Genetic services survey-experience of people with rare diseases and their families accessing genetic services in the Irish Republic.

Irish Health Service objectives state that patients with rare diseases should have timely access to genomic diagnostics with appropriate pre and post-test counselling. However, waiting times for clinical genetics outpatient appointments, during the study period, were up to two years as staffing levels remain low. A targeted public online survey was conducted in January 2022 to capture the experiences of Rare Disease families trying to access genetic testing and clinical genetic clinics in the Irish Republic. Irish patients experience significant waiting times to access clinical genetic services and self-report anxiety and stress, related to delayed access to diagnosis, clarity around recurrence risk and follow-up management. This negatively impacts personal decisions around family planning, education and employment and has a significant impact on family members seeking clarity on their own risk. Mainstream genetic testing activity is significant. Families report concern over the competency of health care professionals arranging and delivering genetic results and delays in accessing clinical genetics expertise to take them through the clinical implications. Timely access to clinical genetics expertise is important to ensure families with rare diseases have an appropriate understanding of the medical and reproductive implications of a genetic diagnosis and access to relevant care pathways. A national framework to develop competency in genomic literacy for health-care professionals including a national genetic test directory may be beneficial. Clinical genetics teams require ongoing support and investment to ensure the delivery of a safe and effective service for Irish families with rare diseases.

Designing rare disease care pathways in the Republic of Ireland: a co-operative model.

BACKGROUND: Rare diseases (RDs) are often complex, serious, chronic and multi-systemic conditions, associated with physical, sensory and intellectual disability. Patients require follow-up management from multiple medical specialists and health and social care professionals involving a high level of integrated care, service coordination and specified care pathways. METHODS AND OBJECTIVES: This pilot study aimed to explore the best approach for developing national RD care pathways in the Irish healthcare system in the context of a lack of agreed methodology. Irish clinical specialists and patient/lived experience experts were asked to map existing practice against evidence-based clinical practice guidelines (CPGs) and best practice recommendations from the European Reference Networks (ERNs) to develop optimal care pathways. The study focused on the more prevalent, multisystemic rare conditions that require multidisciplinary care, services, supports and therapeutic interventions. RESULTS: 29 rare conditions were selected across 18 ERNs, for care pathway development. Multidisciplinary input from multiple specialisms was relevant for all pathways. A high level of engagement was experienced from clinical leads and patient organisations. CPGs were identified for 26 of the conditions. Nurse specialist, Psychology, Medical Social Work and Database Manager roles were deemed essential for all care pathways. Access to the therapeutic Health Service Professionals: Physiotherapy, Occupational Therapy, and Speech and Language Therapy were seen as key requirements for holistic care. Genetic counselling was highlighted as a core discipline in 27 pathways demonstrating the importance of access to Clinical Genetics services for many people with RDs. CONCLUSIONS: This study proposes a methodology for Irish RD care pathway development, in collaboration with patient/service user advocates. Common RD patient needs and health care professional interventions across all pathways were identified. Key RD stakeholders have endorsed this national care pathway initiative. Future research focused on the implementation of such care pathways is a priority.

Unexplained developmental delay/learning disability: guidelines for best practice protocol for first line assessment and genetic/metabolic/radiological investigations.

BACKGROUND: Investigation of patients, particularly children, with unexplained global developmental delay (GDD)/learning disability (LD) has been challenging due to a lack of clear guidance from specialised centres. Limited knowledge of rare diseases and a poor understanding of the purpose or limitations of appropriate investigations have been some of the principal reasons for this difficulty. AIMS: A guideline development group was formed to recommend on appropriate, first line metabolic, genetic and radiological investigations for children and adults with unexplained GDD/ID. METHODS AND RECOMMENDATIONS: A comprehensive literature search was conducted, evaluated and reviewed by the guideline committee and a best practice protocol for first line assessment and genetic, metabolic and radiological investigations was decided upon after considering diagnostic yield, practicality, treatability and costs. CONCLUSION: It is hoped that these recommendations will become national guidelines for the first line metabolic, genetic and radiological investigation of patients presenting with unexplained GDD/ID.

DHEA-PC slows the progression of type 2 diabetes (non-insulin-dependent diabetes mellitus) in the ZDF/Gmi-fa/fa rat.

The etiology of non-insulin-dependent diabetes mellitus (NIDDM) is complex and development is manifested by initial insulin resistance coupled with elevated insulin levels in the early diabetic state with concomitant increases in circulating levels of glucose and triglycerides. This is followed by a decline in insulin levels due to pancreatic exhaustion. Our results show that administration of DHEA-PC, a phosphocholine conjugate of dehydroepiandrosterone (DHEA), delayed the development of NIDDM symptoms and the onset of type 2 diabetes in the ZDF/Gmi-fa/fa rat model. The treatment consisted of weekly implantation of subdermal osmotic infusion pumps in the rats starting at 6 weeks of age (n = 5 animals per group). For the first three weeks the pumps delivered 6 mg/day/rat followed by 12 mg/day/rat for 1 week (control group pumps delivered only carrier vehicle) after which the pumps were removed. Plasma was collected weekly from day 0 through day 58, and glucose, triglycerides, cholesterol, insulin, IGF-1, and IGF-BP3 levels were measured. Data were analyzed by two-way ANOVA. Following 3 weeks of treatment with DHEA-PC, plasma glucose levels in the treated group remained low, 150+/-9 mg/dL, while the levels in the control animals steadily increased to 320+/-100 mg/dL (p < 0.05). After the DHEA-PC treatment ended, plasma glucose plateaued for 10 days and then took 25 days to reach the level in the control animals (p < 0.05). After 2 weeks of DHEA-PC treatment, plasma triglyceride levels in the treated group remained low, 85+/-24 mg/dL, while the level in the control rats increased to 180+/-35 mg/dL (p < 0.05). After the treatment was terminated triglyceride levels in the treated group increased to control levels within 2 days. Insulin, IGF-1, IGF-BP3, cholesterol, body weight, and food consumption were not changed by DHEA-PC treatment (p < 0.05). Therefore, the delay of increases in plasma glucose and triglycerides, caused by DHEA-PC, was not the result of differences in caloric intake, increased insulin, or increased IGF-1 levels. The data suggest that DHEA-PC delayed the onset of the two most important parameters of NIDDM, namely hyperglycemia and hypertriglyceridemia. (ZDF/Gmi-fa/fa rats and their care was supplied by contract with Genetic Models Inc., Indianapolis, IN.).

Immunological properties of dehydroepiandrosterone, its conjugates, and metabolites.

The immunological response to the administration of various C-19 steroids has been of increasing interest. Although the action of dehydroepiandrosterone has been studied, the responses to its metabolites have not been explored. In the present study the ability of dehydroepiandrosterone, its conjugates, and metabolites to oppose the anti-inflammatory action of glucocorticoids on the inflammatory response to 2,4-dinitrochlorobenzene in the sensitized mouse was examined. A clear difference was seen between the antiglucocorticoid activity of dehydroepiandrosterone, its conjugates, and its 5 beta-metabolites on the one hand and the planar 5 alpha- and delta 4-metabolites, which were devoid of antiglucocorticoid activity. The mechanism of this antiglucocorticoid activity remains to be established.

Giant ganglion of the proximal tibiofibular joint: a case report.

Ganglions of the tibiofibular joint are a rare condition. The exact tissue of origin could not be accurately determined despite the use of CAT scanning. At surgery a giant ganglion of the tibiofibular joint was resected with preservation of the peroneal nerve.

Intestinal obstruction. Its serious nature and numerous pitfalls.

Clinical findings and radiographic studies are the most valuable tools in differential diagnosis of intestinal obstruction. Treatment depends on the type of obstruction. Functional ileus does not require surgery, but mechanical obstruction usually does. Ischemic obstruction demands urgent surgery to prevent or remove gangrene. Even when intestinal obstruction seems to be nonmechanical and uncomplicated, repeated follow-up observation is necessary. Functional ileus may transform to mechanical obstruction.

Benign synovioma presenting as mechanical abnormality in large lower limb joints.

Benign synovioma is a rare cause of symptomatic instability of joints of the lower limb. We report two cases presenting in this way. Arthrotomy is indicated to ensure adequate excision of these lesions if recurrence is to be avoided.

Treatment of pancreatitis. When do antibiotics have a role?

Experimental and clinical data on the use of antibiotics in treatment of pancreatitis vary widely, depending on the cause of the disease. Antibiotics have little effect on alcoholic or idiopathic pancreatitis, but they play a major role in treatment of bacterial infections in gallstone pancreatitis. Some antibiotics are effective in necrotizing pancreatitis; however, surgery and extensive debridement are often necessary when abscess is present or multiple-organ failure occurs.

Hypothyroidism and abnormalities in the kinetics of thyroid hormone metabolism in rats treated chronically with polychlorinated biphenyl and polybrominated biphenyl.

Studies were directed at the question of whether polychlorinated biphenyl (PCB; Aroclor 1254) and polybrominated biphenyl (PBB; Fire Master BP-6), when administered in the diets of female Sprague-Dawley rats over long periods of time (5-7 months) and at low dosages (0, 1, 5, 10, and 50 ppm), would depress the thyroid. By examining serum T3 and T4, kinetics of T4 metabolism, and in vivo thyroid response to exogenous TSH injections, an estimate of the degree of hypothyroidism was made, and abnormalities in T4 disappearance from serum were encountered. Serum T3 and T4 levels were greatly suppressed in a dose-related manner by PCB or PBB treatment. There was a diminished response of serum T3 and T4 to TSH injection in rats pretreated with PCB or PBB (5 and 10 ppm), the exception being T3 in the 5 ppm PCB treatment group. Had the PCB and PBB treatment-induced suppression of T4 and T3 been on the hypothalamo-pituitary axis, the response of the treated rats to exogenous TSH might have exceeded that of controls; however, the opposite occurred. Disappearance of injected doses of L-[125I]T4 diminished as treatment concentrations of PCB or PBB increased. Disappearance slopes (r = 0.98) and fractional turnover rate constants (k) were decreased (t1/2 was lengthened) at each treatment level compared to the control values. The T4 distribution space (per 100 g BW) was expanded with increasing dosage by as much as 8-fold in the 50 pmm PCB treatment group. T4 MCRs were not increased by PCB or PBB treatment; thus, decreases in serum T3 and T4 were not caused by increased catabolism. T4 production rates were decreased at all treatment levels, but maximally 6-fold by 50 ppm PCB treatment. Together these data indicate that PCB-PBB-induced decreases in serum T3 and T4 result primarily from direct damage to the thyroid rather than any enhanced hepatic or other peripheral catabolism per se. Expanded T4 distribution space demonstrated that nonthyroid damage was also an important factor in reducing serum T4. Cell membrane damage associated with PCB-PBB intoxication may have expanded pools for T4 dilution. The findings are consistent with reported histological and ultrastructural damage caused by PCB and PBB. It also appears that TSH plays little role in PCB-PBB-induced hypothyroidism.

Hand infections--the academic surgeon's perspective. 1. A historical sketch and the status of surgical drainage.

The academic surgeon must teach by example and action the importance of aseptic technique and proper wound care, practices that were supremely important in the prevention and treatment of surgical infections before the introduction of antibiotics but that remain so even in the modern medical age. The advent of antibiotics has greatly lowered the incidence of hand and other infections, opened the way for prophylactic treatment, and reduced the need for surgical drainage. However, over the years one theme has recurred: Initial care is preeminent in the prevention and treatment of all surgical infections.

Hand infections--the academic surgeon's perspective. 2. A rundown of various causes.

A large number of organisms can cause infections of the hand, and they can enter the body in a number of ways--in animal or human bites, in punctures, by direct inoculation, or through the bloodstream, intravenous needles, or prosthetic implantation procedures. In addition, all types of scratches and abrasions can become contaminated--by bacteria, viruses, fungi, and a wide variety of marine organisms. When the body's defenses are impaired by disease or other factors, the organisms are more likely to take hold. Treatment depends on the organism involved and the extent of infection, but proper wound care and aseptic technique are paramount in all cases.

Kinetic parameters of L-[125I]triiodothyronine degradation in rats pretreated with polyhalogenated biphenyls.

These studies were designed to elucidate the effects on thyroid function and thyroid-hormone activity of the long-term administration of low doses of four polyhalogenated aromatic compounds. The compounds studied were the polychlorinated biphenyls (PCBs) Aroclor 1254 and Aroclor 1242, and the polybrominated biphenyls (PBBs) hexabromobiphenyl and octabromobiphenyl. Groups of eight female Sprague-Dawley rats, specified pathogen free, were fed a diet containing 50 ppm of one of the polyhalogenated biphenyls or control diet for 7 months. Significant effects on serum triiodothyronine (T3) were observed in the group given Aroclor 1254. Analysis of kinetic data revealed a decrease in T3 degradation rate and an increase of biological half-life after long-term exposure to Aroclor 1254. The T3 distribution space was increased in both groups treated with PCB, suggesting that PCB intoxication may open additional fluid pools to T3, possibly because of cell damage. Analysis of values for the same parameters for rats treated with PBBs showed less marked effects. The results of this study indicate that PCBs exert a direct effect on the thyroid gland and that the rate of synthesis of T3 may be reduced, and suggest that the mechanism of thyroid-hormone synthesis may be impaired.