Introduction The patient is the person who experiences both the processes and the outcomes of care. Information held by the patient is vital for clinical and self-management, improving health outcomes, delivery of care, organization of health systems, and formulation of health policies. Patient-reported outcome measures (PROMs) play an important role in supporting patient's self-management. This narrative describes a patient-led use of a PROM to self-manage after a rotator cuff injury. Methods This is a narrative of a patient who tore the supraspinatus tendon in her right shoulder in an accident. The Disabilities of the Arm, Shoulder and Hand, the DASH questionnaire, was used to monitor and self-manage recovery after the accident. The DASH questionnaire is a self-reported questionnaire that measures the difficulty in performing upper extremity activities and pain in the arm, shoulder or hand. It has been widely used in research studies, but here the patient initiated its use for self-management while waiting for and after rotator cuff surgery. The patient created separate sub-scale scores for function and for pain to answer questions from healthcare providers about her recovery. Results There was noticeable improvement over 3 months of conservative treatment, from a high level of disability of 56 to 39 (score changed 17); however, the scores were nowhere near the general population normative score of 10.1. Surgery improved the score from 39 pre-surgery to 28. Post-surgical interventions included physiotherapy, pain management and platelet-riched plasma treatment (PRP). The score was 14 4 weeks post-PRP. Conclusions The patient found the DASH useful in monitoring recovery from a rotator cuff injury (before and after surgery). The DASH contributed to communication with healthcare professionals and supported the clinical management. The DASH questionnaire was able to capture the patient's experience with the injury and surgical recovery, corroborating an improvement in function while there was persistent post-surgical pain.

Roberts syndrome (RS) is a developmental disorder characterized by tetraphocomelia and a broad spectrum of additional clinical features. Most patients with RS exhibit characteristic cytogenetic phenotypes, which include an abnormal appearance of pericentromeric heterochromatin on metaphase chromosomes, referred to as "heterochromatic repulsion." In the present study, we use complementation of this abnormal cytogenetic phenotype as a means to identify a specific region of the normal human genome capable of rendering phenotypic correction. We screened the entire human genome, using a transient chromosome-transfer assay, and demonstrated complementation exclusively after the transfer of proximal chromosome 8p, a result subsequently confirmed by stable microcell-mediated chromosome transfer. Additionally, homozygosity mapping was used to refine the interval of this complementing locus to 8p21. The results are consistent with the notion that the single gene defect responsible for heterochromatic splaying and developmental abnormalities maps to chromosome 8p21.

A girl with mental retardation and the facies associated with the distal 10q duplication syndrome was found to have a tandem duplication of 10q24 to 10q26. This was confirmed by gene dosage studies of glutamic oxaloacetic transaminase 1. The clinical features of this patient are compared with those of other reported cases of the distal 10q duplication syndrome with duplication-deficiency karyotypes due to familial reciprocal translocations or inversions or with tandem duplication of a more proximal region of 10q. Reports of tandem duplications in man and possible mechanisms of origin are discussed.

The objectives of this review include the conceptualization of the health-related quality of life effects of prenatal diagnosis and a brief summary of evidence on the short- and long-term effects of prenatal diagnosis on the health-related quality of life effects associated with chorionic villi sampling and genetic amniocentesis and the identification of important unresolved issues. Although this is not a systematic review, it is an update of published research on the utility approach to assessing the health-related quality of life in prenatal diagnosis. It is based on a search of publications by investigators known to be active in the area and a hand search of selected specialized journals. Important health states associated with prenatal diagnosis include both process (undergoing testing) and outcome. Empirical studies providing preference scores for health states associated with prenatal diagnosis highlight the importance of long-term outcomes relative to process. On average with respect to process, chorionic villi sampling is less burdensome than genetic amniocentesis. On average with respect to infrequent but potentially important outcomes as health states associated with diagnostic inaccuracy, genetic amniocentesis is less burdensome than chorionic villi sampling. Almost all of the existing evidence on the health-related quality of life effects of prenatal diagnosis reports on the experience of the women undergoing prenatal diagnosis. The preferences of partners have not been assessed. Furthermore, few studies have investigated subsequent reproductive behavior. Finally, there is considerable scope for the use of preference elicitation techniques in helping couples to decide on whether or not to undergo prenatal diagnosis and if they do, help them to choose the modality that best suites their preferences.

Many types of chromosome mosaicism have been identified in cases of hypomelanosis of Ito, often in association with chromosome instability; however, there have been very few cases with diploid-tetraploid mosaicism described in the literature. We present a patient with a tetraploid mosaicism: a 17-year-old girl who has hypomelanosis of Ito in association with diploid/tetraploid/t(1;6) mosaicism. She had multiple congenital anomalies of omphalocele, exstrophy of bladder, duodenal web, and imperforate anus. These features have not been described previously in diploid-tetraploid mosaicism.

This study assesses the health-related quality-of-life (HRQL) effects of chorionic villi sampling (CVS) and genetic amniocentesis (GA), including both process and outcomes of prenatal diagnosis. The HRQL of 126 women participating in a randomized controlled clinical trial of CVS versus GA in Toronto and Hamilton, Ontario, was assessed in four interviews at weeks 8, 13, 18, and 22 of pregnancy. Statistical analyses included analysis of variance, repeated measures analysis of covariance, chi-square, Fisher's exact test, Student's t-tests, and paired t-tests. Utility scores for patients undergoing CVS exceeded those for GA patients at week 18 (p = 0.04). Utility scores for hypothetical health states did not differ significantly by trial arm. CVS results in slightly improved HRQL during prenatal diagnosis. This advantage needs to be weighed against the high disutility patients attach to infrequent outcomes associated with pregnancy losses, equivocal diagnoses, and diagnostic inaccuracy.

A 46,X,r(X) karyotype was found in a three and a half year old girl with short stature, facial dysmorphism and developmental delay. The clinical findings were consistent with the phenotype described in a limited number of patients with small ring X chromosomes lacking the XIST locus, a critical player in the process of X chromosome inactivation. Surprisingly, in our patient, fluorescent in situ hybridisation demonstrated that the XIST locus was present on the ring X. However, expression studies showed that there was no XIST transcript in peripheral blood cells, suggesting that the ring X had not been inactivated. This was confirmed by the demonstration that both of the patient's alleles for the androgen receptor gene were unmethylated, and that both of the patient's ZXDA alleles were expressed. The active nature of the ring X would presumably result in overexpression of genes that may account for the developmental delay observed for the patient. Using polymorphic markers along the X chromosome, the ring X was determined to be of paternal origin with one breakpoint in the long arm between DXS8037 and XIST and one in the short arm in Xp11.2 between DXS1126 and DXS991. To attempt to determine why the XIST gene failed to be expressed, the promoter region was sequenced and found to have a base change at the same location as a variant previously associated with nonrandom X chromosome inactivation. This mutation was not seen in over one hundred normal X chromosomes examined; however, it was observed in the paternal grandmother who did not show substantial skewing of X chromosome inactivation.

A 7-year-old female was referred to the Genetics Clinic because of developmental delay and attentional difficulty The patient was adopted and there was a nonspecific prenatal history of drug and alcohol abuse. The patient had clinical signs that were not compatible with typical fetal alcohol syndrome (FAS), although there was a history of alcohol exposure in utero, neurodevelopmental difficulties with learning and behavioral problems, and mild dysmorphisms. Cytogenetic analysis revealed an unbalanced female karyotype with a dup(5) containing additional chromosome 5 material at band 5p15.3. The dup(5) showed normal copy number of the cri-du-chat region on 5p15.2 using locus-specific probes D5S721 and D5S23. Multicolor banding of chromosome 5 (MetaSystems) using partial chromosome paint (pcp) probes showed a duplication of band 5p15.3. The karyotype of the patient was therefore interpreted as follows: 46,XX,add(5)mat.ish dup(5)(p15.3)(wcp5 +,D5S271 +,D5S23 +, C84C11/T3 + +, pcp5p15.3 + +). The patient's biological mother and maternal half-brother were found to carry the identical chromosome duplication. The clinical phenotype of the biological mother is complicated by a difficult lifestyle but there were apparent learning and behavioral difficulties at school. The half-brother is nondysmorphic and presents with learning problems and attention deficit disorder (ADD). His physical examination was normal. To the best of our knowledge, this is the first report of a limited duplication of 5p15.3. The clinical significance of the dup(5)(p15.3) is still uncertain but may be the basis for learning and attention difficulties.

Objective: Maternal cell contamination (MCC) is rare in cultured amniotic fluid samples, but it poses a serious potential source of prenatal misdiagnosis. Our goal was to determine whether the amniocentesis sampling technique influences the incidence of maternal cell contamination.

Roberts syndrome (RS) is a rare autosomal recessive disorder characterized by heterogeneous clinical features, the most notable being tetraphocomelia, cleft lip, and cleft palate. Cells derived from most RS patients exhibit abnormal cytogenetic and cellular phenotypes that include the premature separation of para- and pericentromeric heterochromatin visible on C-banded metaphase chromosomes, a phenomenon referred to as heterochromatic splaying. Previously, it was shown that these abnormal phenotypes can be complemented following somatic cell hybridization between RS cells and control cells. In the current study, a permanent cell line was established from a new RS patient with a more severe phenotype than represented by previously established cells in culture. With a newly developed assay designed to facilitate rapid evaluation of in vitro complementation, we assigned this new patient to the same genetic complementation group defined by other, less severely affected patients. The results demonstrate that a single complementation group defines RS patients with heterochromatic splaying regardless of clinical severity.

Objectives. To assess the health-related quality-of-life (HRQL) effects of chorionic villi sampling (CVS) and genetic amniocentesis (GA) prenatal diagnosis, including factors related to both the processes and the outcomes. Study Design. The HRQL of one hundred twenty six women participating in a randomized controlled clinical trial of CVS versus GA in Toronto and Hamilton, Ontario was assessed in four interviews at weeks 8, 13, 18, and 22 of pregnancy. Statistical analyses included analysis of variance, repeated measures analysis of covariance, chi-square, Fisher’s exact test, Student’s t-tests, and paired t-tests. Results. Utility scores for patients undergoing CVS exceeded those for GA patients at week 18 (p = 0.04). Utility scores for hypothetical health states did not differ significantly by trial arm. Conclusions. CVS results in slightly improved HRQL relative to GA during the second trimester of pregnancy. This advantage needs to be weighed against the high disutility patients attach to infrequent outcomes associated with pregnancy losses, equivocal diagnoses, and diagnostic inaccuracy.

Alobar holoprosencephaly (HPE) was identified by ultrasonography at 18 weeks' gestation in a fetus of a 29‐year‐old G2P0A1 woman. HPE has been described in association with various chromosomal anomalies. Amniocentesis was performed and a rearrangement of chromosome 18 resembling an isochromosome for the long arm of chromosome 18 was found. Subsequently, the mother was found to have a pericentric inversion of chromosome 18 with breakpoints at p11.31 and q11.2. The karyotype of the fetus was re‐interpreted as 46,XX,rec(18)dup(18q)inv(18)(p11.31q11.2)mat. This is the first case of a parental inversion leading to a deficiency of 18p11.31 to 18pter associated with HPE. Copyright © 2000 John Wiley & Sons, Ltd.

We report an infant with holoprosencephaly (HPE), sacral anomalies, and situs ambiguus with a 46,XY,der(7)t(2;7)(p23.2;q36.1) karyotype as a result of an adjacent‐1 segregation of a t(2;7)pat. The chromosomal abnormality was diagnosed prenatally after sonographic detection of HPE in the fetus. The baby was born at 37 weeks gestation, and died in the newborn period; he had dysmorphic features consistent with HPE sequence. Postmortem internal evaluation showed semilobar HPE, abdominal situs ambiguus, multiple segments of bowel atresia, dilatation of the ureters, and bony sacral anomalies. Molecular analysis confirmed hemizygosity for the SHH and HLXB9 genes, which are likely to be responsible for the HPE and sacral phenotypes, respectively. Immunohistochemical studies showed intact dopaminergic pathways in the mesencephalon, suggesting that midbrain dopamine neuron induction appears to require only one functioning SHH allele.

We report on a patient with de novo interstitial deletion of the long arm of chromosome 12: 46,XY,del(12)(q24.31q24.33). To our knowledge this is the first patient with this chromosomal abnormality reported. He was born with minor anomalies, ambiguous genitalia, tracheomalacia, and he was developmentally delayed at age 9 months. The phenotype associated with this deletion may be characteristic. However, because of the absence of reported cases of other patients with loss of this chromosomal region, we cannot delineate the specific phenotype further. Ambiguous genitalia or hypogonadism has been reported in other patients with chromosomal rearrangements involving 12q24.

Cytogenetic results from a large multicentre randomized controlled study of 2108 amniotic fluids obtained at 11+0-12+6 weeks (EA) and 1999 fluids at 15+0-16+6 weeks (MA) were compared. There was no statistically significant difference in the rate of chromosome abnormalities (EA =1.9 per cent; MA=1.7 per cent) or level III mosaicism (EA=0.2 per cent; MA=0.2 per cent) between the groups. Level I and Level II mosaicism occurred more frequently in MA.Maternal cell contamination was not significantly different between the groups, but maternal cells only were analysed from one bloody EA fluid.The number of repeat amniocenteses because of cytogenetic problems was 2.2 per cent in the EA group compared with only 0.3 per cent in the MA group. On average, culture of EA fluids required one day more than MA fluids.Although both culture success (97.7 per cent) and accuracy (99.8 per cent) were high for patients randomized to the EA group, routine amniocentesis prior to 13 weeks' gestation is not recommended for clinical reasons including an increased risk of fetal loss and talipes equinovarus. Copyright (C) 1999 John Wiley & Sons, Ltd.

Background Most published reports on early amniocentesis are of cohort studies rather than randomised trials, This study was designed to assess the safely and cytogenetic accuracy of early amniocentesis in contrast to midtrimester amniocentesis in a randomised multicentre setting,Methods Pregnant women were randomly allocated early amniocentesis (between 11(+0) and 12(+6) gestational weeks(days)) or midtrimester (between 15(+0) and 16(+6) amniocentesis. A detailed fetal ultrasound examination was done between 15 and 20 gestational weeks in ail women. All amniocenteses were done under continuous ultrasound guidance: 11 mt (early amniocentesis) or 20 mt (midtrimester amniocentesis) of amniotic fluid were removed for cytogenic analysis, No more than two needle insertions were done on the same day, All fetal losses (spontaneous or induced abortions) were counted as outcome events and post-procedural losses had cytogenic analysis, Maternal and fetal health were assessed at 20-22 weeks and 5 weeks after delivery, Logistic regression analysis was used to assess the significance of the differences between the early amniocentesis and midtrimester amniocentesis groups.Findings 4374 pregnant women took part in the study, 1916 (87.8%) of 2183 women in the early amniocentesis group had their amniocentesis before 13 gestational weeks. 1775 (81.2%)) of 2185 women in the midtrimester group had their amniocentesis after 15 gestational weeks, There was a significant difference in total fetal losses for early amniocentesis compared with midtrimester amniocentesis (7.6% vs 5.9%; difference 1.7%, one-sided CI 2.98%, p=0.012). There was a significant increase in talipes equinovarus in the early amniocentesis group compared with the midtrimester amniocentesis group (1.3% vs 0.1%, p=0.0001). There was a significant difference in postprocedural amniotic-fluid leakage (early amniocentesis 3.5% vs midtrimester aminocentesis 1.7%, p=0.0007).Interpretation Our study shows that early amniocentesis is associated with an increased risk of fetal loss and talipes equinovarus, Our results should be taken into consideration when invasive prenatal diagnosis is being offered.

Fanconi anemia (FA) is an autosomal recessive disorder, characterised by multiple congenital malformations, bone marrow failure and a predisposition to developing malignancies, especially leukemia. FA cells show increased levels of spontaneous chromosomal aberrations and a hypersensitivity to DNA cross-linking agents such as mitomycin C (MMC) and diepoxybutane (DEB). There are at least eight complementation groups involved in FA, and the genes for two of these groups, FA(A) and FA(C), have been isolated and cloned. Mouse models for FA(C) have been developed by replacing exon 8 or exon 9 of Fac with the neo gene. Mice homozygous for Fac mutations show reduced fertility and hypersensitivity to induction of chromosomal aberrations by MMC and DEB. To facilitate the study of cellular defects in vitro, transformed mouse fibroblast cell lines were established. Cell-killing experiments and cytogenetic analyses were performed on these cells following treatment with MMC and DEB. Fac−/− showed significant hypersensitivity to MMC and DEB as compared with Fac+/+ and +/− for both cellular phenotypes. This is consistent with results obtained from similar studies on human fibroblasts and lymphoblastoid cell lines. Therefore, these isogenic transformed mouse fibroblasts provide an in vitro model for further investigation of the hypersensitivity of Fanconi anemia cells to DNA cross-linking agents.

Ring X chromosomes that do not undergo inactivation may cause malformations and mental retardation. We report on a fetus with anencephaly, total dorsal rachischisis, and diaphragmatic hernia that was found to have a mosaic 45,X/46,X,r(X)(p11.22q12) karyotype. Fluorescent in situ hybridization (FISH) confirmed that the ring chromosome was X-derived. This report expands the phenotypic spectrum of mosaic monosomy X and small ring X chromosomes.

Objectives-To evaluate the risk of having a child with a congenital anomaly in relation to occupational exposure to low level ionising radiation in the pre-conception period.Methods-A case-control study based on the Canadian congenital anomalies registry used record Linkage techniques to identify congenital anomalies among male and female workers in Canada's largest electric company. Cases were defined as parents of a child with a congenital anomaly born between April 1979 and December 1986 who had a congenital anomaly diagnosed within the first year of life. Controls were an individually matched sample of parents of a Liveborn child without an anomaly. Risk of congenital anomaly was assessed in relation to parental exposure to ionising radiation acquired through work within a nuclear generating station of an electric power company. Exposure was assessed according to employment, whether or not the worker was monitored for radiation exposure, and quantitative estimates of radiation dose.Results-Employment within the electric power industry was not associated with an increased risk of congenital anomalies in the offspring of mothers or fathers. Risk estimates for workers monitored (those who are likely to be exposed to ionising radiation) were 1.75 (95% confidence interval (95% CI) 0.86 to 3.55) for mothers and 0.84 (95% CI 0.68 to 1.05) for fathers. Exposure for fathers before conception, defined cumulatively and for six months before conception, was not associated with increased risk of anomalies in their offspring. There were no significant increases in risk found between type of anomaly and any measure of exposure, although the statistical power in these groups was limited. The study had insufficient numbers to evaluate the effects of ionising radiation in mothers as only three mothers had recorded doses >0 mSv.Conclusions-Overall, workers in a nuclear power industry, and specifically those exposed before conception to low levels of ionising radiation, do not appear to be at an increased risk of having a liveborn child with a congenital anomaly.