Thesis (doctoral)--Göteborg University, 2005. / Includes bibliographical references (p. 438-449) and index.

Abstract The purpose of this study was to develop a hypothetical model of genetic counseling for male hereditary breast cancer mutation (BRCA1/2) carriers. The methodological approach involved mixed methods. The aim of the first phase was to describe male BRCA1/2 mutation carriers’ genetic counseling, experiences and needs for developing genetic counseling. Quantitative data were acquired using a patient counseling questionnaire (n=35) based on consecutive sampling, whereas theme-based interviews (n=31) were conducted as a qualitative approach. In the second phase, the theme-based interview data were used to describe males’ experiences after identification as BRCA1/2 mutation carriers and effects of identification as a carrier on their lives (n=31). The data were analyzed using descriptive statistics and inductive content analysis. The results of the study were combined into a model describing genetic counseling for male BRCA1/2 mutation carriers. Based on the quantitative data, the genetic counseling was evaluated as good. Psychosocial support was insufficient. According to the qualitative data, there was lack of noticing individual wishes and needs during the genetic counseling process. Operational conditions of departments of clinical genetics and genetic healthcare professionals’ readiness to provide gentic counseling were varied. Identification as a BRCA1/2 mutation carrier caused varied emotional reactions associated with identification as a carrier, hereditary transmission of the mutation, cancer risks and possibility of developing cancer. However, the duration of the reactions varied. Identification as a carrier had effects on male carriers’ health and social wellbeing. According to the hypothetical model, genetic counseling was based on the backgrounds and individual needs of the male BRCA1/2 mutation carriers, which was implemented with appropriate operational conditions. It included sufficient psychological support, which genetics healthcare professionals had professional responsibility for implementing. The information study provided can be used to broaden the knowledge base of nursing science in clinical genetics. The information may also be utilized in continued nursing education. / Tiivistelmä Tutkimuksen tarkoituksena oli kehittää periytyvän rintasyöpäalttiusmutaation (BRCA1/2) kantajamiesten hypoteettinen perinnöllisyysneuvontamalli. Tutkimuksessa käytettiin monimenetelmämetodologiaa. Ensimmäisessä vaiheessa kuvattiin BRCA1/2-alttiusmutaation kantajamiesten perinnöllisyysneuvontaa, perinnöllisyysneuvontakokemuksia ja kehittämistarpeita. Aineisto kerättiin kokonaisotannalla kvantitatiivisesti Potilasohjaus-kyselylomakkeella (n=35) ja kvalitatiivisesti teemahaastatteluilla (n=31). Toisessa vaiheessa kuvattiin ensimmäisessä vaiheessa kerätyllä haastatteluaineistolla kantajamiesten kokemuksia alttiusmutaation kantajuudesta ja kantajuuden vaikutuksista elämään (n=31). Tutkimuksen aineistot analysoitiin tilastollisin menetelmin ja induktiivisella sisällönanalyysillä. Tutkimuksen tulosten perusteella muodostettiin BRCA1/2-alttiusmutaation kantajamiesten perinnöllisyysneuvontamalli. Kvantitatiivisen tutkimuksen perusteella perinnöllisyysneuvonta arvioitiin hyväksi. Psykososiaalisen tuen saaminen oli vähäistä. Kvalitatiivisen tutkimuksen mukaan kantajamiesten yksilöllisten toiveiden ja tarpeiden huomioiminen perinnöllisyysneuvontaprosessin aikana oli puutteellista. Kliinisen genetiikan yksiköiden toimintaedellytyksissä ja perinnöllisyysneuvonnan antajien ohjausvalmiuksissa oli vaihtelevuutta. BRCA1/2-alttiusmutaation kantajuus aiheutti kantajamiehille eriasteisia ja -kestoisia emotionaalisia tunteita, jotka liittyivät kantajuuteen, alttiusmutaation periytymiseen, syöpäriskiin ja syöpään sairastumiseen. Kantajuudella oli lisäksi vaikutusta kantajamiesten terveydelliseen ja sosiaaliseen hyvinvointiin. Periytyvän rintasyöpäalttiusgeenin hypoteettisen mallin perusteella perinnöllisyysneuvonta oli BRCA1/2-alttiusmutaation kantajamiehen taustatilanteeseen ja yksilölliseen tarpeeseen perustuva neuvonta, joka oli toteutettu asianmukaisin toimintaedellytyksin. Se sisälsi riittävästi psykososiaalista tukea ja sen antajalla oli ammatillinen vastuu perinnöllisyysneuvonnan toteuttamisesta. Tutkimuksessa tuotetun tiedon avulla lisätään hoitotieteellistä tietoperustaa perinnöllisyyslääketieteen alueelle. Tietoa voidaan hyödyntää myös hoitotyön täydennyskoulutuksessa.

Algumas síndromes genéticas monogênicas apresentam fenótipos considerados progeróides, ou seja, desenvolvem precocemente características clínicas semelhantes às observadas no envelhecimento humano normal. A relação fisiopatológica entre essas doenças e o processo de envelhecimento vem sendo estudada, sendo que o entendimento dos mecanismos moleculares em um campo contribui para a compreensão do outro. As síndromes de Hutchinson-Gilford e Rothmund-Thomson são duas condições progeróides raras, já bem caracterizadas clinicamente, que são causadas por alterações nos genes LMNA (em um alelo) e RECQL4 (nos dois alelos), respectivamente. No entanto, em cerca de 40% a 60% dos indivíduos com a síndrome de Rothmund-Thomson, não são encontradas mutações em RECQL4, constituindo um subgrupo chamado de tipo I; desse modo, os casos com alteração no gene constituem o tipo II da síndrome. Indivíduos com o tipo II apresentam um risco aumentado para o desenvolvimento de câncer, particularmente o osteossarcoma. Neste trabalho, nove pacientes com sinais progeróides foram avaliados clinicamente e tiveram o DNA sequenciado. Um paciente recebeu o diagnóstico clínico de síndrome de Hutchinson-Gilford, que foi confirmado pela mutação patogênica mais frequente encontrada no gene LMNA (p.Gly608Gly). Oito pacientes jovens, com mediana de idade de 2 anos e 2 meses, foram diagnosticados clinicamente como afetados pela síndrome de Rothmund-Thomson, cujas características clínicas mais comuns incluíam déficit pôndero-estatural, cabelos e sobrancelhas/cílios esparsos, fronte ampla, lesão cutânea (eritema em face e lesão poiquilodérmica) e anomalias ósseas, alterações típicas da síndrome. Catarata estava presente em 50% dos indivíduos. Nenhum dos pacientes desenvolveu algum tipo de tumor até o momento. O sequenciamento do gene RECQL4 mostrou a presença de três variantes patogênicas diferentes, em três probandos (37,5%), sendo dois em homozigose e um em heterozigose composta, todas já descritas previamente na literatura. Em busca de alterações em outro gene que pudesse explicar o quadro apresentado pelos pacientes sem mutação, três dos probandos, incluindo os genitores de um deles, tiveram o exoma sequenciado. No entanto, não foram encontradas, nessa etapa, variantes adicionais que explicassem na totalidade os fenótipos apresentados. Comparando os achados clínicos dos pacientes com a síndrome de Rothmund-Thomson tipo I e tipo II, foi observada diferença estatisticamente significante na incidência de catarata subcapsular nos pacientes sem mutação (p<0,05), semelhante ao que é descrito na literatura. Diante dos achados clínicos e moleculares obtidos, foi realizado o aconselhamento genético para todos os indivíduos, enfatizando a evolução, os cuidados e acompanhamentos necessários para as duas doenças em questão e fornecendo informações aos genitores dos probandos sobre o risco de recorrência para a prole futura / Some monogenic disorders exhibit progeroid phenotypes, in other words, they develop premature characteristics similar to those observed in normal human aging. The physiopathological correlation between these diseases and the aging process has being studied, and the understanding of the molecular mechanisms in one field contributes to the understanding of the other. The Hutchinson-Gilford and Rothmund-Thomson syndromes are two clinically well-characterized rare progerioid conditions that are caused by changes in the LMNA (in one allele) and RECQL4 (in both alleles) genes, respectively. However, in about 40% to 60% of individuals with Rothmund-Thomson syndrome, no mutations are found in RECQL4, constituting a subgroup called type I; thus, cases with mutations in the gene constitute the type II group of the syndrome. Individuals with type II have an increased risk for the development of cancer, particularly osteosarcoma. In this study, nine patients with progerioid signs were clinically evaluated and had the DNA sequenced. One patient was clinically diagnosed with Hutchinson-Gilford syndrome, which was confirmed by the most frequent pathogenic mutation found in the LMNA gene (p.Gly608Gly). Eight young patients with median age of 2 years and 2 months were clinically diagnosed as affected by Rothmund-Thomson syndrome, whose most common clinical features included: short stature; sparse hair, eyebrows and eyelashes; erythematous skin lesions and poikiloderma; and bone abnormalities; all typical of the syndrome. Cataract was present in 50% of individuals. None of the patients has developed any type of tumor at this time. Sequencing of the RECQL4 gene showed the presence of three different pathogenic variants in three probands (37.5%), two in homozygous and one in compound heterozygosity, all previously described in the literature. In search of alterations in another gene that could explain the phenotype presented by the patients without mutation, three of the probands, including the parents of one of them, had the exoma sequenced. However, there were no additional variants at this stage that fully explained the phenotypes presented by these individuals. Comparing the clinical findings of patients with Rothmund-Thomson syndrome type I and type II, a statistically significant difference was observed in the incidence of subcapsular cataract in patients without mutation (p <0.05), similar to that described in the literature. In light of the clinical and molecular findings, genetic counseling was performed for all individuals, emphasizing the evolution, care and follow-up needed for the two diseases in question and providing information to the parents of the probands on the risk of recurrence for future offspring

O presente estudo é focalizado na avaliação dos achados do sistema nervoso central através de imagens obtidas através de ressonância nuclear magnética (RNM) em pacientes com a Síndrome de Opitz G/BBB. A síndrome de Opitz G/BBB (OMIM; 145410; 300000) é uma síndrome de anomalias congênitas múltiplas que comprometem a linha média, clinica e geneticamente heterogênea, com uma forma ligada ao cromossomo X mapeada em Xp22.3 e uma outra forma supostamente autossômica dominante mapeada em 22q11 cujo gene nunca foi identificado; no entanto, ambas são reconhecidas como uma condição única. Esta síndrome de anomalias da linha média se caracteriza principalmente por hipertelorismo, bico de viúva, ponte nasal larga, hipospádia, fissura de lábio/palato, e anomalias laringo-traqueo-esofágicas. Neste estudo avaliamos 19 pacientes do sexo masculino, brasileiros, sem etnia específica, com idades variando entre 5 e 38 anos, diagnosticados previamente como portadores de síndrome de Opitz G/BBB, selecionados dos arquivos da Seção de Genética Clinica, Divisão de Sindromologia, HRAC-USP Bauru. Destes pacientes, 6 tinham avaliação prévia por estudos de genética molecular gentilmente realizados pelas Dras. Chiara Migliore (Institute for Maternal and Child Health - IRCCS \"Burlo Garofolo\", Trieste, Italy) e Germana Meroni (CBM - Cluster in Biomedicine, AREA Science Park, Trieste, Italy). Os estudos por imagem através de RNM foram realizados em todos os pacientes. Atenção especial foi dedicada a 3 pacientes que mostravam fenótipos clínicos distintos dos demais dentro do espectro da síndrome de Opitz G/BBB: dois pacientes apresentavam ptose, pescoço alado, e anomalias da cintura escapular, enquanto que o terceiro apresentava retardo mental grave e microcefalia associado a graves alterações encefálicas na avaliação por imagem, tais como atrofia cortical generalizada e grande anomalia de Dandy-Walker. Os principais achados por imagem da amostra total são representados por cisterna magna ampla (15 indivíduos = 78,95%), dilatação do 4º ventrículo (14 = 73,68%), hipoplasia do vermis cerebelar (8 = 42,10%), hemisférios cerebelares anômalos e cavum septum vergae (3 = 15,79% cada condição); atrofia de córtex cerebral, alargamento do III ventrículo, aumento da cisterna pré-pontina, hipoplasia de corpo caloso e persistência de septo pelúcido contam, cada um, com dois pacientes acometidos (10,53%). Aparentemente não havia correlação entre o fenótipo clínico e os achados por imagem, existindo grande variabilidade de paciente para paciente, que se estendiam desde discretas alterações da linha média até grave malformação de Dandy-Walker. As alterações comportamentais e cognitivas usualmente descritas na literatura como achados principais em pacientes com hipoplasia do vermis cerebelar e/ou hipoplasia cerebelar não foram reconhecidas como achados marcantes nos pacientes do presente trabalho. A alta frequência de anomalias cerebelares em pacientes com a síndrome de Opitz G/BBB nos leva a recomendação para a reformulação do aconselhamento genético, abordagem e manejo destes pacientes. / The present survey focused on the evaluation of the central nervous system images findings in patients with the Opitz G/BBB syndrome obtained through magnetic nuclear resonance imaging (MRI). The Opitz G/BBB syndrome (OMIM; 145410; 300000) is a midline congenital malformation syndrome, clinical and genetically heterogeneous with an X-linked form mapped on Xp22.3 and a not well defined autosomal dominant form purportedly on 22q11, however they are recognized as one entity. This multiple congenital midline malformation syndrome is mainly characterized by hypertelorism, widows peak, broad nasal bridge, hypospadias, cleft lip/palate, and laryngo-tracheo-esophageal abnormalities. In the present study we have evaluated nineteen male patients of Brazilian extraction, with no preferential ethnic background, with age span ranging from 5 to 38 years old and previously diagnosed with the OS were selected from the files of the Section of Clinical Genetics, Division of Syndromology, HRAC-USP Bauru. From these patients, six had previous evaluation through molecular analysis graciously performed by Chiara Migliore (Institute for Maternal and Child Health - IRCCS \"Burlo Garofolo\", Trieste, Italy) and Germana Meroni (CBM - Cluster in Biomedicine, AREA Science Park, Trieste, Italy). Imaging studies through MRI were performed in all patients. Special attention was given to 3 out the 19 patients who showed unique phenotypes within the OS spectrum: 2 of them presented ptosis, pterigium colli, and abnormal scapular girdle as deviant signs and they presented mild/moderate cerebellar anomalies, and the 3rd presented severe mental retardation and microcephaly associated to generalized severe imaging findings mainly represented by generalized cortical atrophy and huge Dandy-Walker anomaly. Main MRI findings of the whole sample included wide cisterna magna (15 = 78,95%), enlarged 4th ventricle (14 = 73,68%), cerebellar vermis hypoplasia (8 = 42,10%); abnormal cerebellar hemispheres and cavum septum vergae (3 = 15,79% each one); cerebral cortical atrophy, enlarged III ventricle, enlarged prepontine cisterna, calosal hypoplasia and cavum septum pellucidum counts, each one, two patients (10,53%). Apparently there is no correlation between the clinical phenotype and the imaging findings, and there is a wide variability from patients to patients, ranging from mild midline anomalies to severe Dandy Walker anomaly. Behavioral and severe cognitive deficits usually reported in the pertinent literature as main findings associated to cerebellar vermis hypoplasia and/or cerebellar hypoplasia were not recognized as a remarkable finding in the present series. The high frequency of cerebellar anomalies in the OS patients led us to recommend a reformulation in the genetic counseling approach to these patients.

Sickle cell trait (SCT) is a very prevalent disorder in the United States, especially among African Americans or people of African descent. However, even with the prevalence of the disorder, there are no standardized guidelines for providing patients with information about SCT and the implications of the disorder at physicals and well-check visits. The purpose of this evidence-based project was to increase awareness for African American patients 18-44 years old in the practice setting about SCT and to provide options for testing and genetic counseling. Kotter's contemporary change theory was used as a guide to implement the new practice approach. A quasi-experimental, single-group, pretest-posttest-only design was used to explore the relationship between providing consistent SCT education and the impact on the rate of SCT screening and genetic counseling. A total of 71 patients participated in the program. The analysis showed a significant (p < 0.001) mean difference of 18.16 points from the preintervention SCT and genetics test mean, which indicated that the intervention was successful in raising SCT and genetics knowledge scores among the target population. The results demonstrated that the implementation of SCT education in the practice setting can enhance social implications related to SCT awareness and opportunities for SCT testing and genetic counseling. The implementation of SCT clinical guidelines can help to increase awareness about SCT and improve the overall population health and reduce the financial burden affiliated with care of those with sickle cell disease and SCT complications.

Genetic test results have important implications for close family members. Indeterminate negative results are the most common outcome of BRCA1/2 mutation testing. Little is known about family members' understanding of indeterminate negative BRCA1/2 test results. The purpose of this qualitative descriptive study was to investigate how daughters and sisters received and understood genetic test results as shared by their mothers or sisters. Participants included 81 women aged 40-74 with mothers or sisters previously diagnosed with breast cancer and who received indeterminate negative BRCA1/2 test results. Participants had never been diagnosed with breast cancer nor received their own genetic testing or counseling. This IRB approved study utilized semi-structured interviews administered via telephone. The research team developed descriptive codes, and NVIVO software was used during qualitative analysis. Participants reported low amounts of information shared with them. Most women described test results as negative and incorrectly interpreted the test to mean there was no genetic component to the pattern of cancer in their families. Only 7 of 81 women accurately described test results consistent with the meaning of an indeterminate negative result — meaning a genetic cause for cancer in their family could still exist. Our findings demonstrate that indeterminate negative genetic test results are not well understood by family members. Lack of understanding may lead to an inability to effectively communicate results to primary care providers and missed opportunities for prevention, screening and further genetic testing. We recommend providing family members letters they can share with their own primary care providers whenever genetic testing is performed.

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