[Research promotion by a patient organization : The example of PRO RETINA and it's research foundation]. / Forschungsförderung durch eine Patientenorganisation : Das Beispiel der PRO RETINA und ihrer Stiftung.

This article illustrates the development, framework conditions and results of research promotion by the patient self-help organization PRO RETINA Deutschland e. V. and its foundation, with a special focus on patient participation. Instruments of research promotion applied by the patient organization included the articulation and clarification of research needs, cooperation with research institutes on a project level, accompanying of research programs in advisory boards, public acknowledgement of successful researchers, support of patient recruitment for studies, biomaterial banks and registers. As examples for the initiated and supported research work, the isolation of the choroideremia gene, the development of a retinal implant and cooperation on Usher syndrome are described. In 2007 PRO RETINA established its own research foundation as a closely linked but independent organization. This foundation financially supported 52 projects (including PhD grants and small projects), 19 research awards and 3 foundation professorships, with a main focus on the support and encouragement of young scientists. Nowadays, apart from success in research promotion, patient participation also covers drug approval procedures, benefit assessment and decisions on regulations in medical care. The work of PRO RETINA and its foundation demonstrates the potential of self-help organizations for initiation, acceleration and support of patient-oriented medical research.

[CF Lung Disease - a German S3 Guideline: Module 2: Diagnostics and Treatment in Chronic Infection with Pseudomonas aeruginosa]. / S3-Leitlinie: Lungenerkrankung bei Mukoviszidose ­ Modul 2: Diagnostik und Therapie bei der chronischen Infektion mit Pseudomonas aeruginosa.

Cystic Fibrosis (CF) is the most common autosomal-recessive genetic disease affecting approximately 8000 people in Germany. The disease is caused by mutations in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene leading to dysfunction of CFTR, a transmembrane chloride channel. This defect causes insufficient hydration of the epithelial lining fluid which leads to chronic inflammation of the airways. Recurrent infections of the airways as well as pulmonary exacerbations aggravate chronic inflammation, lead to pulmonary fibrosis and tissue destruction up to global respiratory insufficiency, which is responsible for the mortality in over 90 % of patients. The main aim of pulmonary treatment in CF is to reduce pulmonary inflammation and chronic infection. Pseudomonas aeruginosa (Pa) is the most relevant pathogen in the course of CF lung disease. Colonization and chronic infection are leading to additional loss of pulmonary function. There are many possibilities to treat Pa-infection. This is a S3-clinical guideline which implements a definition for chronic Pa-infection and demonstrates evidence-based diagnostic methods and medical treatment for Pa-infection in order to give guidance for individual treatment options.

[Development of disease-specific patient groups within Pro Retina]. / Entwicklung diagnosespezifischer Gruppen in der Pro Retina.

The formation, development and external impact of the following eight disease-specific patient groups with rare forms of retinal degeneration (RRD) within the patient organization Pro Retina are described: Gyrate Atrophy, Bardet-Biedl Syndrome (BBS), Adult Refsum's Disease, Usher Syndrome, Rod-Cone Dystrophy, Leber's Congenital Amaurosis, Choroideremia and Stargardt Disease/juvenile macular degeneration. Within the project sponsored by the German Ministry of Health (BMG) approaches of patient self-help for an adequate organization and interaction with the professional medical care system were supported, analyzed and documented. In syndromic RRD a relatively high proportion of patients are organized in patient groups (Refsum's disease 25%, BBS 14%, Usher Syndrome 8%). Patients with syndromic RRD are more highly motivated to contribute to self-help work than patients with non-syndromic RRD. At the same time, these patients are more dependent on the support from their relatives and on technical aids. The following tendencies in the development of RRD groups were observed: increasing focus on one patient organization (PRO RETINA Deutschland, Self-Help Organisation of People with Retinal Degenerations) all RRD groups in Pro Retina grew; RRD groups became increasingly independent within Pro Retina; external activities of the groups showed considerable increase. Stable work relationships with scientific and medical care institutions have been established. The example of RRD demonstrates how rare and isolated patients receive basic coping support by self-help groups, how they deal with resources in a collective way and how they can interact with the medical care system.

[Patient participation in medical care, taking rare retinal degenerations as examples]. / Patientenselbsthilfe und seltene Erkrankungen. Mitgestaltung der Versorgungsrealität am Beispiel seltener Netzhautdegenerationen.

Eight rare retinal degenerations were chosen to exemplify self-organisation and involvement of patient self-help groups in medical care. They were studied and supported in their development on the following levels: disease-specific groups (level 1), patient organisations (level 2), umbrella organisation (level 3). Databases of defined needs and concerns ("Themenspeicher") of disease-specific patient groups and of patient organisations with respect to care, research and patient networking were established. Priority concerns were implemented in the following areas: specialised medical care; quality assurance; quality management; expert panel with international dialogue of patients and physicians (including consensus statement on treatment recommendations); glossary internet portal; criteria for patient-oriented disease descriptions; structured documentation of patient experiences; patient management of health care records (paper bound and electronic health records). Apart from disease- specific approaches, interdisciplinary disease approaches were also applied, e.g. by contributing to the establishment of the German Alliance for Rare Diseases (ACHSE). This umbrella organisation has substantially improved chances for cooperation and patient advocacy. Patient participation was promoted by a federal regulation in 2004 ("Patientenbeteiligungsverordnung"). The example of rare retinal degenerations demonstrates the advantage of strong patient and umbrella organisations. Further development of qualified self-help resources is required for patient participation in rare diseases.

Prenatal exclusion of choroideremia.

We performed prenatal testing to predict the inheritance of choroideremia (CHM) using a linked polymorphic DNA marker, DXS95. DNA analysis of chorionic villi at the 12th week of pregnancy indicated that the allele at risk had not been passed from the heterozygous mother to the fetus. This prenatal exclusion of choroideremia was confirmed by polymerase chain reaction-single-strand conformation polymorphism (PCR-SSCP) analysis.

Detection and characterization of point mutations in the choroideremia candidate gene by PCR-SSCP analysis and direct DNA sequencing.

By making use of positional cloning strategies we recently isolated a candidate gene for choroideremia (CHM), which is transcribed in retina, choroid, and/or retinal pigment epithelium. The gene contains an open reading frame that is structurally altered in 10 CHM patients with sizable deletions and in a female patient with a balanced translocation involving the Xq21 band. Employing PCR-SSCP analysis and direct DNA sequencing we have now detected and characterized different point mutations in five patients with CHM. Each of these mutations introduces a termination codon into the open reading frame of the CHM candidate gene, thereby predicting a distinct truncated protein product. Together these findings provide convincing evidence for the candidate gene being identical with the choroideremia gene.

Cloning of the breakpoints of a deletion associated with choroidermia.

In order to characterize a previously described submicroscopic deletion encompassing (part of) the choroideremia (tapetochoroidal dystrophy: TCD) gene, we have cloned a 10.5-kb EcoRI fragment from the patient's DNA; this fragment carries the junction between both deletion endpoints ("junction fragment"). The distal portion of this fragment defines a new marker within, or just distal to, the TCD gene. This marker has been employed to confirm the diagnosis in several affected family members, and to rule out carriership in a female at risk with conspicuous clinical signs.

Deletions in patients with classical choroideremia vary in size from 45 kb to several megabases.

Making use of the p1bD5 probe (DXS165), we have isolated several markers from the choroideremia locus by chromosomal jumping, preparative field-inversion gel electrophoresis, and cloning of a deletion junction fragment. With these clones we were able to identify and characterize eight deletions in 69 choroideremia patients investigated. The deletions are heterogeneous, in both size and location. The smallest deletion (patient LGL1134) comprises approximately 45 kb of DNA, whereas the largest ones (patients 25.6 and LGL2905) span a DNA segment of at least 5 megabases, which is comparable in size to the smallest deletion detected in a TCD patient (patient XL45) showing a complex phenotype. The TCD deletions encompass variable parts of 150-200-kb DNA segment that is flanked by p1bD5 (DXS165) at the centromeric side and by pZ 11 at the telomeric side. The deletions in patients 33.1, LGL1101, and LGl1134 do not span a translocation breakpoint which was previously mapped on the X chromosome of a female with TCD. The clones isolated from the TCD locus are valuable diagnostic markers for deletion analysis of patients or carrier females. In addition, they should be useful for the isolation of expressed sequences that are part of the TCD gene.

Chromosomal jumping from the DXS165 locus allows molecular characterization of four microdeletions and a de novo chromosome X/13 translocation associated with choroideremia.

Choroideremia (tapeto-choroidal dystrophy, TCD), an X chromosome-linked disorder of retina and choroid, causes progressive nightblindness and central blindness in affected males by the third to fourth decade of life. Recently, we have been able to map the TCD gene to a small region of overlap between five different, male-viable Xq21 deletions that were found in patients with TCD and other clinical features. Two families were identified in which classical, nonsyndromic TCD is associated with small interstitial deletions that are only detectable with probe p1bD5 (DXS165). To characterize these and two other deletions that were identified more recently, we have used the chromosome walking and jumping techniques to generate a set of five chromosomal-jumping clones flanking the DXS165 locus at various distances. With these clones, we could localize four of the eight deletion endpoints and the breakpoint on the X chromosome of a female with a de novo X/13 translocation and choroideremia. These studies assign the TCD gene, or part of it, to a DNA segment of only 15-20 kilobases.

Deletion of the DXS165 locus in patients with classical choroideremia.

Using various probes from the Xq21 region which is known to carry the choroideremia (tapetochoroideal dystrophy, TCD) locus, we have screened the DNAs from eight unrelated male choroidermia patients for microdeletions. In two of these patients, but not in any of 45 males tested as controls, lack of hybridization signals with probe plbD5 suggested a deletion encompassing the DXS165 locus and (part of) the TCD gene. Absence of additional clinical features in these patients and the fact that two closely linked, and probably flanking, TCD markers (DXYS1 and DXS72) are not deleted may indicate that the physical distance between the DXS165 locus and the TCD gene is small.

Choroideremia-locus maps between DXS3 and DXS11 on Xq.

Choroideremia is a progressive tapetochoroidal dystrophy with X-linked transmission leading frequently to blindness in affected males. The choroideremia-locus (TCD) has recently been assigned to the long arm of the X chromosome by linkage to polymorphic DNA markers. In order to further define the location of the gene defect, two families segregating for choroideremia were examined for DNA restriction fragment length polymorphisms. A search was undertaken for linkage with cloned DNA probes from the proximal short and long arm as well as from the mid-portion of the long arm of the X chromosome. Our data suggest that the most plausible gene order on the Xq is: Xcen-DXYS1-DXS3-TCD-DXS11-Xqter.