Temporal Trends of Legacy and Current-Use Halogenated Flame Retardants in Lake Ontario in Relation to Atmospheric Loadings, Sources, and Environmental Fate.

Since the phase-out of polybrominated diphenyl ethers (PBDEs), large amounts of alternative halogenated flame retardants (AHFRs) have been introduced to the market. Due to their persistence and toxicity, halogenated flame retardants (HFRs) have become a concern for the ecosystem and human health. However, there remains limited assessment of the atmospheric loadings, sources, and environmental fate of HFRs in Lake Ontario, which receives urban-related inputs and cumulative chemical inputs from the upstream Great Lakes from Canada and the United States. We combined long-term measurements with a modified multimedia model based on site-specific environmental parameters from Lake Ontario to understand the trends and fate of HFRs. All HFRs were detected in the air, precipitation, lake trout, and herring gull egg samples throughout the sampling periods. General decreasing trends were found for PBDEs, while the temporal trends for AHFRs were not clear. Physical-chemical properties and emissions significantly influence the levels, profiles, and trends. Using the probabilistic modeling, HFR concentrations in lake water and sediment were predicted to be close to the measurement, suggesting a good performance for the modified model. The loadings from tributaries and wastewater effluent were the primary input pathways. Transformations in the water and sedimentation were estimated to be the dominant output pathway for the three HFRs.

Manual therapy and exercise for adhesive capsulitis: a systematic review with meta-analysis.

BACKGROUND: Adhesive capsulitis (AC) affects approximately 1% of the general population. Current research lacks clear guidance on the dosage of manual therapy and exercise interventions. OBJECTIVE: The purpose of this systematic review was to assess the effectiveness of manual therapy and exercise in the management of AC, with a secondary aim of describing the available literature present on the dosage of interventions. METHODS: Eligible studies were randomized clinical/quasi-experimental trials with complete data analysis and no limits on date of publication, published in English, recruited participants >18 years of age with primary adhesive capsulitis, that had at least two groups with one group receiving manual therapy (MT) alone, exercise alone, or MT and exercise, that included at least one outcome measure of pain, disability, or external rotation range of motion, and that had dosage of visits clearly defined. An electronic search was conducted using PubMed, Embase, Cochrane, Pedro, and clinicaltrials.gov. Risk of bias was assessed using the Cochrane Collaboration Risk of Bias 2 Tool. The Grading of Recommendations Assessment, Development, and Evaluation was used to provide an overall assessment of the quality of evidence. Meta-analyses were conducted when possible, and dosage was discussed in narrative form. RESULTS: Sixteen studies were included. All meta-analyses revealed non-significant effects of pain, disability, and external rotation range of motion at short- and long-term follow-up, with an overall level of evidence ranging from very low to low. CONCLUSION: Non-significant findings with low-to-very-low-quality of evidence were found across meta-analyses, preventing seamless transition of research evidence to clinical practice. Lack of consistency in study designs, manual therapy techniques, dosing parameters, and duration of care impedes the ability to make strong recommendations regarding optimal dosage of physical therapy for individuals with AC.

The cost of rejection: an internal audit of the clinical genetics service active triage pathway at CHI Crumlin, Ireland.

BACKGROUND: Clinical genetics is an under-resourced service in the Republic of Ireland. There can be a number of avenues that lead to barriers in patient triage noted within the department. AIMS: To evaluate the reasons for referral rejection in the triage pathway. To identify the time and cost implications. METHODS: A retrospective analysis of rejected referrals consecutively triaged by one consultant was undertaken over an 18-month period. Calculation of costs used data from a previous study. RESULTS: The consultant rejected 128/1581 (8.3%) of referrals. The rejection reasons included the following: 75% had not included the family/patient genetic report, 10% were conditions not accepted by our service, 8% redirected to other specialities, 3% given written advice in lieu of appointment and 4% for other reasons. Follow-up information was requested on 78% of rejected referrals. For 57% this was received; in 43% no response was received, and these cases remain closed. Median response time was 33 days. Of those who sent back appropriate information, 39% remain on waiting list, 50% attended OPD or were given appropriate advice, 5% did not attend and 4% had alternative follow-up pathways. The estimated time cost of rejected referrals equated to 88.5 h (59 h/year). Using this as our cost of rejection letter, it equated €11,878.4/year departmental cost. CONCLUSION: The majority of referrals are rejected for non-enclosure of patient genetic reports. Many referrals would have accepted to the waiting list if the appropriate report had been attached. This means patients at risk of genetic disorders are not accessing clinical services because the referrer is not providing the necessary information to allow triage. Active management of the waiting list via upfront letters is costly, with a 57% response rate. Should similar rejection rates exist in other specialities, we estimate this would equate to a cost of €2,714,214.40/year to the HSE.

Assessment of the Genetic Spectrum of Uncombable Hair Syndrome in a Cohort of 107 Individuals.

Importance: Uncombable hair syndrome (UHS) is a rare hair shaft anomaly that manifests during infancy and is characterized by dry, frizzy, and wiry hair that cannot be combed flat. Only about 100 known cases have been reported so far. Objective: To elucidate the genetic spectrum of UHS. Design, Setting, and Participants: This cohort study includes 107 unrelated index patients with a suspected diagnosis of UHS and family members who were recruited worldwide from January 2013 to December 2021. Participants of all ages, races, and ethnicities were recruited at referral centers or were enrolled on their own initiative following personal contact with the authors. Genetic analyses were conducted in Germany from January 2014 to December 2021. Main Outcomes and Measures: Clinical photographs, Sanger or whole-exome sequencing and array-based genotyping of DNA extracted from blood or saliva samples, and 3-dimensional protein modeling. Descriptive statistics, such as frequency counts, were used to describe the distribution of identified pathogenic variants and genotypes. Results: The genetic characteristics of patients with UHS were established in 80 of 107 (74.8%) index patients (82 [76.6%] female) who carried biallelic pathogenic variants in PADI3, TGM3, or TCHH (ie, genes that encode functionally related hair shaft proteins). Molecular genetic findings from 11 of these 80 individuals were previously published. In 76 (71.0%) individuals, the UHS phenotype were associated with pathogenic variants in PADI3. The 2 most commonly observed PADI3 variants account for 73 (48.0%) and 57 (37.5%) of the 152 variant PADI3 alleles in total, respectively. Two individuals carried pathogenic variants in TGM3, and 2 others carried pathogenic variants in TCHH. Haplotype analyses suggested a founder effect for the 4 most commonly observed pathogenic variants in the PADI3 gene. Conclusions and Relevance: This cohort study extends and gives an overview of the genetic variant spectrum of UHS based on molecular genetic analyses of the largest worldwide collective of affected individuals, to our knowledge. Formerly, a diagnosis of UHS could only be made by physical examination of the patient and confirmed by microscopical examination of the hair shaft. The discovery of pathogenic variants in PADI3, TCHH, and TGM3 may open a new avenue for clinicians and affected individuals by introducing molecular diagnostics for UHS.

Predicting Employee Participation in, and Satisfaction With, Wellness Programs: The Role of Employee, Supervisor, and Organizational Support.

OBJECTIVE: To examine the role of employee, supervisor, and organizational support in the prediction of employee participation in wellness programs. METHODS: Data were collected at two-time points (T1 and T2) from 194 Australian employees. RESULTS: Hierarchical binary logistic regressions revealed that higher levels of employee and supervisor support for wellness at T1 each predicted T2 participation, and high supervisor support was more effective when organizational support was high and did not compensate for when organizational support was low. Employees with higher perceptions of T1 poor general health had a lower likelihood of T2 participation, and higher levels of T1 supervisor support was a further deterrent to participation. CONCLUSIONS: Different sources of support for wellness predict employee attendance at wellness programs and it is important to ensure that supervisor and organizational support are aligned.

Clinical delineation, sex differences, and genotype-phenotype correlation in pathogenic KDM6A variants causing X-linked Kabuki syndrome type 2.

PURPOSE: The variant spectrum and the phenotype of X-linked Kabuki syndrome type 2 (KS2) are poorly understood. METHODS: Genetic and clinical details of new and published individuals with pathogenic KDM6A variants were compiled and analyzed. RESULTS: Sixty-one distinct pathogenic KDM6A variants (50 truncating, 11 missense) from 80 patients (34 males, 46 females) were identified. Missense variants clustered in the TRP 2, 3, 7 and Jmj-C domains. Truncating variants were significantly more likely to be de novo. Thirteen individuals had maternally inherited variants and one had a paternally inherited variant. Neonatal feeding difficulties, hypoglycemia, postnatal growth retardation, poor weight gain, motor delay, intellectual disability (ID), microcephaly, congenital heart anomalies, palate defects, renal malformations, strabismus, hearing loss, recurrent infections, hyperinsulinism, seizures, joint hypermobility, and gastroesophageal reflux were frequent clinical findings. Facial features of over a third of patients were not typical for KS. Males were significantly more likely to be born prematurely, have shorter stature, and severe developmental delay/ID. CONCLUSION: We expand the KDM6A variant spectrum and delineate the KS2 phenotype. We demonstrate that the variability of the KS2 phenotypic depends on sex and the variant type. We also highlight the overlaps and differences between the phenotypes of KS2 and KS1.

Dying to see you? Deaths on a clinical genetics waiting list in the Republic of Ireland; what are the consequences?

Attempts to put a value on a clinical genetic consultation are challenging as outcome measures are not easily quantified. One technique is to consider the negative consequences to a referred patient who is never seen. In order to estimate possible negative effects and by default the value of a genetics consultation; we sought to identify the consequences both to the proband, who died awaiting appointment, and their relatives. We audited 45 referrals to our service who died on our waiting list since 2008. Of these, 39/45 were new referrals, and the remainder, 6/45, died awaiting a follow up appointment. Relatives from 14/45 (31%) families have been counselled since the proband's death. We estimated a minimal total of 207 living first degree relatives to 45 probands. The majority (30/45) were referred for cancer risk estimation (1 predictive, 29 diagnostic), 11 developmental delay/dysmorphology referrals, 3 cardiac genetic referrals, (2 predictive testing, 1 segregation analysis) and 1 a referral for early onset dementia. The deaths of 17/45 cases were judged by us as having potentially significantly impacted the health of 76 first-degree relatives; 13/45 have potentially moderately impacted the health of 57 first-degree relatives; 12/45 posed a minimal impact to their relatives; and in 3/45 cases families were fully counselled. For each proband, significantly or moderately negatively impacted (n = 30), they have a minimum of 4.4 first-degree relatives, range 1-11, total = 133.

Perfluoroalkyl Acids in Great Lakes Precipitation and Surface Water (2006-2018) Indicate Response to Phase-outs, Regulatory Action, and Variability in Fate and Transport Processes.

The concentrations of perfluoroalkyl acids (PFAAs) were determined in precipitation from three locations across the Great Lakes between 2006 and 2018 and compared to those in surface water. Perfluorooctane sulfonate (PFOS) and perfluorooctanoate (PFOA) concentrations generally decreased in precipitation, likely in response to phase-outs/regulatory actions. In comparison, concentrations of shorter-chained PFAA, which are not regulated in Canada did not decrease and those of perfluorohexanoate and perfluorobutanoate (PFBA) recently increased, which could be due to their use as replacements, as the longer-chained PFAAs are being phased-out by industry. PFOS and PFOA concentrations were greater in Lake Ontario precipitation than in precipitation from more remote locations. In comparison, PFBA concentrations were comparable across locations, suggesting greater atmospheric transport either through its more volatile precursors and/or directly in association with particles/aerosols. In Lake Ontario, the comparison of PFAAs in precipitation to those in surface water provides evidence of sources (e.g., street dust and wastewater effluent) in addition to wet deposition to surface water, whereas wet deposition appears to be dominant in Lakes Huron and Superior. Our results suggest that source control of shorter-chained PFAAs may be slow to be reflected in environmental concentrations due to emissions far from the location of detection and continued volatilization from existing in-use products and waste streams.

Diagnosis of lethal or prenatal-onset autosomal recessive disorders by parental exome sequencing.

OBJECTIVE: Rare genetic disorders resulting in prenatal or neonatal death are genetically heterogeneous, but testing is often limited by the availability of fetal DNA, leaving couples without a potential prenatal test for future pregnancies. We describe our novel strategy of exome sequencing parental DNA samples to diagnose recessive monogenic disorders in an audit of the first 50 couples referred. METHOD: Exome sequencing was carried out in a consecutive series of 50 couples who had 1 or more pregnancies affected with a lethal or prenatal-onset disorder. In all cases, there was insufficient DNA for exome sequencing of the affected fetus. Heterozygous rare variants (MAF < 0.001) in the same gene in both parents were selected for analysis. Likely, disease-causing variants were tested in fetal DNA to confirm co-segregation. RESULTS: Parental exome analysis identified heterozygous pathogenic (or likely pathogenic) variants in 24 different genes in 26/50 couples (52%). Where 2 or more fetuses were affected, a genetic diagnosis was obtained in 18/29 cases (62%). In most cases, the clinical features were typical of the disorder, but in others, they result from a hypomorphic variant or represent the most severe form of a variable phenotypic spectrum. CONCLUSION: We conclude that exome sequencing of parental samples is a powerful strategy with high clinical utility for the genetic diagnosis of lethal or prenatal-onset recessive disorders. © 2017 The Authors Prenatal Diagnosis published by John Wiley & Sons Ltd.

Recurrent large genomic rearrangements in BRCA1 and BRCA2 in an Irish case series.

Mutations in BRCA1 and BRCA2 confer a highly increased risk of cancers, mainly of the breast and ovary. Most variants are point mutations or small insertions/deletions detectable by Sanger sequencing. Large genomic rearrangements, including deletions/duplications of multiple exons, are not routinely detectable by Sanger sequencing, but can be reliably identified by Multiplex Ligation-dependent Probe Amplification (MLPA), and account for 5-17% mutations in different populations. Comprehensive mutation testing using these two methods has been facilitated via our centre since 2005. The aim of this study was to investigate the incidence of and phenotype associated with large genomic rearrangements in BRCA1 and BRCA2 in an Irish cohort. An observational cohort study was undertaken. Patients with large genomic rearrangements in BRCA1/BRCA2 were identified from a prospectively maintained database of MLPA test results. Phenotypic and genotypic data were retrieved by chart review. Large genomic rearrangements in BRCA1 were identified in 49 families; and in BRCA2 in 7 families, representing ~11% of mutations in BRCA1/BRCA2 in Ireland. The most common large genomic rearrangement in BRCA1 was deletion of exons 1-23 (11 families, 7 from Co. Galway). Other common mutations included deletions of exon 3 (8 families) and exons 1-2 (6 families). Deletion of exons 19-20 in BRCA2 represented the familial mutation in five families, all from East Ireland (Wexford/Wicklow/Dublin). It is evident that a significant proportion of highly penetrant pathogenic variants in BRCA1 and BRCA2 will be missed if testing is limited to PCR-based Sanger sequencing alone. Screening for large genomic rearrangements in BRCA1 and BRCA2 in the routine diagnostic workflow is critical to avoid false negative results.

Increased Population Risk of AIP-Related Acromegaly and Gigantism in Ireland.

The aryl hydrocarbon receptor interacting protein (AIP) founder mutation R304* (or p.R304* ; NM_003977.3:c.910C>T, p.Arg304Ter) identified in Northern Ireland (NI) predisposes to acromegaly/gigantism; its population health impact remains unexplored. We measured R304* carrier frequency in 936 Mid Ulster, 1,000 Greater Belfast (both in NI) and 2,094 Republic of Ireland (ROI) volunteers and in 116 NI or ROI acromegaly/gigantism patients. Carrier frequencies were 0.0064 in Mid Ulster (95%CI = 0.0027-0.013; P = 0.0005 vs. ROI), 0.001 in Greater Belfast (0.00011-0.0047) and zero in ROI (0-0.0014). R304* prevalence was elevated in acromegaly/gigantism patients in NI (11/87, 12.6%, P < 0.05), but not in ROI (2/29, 6.8%) versus non-Irish patients (0-2.41%). Haploblock conservation supported a common ancestor for all the 18 identified Irish pedigrees (81 carriers, 30 affected). Time to most recent common ancestor (tMRCA) was 2550 (1,275-5,000) years. tMRCA-based simulations predicted 432 (90-5,175) current carriers, including 86 affected (18-1,035) for 20% penetrance. In conclusion, R304* is frequent in Mid Ulster, resulting in numerous acromegaly/gigantism cases. tMRCA is consistent with historical/folklore accounts of Irish giants. Forward simulations predict many undetected carriers; geographically targeted population screening improves asymptomatic carrier identification, complementing clinical testing of patients/relatives. We generated disease awareness locally, necessary for early diagnosis and improved outcomes of AIP-related disease.

Connecting physical and social dimensions of place attachment: What can we learn from attachment to urban recreational spaces?

This paper is concerned with the ways in which people form attachments to recreational spaces. More specifically it examines the relationship between recreational spaces associated with sporting activity in urban neighbourhoods and place attachment. The focus is on the ways in which changes to these spaces exposes the affective bonds between people and their surroundings. The paper applies a qualitative methodology, namely focus groups and photo elicitation, to the case study of Parkhead, a neighbourhood in the East End of Glasgow. Parkhead has historically been subjected to successive waves of redevelopment as a result of deindustrialization in the late twentieth century. More recently redevelopment associated with the 2014 Commonwealth Games involved further changes to neighbourhood recreational spaces, including refurbishing of existing sports facilities and building new ones. This paper reflects on the cumulative impacts of this redevelopment to conclude (a) that recreational sports spaces provoke multi-layered and complex attachments that are inextricably connected to both temporal and spatial narratives and (b) that research on neighbourhood recreational spaces can develop our understanding of the intricate relationship between the social and physical dimensions of place attachment.

Clinical experience in the screening and management of a large kindred with familial isolated pituitary adenoma due to an aryl hydrocarbon receptor interacting protein (AIP) mutation.

CONTEXT: Germline AIP mutations usually cause young-onset acromegaly with low penetrance in a subset of familial isolated pituitary adenoma families. We describe our experience with a large family with R304* AIP mutation and discuss some of the diagnostic dilemmas and management issues. OBJECTIVE: The aim of the study was to identify and screen mutation carriers in the family. PATIENTS: Forty-three family members participated in the study. SETTING: The study was performed in university hospitals. OUTCOME: We conducted genetic and endocrine screening of family members. RESULTS: We identified 18 carriers of the R304* mutation, three family members with an AIP-variant A299V, and two family members who harbored both changes. One of the two index cases presented with gigantism and pituitary apoplexy, the other presented with young-onset acromegaly, and both had surgery and radiotherapy. After genetic and clinical screening of the family, two R304* carriers were diagnosed with acromegaly. They underwent transsphenoidal surgery after a short period of somatostatin analog treatment. One of these two patients is in remission; the other achieved successful pregnancy despite suboptimal control of acromegaly. One of the A299V carrier family members was previously diagnosed with a microprolactinoma; we consider this case to be a phenocopy. Height of the unaffected R304* carrier family members is not different compared to noncarrier relatives. CONCLUSIONS: Families with AIP mutations present particular problems such as the occurrence of large invasive tumors, poor response to medical treatment, difficulties with fertility and management of pregnancy, and the finding of AIP sequence variants of unknown significance. Because disease mostly develops at a younger age and penetrance is low, the timing and duration of the follow-up of carriers without overt disease requires further study. The psychological and financial impact of prolonged clinical screening must be considered. Excellent relationships between the family, endocrinologists, and geneticists are essential, and ideally these families should be managed in centers with specialist expertise.

From the city to the Lake: loadings of PCBs, PBDEs, PAHs and PCMs from Toronto to Lake Ontario.

Loadings from Toronto, Canada to Lake Ontario were quantified and major sources and pathways were identified, with the goal of informing opportunities for loading reductions. The contaminants were polychlorinated biphenyls (PCBs), polybrominated diphenyl ethers (PBDEs), polycyclic aromatic hydrocarbons (PAHs) and polycyclic musks (PCMs). Loadings were calculated from measured concentrations for three major pathways: atmospheric processes, tributary runoff, and wastewater treatment plant (WWTP) effluents. Although atmospheric deposition to the Great Lakes has received the greatest attention, this was the dominant loading pathway for PCBs only (17 ± 5.3 kg/y or 66% of total loadings). PCB loadings reflected elevated urban PCB air concentrations due to, predominantly, primary emissions. These loadings contribute to consumption advisories for nearshore fish. PBDE loadings to the lake, again from mainly primary emissions, were 48% (9.1 ± 1.3 kg/y) and 42% (8.0 ± 5.7 kg/y) via tributaries and WWTPs, respectively, consistent with emissions deposited and subsequently washed-off of urban surfaces and emissions to the sewage system. PAHs loadings of 1600 ± 280 kg/y (71%) from tributaries were strongly associated with vehicle transportation and impervious surfaces. PCM loadings were 83% (±140 kg/y) from WWTP final effluent, reflecting their use in personal care products. Opportunities for source reduction lie in reducing the current inventories of in-use PCBs and PBDE-containing products, reducing vehicle emissions of PAHs and use of PAHs in the transportation network (e.g., pavement sealants), and improving wastewater treatment technology.

Wet deposition of brominated flame retardants to the Great Lakes basin--status and trends.

This study examined the temporal and spatial trends in wet deposition of 19 legacy and emerging brominated flame retardants (14 polybrominated diphenyl ethers (PBDEs), 1,2-bis(2,4,6-tribromophenoxy)ethane (BTBPE), decabromodiphenylethane (DBDPE), hexabromocyclododecane (HBCD) and pentabromoethylbenzene (PBEB)) at 9 sites in the Canadian Great Lakes between 2004 and 2010. Concentrations of BDE-209 in wet deposition declined significantly. This indicates that the voluntary actions taken to phase out the use of BDE 209 in North America are having an immediate effect on its environment concentrations. The analysis also revealed the presence of 22 short-term high concentration events that dominated overall wet deposition loadings of current-use BFRs to the lakes. For instance, one sample in 2007 was responsible for 37% of the total loadings of HBCD to Lake Huron over the entire six-year sampling period. This questions the current paradigm of how we believe such pollutants enter the environment.

Neonatal lethal Costello syndrome and unusual dinucleotide deletion/insertion mutations in HRAS predicting p.Gly12Val.

De novo heterozygous mutations in HRAS cause Costello syndrome (CS), a condition with high mortality and morbidity in infancy and early childhood due to cardiac, respiratory, and muscular complications. HRAS mutations predicting p.Gly12Val, p.Gly12Asp, and p.Gly12Cys substitutions have been associated with severe, lethal, CS. We report on molecular, clinical, and pathological findings in patients with mutations predicting HRAS p.Gly12Val that were identified in our clinical molecular genetic testing service. Such mutations were identified in four patients. Remarkably, three were deletion/insertion mutations affecting coding nucleotides 35 and 36. All patients died within 6 postnatal weeks, providing further evidence that p.Gly12Val mutations predict a very poor prognosis. High birth weight, polyhydramnios (and premature birth), cardiac hypertrophy, respiratory distress, muscle weakness, and postnatal growth failure were present. Dysmorphism was subtle or non-specific, with edema, coarsened facial features, prominent forehead, depressed nasal bridge, anteverted nares, and low-set ears. Proximal upper limb shortening, a small bell-shaped chest, talipes, and fixed flexion deformities of the wrists were seen. Neonatal atrial arrhythmia, highly suggestive of CS, was also present in two patients. One patient had congenital alveolar dysplasia, and another, born after 36 weeks' gestation, bronchopulmonary dysplasia. A rapidly fatal disease course, and the difficulty of identifying subtle dysmorphism in neonates requiring intensive care, suggest that this condition remains under-recognized, and should enter the differential diagnosis for very sick infants with a range of clinical problems including cardiac hypertrophy and disordered pulmonary development. Clinical management should be informed by knowledge of the poor prognosis of this condition.

Familial pediatric endocrine tumors.

Pediatric endocrine tumors are rare but have fairly characteristic presentations. We describe an approach to diagnosis and management of five of the most common presentations including gonadoblastoma, paraganglioma, medullary thyroid cancer, adrenal cancer, and pituitary adenoma. Genetic testing can aid in the early detection and prevention and management of tumors in patients and in other family members.

Leukoencephalopathy with anterior temporal cysts due to congenital CMV infection diagnosed retrospectively.

Leukoencephalopathy with subcortical cysts has been described in a variety of conditions. However, few reports have highlighted congenital CMV as a cause of this imaging finding. We report a 1-year-old girl with developmental delay and sensorineural hearing loss whose MRI brain showed abnormal white matter and temporal cysts. Congenital CMV infection was diagnosed retrospectively by examination of dried blood spot from the newborn screening card.