Familial adenomatous polyposis: mutation at codon 1309 and early onset of colon cancer

The clinical course of familial adenomatous polyposis (FAP) varies considerably between patients. Prediction of the severity of the disease is important in the interest of effective cancer prevention. We examined whether age at diagnosis of FAP due to gastrointestinal symptoms and age at death due to colorectal cancer are related to the site of mutation in the responsible gene. 225 families with FAP were screened for mutations. The deletion of 5 base pairs at codon 1309 within exon 15 (known to be the most common mutation) was identified in 20 families; other mutations within exons 7-15 were found in 49 families. In patients with the 5 base-pair deletion at codon 1309, gastrointestinal symptoms and death from colorectal cancer occurred about 10 years earlier than in patients with other mutations. The 1309 mutation leads to development of colonic polyps at a younger age, thus giving rise to an earlier malignant transformation. This relationship should be taken into account in strategies for preventing cancer in patients with FAP.

Large linkage analysis in 100 families with autosomal recessive spinal muscular atrophy (SMA) and 11 CEPH families using 15 polymorphic loci in the region 5q11.2-q13.3

The autosomal recessive proximal spinal muscular atrophy (SMA) gene was mapped to the region 5q11.2-q13.3 in 1990. Here, we present a large genetic linkage study of 100 SMA families and 11 CEPH families using 14 polymorphic simple sequence repeats (SSRs) and one RFLP in the region 5q11.2-q13.3. The genetic interval between the closest SMA flanking loci D5S435 and D5S557 comprises 1 cM at zmax = 27.94. Two recombinants were identified between the SMA gene and the closest telomeric marker D5S557 (theta = 0.02 at zmax = 8.63). The first places the SMA gene centromeric to this marker; the second suggests a double recombinant at D5S557, which is very unlikely. More likely explanations are discussed in the paper. No recombinant was found between D5S435 and the SMA gene (theta = 0.00 at zmax = 25.36). We localized a recently described polymorphic marker, D5S351 (Hudson et al., 1992), close to the SMA (theta = 0.00 at zmax = 19.01) and the 3'MAP1B gene (theta = 0.01 at zmax = 38.76). Due to its high PIC value of 0.70, it represents a very useful marker for prenatal diagnosis. In addition, we developed a new reverse primer for the nearest centromeric locus D5S435 (Soares et al., 1993), a useful marker for prenatal diagnosis, which has been very difficult to amplify in the past. Three of the markers presented here are newly developed polymorphic SSRs (one tetranucleotide repeat, D5S507/W15CATT, and two dinucleotide repeats, D5S544/C88.2GT and D5S682/C88.3GT). These markers are too far from the SMA gene to be relevant for cloning; nevertheless, as part of the human genome project, they are contributing to the fine genetic mapping of the region 5q11.2-q13.3. The most likely order of the loci based on two-point and multipoint linkage analyses as well as on specific recombination events and physical mapping studies is D5S76-D5S507- D5S6-D5S125-D5S680-D5S435-SMA-D5S557- D5S351-5'MAP1B-3'MAP1B-JK53CA1/2-(D5S127- D5S39)-(D5S544-D5S682). In general, the genetic distances obtained from the SMA and CEPH families are comparable.

Linkage analysis in nuclear families. 1: Optimality criteria for affected sib-pair tests

The affected sib-pair method can be applied to investigate linkage between a marker locus and a disease. Several statistics have been proposed to test if the observed pattern of marker alleles shared identically by descent (ibd) is compatible with the null hypothesis of no linkage. Here, we consider different optimality criteria for sib-pair linkage tests. While for recessive inherited diseases the mean test is found to be uniformly (in theta) most powerful, it can also be shown that, irrespective of the mode of inheritance, the mean test is the locally optimal test.

Linkage analysis in nuclear families. 2: Relationship between affected sib-pair tests and lod score analysis

It is believed that the main advantage of affected sib-pair tests is that their application requires no information about the underlying genetic mechanism of the disease. However, here it is proved that the mean test, which can be considered the most prominent of the affected sib-pair tests, is equivalent to lod score analysis for an assumed recessive mode of inheritance, irrespective of the true mode of the disease. Further relationships of certain sib-pair tests and lod score analysis under specific assumed genetic modes are investigated.

The costs of accommodation and care. Community provision for former long-stay psychiatric hospital patients

The development of community services to replace two long-stay psychiatric hospitals in the North East Thames Health Authority region of the UK has been the subject of a research programme since 1985. The economic evaluation is conducted by the Personal Social Services Research Unit; research results relating to the first five cohorts of hospital leavers are reported in this paper. When followed up 1 year after discharge, almost half of the sample were living in highly supported residential care units, most of which were managed by district health authorities. More than 40 services provided outside the accommodation facility were used by clients and, although contact with certain professionals remained constant, some changes in service use over time were marked. The average total cost of community care for this group was 493 pounds per week (1992-93 prices), accommodation facility costs comprising approximately 85% of the total. In the new service configuration, district health authorities fund half of the costs of supporting the hospital leavers, 50% less than when they funded long-stay hospital placements. The rest of the funding burden is borne by a range of agencies, resulting in pressure on budgets and staff case loads.

Reduced list costings: examination of an informed short cut in mental health research

The demands for cost information in health services are many and various but the supply of such information is less than might be expected and is compounded by the expense of undertaking costs research. This paper examines a short cut to mental health research which, if certain rules and conventions are obeyed, can still produce valid costs data. By distilling evidence from previous research a reduced list of services is identified which accounts for the greater part of the total costs of care packages. By concentrating on these key services, 94 per cent of the total costs of care were predicted for discharged long-stay patients and no less than 91 per cent for people supported by community psychiatric nurses. The results suggest that this reduced list method can work well where the aim is to obtain broad orders of magnitude for the costs of care. By reducing the resources required for research, the approach could expand the current costs information base and move towards meeting the pressing practice demands for costs data.

The haplotype-relative-risk (HRR) method for analysis of association in nuclear families

One major problem in studying an association between a marker locus and a disease is the selection of an appropriate group of controls. However, this problem of population stratification can be circumvented in a quite elegant manner by family-based methods. The haplotype-relative-risk (HRR) method, which samples nuclear families with a single affected child and uses the parental haplotypes not transmitted to that child as a control individual, represents such a method for estimating the relative risk of a marker phenotype. In the special case of a recessive disease, it was already known that the equivalence of the HRR method with the classical relative risk (RR) obtained from independent samples holds only if the probability theta of a recombination between marker and disease locus is zero. We extend this result to an arbitrary mode of inheritance. Furthermore, we compare the distribution of the estimators for HRR and RR and show that, in the case of a positive linkage disequilibrium between a marker and disease allele, the distribution of the estimator for HRR is (stochastically) smaller than that for RR, irrespective of the recombination fraction. The practical implication of this result is that, for the HRR method, there is no tendency to give unduly high risk estimators, even for theta > 0. Finally, we give an expression for the standard error of the estimator for HRR by taking into account the nonindependence of transmitted and nontransmitted parental marker alleles in the case of theta > 0.

Mapping of the gene for X-chromosomal split-hand/split-foot anomaly to Xq26-q26.1

A large inbred kindred from Pakistan in which an isolated type of split-hand/split-foot anomaly is transmitted as an X-chromosomal trait has previously been described. An X/autosomal translocation and an X-chromosomal rearrangement have been excluded by cytogenetic studies. In order to map the gene responsible for this disorder, linkage analysis has been performed by using 14 highly polymorphic DNA markers distributed over the whole X chromosome. Two-point linkage analysis between the disease locus and X-chromosomal marker loci gives maximal lod scores at theta = 0.00 with the loci DXS294 (Zmax = 5.13) and HPRT (Zmax = 4.43), respectively, suggesting that the gene for the X-chromosomal split-hand/split-foot anomaly is localized at Xq26-q26.1.

Fine mapping and narrowing of the genetic interval of the spinal muscular atrophy region by linkage studies

The gene for autosomal recessive proximal spinal muscular atrophy (SMA) has recently been mapped to chromosome 5q12.2-q13, within a genetic distance of about 6 cM, and is proximally flanked by the locus D5S6 and distally by D5S112. Here, we report linkage analyses in 64 SMA families with nine polymorphic markers closely linked to the SMA gene, which allowed us to narrow the SMA region to about 4 cM and to define a new proximal genetic border by the locus D5S125 (EF(TG/AG)n. Based on haplotype analysis and specific recombination events, the following order of the loci was determined: 5cen-D5S76-D5S6-D5S125-SMA-(5'MAP-1B-3'MAP- 1B)/D5S112-JK53CA1/2-(D5S39-D5S127)-5qter. The location of the SMA gene between D5S125 and MAP-1B is further supported by multipoint linkage analysis.

The effect of misspecifying allele frequencies in incompletely typed families

To examine the effect of a misspecified marker allele frequency, the segregation of a marker unlinked to Alzheimer's disease was simulated for the typed members of the GAW8-FAD4 pedigree. Lod scores were calculated for different assumed marker allele frequencies. The results show that a misspecification of marker frequency can lead to spuriously high lod scores. The affecteds-only method for linkage analysis is even more sensitive in regard to marker frequency misspecification. Therefore, we recommend estimation of marker allele frequencies from the actual family data. The simple estimator we considered in this paper seems to be sufficient.

[Reference values for the concentration of free triiodothyronine (FT3), triiodothyronine (TT3), free thyroxine (FT4), thyroxine (TT4), thyrotropin (TSH) and thyroxine-binding globulin (TBG) in umbilical cord blood. Method: luminescence-enhanced enzyme immunoassay]

Physiological concentrations of FT3, TT3, FT4, TT4, TSH and TBG were determined using the luminescence enhanced enzyme immunoassay method in cord blood serum (n = 100). The results are presented in Table 1.

Ontogeny of the benzodiazepine receptor in human brain: fluorographic, immunochemical, and reversible binding studies

The prenatal and postnatal human ontogeny of the central benzodiazepine receptor was investigated in six different brain regions between week 24 postconception and age 14 years. Binding studies, which were performed with [3H]flunitrazepam [( 3H]FNZ), revealed a steep increase in receptor density postnatally in frontal cortex and cerebellum. Bmax values were higher in medulla oblongata, pons, and thalamus than in cortex and cerebellum up to week 26. After that, receptor densities declined significantly in medulla and olive. The same tendency was apparent in pons, whereas receptor density remained unchanged in thalamus. The early ontogeny of the benzodiazepine receptor was also evaluated in fluorographs [( 3H]FNZ) and immunoblots using the alpha 1-subunit-specific monoclonal antibody (mAb) bd-24. Specific radiolabeled proteins with molecular weights of 53K and 59K were visible in cortical membranes from gestational week 8, the earliest time investigated. During further development, the intensity of the 53K band increased without changes in the 59K band. As in other species, postmortem proteolysis in human brain led to a specifically labeled peptide of 47K. The mAb bd-24 immunolabeled only the 53K protein and the 47K peptide.

Costs, needs, and outcomes

There is a tendency in discussions of mental health policy and psychiatric practice to talk of the cost of a treatment, facility, or policy and to ignore variations. These variations can be considerable, which alone suggests they should not be overlooked, and they can be explored and perhaps exploited to improve the delivery of services. This article describes a theoretical framework for the examination of cost differences, applies it to a particularly rich data base on people with long-term mental health problems moving from hospital to the community, and uses the empirical evidence to address four key policy questions. The study finds encouragingly strong positive associations between costs, needs, and outcomes. It also uncovers significant cost-effectiveness differences between the public and private sectors and between community accommodation types.

Testing for association in SLE families

Systemic lupus erythematosus (SLE) is a complex disease which is partly determined by genetic factors which influence susceptibility to the disease phenotype. In this association study we try to define the high risk haplotypes which are responsible for this disease, together with other environmental factors. In many other association studies a set of SLE patients is compared to a set of controls. The basic assumption about the underlying population is that the disease and control sample should originate from the same genetic population, which is not always completely satisfied in many studies. Therefore, we analyse our family data by applying the Haplotype Frequency Difference (HFD) Method, which constructs its internal control group from those haplotypes not transmitted to the affected individual. Results partially conform with other studies, showing that the haplotypes B8 DR3 as well as B7 DR2 have a high positive association with SLE. When the DR locus was analyzed alone, we found besides the alleles DR2 and DR3 a negative association for DR1, DR5, and DR6.

[Age-specific and sex-specific reference values for the excretion of free amino acids in the 24-hour urine of children]

Free amino acids were determined quantitatively by ion exchange column chromatography in 24 h urine of 354 (male = 187, female = 167) "healthy" infants, children and adolescents. Urine was deproteinised by 5% sulphosalicylic acid (1:1, v/v). The results - 95% confidence range - are presented age-dependent (groups: up to 1 month, 1-24 months, 2-6 years, 6-10 years, 10-14 years) and sex-dependent in table 3 and 4.

The TAPS project. 3: Predicting the community costs of closing psychiatric hospitals

The planning of long-term care in the community as an alternative to in-patient care requires accurate information on the likely expense of altering the balance of provision. Unfortunately, as very few long-stay psychiatric hospitals have yet closed, the planning of these resource requirements has had to proceed in a vacuum. By examining the costs of community reprovision for the first 136 people to leave Claybury and Friern Hospitals, a prediction equation has been estimated from existing data which links the hospital-assessed characteristics (including psychiatric symptoms and behavioural problems) of these people to the subsequent cost of community care. About a third of the observed variation in these costs can be explained statistically by these 'baseline' characteristics. However, the first cohorts exhibit fewer behavioural problems and other symptoms of mental illness, they have been in hospital for shorter lengths of time, and they are younger. The prediction equation for the leavers is thus used to extrapolate community costs for those hospital residents yet to leave. It is found that community costs are lower than hospital costs, not just for the first cohorts of leavers, but for the full populations of the two hospitals scheduled to close.

Costing mental health services

In this paper four principal topics are addressed: (a) the policy and political contexts in which demands arise for cost information; (b) the nature and phasing of those demands; (c) the basic rules of empirical costs research for meeting those demands; and (d) concomitant implications for the design, execution and interpretation of their research. Mental health care policy or practice changes which ignore costs, or which embody cost information without obeying or recognizing the four basic rules, can only be of dubious validity, or can only be used to answer a limited range of questions. But, as the illustrative studies show, it need not be an horrendous, or ideologically compromising or scientifically complex task to add a cost dimension to the evaluation of mental health services. There are enough examples in the literature of bad costs research to demonstrate that it is not as simple as some people think, but there are also enough examples of good research to encourage further attempts.

Gene and haplotype frequencies of HLA antigens in 269 patients with Crohn's disease

Evidence of strong genetic markers in Crohn's disease (CD) is still absent. Many investigations have focused on HLA antigens, with conflicting results. To obtain more detailed information on the relation of HLA to the disease, we used the HLA data from 269 CD patients to compute the maximum-likelihood estimates of HLA gene and haplotype frequencies. These results provide further evidence that HLA B44 and Cw5 do indeed play a role in the development of CD. Furthermore, it is conceivable from our results that HLA Cw7 may protect against being affected with this disease.

[Impedance of the respiratory tract of healthy newborn infants--studies using the polyfrequency oscillation method]

Resistance and reactance of the respiratory tract of 40 healthy newborn were measured by means of the polyfrequent oscillation method. Mean resistance had frequency-dependent values between 20.91 and 9.63 cm H2O per litre per second and mean reactance between -29.11 and -3.81 cm H2O/1/s. The resistance--but not the reactance--was found to depend on the body length and the body weight of the infants.

Diagnostic value of body plethysmographic parameters in healthy and asthmatic young children is not influenced by breathing frequency

In 16 healthy and 16 asymptomatic asthmatic children (age range 5-8 yr; 8 girls, 24 boys) we studied the influence of breathing frequency on the results and the diagnostic value of body plethysmographic measurements. Airway resistance (Raw), specific airway resistance (SRaw), and thoracic gas volume (TGV) were measured during breathing (or breathing efforts against a closed shutter) at 0.4, 1, and 2 Hz. SRaw was computed by a simplified procedure directly from flow at the mouth vs. box volume-curves. The diagnostic value of each parameter was assessed as the percentage of correctly classified healthy and asthmatic subjects by means of discriminant analysis. When frequency was increased from 0.4 to 1 and 2 Hz mean TGV rose by 5 and 14% in healthy children and by 11 and 21% in asthmatic children, respectively. From 0.4 to 1 Hz mean Raw decreased by 16% (P = 0.002) in healthy children and by 25% (P = 0.0004) in asthmatic children. The differences in Raw between both groups decreased with frequency (3.5, 1.8, and 1.5 cm H2O.L-1.s at 0.4, 1, and 2 Hz, respectively) and those of TGV increased (0.13, 0.21, and 0.23 L). SRaw showed similar frequency characteristics as Raw. As intra-group variability changed in parallel with the differences the diagnostic value of the parameters remained constant with frequency. Simplified SRaw alone and TGV combined with Raw exhibited no differences in their diagnostic values (81-84% correctly classified).(ABSTRACT TRUNCATED AT 250 WORDS)

Investigation of genetic markers in patients with Crohn's disease and ulcerative colitis

Inflammatory bowel diseases (IBD) as Crohn's disease (CD) and ulcerative colitis (UC) are believed to have a genetic basis. Additional factors are supposed to promote the development of IBD. However, apart from a few reports of HLA associations which await confirmation by other groups strong associations to (a) particular genetic marker(s) are still lacking. We here report on previously unobserved associations of CD to MNSS and UC to the immunoglobulin heavy chain allotype Gm 1,-2,10. We suggest that these factors play a role in a wider spectrum of genetic markers for the development of IBD.

Isotretinoin embryopathy--a continuing problem

First trimester exposure to isotretinoin is associated with an estimated 20% risk of major fetal malformations. Product labeling in force up to August 1988 included a statement that the drug is contraindicated in pregnancy and suggested procedures for prescribing physicians to follow to prevent inadvertent first trimester exposure to the product. This limited educational intervention did not prevent the continued occurrence of isotretinoin-related birth defects. The effectiveness of recent changes in the package labeling in preventing such birth defects remains to be demonstrated. Two infants with major birth defects associated with first trimester exposure to isotretinoin (Accutane, Roche Laboratories) were reported to the New Jersey Birth Defects Registry within 6 months. Stimulated by these reports, we sought additional cases in New Jersey and found three. We here describe these five cases of isotretinoin embryopathy, including available information on the circumstances which led to maternal use of isotretinoin during the first trimester of pregnancy. In response to a preliminary report of these cases and to investigations by epidemiologists at the U.S. Food and Drug Administration (FDA), the manufacturer altered the package labeling. The revised product information includes a more prominent "contraindication and warning" section and a new "patient information/consent" section. The effectiveness of this educational intervention should be evaluated.

Prevalence of coeliac disease in diabetic children and adolescents. A multicentre study

Screening for coeliac disease (CD) with serum antigliadin antibodies (AGA) was performed in 1032 diabetic children and adolescents. In 8 children CD had been diagnosed before study entry. Of the remaining 1024 children, 33 had an elevated AGA titre in the first serum sample. On follow-up an elevated AGA titre was confirmed in only 17 of 31 patients. Nine of the repeatedly positive patients underwent jejunal biopsy, and CD was diagnosed in two asymptomatic patients; both were positive for IgG- and IgA-AGA. Among 10 AGA-positive patients in whom biopsies could not be performed, only 1 showed IgA-AGA and thus carried a high risk for CD. From our results we estimate a prevalence of CD in Swiss and German diabetic children between 1.1% and 1.3%. False-positive AGA titres occurred significantly more often in patients with diabetes duration of less than 1 year. AGA testing reached a specificity of 99% if performed at least 1 year after the onset of diabetes. Children suffering from both diabetes and CD showed a diabetes manifestation at a significantly younger age than non-coeliac patients, whereas CD tended to be diagnosed at a remarkably late age.

Relationships between blood chemistry and histology of the rectal mucosa in Crohn's disease

In the scope of the ECCDS, established to test the efficacy of prednisolone and/or sulfasalazine in Crohn's disease, the relationships of blood chemistry and CDAI to histology of rectal mucosa were studied in 115 patients by means of univariate and multivariate statistical analyses. Laboratory and histologic markers of inflammation tend to be correlated. But these correlations are definitively weak. Thus, the predictive value of histology for blood chemistry or CDAI is very low. Laboratory indices and CDAI are relatively inaccurate means of assessing disease severity at tissue level and vice versa.

Relationships between drug regime and histology of rectal mucosa in Crohn's disease

In the scope of the ECCDS, testing the efficacy of prednisolone and/or sulfasalazine in Crohn's disease, the relationships between drug regime and histology of rectal mucosa were studied. Rectal biopsies, gained at start and after termination of treatment were available in 57 patients. Additionally, biopsies of 20 normal controls were studied. The biopsies, cut completely in serial sections, were investigated by quantitative histological methods. The data were evaluated by multivariate discriminant analyses. The nearest approach of histologic pattern to normal was found after combined treatment with prednisolone and sulfasalazine, followed by prednisolone monotherapy. The effect of sulfasalazine as monotherapy was poor. The degree of normalisation in histologic pattern agrees very well with the CDAI in our subsets. Overall, effective therapy was reflected in histology of rectal mucosa by a decrease of acute inflammatory alterations and an increase of mononuclear infiltration. Only minor individual effects of the various drug regimes were found.

Early ontogeny of the central benzodiazepine receptor in human embryos and fetuses

The early ontogeny of the central benzodiazepine receptor (BZR) was investigated in human embryos and fetuses between 7 and 26 weeks of gestation. Brain tissue was gained from terminated pregnancies or spontaneous abortions. Binding studies, which were performed with 3H-flunitrazepam (FNZ), revealed that specific benzodiazepine binding is already detectable at an embryonal age of 7 weeks post conceptionem. Binding at this early stage can be displaced potently by clonazepam and the inverse agonist beta-CCE. Additionally, 3H-FNZ binding is enhanced by GABA. Thus, benzodiazepine binding is of the central type. Receptor density increases steeply in whole brain between weeks 8 and 11 of gestation. In frontal cortex receptor density increases gradually between weeks 12 and 26 of gestation. No specific fetal disease entity (including trisomy 21) was consistently associated with exceptionally high or low Bmax-values.

Selective elimination of mRNAs in vivo: complementary oligodeoxynucleotides promote RNA degradation by an RNase H-like activity

Oligodeoxynucleotides lead to translation arrest of complementary mRNAs in the wheat germ translation system by a degradation of the mRNA. In an attempt to develop an effective reverse genetic approach in vivo, we demonstrate that injection of short (15- to 30-nucleotide) oligonucleotides into Xenopus oocytes leads to complete degradation of both injected and endogenous mRNAs by means of an RNase H-like activity.

Effects of filaggrin breakdown products on the growth and maturation of keratinocytes

Filaggrin is degraded to amino acids in the stratum corneum. We tested the hypothesis that the resulting high concentrations of amino acids might be involved in the control of keratinocyte maturation. An amino acid mixture, with the composition of the filaggrin breakdown products, inhibited the growth of cultured human keratinocytes at 0.1 M. Inhibition of protein synthesis was progressive with time. After 24-h exposure, 50% inhibition occurred at 0.3-0.4 M amino acids. When the cultures were incubated with the amino acids for 7 days, the concentration giving half-inhibition was reduced to 0.2 M. No change was observed in the pattern of keratin synthesis, although synthesis of protein with Mr of 36,000 was disproportionately inhibited. It is concluded that filaggrin breakdown products are not involved in the control of keratinocyte differentiation.

Low back pain and x-ray films of the lumbar spine: a prospective study in primary care

We prospectively studied 96 men with low back pain to evaluate the association of x-ray findings with clinical diagnosis, treatment, functional outcome, and satisfaction with care. Degenerative joint disease (DJD) was the most common radiologic finding (70%). Making the diagnosis of spinal DJD has little effect on patient management, but patients with x-ray evidence of DJD were three times more likely than those with normal films to receive nonsteroidal anti-inflammatory drugs other than aspirin. Furthermore, patients given a "diagnostic label" of DJD were more likely to express satisfaction with medical care and less likely to seek care elsewhere than patients with similar x-ray results who were given nonspecific diagnoses. These factors will need to be considered in arriving at an estimate of the net benefits of x-ray examination of the lumbar spine.