP was significantly higher in those patients with a major coronary event (1.71 +/- 1.11 versus 1.03 +/- 0.56%; p=0.048), but not in those with SMI (1.19 +/- 0.72 vs 1.09 +/- 0.67%; p=0.654). In Kaplan-Meier survival analysis, a high CRP was associated with the risk of a major coronary event (log-rank=5.36; p=0.021), whereas SMI was not (log-rank=2.02; p=0.155). The cumulative incidence of MCE in those patients with high and low CRP was 8.08 (0.49-15.67) vs 2.15 (0.06-4.22) events per 100 patient year of follow-up, respectively.

CONCLUSION

CRP had a good predictive value for major coronary events regardless the presence of SMI. Prevention should therefore be focused primarily on patients with high CRP, wether or not they have SMI.