- Inclusion/Exclusion criteria
Patients enrolled in this protocol will have been referred with a known or suspected inborn error of metabolism, heritable disorder, or genetic predisposition. Examples include inherited developmental defects or diatheses toward infections, cancer, or an environmentally induced disease. The principal investigator, along with consulting specialists, will review the medical records of prospective subjects and offer admission based upon the potential to help the individual, to learn from the patient, or to initiate clinical or basic research suggested by the patient's workup. Prior to late 2008, patients enrolled in this protocol had disorders of current or potential future research interest to the Principal Investigator or an Associate Investigator. Approximately 400 such patients were enrolled over the course of 32 years.
Beginning in 2008, the protocol became one of the vehicles for admitting patients with a broader range of inborn errors of metabolism (e.g., those with immune defects, developmental disorders, cancer diatheses, etc.) through the NIH UDP. There are several aspects of this process:
- Screening and triaging. Records are reviewed by the UDP Director for completeness and missing articles (e.g., images, biopsy slides) are requested. The UDP Director assigns records for review to consultants based upon the specialty involved, and copies of the records are distributed to 1-5 experts.
- Criteria for eligibility. Eligibility criteria include novelty of clinical findings, multiple family members affected, or an objective laboratory or imaging clue to pursue. Of course, patients have to be able to travel, as well.
- Roles of the UDP personnel. The UDP Director performs the triage, makes the final decision, and signs the decision letters. The consultants are NIH clinical specialists from the Clinical Center departments and the ICs. A group of nurse practitioners and one physician's assistant communicate about medical issues with patients and referring physicians. Support personnel obtain missing articles, copy records, file them, send out letters of receipt, enter information in the Lab Matrix database, and answer phone calls.
- Consent timing and process. In general, consent is obtained by the care team upon admission. Occasionally, a patient or family member gives consent for a blood draw locally; this is obtained by an Associate Investigator over the phone and in writing.
Patients apply with a summary letter from their referring physician and with their medical records; the cases are then reviewed by members of a large group of NIH consultants. If any of those consultants finds that an applicant qualifies for her/his protocol (in any institute), the patient is invited to enroll in that protocol. The UDP connects the patient with the principal investigator; there is no involvement of protocol 76-HG-0238.
For patients not selected by other services, the UDP Director, based largely on specialists' recommendations, makes the final decision regarding acceptance or rejection with respect to protocol 76-HG-0238. The UDP has evolved such that the majority of its patients are now being enrolled in 76-HG-0238.
Once a patient is enrolled in 76-HG-0238, her/his management is the same regardless of whether or not entry was through the UDP. Specifically, in each case, all testing except the skin biopsy, DNA analysis, and research bloods is medically indicated and directed toward diagnosis.
Some subjects will be relatives of patients with known diagnoses, and their specimens will be obtained for the purpose of heterozygote testing or to serve as controls to help diagnose the proband. All subjects shall be admitted as inpatients or outpatients at the discretion of the principal investigator, based upon particular research interests and expertise.
Individuals will be excluded from this protocol if they already have a diagnosis, if their previous evaluations leave no clue to pursue, if they appear to have a known diagnosis that has not been made, or if their subjective complaints far exceed any objective findings. We will not admit patients under one month of age to this protocol. This exclusion occurs because there is no urgency for a very early diagnosis and care is more readily proffered to older individuals at the Clinical Center. Patients under one year of age will be admitted only if they are medically stable and require admission to the Clinical Center for diagnosis.
Normal adult volunteers will be enrolled to provide control blood and urine specimens.