Predictive genetic testing for Huntington's disease: Exploring participant experiences of uncertainty and ambivalence between clinic appointments.

Ambivalence and uncertainty are key themes throughout the psychology of healthcare literature. This is especially so for individuals at risk of Huntington's disease (HD) deliberating the decision to undergo genetic testing because there is currently no treatment that modifies disease progression. A better understanding of the experience of making a decision about genetic prediction will help practitioners support and guide individuals through this process. Our aim was to capture participants' experiences of uncertainty and ambivalence in between their genetic counseling appointments. We explored these issues through the experiences of nine participants who were referred for predictive HD testing at four regional genetics services in England and Wales. Data consisted of recordings of clinic consultations, diaries, and an in-depth interview conducted at the end of the testing process. Data were analyzed thematically. Four themes were identified representing four possible futures, each future dependent on the decision to undergo testing and the result of that test. Our results showed that participants, as well as attending more to a future that represents their current situation of not having undergone predictive testing, also attended more to a distant future where a positive predictive result is received and symptoms have started. Participants attended less to the two futures that were more immediate once testing was undertaken (a future where a positive result is received and symptoms have not started and a future where a negative result is received). The use of diaries gave us a unique insight into these participants' experiences of ambivalence and uncertainty, psychological distress, and the emotional burden experienced. These findings help inform discussions within the clinic appointment as well as encourage researchers to consider diary use as a method of exploring what happens for individuals outside of clinical encounters.

Ethical preparedness in health research and care: the role of behavioural approaches.

BACKGROUND: Public health scholars have long called for preparedness to help better negotiate ethical issues that emerge during public health emergencies. In this paper we argue that the concept of ethical preparedness has much to offer other areas of health beyond pandemic emergencies, particularly in areas where rapid technological developments have the potential to transform aspects of health research and care, as well as the relationship between them. We do this by viewing the ethical decision-making process as a behaviour, and conceptualising ethical preparedness as providing a health research/care setting that can facilitate the promotion of this behaviour. We draw on an implementation science and behaviour change model, COM-B, to demonstrate that to be ethically prepared requires having the capability (ability), opportunity, and motivation (willingness) to work in an ethically prepared way. METHODS: We use two case examples from our empirical research-one pandemic and one non-pandemic related-to illustrate how our conceptualisation of ethical preparedness can be applied in practice. The first case study was of the UK NHSX COVID-19 contact tracing application case study involved eight in-depth interviews with people involved with the development/governance of this application. The second case involved a complex case regarding familial communication discussed at the UK Genethics Forum. We used deductive qualitative analysis based on the COM-B model categories to analyse the transcripbed data from each case study. RESULTS: Our analysis highlighted that being ethically prepared needs to go beyond merely equipping health professionals with skills and knowledge, or providing research governance actors with ethical principles and/or frameworks. To allow or support these different actors to utilise their skills and knowledge (or principles and frameworks), a focus on the physical and social opportunity is important, as is a better understanding the role of motivation. CONCLUSIONS: To understand ethical preparedness, we need to view the process of ethical decision-making as a behaviour. We have provided insight into the specific factors that are needed to promote this behaviour-using examples from both in the pandemic context as well as in areas of health research and medicine where there have been rapid technological developments. This offers a useful starting point for further conceptual work around the notion of being ethically prepared.

Analysis of expressed sequence tags from Uromyces appendiculatus hyphae and haustoria and their comparison to sequences from other rust fungi.

Hyphae, 2 to 8 days postinoculation (dpi), and haustoria, 5 dpi, were isolated from Uromyces appendiculatus infected bean leaves (Phaseolus vulgaris cv. Pinto 111) and a separate cDNA library prepared for each fungal preparation. Approximately 10,000 hyphae and 2,700 haustoria clones were sequenced from both the 5' and 3' ends. Assembly of all of the fungal sequences yielded 3,359 contigs and 927 singletons. The U. appendiculatus sequences were compared with sequence data for other rust fungi, Phakopsora pachyrhizi, Uromyces fabae, and Puccinia graminis. The U. appendiculatus haustoria library included a large number of genes with unknown cellular function; however, summation of sequences of known cellular function suggested that haustoria at 5 dpi had fewer transcripts linked to protein synthesis in favor of energy metabolism and nutrient uptake. In addition, open reading frames in the U. appendiculatus data set with an N-terminal signal peptide were identified and compared with other proteins putatively secreted from rust fungi. In this regard, a small family of putatively secreted RTP1-like proteins was identified in U. appendiculatus and P. graminis.

Anterior colporrhaphy: a randomized trial of three surgical techniques.

OBJECTIVE: The purpose of this study was to compare outcomes after anterior colporrhaphy with the use of 3 different surgical techniques. STUDY DESIGN: One hundred fourteen women with anterior vaginal prolapse were randomly assigned to undergo anterior repair by one of 3 techniques: standard, standard plus polyglactin 910 mesh, or ultralateral anterior colporrhaphy. Before and after operation, patients underwent physical examination staging of prolapse; the International Continence Society system was used. Symptoms were assessed by questionnaire and visual analog scales. We defined "cure" as satisfactory (stage I) or optimal (stage 0) outcome at points Aa and Ba. RESULTS: Of 114 patients who were originally enrolled, 109 patients underwent operation, and 83 patients (76%) returned for follow-up. Mean age (+/- SD) was 64.7 +/- 11.1 years. At entry, 7 patients (7%) had stage I anterior vaginal prolapse; 35 patients (37%) had stage II anterior vaginal prolapse; 51 patients (54%) had stage III anterior vaginal prolapse; and 2 patients (2%) had stage IV anterior vaginal prolapse. At a median length of follow-up of 23.3 months, 10 of 33 patients (30%) who were randomly assigned to the standard anterior colporrhaphy group experienced satisfactory or optimal anatomic results, compared with 11 of 26 patients (42%) with standard plus mesh and with 11 of 24 patients (46%) with ultralateral anterior colporrhaphy. The severity of symptoms that were related to prolapse improved markedly (preoperative score, 6.9 +/- 2.7; postoperative score, 1.1 +/- 0.8). Twenty-three of 24 patients (96%) no longer required manual pressure to void after operation. CONCLUSION: These 3 techniques of anterior colporrhaphy provided similar anatomic cure rates and symptom resolution for anterior vaginal prolapse repair. The addition of polyglactin 910 mesh did not improve the cure rate compared with standard anterior colporrhaphy.

Characterization of human cytomegalovirus strains by analysis of short tandem repeat polymorphisms.

Human cytomegalovirus (HCMV) strains display genetic polymorphisms, and these polymorphisms can be analyzed to study viral transmission and pathogenesis. Recently, short tandem repeat (STR) length polymorphisms have been identified in the HCMV genome. We assessed the utility of STRs in characterizing HCMV strains and found that a multiplexed PCR assay using primers based upon these STRs accurately maps HCMV strains. Using primers for 10 microsatellite regions, the STR profiles of 44 wild-type and 2 laboratory strains of HCMV were characterized. The results of STR analysis were compared with those for strain characterization using nucleotide sequencing and restriction fragment length polymorphism analysis. In each instance, STR analysis accurately and specifically identified strains that were indistinguishable or distinct by conventional molecular analysis. Analysis of short tandem repeats also detected polymorphisms that supported simultaneous excretion of two HCMV strains. These results indicate that STR analysis allows rapid, precise molecular characterization of HCMV strains.

A molecular variant of the APC gene at codon 1822: its association with diet, lifestyle, and risk of colon cancer.

The adenomatous polyposis coli (APC) gene is important in the etiology of colon cancer. Although germ-line mutations of this gene rarely occur in the population, less penetrant variants of the gene have been reported. One variant, producing an aspartate to valine change at codon 1822 (D1822V) [corrected] has been previously reported as having an allele frequency of 10%. The purpose of this study was to determine whether this D1822V [corrected] variant of the APC gene is associated with colon cancer and whether its association is influenced by other genetic or environmental factors. We used data collected as part of a multicenter study of 1,585 incident cases of colon cancer and 1,945 age- and sex-matched population-based controls to evaluate genetic, dietary, and environmental associations with the D1822V [corrected] variant of the APC gene. The frequency of the valine/valine allele at codon 1,822 was 22.8% in this population. In the control population, 61.5% were homozygote wild type, 33.3% were heterozygotes, and 5.2% were homozygote variant. Cases were slightly less likely to have the homozygous variant APC genotype than were controls [odds ratio (OR), 0.8; 95% confidence interval (CI), 0.6-1.1]; for those diagnosed after age 65, the homozygous APC variant was associated with reduced risk of colon cancer (OR, 0.6; 95% CI, 0.4-1.0). Assessment of the homozygous APC variant with dietary, genetic, and environmental factors showed that individuals with this genotype were at lower risk if they consumed a low-fat diet (OR, 0.2; 95% CI, 0.1-0.5) relative to those who were homozygous wild type and ate a high-fat diet. This finding was specific to a low-fat diet and was unrelated to other dietary variables. These results suggest that the codon 1,822 variant of the APC gene may have functional significance. Individuals who have the valine/valine variant of this gene may be at reduced risk of colon cancer if they eat a low-fat diet.

Multiplex, fluorescent single-strand conformation polymorphism using stepped polymerase chain reaction primers.

A method for high-throughput screening for a well-characterized mutation at the APC locus was developed using stepped PCR primers, pooled product, and fluorescent single-strand conformation polymorphism (SSCP). Using a panel of two known normals, three known heterozygous mutants, and one known homozygous mutant, eight stepped PCR products were developed that showed the same mobility shift on a PE Biosystems 373A. Using this method, up to eight different samples can be pooled for same lane analysis.

Associations between cigarette smoking, lifestyle factors, and microsatellite instability in colon tumors.

BACKGROUND: Microsatellite instability (MSI) has been reported to occur in approximately 10%-15% of colon tumors. MSI is characterized by the presence of mutations in tandemly repeated DNA sequences known as microsatellites. Some individuals with unstable tumors have inherited mutations in mismatch repair genes, but MSI is also observed in sporadic colon cancer. It is unknown whether lifestyle factors associated with colon cancer, such as physical activity, body size, cigarette smoking, or use of aspirin and/or nonsteroidal anti-inflammatory drugs, contribute to MSI in sporadic tumors. METHODS: Data from a population-based, case-control study of colon cancer were used. Case subjects were between 30 and 79 years of age at the time of diagnosis and included both men and women. Questionnaire data were used to obtain information on lifestyle factors. Tumor MSI was determined with the use of a panel of 10 tetranucleotide repeats and two mononucleotide repeats. A total of 1510 case subjects had valid questionnaire data and tumor DNA from which we were able to obtain MSI status. Questionnaire data were compared with lifestyle factors reported by 2410 population-based control subjects. All statistical tests were two-sided. RESULTS: MSI-positive (MSI(+)) tumors were most common in older people and women and in the proximal colon. Patients with MSI(+) tumors were more likely to smoke 20 or more cigarettes a day than case subjects with MSI-negative (MSI(-)) tumors (odds ratio for being a smoker = 1.6 [95% confidence interval = 1.0-2.5] for men and 2.2 [95% confidence interval = 1.4-3.5] for women). The association between MSI(+) tumors and cigarette smoking was strongest among case subjects who started to smoke at a young age, smoked for 35 or more years, and were either current smokers or had stopped fewer than 15 years before diagnosis. A statistically significant linear trend of increased risk of MSI(+) tumors was observed with increasing amount smoked (P<.01). CONCLUSIONS: This study suggests that smoking cigarettes statistically significantly contributes to MSI in colon tumors. We estimate that approximately 21% of MSI in colon tumors may be attributable to cigarette smoking.

Inpatients with menometrorrhagia: etiologies, treatments, and outcomes.

BACKGROUND: Abnormal uterine bleeding is commonly seen in emergency departments and gynecologic clinics. In a southern, inner-city hospital, a seemingly large number of women are admitted with life-threatening anemia of benign gynecologic origin. We examine its causes, review treatments and outcomes, and discuss optimization of therapy. METHODS: A chart review of patients requiring emergency admission for anemia of gynecologic origin yielded 48 patients from July 1, 1994, through April 30, 1998. Patients with known or obvious gynecologic malignancies were excluded. RESULTS: Of 48 patients, 69% were black. Mean age was 41 years. Sixty-three percent had had no previous treatment. Almost one fourth had a history of mental illness and/or substance abuse. Two thirds had uterine leiomyomata. Most (81%) required transfusion; 25% had surgery during initial hospitalization. Of those who did not receive definitive therapy (hysterectomy), 13% were subsequently readmitted for active bleeding and/or symptomatic anemia. CONCLUSIONS: Our study patients were admitted with potentially life-threatening anemia. All were adequately resuscitated using a variety of measures, including high-dose estrogen therapy and transfusion. Optimal therapy for those requiring emergency treatment should include hormonal therapy and transfusion if necessary, early surgical intervention unless otherwise contraindicated, and close follow-up until definitive therapy is achieved.

Effects of high pressure and temperature on the wild-type and F29W mutant forms of the N-domain of avian troponin C.

The N-domain of troponin C (residues 1-90) regulates muscle contraction through conformational changes induced by Ca2+ binding. A mutant form of the isolated domain of avian troponin C (F29W) has been used in previous studies to observe conformational changes that occur upon Ca2+ binding, and pressure and temperature changes. Here we set out to determine whether the point mutation itself has any effects on the protein structure and its stability to pressure and temperature in the absence of Ca2+. Molecular dynamics simulations of the wild-type and mutant protein structures suggested that both structures are identical except in the main chain and the loop I region near the mutation site. Also, the simulations proposed that an additional cavity had been created in the core of the mutant protein. To determine whether such a cavity would affect the behavior of the protein when subjected to high pressures and temperatures, we performed 1H-NMR experiments at 300, 400, and 500 MHz on the wild-type and F29W mutant forms of the chicken N-domain troponin C in the absence of Ca2+. We found that the mutant protein at 5 kbar pressures had a destabilized beta-sheet between the Ca2+-binding loops, an altered environment near Phe-26, and reduced local motions of Phe-26 and Phe-75 in the core of the protein, probably due to a higher compressibility of the mutant. Under the same pressure conditions, the wild-type domain exhibited little change. Furthermore, the hydrophobic core of the mutant protein denatured at temperatures above 47 degrees C, while the wild-type was resistant to denaturation up to 56 degrees C. This suggests that the partially exposed surface mutation (F29W) significantly destabilizes the N-domain of troponin C by altering the packing and dynamics of the hydrophobic core.

Considerations in adding mutation detection services to a sequencing core facility.

Because analysis of single nucleotide polymorphisms (SNPs) can be invaluable in understanding genomic variation and the genetic basis of disease, there is a need for high-throughput, high-accuracy mutation detection methods for identifying SNPs. A sequencing core facility can enhance the services it offers by providing genome analysis methods to search for informative SNPs. Denaturing high-performance liquid chromatography and single-strand conformation polymorphism analysis are methods of mutation detection that are amenable to a sequencing core environment. They are useful for screening large sample sets to identify novel SNPs, eliminating the need to sequence every sample in the set. These methods allow analysis of more samples than would otherwise be economically feasible by sequencing alone.

Posterior vaginal prolapse and bowel function.

OBJECTIVE: This study's objectives were to describe symptoms related to bowel dysfunction in women with uterovaginal prolapse and to compare these symptoms according to extent of posterior vaginal prolapse. STUDY DESIGN: One hundred forty-three women completed a questionnaire assessment of bowel function and underwent standardized physical examination according to the International Continence Society's system for grading uterovaginal prolapse. RESULTS: The mean age was 59.2 years (SD 11.8 years); 78% of the women were postmenopausal. According to the furthest extent of posterior vaginal prolapse at point Bp, 22 (15.5%) were in stage 0, 46 (32.4%) were in stage I, 50 (35.2%) were in stage II, 23 (16.2%) were in stage III, and 1 (0.7%) was in stage IV. Ninety-two percent of women reported having bowel movements at least every other day. When asked whether straining was required for them to have a bowel movement, 38 (26.6%) reported never or rarely, 71 (49.6%) reported sometimes, 20 (14.0%) reported usually, and 14 (9.8%) reported always. When asked whether they ever needed to help stool come out by pushing with a finger in the vagina or rectum, 98 (69.0%) reported never or rarely, 30 (21.1%) reported sometimes, 8 (5.6%) reported usually, and 6 (4.2%) reported always. Twenty-three women (16.1%) had fecal incontinence, with 11 having loss of control of stool less often than once a month and 12 having it more often than once a month. When asked whether to rate how much they were bothered by their bowel function on a scale of 1 to 10, with 1 being not at all and 10 being extremely, 51.7% of women chose 1 to 4, 20.3% chose 5 to 7, and 28% chose >/=8. There were no clinically significant associations between any of the questions related to bowel function and severity of posterior vaginal prolapse. CONCLUSION: Women with uterovaginal prolapse frequently have symptoms related to bowel dysfunction, but this is not associated with the severity of posterior vaginal prolapse.

A high-pressure, high-resolution NMR probe for experiments at 500 MHz.

A novel high-pressure, high-resolution NMR probe is described which operates at a frequency of 500 MHz. The design features an alternative RF coil (8 mm sample tube) for high frequency, sensitivity, probe power, and resolution (< 3.0 x 10(-9)). The probe is capable of pressures to at least 5 kbar over a temperature range of -30 to 80 degreesC, and has a double-tuned 1H/2H circuit which can tune at 1H frequencies of either 300 or 500 MHz. The sensitivity of the 300-MHz circuit is over twice that of previous 10-mm high-pressure NMR probe designs, while at 500 MHz the sensitivity is nearly five times that of previous 300-MHz pressure probes. Potential biochemical applications are demonstrated by 2D NOESY spectra of a Troponin C mutant.

High-resolution, high-pressure NMR studies of proteins.

Advanced high-resolution NMR spectroscopy, including two-dimensional NMR techniques, combined with high pressure capability, represents a powerful new tool in the study of proteins. This contribution is organized in the following way. First, the specialized instrumentation needed for high-pressure NMR experiments is discussed, with specific emphasis on the design features and performance characteristics of a high-sensitivity, high-resolution, variable-temperature NMR probe operating at 500 MHz and at pressures of up to 500 MPa. An overview of several recent studies using 1D and 2D high-resolution, high-pressure NMR spectroscopy to investigate the pressure-induced reversible unfolding and pressure-assisted cold denaturation of lysozyme, ribonuclease A, and ubiquitin is presented. Specifically, the relationship between the residual secondary structure of pressure-assisted, cold-denatured states and the structure of early folding intermediates is discussed.

The chromosome location of the human homolog of the mouse mammary tumor-associated gene INT6 and its status in human breast carcinomas.

The INT6 gene is a common integration site for the mouse mammary tumor virus in mouse mammary tumors. We have determined that the human homolog of INT6 is located on chromosome region 8q22-q23. A processed INT6 pseudogene is located on chromosome 6q. INT6 is composed of 13 exons that span 45 kb of genomic DNA. The deduced amino acid sequence of the gene product is identical to the mouse protein and contains three potential translation start signals. We have examined 100 primary breast carcinoma DNAs for evidence of genetic alteration affecting INT6. Loss of heterozyosity (LOH) was detected in 11 of 39 (28%) of the tumor samples informative for a polymorphic sequence in intron 7 of INT6. Since single-strand conformation and hybrid mismatch analysis of the remaining allele in these tumor DNAs failed to detect any mutations, we conclude that the target gene for LOH must be closely linked to INT6.

Prevalence of hydronephrosis in patients undergoing surgery for pelvic organ prolapse.

OBJECTIVE: To determine the prevalence of hydronephrosis in patients undergoing surgery for pelvic organ prolapse and to determine whether hydronephrosis is associated with the type and severity of prolapse. METHODS: The charts of 375 consecutive patients undergoing surgery for pelvic organ prolapse at the Cleveland Clinic Foundation between January 1, 1990, and December 31, 1993 were reviewed. Preoperative renal ultrasounds and intravenous pyelograms (IVP) were evaluated for hydronephrosis based on the final diagnosis established by the radiologists. The severity of prolapse was determined from the preoperative office examination or from the examination under anesthesia at the time of surgery. RESULTS: Of 375 patients, 323 had either a preoperative renal ultrasound or IVP. The mean age was 66.0 +/- 10.2 years (range 35-93) and median parity was 3.0 (range 0-10). Of the 323 patients, 25 (7.7%, 95% confidence interval 5, 11) had hydronephrosis. Thirteen patients (4.0%) had mild hydronephrosis, nine (2.8%) had moderate hydronephrosis, and three (0.9%) had severe hydronephrosis. The prevalence of hydronephrosis increased with increasing severity of prolapse. Two patients with hydronephrosis had evidence of renal insufficiency (creatinine > or = 1.6), and both had severe bilateral hydronephrosis and complete procidentia. The prevalence of hydronephrosis was lower in patients with vaginal vault prolapse versus uterine prolapse (3.9% compared with 12.6%, P < .01), CONCLUSION: The prevalence of hydronephrosis in patients undergoing surgery primarily for pelvic organ prolapse is low, increases with worsening pelvic organ prolapse, and is lower in patients with vaginal vault prolapse that in those with uterine prolapse.

Pelvic support defects and visceral and sexual function in women treated with sacrospinous ligament suspension and pelvic reconstruction.

OBJECTIVE: Our purpose was to evaluate the efficacy and consequences of sacrospinous ligament suspension and pelvic reconstruction. STUDY DESIGN: Patients who underwent sacrospinous ligament suspension between 1978 and 1991 were evaluated from follow-up visits, telephone interviews, questionnaires, and chart reviews. Before and after operation, vaginal support was graded in three segments. Postoperative visceral and sexual function was evaluated. RESULTS: Mean length of follow-up for 243 patients was 73.6 months. Of these, 102 (42.0%) had a support defect in at least one segment; anterior, posterior, and apical defects were found in 91 (37.4%), 33 (13.6%), and 20 (8.2%) patients, respectively. A clinically significant defect was defined as a symptomatic first-degree or any second-or third-degree prolapse. Defect-free survival rates at 1, 5, and 10 years were 88.3%, 79.7%, and 51.9%, respectively. Eleven patients (4.5%) underwent subsequent pelvic reconstruction. CONCLUSION: Sacrospinous ligament suspension and pelvic reconstruction are effective for vaginal apex support, but vaginal prolapse recurs with time, most commonly in the anterior segment.