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Dortenzio V, Rhodes R, Merkelson A, Naik H. Research biobank participants attitudes towards genetic exceptionalism and health record confidentiality. J Community Genet 2024; 15:267-280. [PMID: 38441842 PMCID: PMC11217258 DOI: 10.1007/s12687-024-00704-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/29/2024] [Indexed: 07/02/2024] Open
Abstract
Understanding attitudes towards genetic exceptionalism and confidentiality is important in guiding policies regarding special protections for genetic/genomic information stored in electronic health records (EHR). The goals of this study were to determine biobank participants' attitudes towards genetic exceptionalism and confidentiality and whether those attitudes are related to their preference for return of genetic results. An online questionnaire was distributed to patients with an EHR and email address who had previously enrolled in the BioMe Biobank program. Most participants responded with similar levels of concern in scenarios involving the use of genetic information and other types of health information, suggesting that participants want similar protections for genetic data as other types of sensitive health information, particularly mental health and family history records. Of the 829 respondents, the majority had genetic exceptionalist views when directly asked, even though their concerns about confidentiality were similar for their genetic information and other health information. There were no differences in genetic exceptionalist views between those who had a documented preference to have genetic results returned and those who did not. Notably, for many participants, their recall of preference did not align with their documented preference. The majority of biobank participants were most anxious about the loss of confidentiality for genetic, mental health, and family history information, indicating that certain types of health information are considered more "sensitive" than others. These findings suggest the importance of assuring people participating in biobank research that the confidentiality of their "sensitive" health information is secured.
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Affiliation(s)
- Victoria Dortenzio
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Roberts Individualized Medical Genetics Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rosamond Rhodes
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Amanda Merkelson
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hetanshi Naik
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- Department of Genetics, Stanford University School of Medicine, 483 Quarry Road, 450E, Stanford, CA, 94304, USA.
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Allen CG, McBride CM, Escoffery C, Guan Y, Hood C, Zaho J, Brody G, An W. Developing and assessing a kin keeping scale with application to identifying central influencers in African American family networks. J Community Genet 2023; 14:593-603. [PMID: 37648941 PMCID: PMC10725405 DOI: 10.1007/s12687-023-00665-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 08/18/2023] [Indexed: 09/01/2023] Open
Abstract
Promoting family communication about inherited disease risk is an arena in which family systems theory is highly relevant. One family systems' construct that can support promotion of family communication regarding inherited disease risk is the notion of "kin keeping." However, kin keeping and whether it might be capitalized on to encourage family communication about inherited risk has been understudied. The goal of this report was to propose a broadened conceptualization of kin keeping that distinguishes between a structural functional perspective (role conceptualization) and transitional behaviors (skill conceptualization), and to develop and evaluate a scale that would enable this assertion to be tested among a sample of African American community health workers. We developed a scale using four steps: item development using concept analysis and content validity, scale development among a national sample (n = 312), scale evaluation using exploratory factor analysis (n = 52), and scale reduction. We then posed suppositions of associations that would indicate whether the developed kin keeping measure was assessing a specific family role or set of behaviors. Our results included the development of the first quantitative measure of kin keeping (9- and 15-item scales). Model fit for 9-item scale (CFI = 0.97, AFGI = 0.89, RMSEA = 0.09, SMRM = 0.06) and model fit for 15-item scale (CFI = 0.97, AFGI = 0.89, RMSEA = 0.06, SMRM = 0.05). These findings allow us to move toward more rigorous research about the role of kin keeping on information sharing and health decision making. Results also suggest that, contrary to the historical structural functional conceptualization of kin keeping as a role, kin keeping might also be conceptualized as a behavior or set of modifiable behaviors. Ultimately, the kin keeping scale could be used to operationalize kin keeping in various theoretical models and frameworks, guide intervention development to encourage or train for kin keeping behaviors, and test assumptions of whether families vary in the density of kin keeping.
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Affiliation(s)
- Caitlin G Allen
- Medical University of South Carolina, Charleston, SC, USA.
- Emory University, Atlanta, GA, USA.
| | | | | | - Yue Guan
- Emory University, Atlanta, GA, USA
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3
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Zhang J, Grant JE. Significance of family history in understanding and subtyping trichotillomania. Compr Psychiatry 2022; 119:152349. [PMID: 36215772 DOI: 10.1016/j.comppsych.2022.152349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 09/28/2022] [Accepted: 09/30/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND AIMS The existence of subtypes of trichotillomania (TTM) have long been hypothesized, and recent studies have further elucidated characteristic subtypes of TTM and possible ramifications of subtyping for treatment. In clinical applications of subtyping for treatment of TTM, family history (FH) of psychiatric disorders in patients may serve as a tool to differentiate disorder presentations and inform care. We compared prevalence of psychiatric illnesses in first-degree relatives of participants with TTM and healthy controls, respectively, in a large sample, and examined associations between those psychiatric disorders that were significantly different in the FH between groups and measures of disability, severity, and neuropsychological constructs. METHODS We compared FHs of 152 participants (mean age = 29.9) with TTM and 71 healthy controls (mean age = 29.6), utilizing chi-squared tests to determine which psychiatric illnesses were more prevalent in FHs of participants with TTM. We then used two-tailed t-tests to compare TTM participants with those more prevalent FHs to participants without those FHs on measures of disorder severity, disability, and neuropsychological constructs. FINDINGS Obsessive-compulsive disorder (OCD), TTM, skin picking disorder (SPD), and major depressive disorder (MDD) were significantly more frequent in first-degree relatives (p < 0.0033) of TTM participants than those of healthy controls. TTM participants with a FH of OCD scored significantly higher on measures of impulsivity and lower on measures of distress tolerance. Those with FH of TTM, SPD, and MDD did not differ significantly across measured variables. CONCLUSION OCD, TTM, SPD, and MDD are more prevalent in the FHs of people with TTM, as compared to healthy controls. TTM participants with a family history of OCD may be more likely to demonstrate decreased distress tolerance and increased impulsivity. In all, as understanding of TTM subtypes develops, the FH may prove a useful tool in delineating subtypes and informing care.
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Affiliation(s)
- James Zhang
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Jon E Grant
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA.
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Dineen M, Sidaway-Lee K, Pereira Gray D, Evans PH. Family history recording in UK general practice: the lIFeLONG study. Fam Pract 2022; 39:610-615. [PMID: 34568898 PMCID: PMC9295608 DOI: 10.1093/fampra/cmab117] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In order to integrate genomic medicine into routine patient care and stratify personal risk, it is increasingly important to record family history (FH) information in general/family practice records. This is true for classic genetic disease as well as multifactorial conditions. Research suggests that FH recording is currently inadequate. OBJECTIVES To provide an up-to-date analysis of the frequency, quality, and accuracy of FH recording in UK general/family practice. METHODS An exploratory study, based at St Leonard's Practice, Exeter-a suburban UK general/family practice. Selected adult patients registered for over 1 year were contacted by post and asked to complete a written FH questionnaire. The reported information was compared with the patients' electronic medical record (EMR). Each EMR was assessed for its frequency (how often information was recorded), quality (the level of detail included), and accuracy (how closely the information matched the patient report) of FH recording. RESULTS Two hundred and forty-one patients were approached, 65 (27.0%) responded and 62 (25.7%) were eligible to participate. Forty-three (69.4%) EMRs contained FH information. The most commonly recorded conditions were bowel cancer, breast cancer, diabetes, and heart disease. The mean quality score was 3.64 (out of 5). There was little negative recording. 83.2% of patient-reported FH information was inaccurately recorded or missing from the EMRs. CONCLUSION FH information in general/family practice records should be better prepared for the genomic era. Whilst some conditions are well recorded, there is a need for more frequent, higher quality recording with greater accuracy, especially for multifactorial conditions.
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Affiliation(s)
- Molly Dineen
- College of Medicine and Health, University of Exeter, Exeter, Devon, United Kingdom.,St Leonard's Practice, Exeter, Devon, United Kingdom
| | | | - Denis Pereira Gray
- College of Medicine and Health, University of Exeter, Exeter, Devon, United Kingdom.,St Leonard's Practice, Exeter, Devon, United Kingdom
| | - Philip H Evans
- College of Medicine and Health, University of Exeter, Exeter, Devon, United Kingdom.,St Leonard's Practice, Exeter, Devon, United Kingdom
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5
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Xu L, Sanders L, Li K, Chow JCL. Chatbot for Health Care and Oncology Applications Using Artificial Intelligence and Machine Learning: Systematic Review. JMIR Cancer 2021; 7:e27850. [PMID: 34847056 PMCID: PMC8669585 DOI: 10.2196/27850] [Citation(s) in RCA: 92] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 07/02/2021] [Accepted: 09/18/2021] [Indexed: 01/01/2023] Open
Abstract
Background Chatbot is a timely topic applied in various fields, including medicine and health care, for human-like knowledge transfer and communication. Machine learning, a subset of artificial intelligence, has been proven particularly applicable in health care, with the ability for complex dialog management and conversational flexibility. Objective This review article aims to report on the recent advances and current trends in chatbot technology in medicine. A brief historical overview, along with the developmental progress and design characteristics, is first introduced. The focus will be on cancer therapy, with in-depth discussions and examples of diagnosis, treatment, monitoring, patient support, workflow efficiency, and health promotion. In addition, this paper will explore the limitations and areas of concern, highlighting ethical, moral, security, technical, and regulatory standards and evaluation issues to explain the hesitancy in implementation. Methods A search of the literature published in the past 20 years was conducted using the IEEE Xplore, PubMed, Web of Science, Scopus, and OVID databases. The screening of chatbots was guided by the open-access Botlist directory for health care components and further divided according to the following criteria: diagnosis, treatment, monitoring, support, workflow, and health promotion. Results Even after addressing these issues and establishing the safety or efficacy of chatbots, human elements in health care will not be replaceable. Therefore, chatbots have the potential to be integrated into clinical practice by working alongside health practitioners to reduce costs, refine workflow efficiencies, and improve patient outcomes. Other applications in pandemic support, global health, and education are yet to be fully explored. Conclusions Further research and interdisciplinary collaboration could advance this technology to dramatically improve the quality of care for patients, rebalance the workload for clinicians, and revolutionize the practice of medicine.
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Affiliation(s)
- Lu Xu
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada.,Department of Medical Biophysics, Western University, London, ON, Canada
| | - Leslie Sanders
- Department of Humanities, York University, Toronto, ON, Canada
| | - Kay Li
- Department of English, York University, Toronto, ON, Canada
| | - James C L Chow
- Department of Medical Physics, Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
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Mahtani K, Park D, Abbott J, Selvam PP, Atwal PS. Importance of Family History in the Era of Exome Analysis: A Report of a Family with Multiple Concurrent Genetic Diseases. Hum Hered 2021; 86:28-33. [PMID: 34706366 DOI: 10.1159/000519356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 08/30/2021] [Indexed: 11/19/2022] Open
Abstract
Multiple familial diseases in a single patient often present with overlapping symptomatology that confers difficulty in delineating a clinical diagnosis. Pedigree analysis has been a long-standing practice in the field of medical genetics to discover familial diseases. In recent years, whole exome sequencing (WES) has proven to be a useful tool for aiding physicians in diagnosing and understanding disease etiology. This report shows that pedigree analysis and WES are co-dependent processes in establishing diagnoses in a family with 4 different genetic disorders: Birt-Hogg-Dubé Syndrome, RRM2B-related mitochondrial disease, CDC73-related primary hyperparathyroidism, and familial prostate cancer.
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Affiliation(s)
- Karishma Mahtani
- Genomic and Personalized Medicine, Atwal Clinic, Palm Beach, Florida, USA,
| | - Diana Park
- Genomic and Personalized Medicine, Atwal Clinic, Palm Beach, Florida, USA
| | - Jessica Abbott
- Genomic and Personalized Medicine, Atwal Clinic, Palm Beach, Florida, USA
| | | | - Paldeep S Atwal
- Genomic and Personalized Medicine, Atwal Clinic, Palm Beach, Florida, USA
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7
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Welch BM, Allen CG, Ritchie JB, Morrison H, Hughes-Halbert C, Schiffman JD. Using a Chatbot to Assess Hereditary Cancer Risk. JCO Clin Cancer Inform 2021; 4:787-793. [PMID: 32897737 DOI: 10.1200/cci.20.00014] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE We developed a Web-based chatbot (ItRunsInMyFamily.com) to help individuals collect their family health history (FHx) and determine their risk for hereditary cancer. The purpose of the current study was to assess the characteristics of users and identify opportunities to improve the FHx collection tool. METHODS During Family Health History Month (November 2019) we launched an FHx campaign using social media advertisements to raise awareness about hereditary cancers and encourage individuals in the general population to use ItRunsInMyFamily to collect their FHx. Through this campaign, we were able to gather information about users and identify opportunities to improve the tool. RESULTS We reached 14,140 users in November 2019 through online marketing campaigns-Facebook, Google, previous ItRuns users, and Web site marketing. Of those, 3,204 completed the full FHx assessment and received risk recommendations. The campaign targeted women between age 40 and 60 years. Users came from 3,783 counties around the United States, 48 unique cancers were reported among probands, and 79 unique cancers were reported among family members, an average of two and a half cancers per family. CONCLUSION Our results demonstrate that it is possible to gather FHx information at the population level, with high levels of engagement and interest in the topic. There is room for future enhancements and improvements to ItRunsInMyFamily to broaden its reach and encourage individuals to learn about and record their health information.
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Affiliation(s)
- Brandon M Welch
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Caitlin G Allen
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Jordon B Ritchie
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | | | - Chanita Hughes-Halbert
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC
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8
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Allen CG, Bethea BJ, McKinney LP, Escoffery C, Akintobi TH, McCray GG, McBride CM. Exploring the Role of Community Health Workers in Improving the Collection of Family Health History: A Pilot Study. Health Promot Pract 2021; 23:504-517. [PMID: 34049463 DOI: 10.1177/15248399211019980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Community health workers (CHWs) have been successful partners in addressing public health and health care challenges but have yet to be engaged in efforts to promote family health history (FHH) collection. FHH information is a key factor in determining disease risk and supporting screening and prevention across multiple diseases. The collection of FHH information could be facilitated by the existing cadre of CHWs already working alongside clients and families. In this qualitative study, we interviewed 30 CHWs from Georgia to better understand the current level of knowledge about FHH, perceptions of how FHH collection aligns with their role, and barriers and facilitators in order to support more active involvement of CHWs in FHH collection. Interviews were completed, transcribed, and double coded by three study team members. More than half of CHWs reported knowing their own FHH information. CHWs showed a strong interest and support for collecting FHH in their job, despite limited current engagement in this role. CHWs acknowledged the collection of FHH as being an opportunity to empower clients to have conversations with their providers. To better support this work, CHWs requested training in using and integrating FHH tools into their workflow and support in communicating about FHH with their clients. Our findings suggest that with support and training, CHWs are uniquely positioned to improve FHH collection among their client base. Ultimately, improving FHH collection skills among the population could allow for better integration of risk-stratified approaches that are informed by FHH information for the prevention, management, and treatment of disease.
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9
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Wang C, Paasche-Orlow MK, Bowen DJ, Cabral H, Winter MR, Norkunas Cunningham T, Trevino-Talbot M, Toledo DM, Cortes DE, Campion M, Bickmore T. Utility of a virtual counselor (VICKY) to collect family health histories among vulnerable patient populations: A randomized controlled trial. PATIENT EDUCATION AND COUNSELING 2021; 104:979-988. [PMID: 33750594 PMCID: PMC8113103 DOI: 10.1016/j.pec.2021.02.034] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 01/25/2021] [Accepted: 02/16/2021] [Indexed: 05/29/2023]
Abstract
OBJECTIVES This study is a randomized controlled trial comparing the efficacy of a virtual counselor (VICKY) to the My Family Health Portrait (MFHP) tool for collecting family health history (FHx). METHODS A total of 279 participants were recruited from a large safety-net hospital and block randomized by health literacy to use one of the digital FHx tools, followed by a genetic counselor interview. A final sample of 273 participants were included for analyses of primary study aims pertaining to tool concordance, which assessed agreement between tool and genetic counselor. RESULTS Tool completion differed significantly between tools (VICKY = 97%, MFHP = 51%; p < .0001). Concordance between tool and genetic counselor was significantly greater for participants randomized to VICKY compared to MFHP for ascertaining first- and second-degree relatives (ps<.0001), and most health conditions examined. There was significant interaction by health literacy, with greater differences in concordance observed between tools among those with limited literacy. CONCLUSIONS A virtual counselor overcomes many of the literacy-related barriers to using traditional digital tools and highlights an approach that may be important to consider when collecting health histories from vulnerable populations. PRACTICE IMPLICATIONS The usability of digital health history tools will have important implications for the quality of the data collected and its downstream clinical utility.
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Affiliation(s)
- Catharine Wang
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA.
| | - Michael K Paasche-Orlow
- Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Deborah J Bowen
- Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle, WA, USA
| | - Howard Cabral
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Michael R Winter
- Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, MA, USA
| | | | - Michelle Trevino-Talbot
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA
| | - Diana M Toledo
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Dharma E Cortes
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA; Health Equity Research Lab, Cambridge Health Alliance, Cambridge, MA, USA
| | - MaryAnn Campion
- Department of Genetics, Stanford University, Stanford, CA, USA
| | - Timothy Bickmore
- Khoury College of Computer Sciences, Northeastern University, Boston, MA, USA
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10
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Hinshaw JC, Zhao LP, Brimm JE, Payne TH, Hisama FM. Value of a genetics clinic evaluation in identifying women at risk for hereditary breast-ovarian cancer syndrome. J Genet Couns 2021; 30:1591-1597. [PMID: 33881185 DOI: 10.1002/jgc4.1425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 03/20/2021] [Accepted: 03/22/2021] [Indexed: 11/08/2022]
Abstract
Our work evaluates the contributions of a genetics clinic visit in assessing patients' risk of hereditary cancers and in meeting National Cancer Comprehensive Network (NCCN) criteria for genetic testing. We reviewed the electronic health records (EHR) of 56 women seen for medical care in our healthcare system who were subsequently seen in the Adult Genetics Clinic. We searched for all personal or family cancer history available in either free-text or structured form within the EHR prior to the genetics visit. For each patient, we then compared the aggregate data with the pedigree information obtained at the Genetics Clinic visit for first-, second-, and third-degree relatives. During the genetics clinic visit, the number of relatives with cancer diagnoses doubled from 121 to 235, and for 17 of 56 (30%) of patients, family histories changed one or more NCCN criteria. For 39/56 (70%) of patients, the family history in the EHR was not changed during the genetics clinic visit. Of 56 women referred to the genetics clinic, 45 (80%) met NCCN guidelines for testing, 40 women underwent genetic testing, and 9 of 40 (23%) tested were positive for a Likely Pathogenic or Pathogenic (LP/P) variant. This study of 56 women quantitatively demonstrates the value of a genetics clinic visit by improved identification of key family history components.
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Affiliation(s)
- Jesse C Hinshaw
- University of Washington School of Medicine, Seattle, WA, USA
| | - Lue-Ping Zhao
- Fred Hutchinson Cancer Research Institute, Seattle, WA, USA
| | - John E Brimm
- University of Washington School of Medicine, Seattle, WA, USA
| | - Thomas H Payne
- Department of Medicine (General Internal Medicine), University of Washington School of Medicine, Seattle, WA, USA.,Brotman Baty Institute for Precision Medicine, University of Washington, Seattle, WA, USA
| | - Fuki M Hisama
- Brotman Baty Institute for Precision Medicine, University of Washington, Seattle, WA, USA.,Department of Medicine (Medical Genetics), University of Washington School of Medicine, Seattle, WA, USA
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Snir M, Nazareth S, Simmons E, Hayward L, Ashcraft K, Bristow SL, Esplin ED, Aradhya S. Democratizing genomics: Leveraging software to make genetics an integral part of routine care. AMERICAN JOURNAL OF MEDICAL GENETICS. PART C, SEMINARS IN MEDICAL GENETICS 2020; 187:14-27. [PMID: 33296144 DOI: 10.1002/ajmg.c.31866] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 12/25/2022]
Abstract
Genetic testing can provide definitive molecular diagnoses and guide clinical management decisions from preconception through adulthood. Innovative solutions for scaling clinical genomics services are necessary if they are to transition from a niche specialty to a routine part of patient care. The expertise of specialists, like genetic counselors and medical geneticists, has traditionally been relied upon to facilitate testing and follow-up, and while ideal, this approach is limited in its ability to integrate genetics into primary care. As individuals, payors, and providers increasingly realize the value of genetics in mainstream medicine, several implementation challenges need to be overcome. These include electronic health record integration, patient and provider education, tools to stay abreast of guidelines, and simplification of the test ordering process. Currently, no single platform offers a holistic view of genetic testing that streamlines the entire process across specialties that begins with identifying at-risk patients in mainstream care settings, providing pretest education, facilitating consent and test ordering, and following up as a "genetic companion" for ongoing management. We describe our vision for using software that includes clinical-grade chatbots and decision support tools, with direct access to genetic counselors and pharmacists within a modular, integrated, end-to-end testing journey.
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Abstract
The aim of this integrative review is to investigate current literature regarding family health history (FHH) taking practices, attitudes, and challenges in the pediatric outpatient setting. FHH is a known clinical tool for providers; however, there are no explicit standards for pediatric FHH collection. The integrative review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. PubMed, Embase, CINAHL, PsycINFO, and Cochrane databases were searched for publications between January 2010 and December 2019, and 8 articles were selected for evaluation. Three themes are explored in this review: FHH collection practices, challenges, and tools. FHH collection practices were found to be inconsistent and the most commonly cited challenge was time. No validated FHH collection tools have been identified for the pediatric population. These findings suggest the need for standardization in FHH collection and further development of tools to improve FHH collection.
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13
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Pyeritz RE. Uncertainty in Genomics Impacts Precision Medicine. Trends Genet 2020; 37:711-716. [PMID: 33218792 DOI: 10.1016/j.tig.2020.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/21/2020] [Accepted: 10/22/2020] [Indexed: 11/25/2022]
Abstract
As exacting as genetic and genomic testing have become, health professionals continue to encounter uncertainty in their applications to medical practice. As examining the human genome at more refined levels increases, so is the likelihood of encountering uncertainty about the meaning of the information. The history of this concept informs how we might confront and deal with uncertainty, and what the future might hold. Precision medicine holds great promise for establishing more accurate diagnoses, directing specific therapy to patients who will most benefit from it, and avoiding treatments in patients who are most likely to suffer adverse consequences, or at best not benefit. But its application depends importantly on the proper interpretation of a person's genotype.
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Affiliation(s)
- Reed E Pyeritz
- Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA.
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14
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Schienda J, Stopfer J. Cancer Genetic Counseling-Current Practice and Future Challenges. Cold Spring Harb Perspect Med 2020; 10:cshperspect.a036541. [PMID: 31548230 DOI: 10.1101/cshperspect.a036541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Cancer genetic counseling practice is rapidly evolving, with services being provided in increasingly novel ways. Pretest counseling for cancer patients may be abbreviated from traditional models to cover the elements of informed consent in the broadest of strokes. Genetic testing may be ordered by a cancer genetics professional, oncology provider, or primary care provider. Increasingly, direct-to-consumer testing options are available and utilized by consumers anxious to take control of their genetic health. Finally, genetic information is being used to inform oncology care, from surgical decision-making to selection of chemotherapeutic agent. This review provides an overview of the current and evolving practice of cancer genetic counseling as well as opportunities and challenges for a wide variety of indications in both the adult and pediatric setting.
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Affiliation(s)
- Jaclyn Schienda
- Division of Cancer Genetics and Prevention, Dana Farber Cancer Institute, Boston, Massachusetts 02215, USA
| | - Jill Stopfer
- Division of Cancer Genetics and Prevention, Dana Farber Cancer Institute, Boston, Massachusetts 02215, USA
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15
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Chin XW, Ang ZLT, Tan RYC, Courtney E, Shaw T, Chen Y, Li S, Ngeow JYY. Use of telephone intake for family history taking at a cancer genetics service in Asia. J Genet Couns 2020; 29:1192-1199. [DOI: 10.1002/jgc4.1286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 03/30/2020] [Accepted: 04/04/2020] [Indexed: 12/29/2022]
Affiliation(s)
- Xin Wei Chin
- Cancer Genetics Service Division of Medical Oncology National Cancer Centre Singapore City Singapore
| | - Zoe L. T. Ang
- Cancer Genetics Service Division of Medical Oncology National Cancer Centre Singapore City Singapore
| | - Ryan Y. C. Tan
- Cancer Genetics Service Division of Medical Oncology National Cancer Centre Singapore City Singapore
| | - Eliza Courtney
- Cancer Genetics Service Division of Medical Oncology National Cancer Centre Singapore City Singapore
| | - Tarryn Shaw
- Cancer Genetics Service Division of Medical Oncology National Cancer Centre Singapore City Singapore
| | - Yanni Chen
- Cancer Genetics Service Division of Medical Oncology National Cancer Centre Singapore City Singapore
| | - Shao‐Tzu Li
- Cancer Genetics Service Division of Medical Oncology National Cancer Centre Singapore City Singapore
| | - Joanne Yuen Yie Ngeow
- Cancer Genetics Service Division of Medical Oncology National Cancer Centre Singapore City Singapore
- Lee Kong Chian School of Medicine Nanyang Technological University Singapore City Singapore
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16
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Haga SB, Orlando LA. The enduring importance of family health history in the era of genomic medicine and risk assessment. Per Med 2020; 17:229-239. [PMID: 32320338 DOI: 10.2217/pme-2019-0091] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Improving disease risk prediction and tailoring preventive interventions to patient risk factors is one of the primary goals of precision medicine. Family health history is the traditional approach to quickly gather genetic and environmental data relevant to the patient. While the utility of family health history is well-documented, its utilization is variable, in part due to lack of patient and provider knowledge and incomplete or inaccurate data. With the advances and reduced costs of sequencing technologies, comprehensive sequencing tests can be performed as a risk assessment tool. We provide an overview of each of these risk assessment approaches, the benefits and limitations and implementation challenges.
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Affiliation(s)
- Susanne B Haga
- Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, 101 Science Drive, Box 3382, Durham, NC 27708, USA
| | - Lori A Orlando
- Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, 101 Science Drive, Box 3382, Durham, NC 27708, USA
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17
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Allen CG, Duquette D, Guan Y, McBride CM. Applying theory to characterize impediments to dissemination of community-facing family health history tools: a review of the literature. J Community Genet 2020; 11:147-159. [PMID: 31267271 PMCID: PMC7062972 DOI: 10.1007/s12687-019-00424-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 04/30/2019] [Indexed: 10/26/2022] Open
Abstract
Uptake of community-facing family health history (FHH) tools to identify those at highest risk of disease and target prevention efforts has been consistently low. This review uses the diffusion of innovations (DOI) as a framework to organize the FHH evidence base and identify potential strategies to improve uptake of community-facing FHH tools. Methods for this literature review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. We completed systematic searches in PubMed, Embase, and Web of Science databases for studies from 2009 to 2017 and hand searched bibliographies of relevant literature to identify additional articles. We abstracted and synthesized results, which were then organized by the DOI including the innovation-decision making process and characteristics of the innovation likely to influence diffusion (e.g., compatibility, relative advantage, complexity, trialability, observa/bility). Of the 290 unique articles identified, 65 were eligible for full-text review after title and abstract screening; a total of 27 were included in the final abstraction. Eleven unique tools were identified. The most commonly used tool was the Surgeon General's My Family Health Portrait (n =9/27). Only six studies directly evaluated participant perceptions shown to be associated with tool uptake. Studies tended to focus on improving compatibility by customizing tools to the target population's needs and use of educational interventions. Results from this review suggest the need to evaluate strategies to increase the pace of uptake of community-facing FHH tools. These include pragmatic trials that compare different approaches to engage and evaluate participant perceptions of the relative advantage and complexity of tools. Ancillary support strategies may include collaborations with community networks to facilitate use and implementation study designs for rigorous evaluation.
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Affiliation(s)
- Caitlin G Allen
- Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA, 30308, USA.
| | - Debra Duquette
- Feinberg School of Medicine, Northwestern University, 420 East Superior Street, Chicago, IL, 60611, USA
| | - Yue Guan
- Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA, 30308, USA
| | - Colleen M McBride
- Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA, 30308, USA
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18
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Cerda Diez M, E. Cortés D, Trevino-Talbot M, Bangham C, Winter MR, Cabral H, Norkunas Cunningham T, M. Toledo D, J. Bowen D, K. Paasche-Orlow M, Bickmore T, Wang C. Designing and Evaluating a Digital Family Health History Tool for Spanish Speakers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E4979. [PMID: 31817849 PMCID: PMC6950582 DOI: 10.3390/ijerph16244979] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 11/25/2019] [Accepted: 12/04/2019] [Indexed: 12/20/2022]
Abstract
Digital family health history tools have been developed but few have been tested with non-English speakers and evaluated for acceptability and usability. This study describes the cultural and linguistic adaptation and evaluation of a family health history tool (VICKY: VIrtual Counselor for Knowing Your Family History) for Spanish speakers. In-depth interviews were conducted with 56 Spanish-speaking participants; a subset of 30 also participated in a qualitative component to evaluate the acceptability and usability of Spanish VICKY. Overall, agreement in family history assessment was moderate between VICKY and a genetic counselor (weighted kappa range: 0.4695 for stroke-0.6615 for heart disease), although this varied across disease subtypes. Participants felt comfortable using VICKY and noted that VICKY was very likeable and possessed human-like characteristics. They reported that VICKY was very easy to navigate, felt that the instructions were very clear, and thought that the time it took to use the tool was just right. Spanish VICKY may be useful as a tool to collect family health history and was viewed as acceptable and usable. The study results shed light on some cultural differences that may influence interactions with family history tools and inform future research aimed at designing and testing culturally and linguistically diverse digital systems.
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Affiliation(s)
- Maria Cerda Diez
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA 02118, USA; (M.C.D.); (M.T.-T.); (C.B.); (T.N.C.)
| | - Dharma E. Cortés
- Health Equity Research Lab, Cambridge Health Alliance, Cambridge, MA 02141, USA;
- Department of Psychiatry, Harvard Medical School, Cambridge, MA 02139, USA
| | - Michelle Trevino-Talbot
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA 02118, USA; (M.C.D.); (M.T.-T.); (C.B.); (T.N.C.)
| | - Candice Bangham
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA 02118, USA; (M.C.D.); (M.T.-T.); (C.B.); (T.N.C.)
| | - Michael R. Winter
- Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, MA 02118, USA;
| | - Howard Cabral
- Department of Biostatistics, Boston University School of Public Health, Boston, MA 02118, USA;
| | - Tricia Norkunas Cunningham
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA 02118, USA; (M.C.D.); (M.T.-T.); (C.B.); (T.N.C.)
| | - Diana M. Toledo
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA;
| | - Deborah J. Bowen
- Department of Bioethics and Humanities, School of Public Health, University of Washington, Seattle, WA 98195, USA;
| | | | - Timothy Bickmore
- College of Computer and Information Science, Northeastern University, Boston, MA 02115, USA;
| | - Catharine Wang
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA 02118, USA; (M.C.D.); (M.T.-T.); (C.B.); (T.N.C.)
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Carroll JC, Allanson J, Morrison S, Miller FA, Wilson BJ, Permaul JA, Telner D. Informing Integration of Genomic Medicine Into Primary Care: An Assessment of Current Practice, Attitudes, and Desired Resources. Front Genet 2019; 10:1189. [PMID: 31824576 PMCID: PMC6882282 DOI: 10.3389/fgene.2019.01189] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 10/28/2019] [Indexed: 01/24/2023] Open
Abstract
Introduction: Preparing primary care providers for genomic medicine (GM) first requires assessment of their educational needs in order to provide clear, purposeful direction and justify educational activities. More understanding is needed about primary care providers’ perspectives on their role in newer areas of GM and what resources would be helpful in practice. Our objective was to determine family physicians’ (FP) current involvement and confidence in GM, attitudes regarding its clinical value, suggestions for integration of GM into practice, and resources and education required. Methods: A self-complete anonymous questionnaire was mailed to a random sample of 2,000 FPs in Ontario, Canada in September 2012. Results: Adjusted response rate was 26% (361/1,365), mean age was 51, and 53% were male. FPs reported many aspects of traditional GM as part of current practice (eliciting family history: 93%; deciding who to refer to genetics: 94%; but few reported confidence (44%, 32% respectively). Newer areas of GM were not part of most FPs’ current practice and confidence was low (pharmacogenetics: 28% part of practice, 5% confident; direct-to-consumer genetic testing: 14%/2%; whole genome sequencing: 8%/2%). Attitudes were mixed with 59% agreeing that GM would improve patient health outcomes, 41% seeing benefits to genetic testing, but only 36% agreeing it was their responsibility to incorporate GM into practice. Few could identify useful sources of genetic information (22%) or find information about genetic tests (21%). Educational resources participants anticipated would be useful included contact information for local genetics clinics (89%), summaries of genetic disorders (86%), and genetic referral (85%) and testing (86%) criteria. About 58% were interested in learning about new genetic technologies. Most (76%) wanted to learn through in-person teaching (lectures, seminars etc.), 66% wanted contact with a local genetic counselor to answer questions, and 59% were interested in a genetics education website. Conclusion: FPs lack confidence in GM skills needed for practice, particularly in emerging areas of GM. They see their role as making appropriate referrals, are somewhat optimistic about the contribution GM may make to patient care, but express caution about its current clinical benefits. There is a need for evidence-based educational resources integrated into primary care and improved communication with genetic specialists.
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Affiliation(s)
- June C Carroll
- Sinai Health System, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Judith Allanson
- Department of Genetics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Shawna Morrison
- Department of Genetics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Fiona A Miller
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Brenda J Wilson
- Division of Community Health and Humanities, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Joanne A Permaul
- Sinai Health System, Ray D Wolfe Department of Family Medicine, Toronto, ON, Canada
| | - Deanna Telner
- South East Toronto Family Health Team, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
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20
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Abstract
The collection of family history has always been a tool for genetic evaluation, but it remains an essential tool even in the age of genomic medicine. Patients may have a risk for a disease based on family history regardless of the results of genetic and genomic tests. How this information is collected is less important than that relevant information is collected in the first place. There are many tools for collecting medical and family history information both by hand and electronically. Genetic and genomic testing should always be interpreted in the context of the personal and family history.
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Affiliation(s)
- Robin L Bennett
- Division of Medical Genetics, Department of Medicine, University of Washington, University of Washington Medical Center, Box 357720, 1959 Northeast Pacific Street, Seattle, WA 98195-7720, USA.
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21
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22
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Manolio TA, Rowley R, Williams MS, Roden D, Ginsburg GS, Bult C, Chisholm RL, Deverka PA, McLeod HL, Mensah GA, Relling MV, Rodriguez LL, Tamburro C, Green ED. Opportunities, resources, and techniques for implementing genomics in clinical care. Lancet 2019; 394:511-520. [PMID: 31395439 PMCID: PMC6699751 DOI: 10.1016/s0140-6736(19)31140-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 04/09/2019] [Accepted: 05/03/2019] [Indexed: 12/19/2022]
Abstract
Advances in technologies for assessing genomic variation and an increasing understanding of the effects of genomic variants on health and disease are driving the transition of genomics from the research laboratory into clinical care. Genomic medicine, or the use of an individual's genomic information as part of their clinical care, is increasingly gaining acceptance in routine practice, including in assessing disease risk in individuals and their families, diagnosing rare and undiagnosed diseases, and improving drug safety and efficacy. We describe the major types and measurement tools of genomic variation that are currently of clinical importance, review approaches to interpreting genomic sequence variants, identify publicly available tools and resources for genomic test interpretation, and discuss several key barriers in using genomic information in routine clinical practice.
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Affiliation(s)
- Teri A Manolio
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA.
| | - Robb Rowley
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | | | - Dan Roden
- Department of Medicine, Department of Pharmacology, and Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Geoffrey S Ginsburg
- Duke Center for Applied Genomic and Precision Medicine, Duke University, Durham, NC, USA
| | - Carol Bult
- The Jackson Laboratory for Mammalian Genetics, Bar Harbor, ME, USA
| | - Rex L Chisholm
- Center for Genetic Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | | | - Howard L McLeod
- DeBartolo Family Personalized Medicine Institute, Moffitt Cancer Center, Tampa, FL, USA
| | - George A Mensah
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Mary V Relling
- Pharmaceutical Sciences Department, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Laura Lyman Rodriguez
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Cecelia Tamburro
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Eric D Green
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
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23
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Allen C, Escoffery C, Haardörfer R, McBride C. Factors Influencing Not Perceiving Family Health History Assessments as Important: Opportunities to Improve Dissemination of Evidence-Based Population Screening for Cancer. Public Health Genomics 2019; 21:144-153. [DOI: 10.1159/000499125] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 02/25/2019] [Indexed: 11/19/2022] Open
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24
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Clinicians’ experiences and perspectives of breast cancer and possible integration of breast cancer prevention and early detection into palliative care. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2019. [DOI: 10.1016/j.ijans.2019.100162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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25
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Esteban I, Lopez-Fernandez A, Balmaña J. A narrative overview of the patients' outcomes after multigene cancer panel testing, and a thorough evaluation of its implications for genetic counselling. Eur J Med Genet 2018; 62:342-349. [PMID: 30476626 DOI: 10.1016/j.ejmg.2018.11.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 11/08/2018] [Accepted: 11/22/2018] [Indexed: 01/07/2023]
Abstract
Massively parallel sequencing is being implemented in clinical practice through the use of multigene panel testing, whole exome sequencing and whole genome sequencing. In this manuscript we explore how the use of massively parallel sequencing, and in particular multigene cancer panel testing, is potentially changing the process of genetic counselling and how patients cope with pre-test genetic counselling and results. We found that the main challenges are around uncertainty, hopes and expectations and the amount and complexity of information that needs to be discussed. This may impact the process of genetic counselling, although genetic counsellors can still use their core skills and enhance some of them in order to evolve and meet patients' needs in the genomics era. Available data suggests that patients can cope with multigene cancer panels although more research is needed to fully understand the psychosocial implications of multigene cancer panels for patients, especially for those who have variants of unknown significance or moderate penetrance variants. Research is also needed to explore and develop communication models that maximize patients' understanding and empower them to make informed decisions.
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Affiliation(s)
- I Esteban
- Department of Clinical Genetics, Ninewells Hospital, Dundee, Scotland, UK.
| | - A Lopez-Fernandez
- High Risk and Cancer Prevention Unit, Vall D'Hebron Institute of Oncology, Barcelona, Spain
| | - J Balmaña
- High Risk and Cancer Prevention Unit, Vall D'Hebron Institute of Oncology, Barcelona, Spain; Medical Oncology Department, Vall D'Hebron Hospital, Barcelona, Spain
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26
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Aday AW, Kreykes SE, Fanola CL. Vascular Genetics: Presentations, Testing, and Prognostics. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:103. [PMID: 30421267 DOI: 10.1007/s11936-018-0703-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW Numerous studies have begun to unravel the genetic basis of not only aortic disease but also other forms of commonly encountered vascular diseases. The goal of this review is to provide clinicians a reference to help identify and diagnose different types of vascular disease with a genetic underpinning. RECENT FINDINGS Ongoing studies have identified numerous genes involved in the TGF-β signaling pathway that are also associated with thoracic aortic aneurysm and dissection, and it is possible to test for pathogenic variants in these genes in the clinical setting using commercially available genetic testing panels. Additional studies have begun to identify genetic variants associated with an increased risk of bicuspid aortic valve, abdominal aortic aneurysm, and fibromuscular dysplasia. With increased availability of low-cost genetic testing, clinicians are now able to not only definitively diagnose some vascular syndromes but also provide information on the risk of disease in other family members, as well as provide guidance in terms of family planning. As the cost of genetic testing continues to drop with the benefit of increasing insurance coverage, genetic data will increasingly become part of clinical care for many patients with vascular disease.
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Affiliation(s)
- Aaron W Aday
- Vanderbilt Translational and Clinical Cardiovascular Research Center, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, 2525 West End Avenue Suite 300, Nashville, TN, 37203, USA.
| | - Sarah E Kreykes
- Adult Congenital and Cardiovascular Genetics Center, Division of Cardiovascular Medicine, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Christina L Fanola
- Adult Congenital and Cardiovascular Genetics Center, Division of Cardiovascular Medicine, University of Minnesota Medical Center, Minneapolis, MN, USA
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27
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Kaminga AC, Dai W, Liu A, Myaba J, Banda R, Wen SW, Pan X. Rate of and time to symptomatic remission in first-episode psychosis in Northern Malawi: A STROBE-compliant article. Medicine (Baltimore) 2018; 97:e13078. [PMID: 30407306 PMCID: PMC6250544 DOI: 10.1097/md.0000000000013078] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Although longer duration of untreated psychosis (DUP) is associated with poor response to antipsychotic treatment, it remains unclear whether it independently influences time to symptomatic remission in first-episode psychosis (FEP). This study examined rate of symptomatic remission, and explored if DUP, premorbid functioning, global functioning, insight and socio-demographic characteristics were independently associated with time to symptomatic remission in FEP.This prospective study enrolled 126 FEP patients (aged 18-65) between June 2009 and September 2012. Subjects were followed-up monthly over 18 months after they had received antipsychotic medication. Remission in positive and negative symptoms was defined as in the Remission in Schizophrenia Working Group (RSWG) criteria. Subjects were defined as "in symptomatic remission" if they remitted in both negative and positive symptoms. At baseline, the following explanatory variables were measured: socio-demographic characteristics; DUP as short (≤5 months) and long (>5 months); premorbid functioning as deteriorating, stable poor, and stable good according to Cannon-Spoor Premorbid Adjustment Scale; global functioning as "worst (1-10) to serious (41-50)" and "moderate (51-60) to superior (91-100)," according to the Global Assessment of Functioning Scale; and insight as poor (≤8) and good (≥9) according to the Insight Scale (Birchwood). Univariate and multivariable analyses were used to generate results.Out of 126 subjects, 98 (78%) completed follow-up, of which 70 (71.4%) achieved symptomatic remission within mean duration of 8.05 (4.54) months. Besides, having long DUP and separated/divorced/widowed (adjusted hazard ratio [aHR] = 0.07, 95%CI = [0.01, 0.46]), long DUP and poor insight (aHR = 0.18, 95%CI = [0.04, 0.89]), poor insight and separated/divorced/widowed (aHR = 0.09, 95%CI = [0.01, 0.70]), deteriorating premorbid functioning (aHR = 0.47, 95%CI = [0.23, 0.97]), family history of psychiatric disorders (aHR = 0.52, 95%CI = (0.30, 0.93]), and being male (aHR = 0.47, 95%CI = [0.24, 0.92]) delayed symptomatic remission.These results propose that psychological interventions and social support for mental health problems are warranted and may enhance better response to antipsychotic medications among separated/divorced/widowed patients with long DUP or poor insight, and poor insight patients with long DUP. Deteriorating premorbid functioning, family history of psychiatric disorders and being male continue being important risk factors for poor odds of remission.
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Affiliation(s)
- Atipatsa Chiwanda Kaminga
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, Hunan, China
- Department of Mathematics and Statistics, Mzuzu University, Private Bag 201, Luwinga,
| | - Wenjie Dai
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, Hunan, China
| | - Aizhong Liu
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, Hunan, China
| | - Japhet Myaba
- Department of Clinical Medicine, Mental Health Research Section, Saint John of God Community Services, Mzuzu, Malawi
| | - Richard Banda
- Department of Clinical Medicine, Mental Health Research Section, Saint John of God Community Services, Mzuzu, Malawi
| | - Shi Wu Wen
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, Hunan, China
- OMNI Research Group, Department of Obstetrics and Gynecology, Faculty of Medicine, University of Ottawa
- Ottawa Hospital Research Institute, Clinical Epidemiology Program
- School of Epidemiology, Public Health, and Preventive Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Xiongfeng Pan
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, Hunan, China
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28
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Christensen KD, Phillips KA, Green RC, Dukhovny D. Cost Analyses of Genomic Sequencing: Lessons Learned from the MedSeq Project. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2018; 21:1054-1061. [PMID: 30224109 PMCID: PMC6444358 DOI: 10.1016/j.jval.2018.06.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 06/11/2018] [Indexed: 05/17/2023]
Abstract
OBJECTIVE To summarize lessons learned while analyzing the costs of integrating whole genome sequencing into the care of cardiology and primary care patients in the MedSeq Project by conducting the first randomized controlled trial of whole genome sequencing in general and specialty medicine. METHODS Case study that describes key methodological and data challenges that were encountered or are likely to emerge in future work, describes the pros and cons of approaches considered by the study team, and summarizes the solutions that were implemented. RESULTS Major methodological challenges included defining whole genome sequencing, structuring an appropriate comparator, measuring downstream costs, and examining clinical outcomes. Discussions about solutions addressed conceptual and practical issues that arose because of definitions and analyses around the cost of genomic sequencing in trial-based studies. CONCLUSIONS The MedSeq Project provides an instructive example of how to conduct a cost analysis of whole genome sequencing that feasibly incorporates best practices while being sensitive to the varied applications and diversity of results it may produce. Findings provide guidance for researchers to consider when conducting or analyzing economic analyses of whole genome sequencing and other next-generation sequencing tests, particularly regarding costs.
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Affiliation(s)
- Kurt D Christensen
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
| | - Kathryn A Phillips
- Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California San Francisco, San Francisco, CA, USA; Philip R. Lee Institute for Health Policy and Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - Robert C Green
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA; Partners HealthCare Personalized Medicine, Boston, MA, USA
| | - Dmitry Dukhovny
- Department of Pediatrics, Oregon Health & Science University, Portland, OR, USA
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29
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Time to rethink the capture and use of family history in primary care. Br J Gen Pract 2017; 66:627-628. [PMID: 27884911 DOI: 10.3399/bjgp16x688273] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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30
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Saul RA, Trotter T, Sease K, Tarini B. Survey of family history taking and genetic testing in pediatric practice. J Community Genet 2017; 8:109-115. [PMID: 28064391 DOI: 10.1007/s12687-016-0291-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 12/26/2016] [Indexed: 12/12/2022] Open
Abstract
Family health history collection and genetic testing are core elements for the successful translation of genomics into primary care practice. Yet, little is known about how pediatric providers implement these elements in practice. We surveyed the membership of the American Academy of Pediatrics regarding family health history (FHH) collection and genetic testing in the primary care setting. Three hundred forty-nine (349) responses were analyzed with the initial response rate of 43.3%. Four principal findings were noted-(1) family health history is still recognized as a critical part of the medical evaluation; (2) perceived obstacles for FHH are time in obtaining the FHH and concerns about the family's knowledge of their FHH; (3) a 3-generation family history is out of the scope of routine care and alternate methods should be considered; (4) most primary care providers (PCPs) do not feel comfortable ordering, interpreting, and counseling regarding current genetic testing. Expanded genetic/genomic education at multiple levels (undergraduate medical education, graduate medical education, and maintenance of certification) is clearly indicated to allow PCPs to integrate these vital elements into a current evaluation (acute care or health maintenance) in the primary care setting.
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Affiliation(s)
- Robert A Saul
- Center for Pediatric Medicine, Children's Hospital, Greenville Health System, 20 Medical Ridge Drive, Greenville, SC, 29605, USA.
| | | | - Kerry Sease
- Center for Pediatric Medicine, Children's Hospital, Greenville Health System, 20 Medical Ridge Drive, Greenville, SC, 29605, USA
| | - Beth Tarini
- Stead Family Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, IL, USA
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31
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Hickey KT, Katapodi MC, Coleman B, Reuter-Rice K, Starkweather AR. Improving Utilization of the Family History in the Electronic Health Record. J Nurs Scholarsh 2016; 49:80-86. [PMID: 28094908 DOI: 10.1111/jnu.12259] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2016] [Indexed: 11/27/2022]
Abstract
PURPOSE The purpose of this article is to provide an overview of Family History in the Electronic Health Record and to identify opportunities to advance the contributions of nurses in obtaining, updating and assessing family history in order to improve the health of all individuals and populations. ORGANIZING CONSTRUCT The article presents an overview of the obstacles to charting Family History within the Electronic Health Record and recommendations for using specific Family History tools and core Family History data sets. METHODS Opportunities to advance nursing contributions in obtaining, updating, and assessing family history in order to improve the health of all individuals were identified. These opportunities are focused within the area of promoting the importance of communication within families and between healthcare providers to obtain, document, and update family histories. FINDINGS Nurses can increase awareness of existing resources that can guide collection of a comprehensive and accurate family history and facilitate family discussions. In this paper, opportunities to advance nursing contributions in obtaining, updating, and assessing family history in order to improve the health of all individuals were identified. CONCLUSIONS Aligned with the clinical preparation of nurses, family health should be used routinely by nurses for risk assessment and to help inform patient and family members on screening, health promotion, and disease prevention. The quality of family health information is critical in order to leverage the use of genomic healthcare information and derive new knowledge about disease biology, treatment efficacy, and drug safety. These actionable steps need to be performed in the context of promoting evidence-based applications of family history that will be essential for implementing personalized genomic healthcare approaches and disease prevention efforts. CLINICAL RELEVANCE Family health history is one of the most important tools for identifying the risk of developing rare and chronic conditions, including cardiovascular disease, cancer, and diabetes, and represents an integration of disease risk from genetic, environmental, and behavioral/lifestyle factors. In fact, family history has long been recognized as a strong independent risk factor for disease and is the current best practice used in clinical practice to guide risk assessment.
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Affiliation(s)
| | - Maria C Katapodi
- Professor of Nursing Science, University of Basel Institute of Nursing Science, Basel, Switzerland
| | - Bernice Coleman
- Nurse Scientist II, Nurse Practitioner, Heart Transplantation and Mechanical Assist Device Programs, Nursing Research and Development, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Karin Reuter-Rice
- Associate Professor, Duke University School of Nursing, Durham, NC, USA
| | - Angela R Starkweather
- Professor and Director, Center for Advancement in Managing Pain, University of Connecticut School of Nursing, Storrs, CT, USA
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Boone PM. Adolescents, Family History, and Inherited Disease Risk: An Opportunity. Pediatrics 2016; 138:peds.2016-0579. [PMID: 27371759 DOI: 10.1542/peds.2016-0579] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2016] [Indexed: 11/24/2022] Open
Affiliation(s)
- Philip M Boone
- Boston Combined Residency Program in Pediatrics, Boston, Massachusetts and Harvard Medical School Genetics Training Program, Boston, Massachusetts
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Rinke ML, Driscoll A, Mikat-Stevens N, Healy J, Colantuoni E, Elias AF, Pletcher BA, Gubernick RS, Larson I, Chung WK, Tarini BA. A Quality Improvement Collaborative to Improve Pediatric Primary Care Genetic Services. Pediatrics 2016; 137:e20143874. [PMID: 26823539 DOI: 10.1542/peds.2014-3874] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/17/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To investigate if a national pediatric primary care quality improvement collaborative (QIC) could improve and sustain adherence with process measures related to diagnosis and management of children with genetic disorders. METHODS Thirteen practices in 11 states from the American Academy of Pediatrics' Quality Improvement Innovation Networks participated in a 6-month QIC that included regular educational opportunities, access to genetic professionals, and performance feedback. The QIC identified 11 aims related to improving diagnosis and management of children with genetic disorders. The practices evaluated adherence by reviewing patient records at baseline, monthly for 6 months (active improvement period), and then once 6 months after the QIC's conclusion to check for sustainability. Random intercept binomial regression models with practice level random intercepts were used to compare adherence over time for each aim. RESULTS During the active improvement period, statistically significant improvements in adherence were observed for 4 of the 7 aims achieving minimal data submission levels. For example, adherence improved for family histories created/maintained at health supervision visits documenting all components of the family history (6% vs 60%, P < .001), and for patients with specific genetic disorders who received recommended care (58% vs 85%, P < .001). All 4 of these aims also demonstrated statistically significant improvements during the sustainability period. CONCLUSIONS A national QIC reveals promise in improving and sustaining adherence with process measures related to the diagnosis and management of genetic disorders. Future research should focus on patient outcome measures and the optimal number of aims to pursue in QICs.
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Affiliation(s)
- Michael L Rinke
- Department of Pediatrics, Children's Hospital at Montefiore, Bronx, New York;
| | - Amy Driscoll
- Peakview Pediatrics, University of Colorado Health, Greely, Colorado
| | | | - Jill Healy
- American Academy of Pediatrics, Elk Grove Village, Illinois
| | - Elizabeth Colantuoni
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Abdallah F Elias
- Department of Medical Genetics, Shodair Children's Hospital, Helena, Montana
| | | | | | - Ingrid Larson
- Department of General Academic Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
| | - Wendy K Chung
- Department of Pediatrics, New York Presbyterian Hospital, Columbia University, New York, New York; and
| | - Beth A Tarini
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan
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Baumgart LA, Postula KJV, Knaus WA. Initial clinical validation of Health Heritage, a patient-facing tool for personal and family history collection and cancer risk assessment. Fam Cancer 2015; 15:331-9. [DOI: 10.1007/s10689-015-9863-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Goetsch AL, Wicklund C, Clayman ML, Woodruff TK. Reproductive Endocrinologists' Utilization of Genetic Counselors for Oncofertility and Preimplantation Genetic Diagnosis (PGD) Treatment of BRCA1/2 Mutation Carriers. J Genet Couns 2015; 25:561-71. [PMID: 26567039 DOI: 10.1007/s10897-015-9908-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 10/30/2015] [Indexed: 11/25/2022]
Abstract
Genetic counselors believe fertility preservation and preimplantation genetic diagnosis (PGD) discussions to be a part of their role when counseling BRCA1/2 mutation-positive patients. This study is the first to explore reproductive endocrinologists' (REI) practices and attitudes regarding involvement of genetic counselors in the care of BRCA1/2 mutation carriers seeking fertility preservation and PGD. A survey was mailed to 1000 REIs from Reproductive Endocrinology & Infertility (SREI), an American Society for Reproductive Medicine (ASRM) affiliate group. A 14.5 % response rate was achieved; data was analyzed using SPSS software. The majority of participating REIs were found to recommend genetic counseling to cancer patients considering fertility preservation (82 %) and consult with a genetic counselor regarding PGD for hereditary cancer syndromes (92 %). Additionally, REIs consult genetic counselors regarding PGD patient counseling (88 %), genetic testing (78 %), and general genetics questions (66 %). Two areas genetic counselors may further aid REIs are: elicitation of family history, which is useful to determine fertility preservation and PGD intervention timing (32 % of REIs utilize a cancer family history to determine intervention timing); and, interpretation of variants of uncertain significance (VOUS) as cancer panel genetic testing becomes more common (36 % of REIs are unfamiliar with VOUS). Given our findings, the Oncofertility Consortium® created an online resource for genetic counselors focused on fertility preservation education and communication strategies.
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Affiliation(s)
- Allison L Goetsch
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 303 E. Superior St, Lurie 10-231, Chicago, IL, USA.
| | - Catherine Wicklund
- Graduate Program in Genetic Counseling, Northwestern University, Chicago, IL, USA
| | - Marla L Clayman
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Teresa K Woodruff
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 303 E. Superior St, Lurie 10-231, Chicago, IL, USA
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Abstract
Psychiatric treatment relies on a solid armamentarium of pharmacologic and nonpharmacologic treatment modalities that perform reasonably well for many patients but leave others in a state of chronic disability or troubled by problematic side effects. Treatment planning in psychiatry remains an art that depends on considerable trial and error. Thus, there is an urgent need for better tools that will provide a means for matching individual patients with the most effective treatments while minimizing the risk of adverse events. This review will consider the current state of the science in predicting treatment outcomes in psychiatry. Genetic and other biomarkers will be considered alongside clinical diagnostic, and family history data. Problems inherent in prediction medicine will also be discussed, along with recent developments that support the hope that psychiatry can do a better job in quickly identifying the best treatments for each patient.
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Affiliation(s)
- Francis J McMahon
- International Society of Psychiatric Genetics, Brentwood, Tennessee, USA; Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Human Genetics Branch, National Institute of Mental Health Intramural Research Program, Bethesda, Maryland, USA
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Bradbury AR, Patrick-Miller L, Schwartz L, Egleston B, Sands CB, Chung WK, Glendon G, McDonald JA, Moore C, Rauch P, Tuchman L, Andrulis IL, Buys SS, Frost CJ, Keegan TH, Knight JA, Terry MB, John EM, Daly MB. Psychosocial Adjustment in School-age Girls With a Family History of Breast Cancer. Pediatrics 2015; 136:927-37. [PMID: 26482668 PMCID: PMC4972044 DOI: 10.1542/peds.2015-0498] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/19/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Understanding how young girls respond to growing up with breast cancer family histories is critical given expansion of genetic testing and breast cancer messaging. We examined the impact of breast cancer family history on psychosocial adjustment and health behaviors among >800 girls in the multicenter LEGACY Girls Study. METHODS Girls aged 6 to 13 years with a family history of breast cancer or familial BRCA1/2 mutation (BCFH+), peers without a family history (BCFH-), and their biological mothers completed assessments of psychosocial adjustment (maternal report for 6- to 13-year-olds, self-report for 10- to 13-year-olds), breast cancer-specific distress, perceived risk of breast cancer, and health behaviors (10- to 13-year-olds). RESULTS BCFH+ girls had better general psychosocial adjustment than BCFH- peers by maternal report. Psychosocial adjustment and health behaviors did not differ significantly by self-report among 10- to 13-year-old girls. BCFH+ girls reported higher breast cancer-specific distress (P = .001) and were more likely to report themselves at increased breast cancer risk than BCFH- peers (38.4% vs 13.7%, P < .001), although many girls were unsure of their risk. In multivariable analyses, higher daughter anxiety was associated with higher maternal anxiety and poorer family communication. Higher daughter breast cancer-specific distress was associated with higher maternal breast cancer-specific distress. CONCLUSIONS Although growing up in a family at risk for breast cancer does not negatively affect general psychosocial adjustment among preadolescent girls, those from breast cancer risk families experience greater breast cancer-specific distress. Interventions to address daughter and mother breast cancer concerns and responses to genetic or familial risk might improve psychosocial outcomes of teen daughters.
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Affiliation(s)
- Angela R. Bradbury
- Division of Hematology/Oncology, Department of Medicine, and,Department of Medical Ethics and Health Policy, The Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania;,Address correspondence to Angela R. Bradbury, MD, Perelman School of Medicine at the University of Pennsylvania, 3 West Perelman Center, 3400 Civic Center Blvd, Philadelphia, PA 19104. E-mail:
| | - Linda Patrick-Miller
- Division of Hematology-Oncology, Department of Medicine, and the Center for Clinical Cancer Genetics and Global Health, The University of Chicago, Chicago, Illinois
| | - Lisa Schwartz
- Department of Pediatrics, Division of Oncology, The Children’s Hospital of Philadelphia and Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | - Gord Glendon
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada
| | - Jasmine A. McDonald
- Mailman School of Public Health, Columbia University Medical Center, New York, New York
| | - Cynthia Moore
- Department of Child and Adolescent Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Paula Rauch
- Department of Child and Adolescent Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Lisa Tuchman
- Department of Adolescent Medicine, Children’s National Medical Center, Washington, District of Columbia
| | - Irene L. Andrulis
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada;,Departments of Molecular Genetics and Laboratory Medicine, and
| | - Saundra S. Buys
- Department of Medicine, Division of Oncology, The University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Caren J. Frost
- College of Social Work, The University of Utah, Salt Lake City, Utah
| | - Theresa H.M. Keegan
- Cancer Prevention Institute of California, Fremont, California; and,Department of Health Research and Policy (Epidemiology), Stanford University School of Medicine, and Stanford Cancer Institute, Stanford, California
| | - Julia A. Knight
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada;,Dalla Lana School of Public Health, The University of Toronto, Toronto, Canada
| | - Mary Beth Terry
- Herbert Irving Comprehensive Cancer Center, and,Mailman School of Public Health, Columbia University Medical Center, New York, New York
| | - Esther M. John
- Cancer Prevention Institute of California, Fremont, California; and,Department of Health Research and Policy (Epidemiology), Stanford University School of Medicine, and Stanford Cancer Institute, Stanford, California
| | - Mary B. Daly
- Department of Clinical Genetics, Fox Chase Cancer Center, Temple University Health System, Philadelphia, Pennsylvania
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Underwood SM, Kelber S. Enhancing the Collection, Discussion and Use of Family Health History by Consumers, Nurses and Other Health Care Providers: Because Family Health History Matters. Nurs Clin North Am 2015; 50:509-29. [PMID: 26333607 DOI: 10.1016/j.cnur.2015.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The family health history (FHH) has long been used by nurses and other health care providers in clinical practice to determine if an individual, their family members, or their future generations are at an increased risk of heritable disease development. Information gleaned from the FHH can be used to better integrate preventive strategies into the plan of care. This report presents a summary of an exploratory pilot study that focused on the collection and use of FHH among a targeted group of Midwestern men and women. Findings suggest a need for efforts to further enhance the public's awareness of the importance of FHH.
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Affiliation(s)
- Sandra Millon Underwood
- University of Wisconsin Milwaukee College of Nursing, 1921 East Hartford, Milwaukee, WI 53211, USA.
| | - Sheryl Kelber
- Harriet H. Werley Center for Nursing Research and Evaluation, University of Wisconsin Milwaukee College of Nursing, 1921 East Hartford, Milwaukee, WI 53211, USA
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Chen ES, Carter EW, Winden TJ, Sarkar IN, Wang Y, Melton GB. Multi-source development of an integrated model for family health history. J Am Med Inform Assoc 2015; 22:e67-80. [PMID: 25336591 PMCID: PMC5901119 DOI: 10.1136/amiajnl-2014-003092] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 08/20/2014] [Accepted: 09/04/2014] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To integrate data elements from multiple sources for informing comprehensive and standardized collection of family health history (FHH). MATERIALS AND METHODS Three types of sources were analyzed to identify data elements associated with the collection of FHH. First, clinical notes from multiple resources were annotated for FHH information. Second, questions and responses for family members in patient-facing FHH tools were examined. Lastly, elements defined in FHH-related specifications were extracted for several standards development and related organizations. Data elements identified from the notes, tools, and specifications were subsequently combined and compared. RESULTS In total, 891 notes from three resources, eight tools, and seven specifications associated with four organizations were analyzed. The resulting Integrated FHH Model consisted of 44 data elements for describing source of information, family members, observations, and general statements about family history. Of these elements, 16 were common to all three source types, 17 were common to two, and 11 were unique. Intra-source comparisons also revealed common and unique elements across the different notes, tools, and specifications. DISCUSSION Through examination of multiple sources, a representative and complementary set of FHH data elements was identified. Further work is needed to create formal representations of the Integrated FHH Model, standardize values associated with each element, and inform context-specific implementations. CONCLUSIONS There has been increased emphasis on the importance of FHH for supporting personalized medicine, biomedical research, and population health. Multi-source development of an integrated model could contribute to improving the standardized collection and use of FHH information in disparate systems.
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Affiliation(s)
- Elizabeth S Chen
- Center for Clinical and Translational Science—Biomedical Informatics Unit, University of Vermont, Burlington, Vermont, USA
- Department of Medicine—Division of General Internal Medicine, University of Vermont, Burlington, Vermont, USA
- Department of Computer Science, University of Vermont, Burlington, Vermont, USA
| | - Elizabeth W Carter
- Center for Clinical and Translational Science—Biomedical Informatics Unit, University of Vermont, Burlington, Vermont, USA
| | - Tamara J Winden
- Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota, USA
- Division of Applied Research, Allina Health, Minneapolis, Minnesota, USA
| | - Indra Neil Sarkar
- Center for Clinical and Translational Science—Biomedical Informatics Unit, University of Vermont, Burlington, Vermont, USA
- Department of Computer Science, University of Vermont, Burlington, Vermont, USA
- Department of Microbiology and Molecular Genetics, University of Vermont, Burlington, Vermont, USA
| | - Yan Wang
- Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Genevieve B Melton
- Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
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Is it Time for Genomic Counseling? Retrofitting Genetic Counseling for the Era of Genomic Medicine. CURRENT GENETIC MEDICINE REPORTS 2015. [DOI: 10.1007/s40142-015-0068-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Wilson BJ, Nicholls SG. The Human Genome Project, and recent advances in personalized genomics. Risk Manag Healthc Policy 2015; 8:9-20. [PMID: 25733939 PMCID: PMC4337712 DOI: 10.2147/rmhp.s58728] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The language of “personalized medicine” and “personal genomics” has now entered the common lexicon. The idea of personalized medicine is the integration of genomic risk assessment alongside other clinical investigations. Consistent with this approach, testing is delivered by health care professionals who are not medical geneticists, and where results represent risks, as opposed to clinical diagnosis of disease, to be interpreted alongside the entirety of a patient’s health and medical data. In this review we consider the evidence concerning the application of such personalized genomics within the context of population screening, and potential implications that arise from this. We highlight two general approaches which illustrate potential uses of genomic information in screening. The first is a narrowly targeted approach in which genetic profiling is linked with standard population-based screening for diseases; the second is a broader targeting of variants associated with multiple single gene disorders, performed opportunistically on patients being investigated for unrelated conditions. In doing so we consider the organization and evaluation of tests and services, the challenge of interpretation with less targeted testing, professional confidence, barriers in practice, and education needs. We conclude by discussing several issues pertinent to health policy, namely: avoiding the conflation of genetics with biological determinism, resisting the “technological imperative”, due consideration of the organization of screening services, the need for professional education, as well as informed decision making and public understanding.
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Affiliation(s)
- Brenda J Wilson
- Department of Epidemiology and Community Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Stuart G Nicholls
- Department of Epidemiology and Community Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
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Wang C, Bickmore T, Bowen DJ, Norkunas T, Campion M, Cabral H, Winter M, Paasche-Orlow M. Acceptability and feasibility of a virtual counselor (VICKY) to collect family health histories. Genet Med 2015; 17:822-30. [PMID: 25590980 DOI: 10.1038/gim.2014.198] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 12/05/2014] [Indexed: 12/21/2022] Open
Abstract
PURPOSE To overcome literacy-related barriers in the collection of electronic family health histories, we developed an animated Virtual Counselor for Knowing your Family History, or VICKY. This study examined the acceptability and accuracy of using VICKY to collect family histories from underserved patients as compared with My Family Health Portrait (MFHP). METHODS Participants were recruited from a patient registry at a safety net hospital and randomized to use either VICKY or MFHP. Accuracy was determined by comparing tool-collected histories with those obtained by a genetic counselor. RESULTS A total of 70 participants completed this study. Participants rated VICKY as easy to use (91%) and easy to follow (92%), would recommend VICKY to others (83%), and were highly satisfied (77%). VICKY identified 86% of first-degree relatives and 42% of second-degree relatives; combined accuracy was 55%. As compared with MFHP, VICKY identified a greater number of health conditions overall (49% with VICKY vs. 31% with MFHP; incidence rate ratio (IRR): 1.59; 95% confidence interval (95% CI): 1.13-2.25; P = 0.008), in particular, hypertension (47 vs. 15%; IRR: 3.18; 95% CI: 1.66-6.10; P = 0.001) and type 2 diabetes (54 vs. 22%; IRR: 2.47; 95% CI: 1.33-4.60; P = 0.004). CONCLUSION These results demonstrate that technological support for documenting family history risks can be highly accepted, feasible, and effective.
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Affiliation(s)
- Catharine Wang
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Timothy Bickmore
- Northeastern University College of Computer and Information Science, Boston, Massachusetts, USA
| | - Deborah J Bowen
- Department of Bioethics & Humanities, University of Washington School of Medicine, Seattle, Washington, USA
| | - Tricia Norkunas
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts, USA
| | - MaryAnn Campion
- Master of Science Program in Genetic Counseling, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Howard Cabral
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Michael Winter
- Data Coordinating Center, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Michael Paasche-Orlow
- General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
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Evaluation of a novel electronic genetic screening and clinical decision support tool in prenatal clinical settings. Matern Child Health J 2015; 18:1233-45. [PMID: 24101435 DOI: 10.1007/s10995-013-1358-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
"The Pregnancy and Health Profile" (PHP) is a free prenatal genetic screening and clinical decision support (CDS) software tool for prenatal providers. PHP collects family health history (FHH) during intake and provides point-of-care risk assessment for providers and education for patients. This pilot study evaluated patient and provider responses to PHP and effects of using PHP in practice. PHP was implemented in four clinics. Surveys assessed provider confidence and knowledge and patient and provider satisfaction with PHP. Data on the implementation process were obtained through semi-structured interviews with administrators. Quantitative survey data were analyzed using Chi square test, Fisher's exact test, paired t tests, and multivariate logistic regression. Open-ended survey questions and interviews were analyzed using qualitative thematic analysis. Of the 83% (513/618) of patients that provided feedback, 97% felt PHP was easy to use and 98% easy to understand. Thirty percent (21/71) of participating physicians completed both pre- and post-implementation feedback surveys [13 obstetricians (OBs) and 8 family medicine physicians (FPs)]. Confidence in managing genetic risks significantly improved for OBs on 2/6 measures (p values ≤0.001) but not for FPs. Physician knowledge did not significantly change. Providers reported value in added patient engagement and reported mixed feedback about the CDS report. We identified key steps, resources, and staff support required to implement PHP in a clinical setting. To our knowledge, this study is the first to report on the integration of patient-completed, electronically captured and CDS-enabled FHH software into primary prenatal practice. PHP is acceptable to patients and providers. Key to successful implementation in the future will be customization options and interoperability with electronic health records.
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Rothstein MA, Roberts J, Guidotti TL. LIMITING OCCUPATIONAL MEDICAL EVALUATIONS UNDER THE AMERICANS WITH DISABILITIES ACT AND THE GENETIC INFORMATION NONDISCRIMINATION ACT. AMERICAN JOURNAL OF LAW & MEDICINE 2015; 41:523-567. [PMID: 26863849 DOI: 10.1177/0098858815622190] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Although medical care delivery by one's personal physician is the paradigmatic American healthcare arrangement, in the workplace setting, many Americans undergo medical evaluations to assess their fitness for duty or degree of impairment. This Article explores the complex and evolving legal status of occupational medical evaluations. Beginning with the legal and ethical frameworks of occupational medical practice, the Article then examines the effects of increasingly detailed legal regulation under the Americans with Disabilities Act and the Genetic Information Nondiscrimination Act on employees, employers, and physicians.
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Birt L, Emery JD, Prevost AT, Sutton S, Walter FM. Psychological impact of family history risk assessment in primary care: a mixed methods study. Fam Pract 2014; 31:409-18. [PMID: 24728773 PMCID: PMC5926455 DOI: 10.1093/fampra/cmu012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Routine family history risk assessment for chronic diseases could enable primary care practitioners to efficiently identify at-risk patients and promote preventive management strategies. OBJECTIVES To investigate patients' understanding and responses to family history risk assessment in primary care. METHOD A mixed methods study set in 10 Eastern England general practices. Participants in a family history questionnaire validation study were triaged into population or increased risk for four chronic diseases (type 2 diabetes, cardiovascular disease, breast cancer, colorectal cancer). Questionnaires completed immediately prior to the family history consultation (baseline) and 4 weeks later (follow-up) assessed the psychological impact, including State-Trait Anxiety Inventory scores. Semi-structured interviews explored the meaning participants gave to their personal familial disease risk. RESULTS Four hundred and fifty-three participants completed both baseline and follow-up questionnaires and 30 were interviewed. At follow-up, there was no increase in anxiety among either group, or differences between the groups [difference in mean change 0.02, 95% confidence interval -2.04, 2.08, P = 0.98]. There were no significant changes over time in self-rated health in either group. At follow-up, participants at increased risk (n = 153) were more likely to have recent changes to behaviour and they had stronger intentions to make changes to diet (P = 0.001), physical activity (P = 0.006) and to seek further information in the future than those at population risk (n = 300; P < 0.001). Using qualitative analysis, five themes were developed representing ways in which participants gave meaning to familial disease risk ('Being reassured', 'Controlling risk', 'Dealing with it later', 'Beyond my control', 'Disbelieving the risk'). The meanings they attributed to increased risk appeared to shape their intention to undertake behaviour change. CONCLUSION Routine assessment for familial risk of chronic diseases may be undertaken in primary care without causing anxiety or reducing self-rated health. Patient responses to family history risk assessment may inform promotion of preventive management strategies.
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Affiliation(s)
- Linda Birt
- The Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Cambridge, CB2 0SR, UK,
| | - Jon D Emery
- The Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Cambridge, CB2 0SR, UK, General Practice and Primary Care Academic Centre, University of Melbourne, Parkville VIC 3010, Australia, School of Primary Aboriginal and Rural Health Care, University of Western Australia, Crawley WA 6009, Australia
| | - A Toby Prevost
- The Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Cambridge, CB2 0SR, UK, King's College London, Department of Primary Care and Public Health Sciences, Capital House, London, UK and
| | - Stephen Sutton
- Behavioural Science Group, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, CB2 0SR
| | - Fiona M Walter
- The Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Cambridge, CB2 0SR, UK, General Practice and Primary Care Academic Centre, University of Melbourne, Parkville VIC 3010, Australia, School of Primary Aboriginal and Rural Health Care, University of Western Australia, Crawley WA 6009, Australia
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Camp KM, Trujillo E. Position of the Academy of Nutrition and Dietetics: nutritional genomics. J Acad Nutr Diet 2014; 114:299-312. [PMID: 24439821 DOI: 10.1016/j.jand.2013.12.001] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Indexed: 01/28/2023]
Abstract
It is the position of the Academy of Nutrition and Dietetics that nutritional genomics provides insight into how diet and genotype interactions affect phenotype. The practical application of nutritional genomics for complex chronic disease is an emerging science and the use of nutrigenetic testing to provide dietary advice is not ready for routine dietetics practice. Registered dietitian nutritionists need basic competency in genetics as a foundation for understanding nutritional genomics; proficiency requires advanced knowledge and skills. Unlike single-gene defects in which a mutation in a single gene results in a specific disorder, most chronic diseases, such as cardiovascular disease, diabetes, and cancer are multigenetic and multifactorial and therefore genetic mutations are only partially predictive of disease risk. Family history, biochemical parameters, and the presence of risk factors in individuals are relevant tools for personalizing dietary interventions. Direct-to-consumer genetic testing is not closely regulated in the United States and may not be accompanied by access to health care practitioners. Applying nutritional genomics in clinical practice through the use of genetic testing requires that registered dietitian nutritionists understand, interpret, and communicate complex test results in which the actual risk of developing a disease may not be known. The practical application of nutritional genomics in dietetics practice will require an evidence-based approach to validate that personalized recommendations result in health benefits to individuals and do not cause harm.
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An investigation of genetic counselors' testing recommendations: pedigree analysis and the use of multiplex breast cancer panel testing. J Genet Couns 2014; 23:618-32. [PMID: 24569857 DOI: 10.1007/s10897-014-9692-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 01/21/2014] [Indexed: 01/05/2023]
Abstract
Genetic testing recommendations for hereditary breast and ovarian cancer involve pedigree analysis and consultation of testing guidelines. The testing landscape for hereditary cancer syndromes is shifting as multiplex panel tests become more widely integrated into clinical practice. The purpose of the current study was to assess how genetic counselors utilize pedigrees to make recommendations for genetic testing, to determine consistency of these recommendations with National Comprehensive Cancer Network (NCCN) Guidelines and to explore current use of multiplex panel testing. Sixty-nine genetic counselors were recruited through the National Society of Genetic Counselors Cancer Special Interest Group's Discussion Forum. Participation involved pedigree analysis and completion of an online questionnaire assessing testing recommendations and use of multiplex panel testing. Pedigree analysis and test recommendations were scored for consistency with NCCN guidelines. The average score was 12.83/15 indicating strong consistency with NCCN guidelines. Participants were more likely to consider multiplex testing when pedigrees demonstrated highly penetrant dominant inheritance but were not indicative of a particular syndrome. Participant concerns about multiplex panel testing include limited guidelines for both testing eligibility and medical management. This study demonstrates high utilization of pedigree analysis and raises new questions about its use in multiplex genetic testing.
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Affiliation(s)
- Kelly E Ormond
- Department of Genetics and Stanford Center for Biomedical Ethics, Stanford University School of Medicine Stanford, CA, 94305-5208
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Abstract
The family history has been called the first genetic test; it was a core element of primary care long before the current wave of genetics technologies and services became clinically relevant. Risk assessment based on family history allows providers to personalize and prioritize health messages, shifts the focus of health care from treatment to prevention, and can empower individuals and families to be stewards of their own health. In a world of rising health care costs, the family history is an important tool, with its primary cost being the clinician's time. However, a recent National Institutes of Health conference highlighted the lack of substantive evidence to support the clinical utility of family histories. Annual collection of a comprehensive 3-generation family history has been held up as the gold standard for practice. However, interval family histories targeted to symptoms and family histories tailored to a child's life stage (ie, age-based health) may be important and underappreciated methods of collecting family history that yield clinically actionable data and supplement existing family history information. In this article, we review the various applications, as well as capabilities and limitations, of the family history for primary care providers.
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Affiliation(s)
- Beth A. Tarini
- Child Health Evaluation and Research Unit, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan; and
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50
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Rinke ML, Mikat-Stevens N, Saul R, Driscoll A, Healy J, Tarini BA. Genetic services and attitudes in primary care pediatrics. Am J Med Genet A 2013; 164A:449-55. [PMID: 24254914 DOI: 10.1002/ajmg.a.36339] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Accepted: 10/04/2013] [Indexed: 11/09/2022]
Abstract
Given the integral role primary care pediatricians (PCPs) play in caring for children with genetic conditions, we aimed to identify current practices of PCPs regarding genetic patients, their attitudes toward genetic medical care and their choices regarding family history taking. We conducted an on-line survey of a national convenience sample of PCPs associated with the American Academy of Pediatrics' Quality Improvement Innovation Networks. Eighty-eight respondents (29% response rate) were included in the analysis. Seventy-four (86%) reported ordering genetic based tests three or less times annually. Eleven (13%) strongly agreed that they discuss with patients the potential risks, benefits, and limitations of genetic tests. Forty-three (49%) agreed or strongly agreed that they feel competent in providing healthcare to patients related to genetics and genomics. Perceived competence was not associated with more recent training (P = 0.29), number of genetic tests ordered annually (P = 0.84) or mean number of weekly patient encounters (P = 0.15). 100% of participants stated that taking a family history is important. 27 (31%) agreed or strongly agreed that they gather a minimum of a three-generation family history. Forty-one of the 63 participants with an electronic health record (65%) reported their system was fair or poor in its ability to easily capture a three-generation family history. PCPs interested in quality improvement reported variation in care practices for children with genetic diseases and a majority did not feel competent to provide genetic related healthcare. Research should focus on improving the care and diagnosis of children with genetic disorders and enhanced integration of genetic medicine into routine primary preventative care.
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Affiliation(s)
- Michael L Rinke
- Department of Pediatrics, Children's Hospital at Montefiore, Bronx, New York
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