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Sivakumar A, Balayla J. Prevalence threshold and positive predictive value of noninvasive prenatal testing. Int J Gynaecol Obstet 2024; 167:434-438. [PMID: 38746985 DOI: 10.1002/ijgo.15606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 04/21/2024] [Accepted: 04/28/2024] [Indexed: 09/25/2024]
Abstract
OBJECTIVE Noninvasive prenatal testing (NIPT) has increased the number of conditions that can be screened. However, the prevalence of conditions assessed by NIPT has remained stable. The "prevalence threshold," a novel epidemiological concept, uses a test's sensitivity and specificity to determine the prevalence below which a test's positive predictive value declines most sharply relative to disease prevalence. In this article, we calculated the prevalence threshold for common conditions assessed through NIPT and compared the value with the actual prevalence of each condition to best ascertain the reliability of NIPT results. METHODS Six databases and PubMed were searched from January 2010 to March 2023 for sensitivity and specificity parameters of common conditions tested through NIPT. Using an equation previously derived by the authors of the current paper, the prevalence threshold for each condition was calculated. The theoretical number of test iterations required to reach the prevalence threshold was also reported. RESULTS None of the conditions tested through the NIPT had a prevalence rate that met or exceeded the calculated prevalence threshold. Trisomy 21 had the greatest concordance between the prevalence rate and the prevalence threshold. In contrast, Angelman, Cri-du-chat, and Prader-Willi syndromes had the most significant discordance. Apart from trisomy 21 and XXY, all remaining conditions required more than one test iteration to reach their respective prevalence threshold. CONCLUSION We conclude that at the current prevalence levels, the positive predictive value of NIPT remains low, with the prevalence of disease levels significantly lower than the prevalence threshold for each condition tested.
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Affiliation(s)
- Aditi Sivakumar
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jacques Balayla
- Lady Davis Institute (LDI), Jewish General HospitalDepartment of Obstetrics and Gynecology, McGill University, McGill University, Montreal, Quebec, Canada
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Shorthouse D, Lister H, Freeman GS, Hall BA. Understanding large scale sequencing datasets through changes to protein folding. Brief Funct Genomics 2024; 23:517-524. [PMID: 38521964 PMCID: PMC11428155 DOI: 10.1093/bfgp/elae007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 02/26/2024] [Accepted: 03/01/2024] [Indexed: 03/25/2024] Open
Abstract
The expansion of high-quality, low-cost sequencing has created an enormous opportunity to understand how genetic variants alter cellular behaviour in disease. The high diversity of mutations observed has however drawn a spotlight onto the need for predictive modelling of mutational effects on phenotype from variants of uncertain significance. This is particularly important in the clinic due to the potential value in guiding clinical diagnosis and patient treatment. Recent computational modelling has highlighted the importance of mutation induced protein misfolding as a common mechanism for loss of protein or domain function, aided by developments in methods that make large computational screens tractable. Here we review recent applications of this approach to different genes, and how they have enabled and supported subsequent studies. We further discuss developments in the approach and the role for the approach in light of increasingly high throughput experimental approaches.
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Affiliation(s)
- David Shorthouse
- School of Pharmacy, University College London, 29-39 Brunswick Square, London WC1N 1AX, UK
| | - Harris Lister
- Department of Medical Physics and Biomedical Engineering, Malet Place Engineering Building, University College London, Gower Street, London WC1E 6BT, UK
| | - Gemma S Freeman
- Department of Medical Physics and Biomedical Engineering, Malet Place Engineering Building, University College London, Gower Street, London WC1E 6BT, UK
| | - Benjamin A Hall
- Department of Medical Physics and Biomedical Engineering, Malet Place Engineering Building, University College London, Gower Street, London WC1E 6BT, UK
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McMahon G, Kennedy S, Miremberg H, O'Donoghue K. Non-invasive prenatal testing: Assessing the availability and accessibility of information available to the pregnant population within the Republic of Ireland. Eur J Obstet Gynecol Reprod Biol 2024; 302:149-154. [PMID: 39276565 DOI: 10.1016/j.ejogrb.2024.09.014] [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: 03/15/2024] [Revised: 09/05/2024] [Accepted: 09/10/2024] [Indexed: 09/17/2024]
Abstract
OBJECTIVE While non-invasive prenatal testing (NIPT) has been widely adopted throughout Europe, Australia, and the USA, population level access to NIPT varies considerably. Ireland has no national screening programme for fetal anomalies, although NIPT is available from out-of-country providers. We aimed to describe the availability of NIPT in Ireland and the quality of information available online from NIPT providers. METHODS Information available online from NIPT providers in the Republic of Ireland was analysed by examining all healthcare facilities websites and reviewing private health insurance directories. Data on information provided by NIPT providers was collected by two independent researchers from April to May 2023. RESULTS Four of the 19 maternity hospitals/units in Ireland had information on NIPT on their websites, with three including an explanation of NIPT, testing accuracy, and associated fees (€380-480). Twenty private clinics led by obstetric consultants advertised NIPT online, of which seventeen clinics included an explanation of NIPT, testing accuracy, and associated fees (€380-€650). Twenty-nine other providers, which included ultrasound clinics, direct-to-consumer laboratory testing, and General Practitioners, advertised NIPT with 18 of these providers including an explanation of NIPT, testing accuracy, and associated fees (€179-€630). CONCLUSION While there is apparent demand for NIPT and it is available in Ireland, there is disparity between providers on the type and quality of information available. Difficulty obtaining accessible information, the associated financial costs and location of providers advertising NIPT are likely to be barriers to accessing NIPT. A national screening programme for aneuploidy should be considered to ensure both equitable access to and reliable information about prenatal screening.
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Affiliation(s)
- Gabriela McMahon
- Pregnancy Loss Research Group, Department of Obstetrics & Gynaecology University College Cork, Cork, Ireland.
| | - Sarah Kennedy
- Pregnancy Loss Research Group, Department of Obstetrics & Gynaecology University College Cork, Cork, Ireland
| | - Hadas Miremberg
- Pregnancy Loss Research Group, Department of Obstetrics & Gynaecology University College Cork, Cork, Ireland
| | - Keelin O'Donoghue
- Pregnancy Loss Research Group, Department of Obstetrics & Gynaecology University College Cork, Cork, Ireland; INFANT Research Centre, University College Cork, Cork, Ireland
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Skojo M, Srebniak MI, Henneman L, Sistermans EA, van der Meij KRM. Implementing non-invasive prenatal testing in a national screening program: Lessons learned from the TRIDENT studies. Best Pract Res Clin Obstet Gynaecol 2024; 97:102543. [PMID: 39243520 DOI: 10.1016/j.bpobgyn.2024.102543] [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: 06/07/2024] [Revised: 07/04/2024] [Accepted: 09/02/2024] [Indexed: 09/09/2024]
Abstract
The Dutch NIPT Consortium, a multidisciplinary collaboration of stakeholders in prenatal care initiated and launched the TRIDENT studies. The goal of the TRIDENT studies was to implement non-invasive prenatal testing (NIPT), first as a contingent (second-tier) and later as a first-tier test, and to evaluate this implementation. This paper describes how NIPT can be successfully implemented in a country or state. Important factors include the significance of forming a consortium and encouraging cooperation among relevant stakeholders, appropriate training for obstetric care professionals, and taking into account the perspectives of pregnant women when implementing prenatal tests. We describe the advantages of high sensitivity and specificity when comparing contingent NIPT with first-tier NIPT. This paper emphasizes the value of pre- and post-test counselling and the requirement for a standardized method of information delivery and value clarification, to assist couples in decision making for prenatal screening.
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Affiliation(s)
- Matea Skojo
- Department of Clinical Genetics, Erasmus University Medical Centre, 3015 GD, Rotterdam, the Netherlands
| | - Malgorzata I Srebniak
- Department of Clinical Genetics, Erasmus University Medical Centre, 3015 GD, Rotterdam, the Netherlands
| | - Lidewij Henneman
- Department of Human Genetics, Amsterdam UMC, Vrije Universiteit Amsterdam, 1007 MB, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, 1007 MB, Amsterdam, the Netherlands
| | - Erik A Sistermans
- Department of Human Genetics, Amsterdam UMC, Vrije Universiteit Amsterdam, 1007 MB, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, 1007 MB, Amsterdam, the Netherlands
| | - Karuna R M van der Meij
- Department of Human Genetics, Amsterdam UMC, Vrije Universiteit Amsterdam, 1007 MB, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, 1007 MB, Amsterdam, the Netherlands.
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Ferrari A, Pennestrì F, Bonciani M, Banfi G, Vainieri M, Tomaiuolo R. The role of patient-reported experiences in disclosing genetic prenatal testing: Findings from a large-scale survey on pregnant women. Eur J Obstet Gynecol Reprod Biol X 2024; 23:100327. [PMID: 39130210 PMCID: PMC11315116 DOI: 10.1016/j.eurox.2024.100327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 07/10/2024] [Accepted: 07/12/2024] [Indexed: 08/13/2024] Open
Abstract
Introduction Pregnant women can choose from different prenatal genetic tests throughout their maternity journey. We aim to investigate the clinical, societal, and economic determinants influencing the selection of different options (non-invasive, invasive, or both). Methods A systematic survey focusing on maternity pathways was launched by the Region of Tuscany, Italy, to collect data on pregnant women's experience, outcomes and satisfaction levels. Drawing from this survey, we retrospectively analyzed data on women who filled out the second-trimester questionnaire between March 2019 and February 2023 (n = 27,337), providing complete data on relevant variables. Logistic regression models were applied to identify the factors contributing to a higher likelihood of opting for non-invasive prenatal testing (NIPT) and invasive testing. Results Among the participants, 42.7 % chose only NIPT, 3.8 % opted for invasive tests exclusively, 1.3 % underwent both tests, and 52.2 % did not pursue any genetic testing. NIPT was more often chosen by older, Italian, highly educated, nulliparous women, who perceived better health, were employed (versus unemployed), had higher economic status, planned pregnancy, received hospital-based care (versus counseling center), under gynecologist supervision (versus midwife), not opted for combined testing and received pregnancy vaccinations. Conversely, invasive testing was more prevalent among older women but less common among those who were nulliparous, had Italian nationality, and had a perceived better health status. This group also tended to experience unplanned and high-risk pregnancy, did not take folate during pregnancy, received public hospital-based assistance, less frequently chose combined tests or NIPT, and had frequent delays in examinations. Conclusions Various factors beyond clinical considerations influence the selection of a prenatal test. Therefore, NIPT pathways should include balanced, high-quality information about benefits and limitations, ensuring laboratory specialists' active and integrated involvement in decision-making.
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Affiliation(s)
- Amerigo Ferrari
- Institute of Management, MeS (Management and Health) Laboratory, Scuola Superiore Sant’Anna, Pisa, Italy
- Department of Clinical and Experimental Medicine, Division of Obstetrics and Gynecology, University of Pisa, Pisa, Italy
| | | | - Manila Bonciani
- Institute of Management, MeS (Management and Health) Laboratory, Scuola Superiore Sant’Anna, Pisa, Italy
- Meyer Center for Health and Happiness, A. Meyer Children's Hospital, Florence, Italy
| | - Giuseppe Banfi
- IRCCS Ospedale Galeazzi Sant’Ambrogio, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Milena Vainieri
- Institute of Management, MeS (Management and Health) Laboratory, Scuola Superiore Sant’Anna, Pisa, Italy
| | - Rossella Tomaiuolo
- IRCCS Ospedale Galeazzi Sant’Ambrogio, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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Wang S, Mouliere F, Pegtel DM, Chamuleau MED. Turning the tide in aggressive lymphoma: liquid biopsy for risk-adapted treatment strategies. Trends Mol Med 2024; 30:660-672. [PMID: 38692937 DOI: 10.1016/j.molmed.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/30/2024] [Accepted: 04/04/2024] [Indexed: 05/03/2024]
Abstract
Diffuse large B cell lymphoma (DLBCL) exhibits significant biological and clinical heterogeneity that presents challenges for risk stratification and disease surveillance. Existing tools for risk stratification, including the international prognostic index (IPI), tissue molecular analyses, and imaging, have limited accuracy in predicting outcomes. The therapeutic landscape for aggressive lymphoma is rapidly evolving, and there is a pressing need to identify patients at risk of refractory or relapsed (R/R) disease in the context of personalized therapy. Liquid biopsy, a minimally invasive method for cancer signal detection, has been explored to address these challenges. We review advances in liquid biopsy strategies focusing on circulating nucleic acids in DLBCL patients and highlight their clinical potential. We also provide recommendations for biomarker-guided trials to support risk-adapted treatment modalities.
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Affiliation(s)
- Steven Wang
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan, 1117, Amsterdam, The Netherlands; Imaging and Biomarkers, Cancer Center Amsterdam, De Boelelaan, 1117, Amsterdam, The Netherlands
| | - Florent Mouliere
- Department of Pathology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan, 1117, Amsterdam, The Netherlands; Imaging and Biomarkers, Cancer Center Amsterdam, De Boelelaan, 1117, Amsterdam, The Netherlands; Cancer Research UK National Biomarker Centre, University of Manchester, Wilmslow Road, Manchester, UK
| | - D Michiel Pegtel
- Department of Pathology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan, 1117, Amsterdam, The Netherlands; Imaging and Biomarkers, Cancer Center Amsterdam, De Boelelaan, 1117, Amsterdam, The Netherlands
| | - Martine E D Chamuleau
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan, 1117, Amsterdam, The Netherlands; Imaging and Biomarkers, Cancer Center Amsterdam, De Boelelaan, 1117, Amsterdam, The Netherlands.
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Abstract
This review delves into the rapidly evolving landscape of liquid biopsy technologies based on cell-free DNA (cfDNA) and cell-free RNA (cfRNA) and their increasingly prominent role in precision medicine. With the advent of high-throughput DNA sequencing, the use of cfDNA and cfRNA has revolutionized noninvasive clinical testing. Here, we explore the physical characteristics of cfDNA and cfRNA, present an overview of the essential engineering tools used by the field, and highlight clinical applications, including noninvasive prenatal testing, cancer testing, organ transplantation surveillance, and infectious disease testing. Finally, we discuss emerging technologies and the broadening scope of liquid biopsies to new areas of diagnostic medicine.
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Affiliation(s)
- Conor Loy
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York, USA;
| | - Lauren Ahmann
- Department of Pathology, Stanford University, Stanford, California, USA;
| | - Iwijn De Vlaminck
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York, USA;
| | - Wei Gu
- Department of Pathology, Stanford University, Stanford, California, USA;
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Johnston M, Hui L, Bowman-Smart H, Taylor-Sands M, Pertile MD, Mills C. Disparities in integrating non-invasive prenatal testing into antenatal healthcare in Australia: a survey of healthcare professionals. BMC Pregnancy Childbirth 2024; 24:355. [PMID: 38745131 PMCID: PMC11092221 DOI: 10.1186/s12884-024-06565-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 05/06/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Non-invasive prenatal testing (NIPT) has been clinically available in Australia on a user-pays basis since 2012. There are numerous providers, with available tests ranging from targeted NIPT (only trisomies 21, 18, and 13 +/- sex chromosome aneuploidy) to genome-wide NIPT. While NIPT is being implemented in the public health care systems of other countries, in Australia, the implementation of NIPT has proceeded without public funding. The aim of this study was to investigate how NIPT has been integrated into antenatal care across Australia and reveal the successes and challenges in its implementation in this context. METHODS An anonymous online survey was conducted from September to October 2022. Invitations to participate were sent to healthcare professionals (HCPs) involved in the provision of NIPT in Australia through professional society mailing lists and networks. Participants were asked questions on their knowledge of NIPT, delivery of NIPT, and post-test management of results. RESULTS A total of 475 HCPs responded, comprising 232 (48.8%) obstetricians, 167 (35.2%) general practitioners, 32 (6.7%) midwives, and 44 (9.3%) genetic specialists. NIPT was most commonly offered as a first-tier test, with most HCPs (n = 279; 60.3%) offering it to patients as a choice between NIPT and combined first-trimester screening. Fifty-three percent (n = 245) of respondents always offered patients a choice between NIPT for the common autosomal trisomies and expanded (including genome-wide) NIPT. This choice was understood as supporting patient autonomy and informed consent. Cost was seen as a major barrier to access to NIPT, for both targeted and expanded tests. Equitable access, increasing time demands on HCPs, and staying up to date with advances were frequently reported as major challenges in delivering NIPT. CONCLUSIONS Our findings demonstrate substantial variation in the clinical implementation of NIPT in Australia, including in the offers of expanded screening options. After a decade of clinical use, Australian clinicians still report ongoing challenges in the clinical and equitable provision of NIPT.
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Affiliation(s)
- Molly Johnston
- Monash Bioethics Centre, Monash University, Wellington Rd, Clayton, 3800, Australia.
| | - Lisa Hui
- Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne, Parkville, 3010, Australia
- Reproductive Epidemiology Group, Murdoch Children's Research Institute, Parkville, 3052, Australia
- Mercy Hospital for Women, Heidelberg, 3084, Australia
- Northern Health, Epping, 3076, Australia
| | - Hilary Bowman-Smart
- Monash Bioethics Centre, Monash University, Wellington Rd, Clayton, 3800, Australia
- Australian Centre for Precision Health, University of South Australia, Adelaide, 5061, Australia
- Biomedical Ethics Research Group, Murdoch Children's Research Institute, Parkville, 3052, Australia
| | | | - Mark D Pertile
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, VIC, 3052, Australia
| | - Catherine Mills
- Monash Bioethics Centre, Monash University, Wellington Rd, Clayton, 3800, Australia
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Cornel MC, van der Meij KRM, van El CG, Rigter T, Henneman L. Genetic Screening-Emerging Issues. Genes (Basel) 2024; 15:581. [PMID: 38790210 PMCID: PMC11121342 DOI: 10.3390/genes15050581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 04/25/2024] [Accepted: 04/30/2024] [Indexed: 05/26/2024] Open
Abstract
In many countries, some form of genetic screening is offered to all or part of the population, either in the form of well-organized screening programs or in a less formalized way. Screening can be offered at different phases of life, such as preconception, prenatal, neonatal and later in life. Screening should only be offered if the advantages outweigh the disadvantages. Technical innovations in testing and treatment are driving changes in the field of prenatal and neonatal screening, where many jurisdictions have organized population-based screening programs. As a result, a greater number and wider range of conditions are being added to the programs, which can benefit couples' reproductive autonomy (preconception and prenatal screening) and improve early diagnosis to prevent irreversible health damage in children (neonatal screening) and in adults (cancer and cascade screening). While many developments in screening are technology-driven, citizens may also express a demand for innovation in screening, as was the case with non-invasive prenatal testing. Relatively new emerging issues for genetic screening, especially if testing is performed using DNA sequencing, relate to organization, data storage and interpretation, benefit-harm ratio and distributive justice, information provision and follow-up, all connected to acceptability in current healthcare systems.
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Affiliation(s)
- Martina C. Cornel
- Section Community Genetics, Department of Human Genetics, Amsterdam UMC, Vrije Universiteit Amsterdam, 1007 MB Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, 1100 DD Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, 1100 DD Amsterdam, The Netherlands
| | - Karuna R. M. van der Meij
- Section Community Genetics, Department of Human Genetics, Amsterdam UMC, Vrije Universiteit Amsterdam, 1007 MB Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, 1100 DD Amsterdam, The Netherlands
| | - Carla G. van El
- Section Community Genetics, Department of Human Genetics, Amsterdam UMC, Vrije Universiteit Amsterdam, 1007 MB Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, 1100 DD Amsterdam, The Netherlands
| | - Tessel Rigter
- Section Community Genetics, Department of Human Genetics, Amsterdam UMC, Vrije Universiteit Amsterdam, 1007 MB Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, 1100 DD Amsterdam, The Netherlands
| | - Lidewij Henneman
- Section Community Genetics, Department of Human Genetics, Amsterdam UMC, Vrije Universiteit Amsterdam, 1007 MB Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, 1100 DD Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, 1100 DD Amsterdam, The Netherlands
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Elron E, Maya I, Shefer-Averbuch N, Kahana S, Matar R, Klein K, Agmon-Fishman I, Gurevitch M, Basel-Salmon L, Levy M. The Diagnostic Yield of Chromosomal Microarray Analysis in Third-Trimester Fetal Abnormalities. Am J Perinatol 2024. [PMID: 38688298 DOI: 10.1055/s-0044-1786514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
OBJECTIVE This study aimed to determine the diagnostic yield of chromosomal microarray analysis (CMA) performed in cases of fetal abnormalities detected during the third trimester of pregnancy. STUDY DESIGN A retrospective review of medical records was conducted for women who underwent amniocentesis at or beyond 28 weeks of gestation between January 2017 and February 2023. CMA results of pregnancies with abnormal sonographic findings not detected before 28 weeks were included. RESULTS A total of 482 fetuses met the inclusion criteria. The average maternal age was 31.3 years, and the average gestational age at amniocentesis was 32.3 weeks. The overall diagnostic yield of CMA was 6.2% (30 clinically significant copy number variations [CNVs]). The yield was 16.4% in cases with two or more fetal malformations, while cases with a single anomaly revealed a diagnostic yield of 7.3%. Cases presenting isolated polyhydramnios or isolated fetal growth restriction had a lower yield of 9.3 and 5.4%, respectively. Of the 30 clinically significant cases, 19 (or 63.4%) exhibited recurrent CNVs. The remaining 11 cases (or 36.6%) presented unique CNVs. The theoretical yield of Noninvasive Prenatal Testing (NIPT) in our cohort is 2% for aneuploidy, which implies that it could potentially miss up to 70% of the significant findings that could be identified by CMA. In 80% of the fetuses (or 24 out of 30) with clinically significant CNVs, the structural abnormalities detected on fetal ultrasound examinations corresponded with the CMA results. CONCLUSION The 6.2% detection rate of significant CNVs in late-onset fetal anomalies confirms the value of CMA in third-trimester amniocentesis. The findings underscore the necessity of CMA for detecting CNVs potentially overlooked by NIPT and emphasize the importance of thorough genetic counseling. KEY POINTS · CMA yields 6.2% for third-trimester anomalies.. · NIPT may miss 70% of CMA findings.. · Ultrasound matched 80% of CMA results..
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Affiliation(s)
- Eyal Elron
- Department of Neonatology, Schneider Children's Medical Center, Petah Tikva, Israel
- Pediatric Genetics Unit, Schneider Children's Medical Center, Petah Tikva, Israel
- The Raphael Recanati Genetic Institute, Rabin Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Idit Maya
- The Raphael Recanati Genetic Institute, Rabin Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noa Shefer-Averbuch
- Pediatric Genetics Unit, Schneider Children's Medical Center, Petah Tikva, Israel
- The Raphael Recanati Genetic Institute, Rabin Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Jesse Z. and Sara Lea Shafer Institute for Endocrinology and Diabetes, Schneider Children's Medical Center of Israel, The Raphael Recanati Genetics Institute, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel
| | - Sarit Kahana
- The Raphael Recanati Genetic Institute, Rabin Medical Center, Petah Tikva, Israel
| | - Reut Matar
- The Raphael Recanati Genetic Institute, Rabin Medical Center, Petah Tikva, Israel
| | - Kochav Klein
- The Raphael Recanati Genetic Institute, Rabin Medical Center, Petah Tikva, Israel
| | - Ifat Agmon-Fishman
- The Raphael Recanati Genetic Institute, Rabin Medical Center, Petah Tikva, Israel
| | - Merav Gurevitch
- The Raphael Recanati Genetic Institute, Rabin Medical Center, Petah Tikva, Israel
| | - Lina Basel-Salmon
- Pediatric Genetics Unit, Schneider Children's Medical Center, Petah Tikva, Israel
- The Raphael Recanati Genetic Institute, Rabin Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Felsenstein Medical Research Center, Petach Tikva, Israel
| | - Michal Levy
- The Raphael Recanati Genetic Institute, Rabin Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Bowman-Smart H, Perrot A, Horn R. Supporting patient decision-making in non-invasive prenatal testing: a comparative study of professional values and practices in England and France. BMC Med Ethics 2024; 25:34. [PMID: 38515078 PMCID: PMC10956335 DOI: 10.1186/s12910-024-01032-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 03/06/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND Non-invasive prenatal testing (NIPT), which can screen for aneuploidies such as trisomy 21, is being implemented in several public healthcare systems across Europe. Comprehensive communication and information have been highlighted in the literature as important elements in supporting women's reproductive decision-making and addressing relevant ethical concerns such as routinisation. Countries such as England and France are adopting broadly similar implementation models, offering NIPT for pregnancies with high aneuploidy probability. However, we do not have a deeper understanding of how professionals' counselling values and practices may differ between these contexts. METHODS In this paper, we explore how professionals in England and France support patient decision-making in the provision of NIPT and critically compare professional practices and values. We draw on data from semi-structured interviews with healthcare professionals. RESULTS Both English and French professionals emphasised values relating to patient choice and consent. However, understandings and application of these values into the practice of NIPT provision differed. English interviewees placed a stronger emphasis on interpreting and describing the process of counselling patients and clinical care through a "principle" lens. Their focus was on non-directiveness, standardisation, and the healthcare professional as "decision-facilitator" for patients. French interviewees described their approach through a "procedural" lens. Their focus was on formal consent, information, and the healthcare professional as "information-giver". Both English and French professionals indicated that insufficient resources were a key barrier in effectively translating their values into practice. CONCLUSION Our findings illustrate that supporting patient choice in the provision of NIPT may be held as an important value in common on a surface level, but can be understood and translated into practice in different ways. Our findings can guide further research and beneficially inform practice and policy around NIPT provision.
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Affiliation(s)
- Hilary Bowman-Smart
- Ethox Centre, University of Oxford, Oxford, UK
- Monash Bioethics Centre, Monash University, Melbourne, Australia
- Biomedical Ethics Research Group, Murdoch Children's Research Institute, Melbourne, Australia
- Australian Centre for Precision Health, Clinical and Health Sciences, University of South Australia, Adelaide, Australia
| | | | - Ruth Horn
- Ethox Centre, University of Oxford, Oxford, UK.
- Institute of Ethics and History of Health in Society, University of Augsburg, Augsburg, Germany.
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Bakkeren IM, Henneman L, van Vliet-Lachotzki EH, Martin L, Gitsels-van der Wal JT, Polak MG, Bekker MN, Galjaard RJH. Psychological impact of additional findings detected by genome-wide Non-Invasive Prenatal Testing (NIPT): TRIDENT-2 study. Eur J Hum Genet 2024; 32:302-308. [PMID: 38057584 PMCID: PMC10923886 DOI: 10.1038/s41431-023-01504-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/01/2023] [Accepted: 11/16/2023] [Indexed: 12/08/2023] Open
Abstract
In the Netherlands, genome-wide non-invasive prenatal testing (NIPT) is offered to all pregnant women as part of the nationwide TRIDENT-2 study. Findings other than trisomy 21, 18, or 13, which are called "additional findings", are reported only on request of the pregnant woman. This study examined: (1) women's pre-test perceptions and reasons to opt for additional findings and (2) women's experiences with- and the psychological impact of being informed about an additional finding. A questionnaire, consisting of the anxiety measure State-Trait Anxiety Inventory (STAI), distress measure Impact of Event Scale (IES) and questions developed specifically for this study, was retrospectively administered to 402 women who received an additional finding. A total of 227 (56.5%) women completed the questionnaire. Most (60.2%) chose to know additional findings because they wanted as much information as possible about the health of their fetus. Almost all (92%) stated that receiving the additional finding was unexpected, a shock, and/or they were in disbelief, for 85% it caused a lot of worry. Post-test, high anxiety (STAI) levels were reported in 15.5% of women, and 7.5% reported severe distress (IES). Women who gave birth to an affected child (n = 10) experienced most psychological impact (STAI and IES). Eighty-six percent of women with a fetal aberration would opt for additional findings again, compared to 49.2% of women whose result was confined to the placenta. Pre-test counseling should focus on explaining the different results NIPT can generate. Post-test counseling should focus on guiding pregnant women through this uncertain and anxious time.
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Affiliation(s)
- Iris M Bakkeren
- Department of Clinical Genetics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - Lidewij Henneman
- Department of Human Genetics and Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | | | - Linda Martin
- Department of Midwifery Science, AVAG, Amsterdam Public Health research institute, Amsterdam UMC, location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Janneke T Gitsels-van der Wal
- Department of Midwifery Science, AVAG, Amsterdam Public Health research institute, Amsterdam UMC, location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Marike G Polak
- Department of Psychology, Education & Child Studies (DPECS), Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Mireille N Bekker
- Department of Obstetrics and Gynecology, Utrecht University Medical Center, Utrecht, the Netherlands
| | - Robert-Jan H Galjaard
- Department of Clinical Genetics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
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Claesen-Bengtson Z, Bowman-Smart H, Vermeersch E, Vermeesch JR, Henneman L, Borry P. Should non-invasive prenatal testing (NIPT) be used for fetal sex determination? Perspectives and experiences of healthcare professionals. Eur J Hum Genet 2024; 32:309-316. [PMID: 38278868 PMCID: PMC10923812 DOI: 10.1038/s41431-024-01536-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 12/04/2023] [Accepted: 01/08/2024] [Indexed: 01/28/2024] Open
Abstract
Non-invasive prenatal testing (NIPT) can not only accurately detect early in pregnancy the presence of chromosomal abnormalities but also fetal sex. However, whether fetal sex should be reported after performing NIPT is ethically contentious. In Belgium, NIPT is practically fully reimbursed and offered to all pregnant women as a first-tier screening. In practice, fetal sex is reported upon request of the expectant parents; however, this is not stipulated in guidelines. As more countries are offering NIPT and looking to implement it in public healthcare, challenges and insights of healthcare professionals working in Belgium can be of value for others. We assessed healthcare professionals' experiences with and perspectives on sex determination and reporting following NIPT in Belgium by conducting a semi-structured interview study. We interviewed 30 professionals involved in prenatal screening. While overall healthcare professionals did not consider reporting fetal sex to be an issue if the expectant parents want to know, some consider the reporting of a non-medical trait like fetal sex problematic when it is reimbursed or if it could lead to sex-selective termination of pregnancy. Moreover, the strong desire of expectant parents to know fetal sex risks compromising informed decision-making about NIPT. In this way, fetal sex may distract from the primary aim of NIPT as a test for medical conditions. Improving pre-test counseling both in terms of quality and availability may help overcome some of these issues.
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Affiliation(s)
- Zoë Claesen-Bengtson
- Centre for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.
| | - Hilary Bowman-Smart
- Australian Centre for Precision Health, University of South Australia, Adelaide, SA, Australia
- Biomedical Ethics Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Monash Bioethics Centre, Monash University, Clayton, VIC, Australia
| | - Eline Vermeersch
- Centre for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Joris Robert Vermeesch
- Laboratory for Cytogenetics and Genome Research, Department of Human Genetics, UZ Leuven, Leuven, Belgium
| | - Lidewij Henneman
- Department of Human Genetics, and Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, location Vrije Universiteit, Amsterdam, The Netherlands
| | - Pascal Borry
- Centre for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
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Clifford CM, Askew N, Smith D, Iniguez J, Smith A, House MD, Leech AA. Prenatal aneuploidy screening in a low-risk Hispanic population: price elasticity and cost-effectiveness. AJOG GLOBAL REPORTS 2024; 4:100293. [PMID: 38205132 PMCID: PMC10777109 DOI: 10.1016/j.xagr.2023.100293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND In October 2015, the Massachusetts Medicaid program temporarily stopped reimbursement for procedures in which the International Classification of Diseases, Tenth Edition, code for serum aneuploidy screening used by certain communities was stipulated. This change led to a substantial number of patients who went without aneuploidy screening for approximately 3 years. OBJECTIVE This study aimed to determine the change in use and cost-effectiveness of prenatal aneuploidy serum screening in a low-risk Hispanic Medicaid population in Massachusetts. STUDY DESIGN We conducted a retrospective chart review of Spanish-speaking pregnant patients younger than 35 years of age who underwent aneuploidy serum screening at a Massachusetts community health center. The study compared the aneuploidy serum screening rates for the periods before and after May 2016 when the Massachusetts Medicaid program, MassHealth, temporarily discontinued reimbursement for the screening. Based on these rates, we developed a Markov cohort simulation model to assess the economic value of reimbursed aneuploidy screening vs nonreimbursed or limited screening. Clinical outcomes included trisomy 21, live births, and therapeutic abortions for a trisomy 21 diagnosis. Economic outcomes included discounted quality-adjusted life years and lifetime medical costs, net health benefit, and incremental cost-effectiveness ratios. RESULTS Before the MassHealth policy change, 69% (55/80) of pregnant individuals selected quad or sequential screens in comparison with only 9% (10/112) who selected screens after the policy change. Traditional aneuploidy serum screening in a low-risk (aged <35 years) Hispanic population was considered to be cost-saving (ie, led to lower incremental costs and higher incremental benefits when compared with nonreimbursed or limited screening). CONCLUSION From a United States healthcare payer perspective, aneuploidy serum screening for Hispanic pregnant individuals under 35 years of age is economically advantageous when compared with limited screening.
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Affiliation(s)
- Caitlin M. Clifford
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tufts Medical Center, Boston, MA (Dr Clifford)
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI (Drs Clifford and House)
| | - Neil Askew
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN (Mr Askew and Dr Leech)
| | - Diane Smith
- Greater Lawrence Family Health Center, Lawrence, MA (Drs Smith and Iniquez)
| | - Jesus Iniguez
- Greater Lawrence Family Health Center, Lawrence, MA (Drs Smith and Iniquez)
- Department of Family Medicine, University of Washington, Seattle, WA (Dr Iniquez)
| | - Andrew Smith
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, TN (Drs Smith and Leech)
| | - Michael D. House
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI (Drs Clifford and House)
| | - Ashley A. Leech
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN (Mr Askew and Dr Leech)
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, TN (Drs Smith and Leech)
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15
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Rehmann-Sutter C, Timmermans DRM, Raz A. Non-invasive prenatal testing (NIPT): is routinization problematic? BMC Med Ethics 2023; 24:87. [PMID: 37884894 PMCID: PMC10604734 DOI: 10.1186/s12910-023-00970-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/12/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND The introduction and wide application of non-invasive prenatal testing (NIPT) has triggered further evolution of routines in the practice of prenatal diagnosis. 'Routinization' of prenatal diagnosis however has been associated with hampered informed choice and eugenic attitudes or outcomes. It is viewed, at least in some countries, with great suspicion in both bioethics and public discourse. However, it is a heterogeneous phenomenon that needs to be scrutinized in the wider context of social practices of reproductive genetics. In different countries with their different regulatory frameworks, different patterns of routines emerge that have different ethical implications. This paper discusses an ethics of routines informed by the perspectives of organizational sociology and psychology, where a routine is defined as a repetitive, recognizable pattern of interdependent organizational actions that is carried out by multiple performers. We favour a process approach that debunks the view - which gives way to most of the concerns - that routines are always blindly performed. If this is so, routines are therefore not necessarily incompatible with responsible decision-making. Free and informed decision-making can, as we argue, be a key criterion for the ethical evaluation of testing routines. If free and informed decision-making by each pregnant woman is the objective, routines in prenatal testing may not be ethically problematic, but rather are defensible and helpful. We compare recent experiences of NIPT routines in the context of prenatal screening programmes in Germany, Israel and the Netherlands. Notable variation can be observed between these three countries (i) in the levels of routinization around NIPT, (ii) in the scope of routinization, and (iii) in public attitudes toward routinized prenatal testing. CONCLUSION An ethics of routines in the field of prenatal diagnostics should incorporate and work with the necessary distinctions between levels and forms of routines, in order to develop sound criteria for their evaluation.
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Affiliation(s)
| | - Daniëlle R M Timmermans
- Amsterdam UMC, Vrije Universiteit Amsterdam, Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Aviad Raz
- Department of Sociology and Anthropology, Ben-Gurion University of the Negev, Be'er Sheva, Israel
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Wongkrajang P, Jittikoon J, Udomsinprasert W, Talungchit P, Sangroongruangsri S, Turongkaravee S, Chaikledkaew U. Economic evaluation of prenatal screening for fetal aneuploidies in Thailand. PLoS One 2023; 18:e0291622. [PMID: 37713438 PMCID: PMC10503713 DOI: 10.1371/journal.pone.0291622] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 09/02/2023] [Indexed: 09/17/2023] Open
Abstract
Historically, there has been a lack of cost-effectiveness data regarding the inclusion of universal non-invasive prenatal testing (NIPT) for trisomy 21, 18, and 13 in the benefit package of the Universal Health Coverage (UHC) in Thailand. Therefore, this study aimed to perform the cost-benefit analysis of prenatal screening tests and calculate the budget impact that would result from the implementation of a universal NIPT program. A decision-tree model was employed to evaluate cost and benefit of different prenatal chromosomal abnormalities screenings: 1) first-trimester screening (FTS), 2) NIPT, and 3) definitive diagnostic (amniocentesis). The comparison was made between these screenings and no screening in three groups of pregnant women: all ages, < 35 years, and ≥ 35 years. The analysis was conducted from societal and governmental perspectives. The costs comprised direct medical, direct non-medical, and indirect costs, while the benefit was cost-avoidance associated with caring for children with trisomy and the loss of productivity for caregivers. Parameter uncertainties were evaluated through one-way and probabilistic sensitivity analyses. From a governmental perspective, all three methods were found to be cost-beneficial. Among them, FTS was identified as the most cost-beneficial, especially for pregnant women aged ≥ 35 years. From a societal perspective, the definitive diagnostic test was not cost-effective, but the other two screening tests were. The most sensitive parameters for FTS and NIPT strategies were the productivity loss of caregivers and the incidence of trisomy 21. Our study suggested that NIPT was the most cost-effective strategy in Thailand, if the cost was reduced to 47 USD. This evidence-based information can serve as a crucial resource for policymakers when making informed decisions regarding the allocation of resources for prenatal care in Thailand and similar context.
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Affiliation(s)
- Preechaya Wongkrajang
- Social, Economic and Administrative Pharmacy (SEAP) Graduate Program, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
- Department of Clinical Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jiraphun Jittikoon
- Department of Biochemistry, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | | | - Pattarawalai Talungchit
- Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand
| | - Sermsiri Sangroongruangsri
- Social and Administrative Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Saowalak Turongkaravee
- Social and Administrative Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Usa Chaikledkaew
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand
- Social and Administrative Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
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17
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Okoror CEM, Arora S. Prenatal diagnosis after high chance non-invasive prenatal testing for trisomies 21, 18 and 13, chorionic villus sampling or amniocentesis? - Experience at a district general hospital in the United Kingdom. Eur J Obstet Gynecol Reprod Biol X 2023; 19:100211. [PMID: 37456970 PMCID: PMC10345242 DOI: 10.1016/j.eurox.2023.100211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 04/30/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023] Open
Abstract
The non-invasive prenatal testing (NIPT) analyses cell-free DNA (cfDNA) derived from the placental tissue in the maternal circulation. Though highly sensitive and specific, a major limitation is in cases of confined placental mosaicism (CPM). Whether to perform chorionic villus sampling (CVS) or amniocentesis to confirm a positive NIPT result is controversial. One major drawback of CVS is that cytogenetic diagnosis may not always reflect the true chromosomal make-up of the fetus. This work, therefore, proposes the use of amniocentesis in the presence of normal ultrasound findings, and the option of either CVS or amniocentesis when there are abnormal USS findings.
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18
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Griffin LB, McCarthy M, Russo ML. Navigation of Prenatal Care With Sex Discordance Between Cell-free DNA and Ultrasound Findings. Clin Obstet Gynecol 2023; 66:616-623. [PMID: 37650671 DOI: 10.1097/grf.0000000000000802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
The utilization of cell-free DNA (cfDNA) screening has expanded rapidly across the age spectrum of pregnant persons. With cfDNA's widespread adoption, genetic fetal sex is now often known before a phenotypic assessment on anatomic survey. CfDNA detects sex discordance in 1/1500 to 2000 pregnancies. Upon detection of sex discordance, lab error or other factors should first be assessed. Once other causes have been ruled out, this may indicate an underlying disorder/difference in sex development. A multidisciplinary team should coordinate diagnosis, treatment, and support for the family. This review discusses the diagnostic workup, emphasizing the multidisciplinary counseling and management of disorder/differences in sex development.
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Affiliation(s)
- Laurie B Griffin
- Brown University, Warren Alpert School of Medicine, Providence, Rhode Island
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19
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Moufarrej MN, Bianchi DW, Shaw GM, Stevenson DK, Quake SR. Noninvasive Prenatal Testing Using Circulating DNA and RNA: Advances, Challenges, and Possibilities. Annu Rev Biomed Data Sci 2023; 6:397-418. [PMID: 37196360 PMCID: PMC10528197 DOI: 10.1146/annurev-biodatasci-020722-094144] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
Prenatal screening using sequencing of circulating cell-free DNA has transformed obstetric care over the past decade and significantly reduced the number of invasive diagnostic procedures like amniocentesis for genetic disorders. Nonetheless, emergency care remains the only option for complications like preeclampsia and preterm birth, two of the most prevalent obstetrical syndromes. Advances in noninvasive prenatal testing expand the scope of precision medicine in obstetric care. In this review, we discuss advances, challenges, and possibilities toward the goal of providing proactive, personalized prenatal care. The highlighted advances focus mainly on cell-free nucleic acids; however, we also review research that uses signals from metabolomics, proteomics, intact cells, and the microbiome. We discuss ethical challenges in providing care. Finally, we look to future possibilities, including redefining disease taxonomy and moving from biomarker correlation to biological causation.
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Affiliation(s)
| | - Diana W Bianchi
- Eunice Kennedy Shriver National Institute of Child Health and Human Development and Section on Prenatal Genomics and Fetal Therapy, Center for Precision Health Research, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Gary M Shaw
- Department of Pediatrics and March of Dimes Prematurity Research Center at Stanford University, Stanford University School of Medicine, Stanford, California, USA
| | - David K Stevenson
- Department of Pediatrics and March of Dimes Prematurity Research Center at Stanford University, Stanford University School of Medicine, Stanford, California, USA
| | - Stephen R Quake
- Department of Bioengineering and Department of Applied Physics, Stanford University, Stanford, California, USA
- Chan Zuckerberg Initiative, Redwood City, California, USA
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20
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Hong K, Park HJ, Jang HY, Shim SH, Jang Y, Kim SH, Cha DH. A Novel Paradigm for Non-Invasive Prenatal Genetic Screening: Trophoblast Retrieval and Isolation from the Cervix (TRIC). Diagnostics (Basel) 2023; 13:2532. [PMID: 37568895 PMCID: PMC10417081 DOI: 10.3390/diagnostics13152532] [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: 06/30/2023] [Revised: 07/27/2023] [Accepted: 07/28/2023] [Indexed: 08/13/2023] Open
Abstract
As the prevalence of pregnancies with advanced maternal age increases, the risk of fetal chromosomal abnormalities is on the rise. Therefore, prenatal genetic screening and diagnosis have become essential elements in contemporary obstetrical care. Trophoblast retrieval and isolation from the cervix (TRIC) is a non-invasive procedure that can be utilized for prenatal genetic diagnosis. The method involves the isolation of fetal cells (extravillous trophoblasts) by transcervical sampling; along with its non-invasiveness, TRIC exhibits many other advantages such as its usefulness in early pregnancy at 5 weeks of gestation, and no interference by various fetal and maternal factors. Moreover, the trophoblast yields from TRIC can provide valuable information about obstetrical complications related to abnormal placentation even before clinical symptoms arise. The standardization of this clinical tool is still under investigation, and the upcoming advancements in TRIC are expected to meet the increasing need for a safe and accurate option for prenatal diagnosis.
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Affiliation(s)
- Kirim Hong
- CHA Gangnam Medical Center, Department of Obstetrics and Gynecology, CHA University, Seoul 06125, Republic of Korea; (K.H.); (H.J.P.); (Y.J.)
| | - Hee Jin Park
- CHA Gangnam Medical Center, Department of Obstetrics and Gynecology, CHA University, Seoul 06125, Republic of Korea; (K.H.); (H.J.P.); (Y.J.)
| | - Hee Yeon Jang
- Department of Biomedical Science, College of Life Science, CHA University, Seongnam 13488, Republic of Korea; (H.Y.J.); (S.H.S.)
| | - Sung Han Shim
- Department of Biomedical Science, College of Life Science, CHA University, Seongnam 13488, Republic of Korea; (H.Y.J.); (S.H.S.)
| | - Yoon Jang
- CHA Gangnam Medical Center, Department of Obstetrics and Gynecology, CHA University, Seoul 06125, Republic of Korea; (K.H.); (H.J.P.); (Y.J.)
| | - Soo Hyun Kim
- CHA Gangnam Medical Center, Department of Obstetrics and Gynecology, CHA University, Seoul 06125, Republic of Korea; (K.H.); (H.J.P.); (Y.J.)
| | - Dong Hyun Cha
- CHA Gangnam Medical Center, Department of Obstetrics and Gynecology, CHA University, Seoul 06125, Republic of Korea; (K.H.); (H.J.P.); (Y.J.)
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Baldus M. "Overestimated technology - underestimated consequences" - reflections on risks, ethical conflicts, and social disparities in the handling of non-invasive prenatal tests (NIPTs). MEDICINE, HEALTH CARE, AND PHILOSOPHY 2023; 26:271-282. [PMID: 36932273 PMCID: PMC10023216 DOI: 10.1007/s11019-023-10143-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/15/2023] [Indexed: 05/13/2023]
Abstract
New technologies create new complexities. Since non-invasive prenatal tests (NIPTs) were first introduced, keeping pace with complexity constitutes an ongoing task for medical societies, politics, and practice. NIPTs analyse the chromosomes of the fetus from a small blood sample. Initially, NIPTs were targeted at detecting trisomy 21 (Down syndrome): meanwhile there are sequencing techniques capable of analysing the entire genome of the unborn child. These yield findings of unclear relevance for the child's future life, resulting in new responsibility structures and dilemmas for the parents-to-be.The industry's marketing strategies overemphasize the benefits of the tests while disregarding their consequences. This paper chooses the opposite path: starting with the underestimated consequences, it focuses on adverse developments and downsides. Disparities, paradoxes, and risks associated with NIPTs are illustrated, ethical conflicts described. Indications that new technologies developed to solve problems create new ones are examined. In the sense of critical thinking, seemingly robust knowledge is scrutinized for uncertainties and ambiguities. It analyses how the interplay between genetic knowledge and social discourse results in new dimensions of responsibility not only for parents-to-be, but also for decision-makers, authorities, and professional societies, illustrated by a review of different national policies and implementation programmes. As shown by the new NIPT policy in Norway, the consequences can be startling. Finally, a lawsuit in the United States illustrates how an agency can risk forfeiting its legitimation in connection with the inaccuracy of NIPTs.
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Affiliation(s)
- Marion Baldus
- Faculty of Social Work, Hochschule Mannheim / Mannheim University of Applied Sciences, Paul-Wittsack-Str. 10, Mannheim, Germany.
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22
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Dubois ML, Winters PD, Rodrigue MA, Gekas J. Patient attitudes and preferences about expanded noninvasive prenatal testing. Front Genet 2023; 14:976051. [PMID: 37152999 PMCID: PMC10161390 DOI: 10.3389/fgene.2023.976051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 04/03/2023] [Indexed: 05/09/2023] Open
Abstract
Introduction: Noninvasive prenatal testing (NIPT) using cell-free DNA (cfDNA) is typically carried out to screen for common fetal chromosomal anomalies, with the option to screen for a wider range of chromosomal changes (expanded NIPT) becoming increasingly available. However, little is known about pregnant patients' attitudes and preferences regarding expanded NIPT. Methods: To address this gap, we surveyed general-risk patients having first-tier cfDNA screening at a private prenatal clinic on their expectations for expanded NIPT. Patients were asked questions regarding their current pregnancy and previous pregnancy history, their opinions on fetal DNA screenings during pregnancy and incidental findings, information and opinions on financial resources for NIPT, as well as socio-cultural questions to determine patient demographics. Results: Of the 200 survey participants, the majority were educated, self-reported as white, had a higher than average income, and reported no aneuploidy risk factors. When asked what information they would like to receive from cfDNA screening, the vast majority of participants wanted all information available that could have an immediate impact on fetal health (88%) or an immediate impact on infant health from birth (82%). Many participants also wanted information that could have a future impact on the child's health or an immediate or future impact on the pregnant woman's own health. Most participants wanted information about the sex of fetus (86%) and common trisomies (71%), with almost half of participants desiring information about rare autosomal aneuploidies and/or all genetic information that may affect the baby. In addition, participants were found to be comfortable screening for conditions that are well-known, influence care during pregnancy, and are treatable. Finally, while most respondents either had insurance coverage for NIPT or were able to afford NIPT out of pocket, the majority of our participants felt that expanded NIPT should be either free for everyone or for those considered high risk. Discussion: Our findings suggest that with appropriate pre-test counseling, pregnant patients may choose NIPT for an expanding list of conditions.
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Affiliation(s)
| | | | - Marc-André Rodrigue
- CHU de Quebec Research and Mother and Child Center, Department of Medical Genetics, University Hospital of Quebec, Laval University, Quebec City, QC, Canada
| | - Jean Gekas
- Faculty of Medicine, Laval University, Quebec City, QC, Canada
- CHU de Quebec Research and Mother and Child Center, Department of Medical Genetics, University Hospital of Quebec, Laval University, Quebec City, QC, Canada
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23
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Hui L, Halliday J. A decade of non-invasive prenatal screening in Australia: National impact on prenatal screening and diagnostic testing. Aust N Z J Obstet Gynaecol 2023; 63:264-267. [PMID: 36529142 PMCID: PMC10952159 DOI: 10.1111/ajo.13638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 11/15/2022] [Indexed: 12/23/2022]
Abstract
Prenatal screening for aneuploidy has undergone immense changes over the past two decades. In 2013 cell-free DNA-based non-invasive prenatal testing (NIPT) became a new self-funded option primarily for Down syndrome screening, but also other aneuploidies and genetic conditions. The numbers of Medicare item claims for prenatal diagnostic procedures have halved since the introduction of NIPT, while billings for serum screening fell by 40% over the same period, on a background of steady births. Australia is now observing historically low rates of prenatal diagnostic testing. These data provide an informative snapshot of historic changes in prenatal screening and diagnosis, as our sector prepares for the impending impacts of other advances in genomics on maternity care. They also highlight the need to address equity and quality issues that arise when consumers must bear the full costs of improved genomic tests in the absence of Medicare funding.
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Affiliation(s)
- Lisa Hui
- Reproductive Epidemiology GroupMurdoch Children's Research InstituteMelbourneVictoriaAustralia
- Department of Obstetrics and GynaecologyUniversity of MelbourneMelbourneVictoriaAustralia
- Department of Perinatal MedicineMercy Hospital for WomenMelbourneVictoriaAustralia
- Department of Obstetrics and GynaecologyNorthern HealthMelbourneVictoriaAustralia
| | - Jane Halliday
- Reproductive Epidemiology GroupMurdoch Children's Research InstituteMelbourneVictoriaAustralia
- Department of PaediatricsUniversity of MelbourneMelbourneVictoriaAustralia
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Claesen Z, Crombag N, Henneman L, Vermeesch JR, Borry P. Expanded Non-invasive Prenatal Testing (NIPT) : Can the Child's Right to an Open Future Help Set the Scope? JOURNAL OF BIOETHICAL INQUIRY 2023; 20:41-49. [PMID: 36630060 DOI: 10.1007/s11673-022-10222-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 06/10/2022] [Indexed: 05/04/2023]
Abstract
Expanded non-invasive prenatal testing (NIPT) has provoked ethical concerns about its justifiable scope. In this paper, we evaluate the role of the child's right to an open future in setting the scope of NIPT. This 'open future principle' has been cited in arguments both limiting and expanding parental freedoms. This moral right holds that adult autonomy rights which children cannot yet exercise should nonetheless be protected until they can. Its purpose is to protect the future autonomy of the child as a future adult. Several authors have extended this rationale from child to fetus. However, the right was not anticipated to apply to the fetus, a non-legal entity in many jurisdictions. The aim of this paper is to reconsider whether this principle is useful to help deliberate the scope of NIPT. We find that extending the open future principle to delineate the scope of NIPT is theoretically flawed. We contend that in the prenatal context its value primarily lies with counselling for prenatal screening where it can be used to encourage parents' reflection on the implications of knowing for the sake of knowing on their future children and their relationship with them.
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Affiliation(s)
- Zoë Claesen
- Department of Public Health and Primary Care, Centre for Biomedical Ethics and Law, KU Leuven, Kapucijnenvoer 35/3 (box 7001), 3000, Leuven, Belgium.
| | - Neeltje Crombag
- Department of Development and Regeneration, Urogenital, Abdominal and Plastic Surgery, University Hospitals Leuven, Herestraat 49 (box 611), ON, 3000, Leuven, Belgium
| | - Lidewij Henneman
- Department of Human Genetics, Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, Location Vrije Universiteit, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Joris Robert Vermeesch
- Department of Human Genetics, Laboratory for Cytogenetics and Genome Research, University Hospitals Leuven, ON I Herestraat 49 (box 606), 3000, Leuven, Belgium
| | - Pascal Borry
- Department of Public Health and Primary Care, Centre for Biomedical Ethics and Law, KU Leuven, Kapucijnenvoer 35/3 (box 7001), 3000, Leuven, Belgium
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Zhang H, Wang J, Qin Y, Zhang C, Wang B, Wang Y. Anticipatory Governance of Noninvasive Prenatal Testing for "Non-Medical" Traits: Lessons from Regulation of Medically Assisted Reproduction. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:45-47. [PMID: 36919543 DOI: 10.1080/15265161.2023.2169398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Affiliation(s)
- Hui Zhang
- Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University
| | - Jing Wang
- Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University
| | - Yan Qin
- Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University
| | - Chuanfeng Zhang
- Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University
| | - Bingwei Wang
- The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital
| | - Yuming Wang
- Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University
- National Health Commission Key Laboratory of Birth Defects Prevention, Henan Provincial Key Laboratory of Genetic Diseases and Functional Genomics
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26
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Yang W, Guo Z, Shi W, Qin L, Xia X, Hao B, Liao S. Security and Sharing of NIPT Data Are the Basis of Ethical Decision-Making Related to Non-Medical Traits. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:29-31. [PMID: 36919545 DOI: 10.1080/15265161.2023.2169392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Affiliation(s)
- Wenke Yang
- Henan Provincial People's Hospital, People's Hospital of Henan University, People's Hospital of Zhengzhou University; and National Health Commission Key Laboratory of Birth Defects Prevention, Henan Provincial Key Laboratory of Genetic Diseases and Functional Genomics
| | - Zhenglong Guo
- Henan Provincial People's Hospital, People's Hospital of Henan University, People's Hospital of Zhengzhou University; and National Health Commission Key Laboratory of Birth Defects Prevention, Henan Provincial Key Laboratory of Genetic Diseases and Functional Genomics
| | - Weili Shi
- Henan Provincial People's Hospital, People's Hospital of Henan University, People's Hospital of Zhengzhou University; and National Health Commission Key Laboratory of Birth Defects Prevention, Henan Provincial Key Laboratory of Genetic Diseases and Functional Genomics
| | - Litao Qin
- Henan Provincial People's Hospital, People's Hospital of Henan University, People's Hospital of Zhengzhou University; and National Health Commission Key Laboratory of Birth Defects Prevention, Henan Provincial Key Laboratory of Genetic Diseases and Functional Genomics
| | - Xiaoliang Xia
- Henan Provincial People's Hospital, People's Hospital of Henan University, People's Hospital of Zhengzhou University; and National Health Commission Key Laboratory of Birth Defects Prevention, Henan Provincial Key Laboratory of Genetic Diseases and Functional Genomics
| | - Bingtao Hao
- Henan Provincial People's Hospital, People's Hospital of Henan University, People's Hospital of Zhengzhou University; and National Health Commission Key Laboratory of Birth Defects Prevention, Henan Provincial Key Laboratory of Genetic Diseases and Functional Genomics
| | - Shixiu Liao
- Henan Provincial People's Hospital, People's Hospital of Henan University, People's Hospital of Zhengzhou University; and National Health Commission Key Laboratory of Birth Defects Prevention, Henan Provincial Key Laboratory of Genetic Diseases and Functional Genomics
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27
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Adamova P, Lotto RR, Powell AK, Dykes IM. Are there foetal extracellular vesicles in maternal blood? Prospects for diagnostic biomarker discovery. J Mol Med (Berl) 2023; 101:65-81. [PMID: 36538060 PMCID: PMC9977902 DOI: 10.1007/s00109-022-02278-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 11/14/2022] [Accepted: 12/05/2022] [Indexed: 03/02/2023]
Abstract
Prenatal diagnosis of congenital disease improves clinical outcomes; however, as many as 50% of congenital heart disease cases are missed by current ultrasound screening methods. This indicates a need for improved screening technology. Extracellular vesicles (EVs) have attracted enormous interest in recent years for their potential in diagnostics. EVs mediate endocrine signalling in health and disease and are known to regulate aspects of embryonic development. Here, we critically evaluate recent evidence suggesting that EVs released from the foetus are able to cross the placenta and enter the maternal circulation. Furthermore, EVs from the mother appear to be transported in the reverse direction, whilst the placenta itself acts as a source of EVs. Experimental work utilising rodent models employing either transgenically encoded reporters or application of fluorescent tracking dyes provide convincing evidence of foetal-maternal crosstalk. This is supported by clinical data demonstrating expression of placental-origin EVs in maternal blood, as well as limited evidence for the presence of foetal-origin EVs. Together, this work raises the possibility that foetal EVs present in maternal blood could be used for the diagnosis of congenital disease. We discuss the challenges faced by researchers in translating these basic science findings into a clinical non-invasive prenatal test.
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Affiliation(s)
- Petra Adamova
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Byrom St, Liverpool, L3 3AF, UK.,Liverpool Centre for Cardiovascular Science, Liverpool John Moores University, Liverpool, UK
| | - Robyn R Lotto
- Liverpool Centre for Cardiovascular Science, Liverpool John Moores University, Liverpool, UK.,School of Nursing and Allied Health, Liverpool John Moores University, Tithebarn St, Liverpool, L2 2ER, UK
| | - Andrew K Powell
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Byrom St, Liverpool, L3 3AF, UK.,Liverpool Centre for Cardiovascular Science, Liverpool John Moores University, Liverpool, UK
| | - Iain M Dykes
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Byrom St, Liverpool, L3 3AF, UK. .,Liverpool Centre for Cardiovascular Science, Liverpool John Moores University, Liverpool, UK.
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28
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Tian M, Feng L, Li J, Zhang R. Focus on the frontier issue: progress in noninvasive prenatal screening for fetal trisomy from clinical perspectives. Crit Rev Clin Lab Sci 2023; 60:248-269. [PMID: 36647189 DOI: 10.1080/10408363.2022.2162843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The discovery of cell-free fetal DNA (cffDNA) in maternal blood and the rapid development of massively parallel sequencing have revolutionized prenatal testing from invasive to noninvasive. Noninvasive prenatal screening (NIPS) based on cffDNA enables the detection of fetal trisomy through sequencing, comparison, and bioassays. Its accuracy is better than that of traditional screening methods, and it is the most advanced clinical application of high-throughput sequencing technologies. However, the existing sequencing methods are limited by high costs and complex sequencing procedures. These limitations restrict the availability of NIPS for pregnant women. Many amplification methods have been developed to overcome the limitations of sequencing methods. The rapid development of non-sequencing methods has not been accompanied by reviews to summarize them. In this review, we initially describe the detection principles for sequencing-based NIPS. We summarize the rapidly evolving amplification technologies, focusing on the need to reduce costs and simplify the procedures. To ensure that the testing systems are feasible and that the testing processes are reliable, we expand our vision to the clinic. We evaluate the clinical validity of NIPS in terms of sensitivity, specificity, and positive predictive value. Finally, we summarize the application guidelines and discuss the corresponding quality control methods for NIPS. In addition to cffDNA, extracellular vesicle DNA, RNA, protein/peptide, and fetal cells can also be detected as biomarkers of NIPS. With the development of prenatal testing, NIPS has become increasingly important. Notably, NIPS is a screening test instead of a diagnostic test. The testing methods and procedures used in the NIPS process require standardization.
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Affiliation(s)
- Meng Tian
- National Center for Clinical Laboratories, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology, Beijing, P. R. China.,Peking University Fifth School of Clinical Medicine, Beijing, P. R. China.,Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, Beijing, P. R. China
| | - Lei Feng
- National Center for Clinical Laboratories, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology, Beijing, P. R. China.,Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, Beijing, P. R. China.,Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, P. R. China
| | - Jinming Li
- National Center for Clinical Laboratories, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology, Beijing, P. R. China.,Peking University Fifth School of Clinical Medicine, Beijing, P. R. China.,Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, Beijing, P. R. China.,Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, P. R. China
| | - Rui Zhang
- National Center for Clinical Laboratories, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology, Beijing, P. R. China.,Peking University Fifth School of Clinical Medicine, Beijing, P. R. China.,Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital, Beijing, P. R. China.,Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, P. R. China
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29
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Bowman-Smart H, Wiesemann C, Horn R. Non-invasive prenatal testing in Germany: a unique ethical and policy landscape. Eur J Hum Genet 2022; 31:562-567. [PMID: 36509835 PMCID: PMC10172332 DOI: 10.1038/s41431-022-01256-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 11/21/2022] [Accepted: 11/25/2022] [Indexed: 12/14/2022] Open
Abstract
Non-invasive prenatal testing (NIPT) has been available commercially in Europe since approximately 2012. Currently, many countries are in the process of integrating NIPT into their publicly funded healthcare systems to screen for chromosomal aneuploidies such as trisomy 21 (Down syndrome), with a variety of implementation models. In 2019, the German Federal Joint Committee (G-BA), which plays a significant role in overseeing healthcare decisions in Germany, recommended that NIPT be reimbursed through public insurance. Following this recommendation, NIPT will be offered on a case-by-case basis, when a pregnant woman, after being counselled, makes an informed decision that the test is necessary in her personal situation. This model differs significantly from many other European countries, where NIPT is being implemented either as a first-tier screening offer available for all pregnancies, or a contingent screen for those with a high probability of foetal aneuploidy (with varying probability cut-offs). In this paper we examine how this unique approach to implementing NIPT in Germany is produced by an ethical and policy landscape resulting from a distinctive cultural and historical context with a significant influence on healthcare decision-making. Due in part to the specific legal and regulatory environment, as well as strong objections from various stakeholders, Germany did not implement NIPT as a first-tier screen. However, as Germany does not currently publicly fund as standard other forms of prenatal aneuploidy screening (such as combined first trimester screening), neither can it be implemented as a screen contingent on specific probability cut-offs. We discuss how German policy reflects the echoes of the past shaping approaches to new biotechnologies, and the implications of this unique model for implementing NIPT in a public healthcare system.
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Affiliation(s)
- Hilary Bowman-Smart
- Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Monash Bioethics Centre, Monash University, Clayton, VIC, Australia.,Biomedical Ethics Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Claudia Wiesemann
- Department for Medical Ethics and History of Medicine, Göttingen University Medical Center, Göttingen, Germany
| | - Ruth Horn
- Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK. .,Ethics in Medicine, University of Augsburg, Augsburg, Germany.
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30
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Experiences of pregnant women with genome-wide non-invasive prenatal testing in a national screening program. Eur J Hum Genet 2022; 31:555-561. [PMID: 36481825 PMCID: PMC10172316 DOI: 10.1038/s41431-022-01248-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 11/07/2022] [Accepted: 11/15/2022] [Indexed: 12/13/2022] Open
Abstract
AbstractPregnant women’s perspectives should be included in the dialogue surrounding the expanding offers of non-invasive prenatal testing (NIPT), especially now that technological possibilities are rapidly increasing. This study evaluated women’s experiences with the offer of genome-wide (GW) first-tier NIPT in a national screening program. A nationwide pre-and post-test questionnaire was completed by 473 pregnant women choosing between targeted NIPT (trisomies 21, 18 and 13 only) and GW-NIPT (also other findings) within the Dutch TRIDENT-2 study. Measures included satisfaction, reasons for or against choosing GW-NIPT, anxiety, and opinion on the future scope of NIPT. Most respondents (90.4%) were glad to have been offered the choice between GW-NIPT and targeted NIPT; 76.5% chose GW-NIPT. Main reasons to choose GW-NIPT were ‘wanting as much information as possible regarding the child’s health’ (38.6%) and ‘to be prepared for everything’ (23.8%). Main reasons to choose targeted NIPT were ‘avoiding uncertain results/outcomes’ (33.7%) and ‘not wanting to unnecessarily worry’ (32.6%). Nearly all respondents received a low-risk NIPT result (98.7%). No differences were found in anxiety between women choosing GW-NIPT and targeted NIPT. Most respondents were favorable toward future prenatal screening for a range of conditions, including life-threatening disorders, mental disabilities, disorders treatable in pregnancy and severe physical disabilities, regardless of their choice for GW-NIPT or targeted NIPT. In conclusion, women who chose first-tier NIPT were satisfied with the choice between GW-NIPT and targeted NIPT, and most women were favorable toward a broader future screening offer. Our results contribute to the debate concerning the expansion of NIPT.
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McKinn S, Javid N, Newson AJ, Freeman L, Bonner C, Shand AW, Nassar N, Bell KJ. Clinician views and experiences of non-invasive prenatal genetic screening tests in Australia. Aust N Z J Obstet Gynaecol 2022; 62:830-837. [PMID: 35538635 PMCID: PMC10946867 DOI: 10.1111/ajo.13533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/10/2022] [Accepted: 03/24/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Non-invasive prenatal screening (NIPS) is being increasingly used by expectant parents. Much provision of this test in Australia is occurring in clinical settings where specialised genetic counselling is unavailable, such as general practice. Potential psychosocial consequences from this kind of prenatal genetic screening remain largely unexplored. AIMS To explore clinicians' experiences with NIPS for aneuploidy, their perspectives of the benefits and harms of NIPS, clinicians' information needs, and their perceptions of the needs of expectant parents. MATERIALS AND METHODS Qualitative, semi-structured interviews with 17 health professionals (clinical geneticists, obstetricians, genetic counsellors and general practitioners) who request and counsel for NIPS in Australian hospital and private practice settings, conducted between June 2019 and February 2020. RESULTS Five themes were identified relating to clinicians' perceptions and experiences of NIPS in their practice: perceived benefits of NIPS, perceived harms of NIPS (with two subthemes: clinical harms and psychosocial harms), financial and equity-related concerns, counselling as a protective buffer against perceived harms, and clinicians' unmet education needs. While clinicians view NIPS as a useful and high-quality screening test, especially for detection of common trisomies, many participants had concerns about how NIPS has been implemented in practice, particularly the quality (and often absence) of pre-/post-test counselling and the routinisation of testing for sex chromosome aneuploidies, microdeletion and microduplication syndromes. CONCLUSION These findings support the need for targeted clinician training around NIPS, and for a shared decision-making approach to support expectant parents' autonomous decisions about NIPS.
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Affiliation(s)
- Shannon McKinn
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
| | - Nasrin Javid
- Sydney Institute for Women, Children and their FamiliesSydney Local Health DistrictSydneyNew South WalesAustralia
- Royal Prince Alfred Hospital Women and Babies Ambulatory CareRoyal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - Ainsley J. Newson
- Bioethics, Wiser Healthcare and Sydney Health Ethics, Sydney School of Public Health, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
| | - Lucinda Freeman
- School of Women and Children's HealthUniversity of New South WalesSydneyNew South WalesAustralia
| | - Carissa Bonner
- Sydney School of Public Health, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
| | - Antonia W. Shand
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and HealthThe University of SydneySydneyAustralia
- Royal Hospital for WomenDepartment of Maternal Fetal MedicineSydneyNew South WalesAustralia
| | - Natasha Nassar
- Paediatric and Perinatal Epidemiology, Children's Hospital at Westmead Clinical School, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
| | - Katy J.L. Bell
- Clinical Epidemiology, Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
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Navon D. How do genetic tests answer questions about neurodevelopmental differences? A sociological take. Dev Med Child Neurol 2022; 64:1462-1469. [PMID: 35962997 DOI: 10.1111/dmcn.15376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 03/11/2022] [Accepted: 06/13/2022] [Indexed: 01/31/2023]
Abstract
When it comes to neurodevelopmental differences, a genetic test result can provide compelling answers. However, it is not always clear what the relevant question is. If we want to understand the impact of a genetic diagnosis such as NGLY1 deficiency or the fragile X, trisomy X, or 22q11.2 deletion syndromes on people with neurodevelopmental differences, we must be mindful about what exactly a genetic test is supposed to tell us, where and for whom it matters, and which avenues for action it opens or forecloses. These are all moving targets. Specifically, I discuss the shifting ways a genetic test result can answer the following questions. What is this person's diagnosis? What symptoms and developmental differences are they likely to experience? What is the best way to approach their development, treatment, and care? Will they have a life worth living? When you unpack the sociological nuances of each question, the history behind them, and the uneven ways they are asked, the meanings of the answers change quite radically. I discuss the implications for social inequalities and urge experts and stakeholders to exercise agency when they interpret a genetic diagnosis. WHAT THIS PAPER ADDS: The questions a genetic test can answer depend on a range of social factors. Whether and how a genetic test result affects diagnosis, identity, prognosis, and treatment is a moving target. Genetics creates questions about a life worth living that it cannot answer alone. Stakeholders must choose the questions about neurodevelopmental differences that genetics should answer.
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Affiliation(s)
- Daniel Navon
- Department of Sociology, University of California, La Jolla, CA, USA
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33
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Hanson B, Scotchman E, Chitty LS, Chandler NJ. Non-invasive prenatal diagnosis (NIPD): how analysis of cell-free DNA in maternal plasma has changed prenatal diagnosis for monogenic disorders. Clin Sci (Lond) 2022; 136:1615-1629. [PMID: 36383187 PMCID: PMC9670272 DOI: 10.1042/cs20210380] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/04/2022] [Accepted: 11/07/2022] [Indexed: 07/30/2023]
Abstract
Cell-free fetal DNA (cffDNA) is released into the maternal circulation from trophoblastic cells during pregnancy, is detectable from 4 weeks and is representative of the entire fetal genome. The presence of this cffDNA in the maternal bloodstream has enabled clinical implementation of non-invasive prenatal diagnosis (NIPD) for monogenic disorders. Detection of paternally inherited and de novo mutations is relatively straightforward, and several methods have been developed for clinical use, including quantitative polymerase chain reaction (qPCR), and PCR followed by restriction enzyme digest (PCR-RED) or next-generation sequencing (NGS). A greater challenge has been in the detection of maternally inherited variants owing to the high background of maternal cell-free DNA (cfDNA). Molecular counting techniques have been developed to measure subtle changes in allele frequency. For instance, relative haplotype dosage analysis (RHDO), which uses single nucleotide polymorphisms (SNPs) for phasing of high- and low-risk alleles, is clinically available for several monogenic disorders. A major drawback is that RHDO requires samples from both parents and an affected or unaffected proband, therefore alternative methods, such as proband-free RHDO and relative mutation dosage (RMD), are being investigated. cffDNA was thought to exist only as short fragments (<500 bp); however, long-read sequencing technologies have recently revealed a range of sizes up to ∼23 kb. cffDNA also carries a specific placental epigenetic mark, and so fragmentomics and epigenetics are of interest for targeted enrichment of cffDNA. Cell-based NIPD approaches are also currently under investigation as a means to obtain a pure source of intact fetal genomic DNA.
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Affiliation(s)
- Britt Hanson
- North Thames Genomic Laboratory Hub, Great Ormond Street NHS Foundation Trust, London, U.K
| | - Elizabeth Scotchman
- North Thames Genomic Laboratory Hub, Great Ormond Street NHS Foundation Trust, London, U.K
| | - Lyn S. Chitty
- North Thames Genomic Laboratory Hub, Great Ormond Street NHS Foundation Trust, London, U.K
- Genetic and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, U.K
| | - Natalie J. Chandler
- North Thames Genomic Laboratory Hub, Great Ormond Street NHS Foundation Trust, London, U.K
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Haidar H, Birko S, Laberge AM, Le Clerc-Blain J, Ravitsky V. Views of Canadian healthcare professionals on the future uses of non-invasive prenatal testing: a mixed method study. Eur J Hum Genet 2022; 30:1269-1275. [PMID: 35902698 PMCID: PMC9626560 DOI: 10.1038/s41431-022-01151-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/11/2022] [Accepted: 07/05/2022] [Indexed: 02/04/2023] Open
Abstract
Non-invasive prenatal testing's (NIPT) potential to screen for a wide range of conditions is receiving growing attention. This study explores Canadian healthcare professionals' perceptions towards NIPT's current and possible future uses, including paternity testing, sex determination, and fetal whole genome sequencing. Semi-structured interviews were conducted with ten healthcare professionals, and another 184 participated in a survey. The triangulation of our findings shows that there is considerable agreement among healthcare professionals on expanding NIPT use for medical conditions including fetal aneuploidies and monogenic diseases, but not for non-medical conditions (sex determination for non-medical reasons and paternity testing), nor for risk predisposition information (late onset diseases and Fetal Whole Genome Sequencing). Healthcare professionals raise concerns related to eugenics, the future child's privacy, and psychological and emotional burdens to prospective parents. Professional societies need to take these concerns into account when educating healthcare professionals on the uses of NIPT to ensure prospective parents' reproductive decisions are optimal for them and their families.
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Affiliation(s)
- Hazar Haidar
- Ethics programs, Department of Letters and Humanities, University of Quebec at Rimouski (UQAR), Rimouski, QC, Canada.
| | - Stanislav Birko
- School of Public Health, University of Montreal, C.P.6128, Succ. Centre-Ville, Montreal, QC, H3C 3J7, Canada
| | - Anne-Marie Laberge
- School of Public Health, University of Montreal, C.P.6128, Succ. Centre-Ville, Montreal, QC, H3C 3J7, Canada
- Medical Genetics, Department of Pediatrics, and Research Center, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
- Department of Pediatrics, and Research Center, Centre Hospitalier Universitaire Sainte-Justine, Montréal, QC, Canada
| | - Jessica Le Clerc-Blain
- Medical Genetics, Department of Pediatrics, and Research Center, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
| | - Vardit Ravitsky
- School of Public Health, University of Montreal, C.P.6128, Succ. Centre-Ville, Montreal, QC, H3C 3J7, Canada
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35
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Kristalijn SA, White K, Eerbeek D, Kostenko E, Grati FR, Bilardo CM. Patient experience with non-invasive prenatal testing (NIPT) as a primary screen for aneuploidy in the Netherlands. BMC Pregnancy Childbirth 2022; 22:782. [PMID: 36266611 PMCID: PMC9585792 DOI: 10.1186/s12884-022-05110-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 10/04/2022] [Indexed: 11/17/2022] Open
Abstract
Background Non-invasive prenatal testing (NIPT) as a screening method for trisomy 21 and other chromosomal abnormalities has been adopted widely across the globe. However, while many clinical validation studies have been performed, less is known regarding the patient experience with NIPT. This study explored how individuals experience NIPT in a pre- and post-test setting, where NIPT is broadly available as a primary screening method with the option of reporting beyond common trisomies. Methods Participants were recruited using social media with a strategy designed to select individuals who had the option to have NIPT as part of the TRIDENT-2 study (In the Netherlands, NIPT is only available within the TRIDENT studies executed by the NIPT consortium. This research was done independently from the NIPT consortium.) in the Netherlands. The study used online questionnaires and semi-structured interviews. Both were developed around a patient experience framework consisting of seven themes: information, patient as active participant, responsiveness of services, lived experience, continuity of care and relationships, communication, and support. Results Overall, 4539 questionnaire responses were analyzed and 60% of the respondents had experienced NIPT. Of those, 1.7% received a high-risk result for trisomy or another chromosomal copy number variant (referred to as an “additional finding”). Overall, participants felt they had received sufficient information and had control over their decision regarding whether or not to choose NIPT. The vast majority of respondents who had NIPT were positive about their experience and would use it again. Those with results showing an increased probability for trisomy or additional findings were more likely to report negative feelings such as tension and anxiety, and less likely to feel that they had been sufficiently prepared for the implications of their results. Conclusions The patient experience with first-tier NIPT in the Netherlands was largely positive. Areas for improvement included counseling on the implications of screening and the different possible outcomes of NIPT, including additional findings that may be uncovered by expanding NIPT beyond the common trisomies. The experiences reported in this study may be useful for other countries intending to implement NIPT.
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Affiliation(s)
| | | | - Deanna Eerbeek
- Management Policy Analysis and Entrepreneurship, VU University Amsterdam, Amsterdam, The Netherlands
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Davis TH. QnAs with Yuk-Ming Dennis Lo: Winner of the 2022 Lasker∼DeBakey Clinical Medical Research Award. Proc Natl Acad Sci U S A 2022; 119:e2213996119. [PMID: 36170248 PMCID: PMC9546625 DOI: 10.1073/pnas.2213996119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Identifying the minimum concentrations of cell-free fetal DNA in maternal blood required for bovine fetal sexing using PCR. Theriogenology 2022; 191:192-199. [PMID: 35998402 DOI: 10.1016/j.theriogenology.2022.08.015] [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: 05/12/2022] [Revised: 07/27/2022] [Accepted: 08/07/2022] [Indexed: 11/21/2022]
Abstract
We evaluated the feasibility of cffDNA extraction from the maternal blood samples regarding the threshold concentrations required for fetal sexing in pregnant cattle by PCR. In four trials, we 1) compared the extraction efficiency of seven methods using freshly harvested plasma/blood of cows carrying male fetii (150-240 d gestation) bovine amelogenin (bAML) and Y-specific gene sequences, 2) identified the minimum amounts of spiked cffDNA needed for a PCR for fetal sexing, 3) determined the most optimal protocol among three commercial kits for cffDNA extraction from neat and spiked plasma samples (181-240 d gestation) for PCR detection of Y-specific sequence and 4) tested Y-specific sequence PCR on pregnant cows at different stages of gestation (60-150 versus 151-240 d pregnant). In these experiments, blood samples from unbred dairy heifers (Canadian Holstein, n = 10), pregnant dairy cows (Canadian Holstein, 60-240 d gestation, n = 25 with male fetii), and aborting beef cows (Angus cross, n = 5, 100-150 d pregnant) were used for DNA extraction, spiking, and PCR. Extracted DNA from the blood samples of unbred heifers (n = 5) and bull calves (n = 5) served as controls in all trials. In the first trial, DNeasy Blood and Tissue, Qiagen DSP Virus, and NucleoMag cfDNA isolation kits were relatively successful among seven methods to isolate cffDNA from freshly harvested maternal plasma/blood of pregnant cows. In trial 2, using serial dilutions of cffDNA from male fetii spiked in cow plasma samples, a positive and unambiguous detection by PCR targeting Y-specific sequence and bAML gene was observed when spiked cffDNA concentration in plasma was >31.3 pg/ml and >2 ng/ml, respectively. In the third trial, the DNeasy Blood and Tissue kit was most successful in extracting cffDNA spiked at the minimum concentrations in maternal plasma and subsequent PCR for Y-specific sequence. In our fourth trial, more cows in the second half (9/10) of gestation showed a positive Y-specific PCR outcome than those in the first half (3/9, Fischer's exact test; P < 0.05, 90%; CI: 55.5-99.75 vs 33%; CI: 7.5-70.1). In conclusion, we observed variability between different DNA extraction methodologies and stages of gestation results in the PCR for prenatal sexing. Thus, the current PCR methodologies are unreliable for detecting cffDNA in pregnant cows. Additionally, ≥10 (≥31.3 pg/ml of cffDNA) and ≥648 (≥2 ng/ml of cffDNA) copies of the whole fetal genome in bovine maternal plasma are needed for Y-specific PCR and bAML PCR, respectively.
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van Dijke I, van El CG, Lakeman P, Goddijn M, Rigter T, Cornel MC, Henneman L. Dynamics of reproductive genetic technologies: Perspectives of professional stakeholders. PLoS One 2022; 17:e0269719. [PMID: 35727796 PMCID: PMC9212161 DOI: 10.1371/journal.pone.0269719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 05/26/2022] [Indexed: 11/19/2022] Open
Abstract
Reproductive and genetic medicine are evolving rapidly, and new technologies are already impacting current practices. This includes technologies that can identify a couples' risk of having a child with a genetic disorder. Responsible implementation of new technologies requires evaluation of safety and ethics. Valuable insights for shaping governance processes are provided by various stakeholders involved, including healthcare professionals. Their willingness to adopt these technologies and guide the necessary systemic changes is required for the successful implementation of these technologies. In this study, twenty-one semi-structured interviews were conducted with professionals from different disciplines in the field of reproductive and genetic healthcare in the Netherlands. Three emerging technologies were discussed: expanded carrier screening (ECS), non-invasive prenatal diagnosis (NIPD) and germline genome editing (GGE). By probing stakeholders' views, we explored how culture, structure and practice in healthcare is being shaped by innovations and changing dynamics in genetic and reproductive medicine. The general consensus was that the implementation of reproductive genetic technologies nationwide is a slow process in Dutch healthcare. A "typical Dutch approach" emerged that is characterized by restrictive legislation, broad support for people living with disabilities, values of an egalitarian society and limited commercialisation. Different scenarios for embedding ECS in future practice were envisioned, while implementation of NIPD in clinical practice was considered obvious. Views on GGE varied among stakeholders. Previous implementation examples in the Netherlands suggest introduction of new technology involves an organized collective learning process, with pilot studies and stepwise implementation. In addition, introducing and scaling up new technologies is complex due to perceived barriers from the legislative framework and the complex relationship between the government and stakeholders in this area. This paper describes how the international trends and advances of technologies are expected to manifest itself in a national setting.
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Affiliation(s)
- Ivy van Dijke
- Department of Human Genetics and Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam UMC, University of Amsterdam, Center for Reproductive Medicine and Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
| | - Carla G. van El
- Department of Human Genetics and Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Phillis Lakeman
- Department of Human Genetics and Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Mariëtte Goddijn
- Amsterdam UMC, University of Amsterdam, Center for Reproductive Medicine and Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
| | - Tessel Rigter
- Department of Human Genetics and Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Martina C. Cornel
- Department of Human Genetics and Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Lidewij Henneman
- Department of Human Genetics and Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Winters P, Curnow KJ, Benachi A, Gil MM, Santacruz B, Nishiyama M, Hasegawa F, Sago H. Multisite assessment of the impact of a prenatal testing educational App on patient knowledge and preparedness for prenatal testing decision making. J Community Genet 2022; 13:435-444. [PMID: 35680723 PMCID: PMC9314500 DOI: 10.1007/s12687-022-00596-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 05/25/2022] [Indexed: 10/25/2022] Open
Abstract
In this study, we wanted to assess the impact of the use of a patient educational app on patient knowledge about noninvasive prenatal testing (NIPT) and preparedness for prenatal screening decision-making. A randomized control study was carried out at three international sites between January 2019 and October 2020. Study participants completed a pre-consultation survey and post-consultation survey to assess knowledge, satisfaction, and preparedness for prenatal screening consultation. Providers completed a post-consultation survey. In the control arm, the pre-consultation survey was completed prior to consultation with their prenatal care provider. In the intervention arm, the pre-consultation survey was completed after using the app but prior to consultation with their prenatal care provider. Mean knowledge scores in the 203 participants using the app were significantly higher pre-consultation (p < 0.001) and post-consultation (p < 0.005) than those not using the app. Higher pre-consultation knowledge scores in the intervention group were observed at all sites. Most (86%) app users stated they were "Satisfied" or "Very Satisfied" with it as a tool. Providers rated the intervention group as more prepared than controls (p = 0.027); provider assessment of knowledge was not significantly different (p = 0.073). This study shows that clinical implementation of a patient educational app in a real-world setting was feasible, acceptable to pregnant people, and positively impacted patient knowledge.
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Affiliation(s)
| | | | - Alexandra Benachi
- Obstetrics and Gynecology Department, Hôpital Antoine Béclère, AP-HP, Université Paris Saclay, Clamart, France
| | - Maria Mar Gil
- Obstetrics and Gynecology Department, Hospital Universitario de Torrejón and School of Medicine, Universidad Francisco de Vitoria, Madrid, Spain
| | - Belen Santacruz
- Obstetrics and Gynecology Department, Hospital Universitario de Torrejón and School of Medicine, Universidad Francisco de Vitoria, Madrid, Spain
| | - Miyuki Nishiyama
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Fuyuki Hasegawa
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Haruhiko Sago
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
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Chromosomal microarray analysis versus noninvasive prenatal testing in fetuses with increased nuchal translucency. J Hum Genet 2022; 67:533-539. [PMID: 35578003 PMCID: PMC9402435 DOI: 10.1038/s10038-022-01041-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 04/14/2022] [Accepted: 04/24/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate if the NT value of 2.5 mm ≤ NT < 3.0 mm is an appropriate indication for CMA tests among fetuses with isolated increased NT and NIPT is more suitable instead. METHODS A total of 442 fetuses with NT ≥ 2.5 mm were included, in which 241 fetuses underwent karyotype. CMA tests were then carried out when cytogenic analysis showed normal chromosomes and CNV status was compared between 2.5 mm ≤ NT < 3.0 mm and ≥3.0 mm subgroups. For the NIPT evaluation, 201 of 442 fetuses with smaller increased NT (2.5 mm ≤ NT < 3.0 mm) was examined by either NIPT or karyotype. RESULTS Of the 241 fetuses with NT ≥ 2.5 mm, 47(19.50%) were identified by karyotype with chromosomal abnormalities. Among 194 cases with normal karyotype, CMA unraveled additional CNVs in 16(8.25%) cases, including 3(1.55%) pathogenic CNVs, 2(1.03%) likely pathogenic CNVs and 11(5.67%) VOUS. After the subgroup analysis, however, only one case (1.16%) of likely pathogenic was identified by CMA among 86 fetuses with NT between 2.5 mm and 3.0 mm, whereas the rest of 15 CNV cases were all presented in fetuses with NT ≥ 3.0 mm. For the NIPT evaluation, the detection rate of 201 fetuses with isolated increased NT between 2.5 and 3.0 mm was 3.98%, which was indifferent to karyotype with the rate of 5%. In comparison with fetuses with 2.5-3.0 mm combined with other risks, the detection rate of karyotype was 26.92%. CONCLUSION While no pathogenic CNVs were detected in fetuses, chromosomal aneuploidies and genomic imbalance were found to be the major type of abnormalities when NT was 2.5-3.0 mm. Therefore, our data suggested that CMA should not be recommended when fetuses with an NT value less than 3.0 mm. Instead, NIPT with similar rate of detection as karyotype was recommended for fetuses with isolated increased NT between 2.5 and 3.0 mm.
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Brown JEH, Koenig BA. How Ought Decisions That Weigh on Life and Death Be Justly Informed and Governed to Benefit More than the Privileged Few with Access to a Trusted Clinician? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2022; 22:1-3. [PMID: 35089829 DOI: 10.1080/15265161.2021.2019526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
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Deng Y, Zhou Y, Shi J, Yang J, Huang H, Zhang M, Wang S, Ma Q, Liu Y, Li B, Yan J, Yang H. Potential genetic biomarkers predict adverse pregnancy outcome during early and mid-pregnancy in women with systemic lupus erythematosus. Front Endocrinol (Lausanne) 2022; 13:957010. [PMID: 36465614 PMCID: PMC9708709 DOI: 10.3389/fendo.2022.957010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 11/01/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Effectively predicting the risk of adverse pregnancy outcome (APO) in women with systemic lupus erythematosus (SLE) during early and mid-pregnancy is a challenge. This study was aimed to identify potential markers for early prediction of APO risk in women with SLE. METHODS The GSE108497 gene expression dataset containing 120 samples (36 patients, 84 controls) was downloaded from the Gene Expression Omnibus database. Weighted gene co-expression network analysis (WGCNA) was performed, and differentially expressed genes (DEGs) were screened to define candidate APO marker genes. Next, three individual machine learning methods, random forest, support vector machine-recursive feature elimination, and least absolute shrinkage and selection operator, were combined to identify feature genes from the APO candidate set. The predictive performance of feature genes for APO risk was assessed using area under the receiver operating characteristic curve (AUC) and calibration curves. The potential functions of these feature genes were finally analyzed by conventional gene set enrichment analysis and CIBERSORT algorithm analysis. RESULTS We identified 321 significantly up-regulated genes and 307 down-regulated genes between patients and controls, along with 181 potential functionally associated genes in the WGCNA analysis. By integrating these results, we revealed 70 APO candidate genes. Three feature genes, SEZ6, NRAD1, and LPAR4, were identified by machine learning methods. Of these, SEZ6 (AUC = 0.753) showed the highest in-sample predictive performance for APO risk in pregnant women with SLE, followed by NRAD1 (AUC = 0.694) and LPAR4 (AUC = 0.654). After performing leave-one-out cross validation, corresponding AUCs for SEZ6, NRAD1, and LPAR4 were 0.731, 0.668, and 0.626, respectively. Moreover, CIBERSORT analysis showed a positive correlation between regulatory T cell levels and SEZ6 expression (P < 0.01), along with a negative correlation between M2 macrophages levels and LPAR4 expression (P < 0.01). CONCLUSIONS Our preliminary findings suggested that SEZ6, NRAD1, and LPAR4 might represent the useful genetic biomarkers for predicting APO risk during early and mid-pregnancy in women with SLE, and enhanced our understanding of the origins of pregnancy complications in pregnant women with SLE. However, further validation was required.
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Affiliation(s)
- Yu Deng
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Beijing, China
| | - Yiran Zhou
- Department of Medicinal Chemistry, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Jiangcheng Shi
- School of Life Sciences, Tiangong University, Tianjin, China
| | - Junting Yang
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Hong Huang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Muqiu Zhang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Beijing, China
| | - Shuxian Wang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Beijing, China
| | - Qian Ma
- Department of Clinical Laboratory, Peking University First Hospital, Beijing, China
| | - Yingnan Liu
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Beijing, China
| | - Boya Li
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Beijing, China
| | - Jie Yan
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Beijing, China
| | - Huixia Yang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Beijing, China
- *Correspondence: Huixia Yang,
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Cornell P, Armstrong T, Fyfe R, Mallise CA, Dudding-Byth T, Campbell LE. Experiences of non-invasive prenatal screening: A survey study. Aust N Z J Obstet Gynaecol 2021; 62:241-249. [PMID: 34570369 DOI: 10.1111/ajo.13436] [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] [Received: 07/01/2021] [Accepted: 08/30/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND In Australia, using non-invasive prenatal testing (NIPT) to screen for fetal abnormalities is becoming more commonplace. However, there is a lack of standardised procedures surrounding pre-test counselling. This holds the potential for variability in pregnant people's experiences when undergoing NIPT, which subsequently may impact their ability to make informed decisions surrounding NIPT results. AIM This study sought to characterise the experiences of Australian women undergoing NIPT, including perceptions of informed choice, counselling experiences and decision to undergo NIPT. MATERIALS AND METHODS Australian women who had been recently pregnant (n = 94) completed an online survey which assessed: their knowledge of and attitude toward NIPT; satisfaction with counselling; satisfaction with their decision; and decisional conflict to undergo NIPT. The survey also allowed participants to provide qualitative information about their counselling experience and reasons for undergoing NIPT. RESULTS Overall, participants had good knowledge of and positive attitudes toward NIPT, experienced low decisional conflict and were overall satisfied with their counselling experience and decision to undergo NIPT. However, some participants expressed dissatisfaction with the lack of information provided, and biased language, by counselling providers. The desire to be informed was the most frequent reason for undergoing NIPT. CONCLUSION The provision of accurate and objective information in pre-test counselling is important to reduce decisional conflict and improve satisfaction with the decision to undergo NIPT. It is recommended counselling providers present pregnant people with neutral, objective, and accurate information at the time of pre-test counselling.
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Affiliation(s)
- Paige Cornell
- School of Psychological Sciences, College of Engineering, Science and Environment, University of Newcastle, Callaghan, NSW, Australia
| | - Taylah Armstrong
- School of Psychological Sciences, College of Engineering, Science and Environment, University of Newcastle, Callaghan, NSW, Australia
| | - Rina Fyfe
- Maternal Fetal Medicine Unit, John Hunter Hospital, New Lambton Heights, NSW, Australia
| | - Carly A Mallise
- School of Psychological Sciences, College of Engineering, Science and Environment, University of Newcastle, Callaghan, NSW, Australia
| | - Tracy Dudding-Byth
- Hunter Genetics, Callaghan, NSW, Australia.,School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia
| | - Linda E Campbell
- School of Psychological Sciences, College of Engineering, Science and Environment, University of Newcastle, Callaghan, NSW, Australia
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van der Meij KRM, Kooij C, Bekker MN, Galjaard RJH, Henneman L. Non-invasive prenatal test uptake in socioeconomically disadvantaged neighborhoods. Prenat Diagn 2021; 41:1395-1400. [PMID: 34505288 PMCID: PMC9291196 DOI: 10.1002/pd.6043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/18/2021] [Accepted: 09/03/2021] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Non-Invasive Prenatal Testing (NIPT) is increasingly being implemented worldwide. In public health programs, equitable access to healthcare is a fundamental principle which also applies to fetal aneuploidy screening. However, the out-of-pocket costs of NIPT may lead to sociodemographic disparities in uptake of screening. This study assessed whether there is a difference in the uptake of NIPT in socioeconomically disadvantaged neighborhoods compared to all other neighborhoods in the Netherlands, where NIPT is implemented in a national screening program (TRIDENT-2 study). METHOD NIPT uptake, postal code and age of 156,562 pregnant women who received pre-test counselling for prenatal screening in 2018 were retrieved from the national prenatal screening database. Postal codes were used as a proxy to categorize neighborhoods as being either socioeconomically disadvantaged or other. The out-of-pocket costs for NIPT were €175. RESULTS NIPT uptake in socioeconomically disadvantaged neighborhoods was 20.3% whereas uptake in all other neighborhoods was 47.6% (p < 0.001). The difference in NIPT uptake between socioeconomic disadvantaged neighborhoods and other areas was smaller for the youngest maternal age-group (≤25 years) compared to other age-groups. CONCLUSION The variation in uptake suggest underlying disparities in NIPT uptake, which undermines the goals of a national fetal aneuploidy screening program of providing reproductive autonomy and equitable access. This has ethical and policy implications for ensuring fair and responsible implementation of fetal aneuploidy screening.
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Affiliation(s)
- Karuna R M van der Meij
- Department of Human Genetics and Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Caroline Kooij
- Department of Human Genetics and Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Mireille N Bekker
- Department of Obstetrics and Gynecology, Utrecht University Medical Center, Utrecht, The Netherlands
| | | | - Lidewij Henneman
- Department of Human Genetics and Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Comparing Germany and Israel regarding debates on policy-making at the beginning of life: PGD, NIPT and their paths of routinization. Ethik Med 2021. [DOI: 10.1007/s00481-021-00652-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
Definition
The routinization of prenatal diagnosis is the source of bioethical and policy debates regarding choice, autonomy, access, and protection. To understand these debates in the context of cultural diversity and moral pluralism, we compare Israel and Germany, focusing on two recent repro-genetic “hot spots” of such policy-making at the beginning of life: pre-implantation genetic diagnosis (PGD) and non-invasive prenatal genetic testing (NIPT), two cutting-edge repro-genetic technologies that are regulated and viewed very differently in Germany and Israel, reflecting different medicolegal policies as well as public and bioethical considerations.
Arguments
First, we compare policy-making in the context of PGD for HLA (human leukocyte antigen) typing, used to create sibling donors, approved in Israel under specific conditions while prohibited in Germany. Second, we compare policy-making in the context of NIPT, which came under fire in Germany, while in Israel there has been little public debate about it.
Conclusion
Both countries justify their contrasting policies as reflecting a concern for the well-being and care of the embryo/child, thus highlighting different concepts of embryo/child protection, (relational) autonomy, family relations, and the impact of religion and history on the promotion/protection of life. We use the juxtaposition of PGD and NIPT to highlight some inconsistencies in policies concerning the protection of extra- and intra-corporeal embryos. We conclude by drawing on the comparison to show how national variations exist alongside co-evolution.
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van der Meij KRM, Njio A, Martin L, Gitsels-van der Wal JT, Bekker MN, van Vliet-Lachotzki EH, van der Ven AJEM, Kater-Kuipers A, Timmermans DRM, Sistermans EA, Galjaard RJH, Henneman L. Routinization of prenatal screening with the non-invasive prenatal test: pregnant women's perspectives. Eur J Hum Genet 2021; 30:661-668. [PMID: 34385671 PMCID: PMC9177612 DOI: 10.1038/s41431-021-00940-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/03/2021] [Accepted: 07/13/2021] [Indexed: 11/13/2022] Open
Abstract
Due to the favorable test characteristics of the non-invasive prenatal test (NIPT) in the screening of fetal aneuploidy, there has been a strong and growing demand for implementation. In the Netherlands, NIPT is offered within a governmentally supported screening program as a first-tier screening test for all pregnant women (TRIDENT-2 study). However, concerns have been raised that the test’s favorable characteristics might lead to uncritical use, also referred to as routinization. This study addresses women’s perspectives on prenatal screening with NIPT by evaluating three aspects related to routinization: informed choice, freedom to choose and (personal and societal) perspectives on Down syndrome. Nationwide, a questionnaire was completed by 751 pregnant women after receiving counseling for prenatal screening. Of the respondents, the majority (75.5%) made an informed choice for prenatal screening as measured by the multidimensional measure of informed choice (MMIC). Education level and religious affiliation were significant predictors of informed choice. The main reason to accept screening was “seeking reassurance” (25.5%), and the main reason to decline was “every child is welcome” (30.6%). The majority of respondents (87.7%) did not perceive societal pressure to test. Differences between test-acceptors and test-decliners in personal and societal perspectives on Down syndrome were found. Our study revealed high rates of informed decision-making and perceived freedom to choose regarding fetal aneuploidy screening, suggesting that there is little reason for concern about routinization of NIPT based on the perspectives of Dutch pregnant women. Our findings highlight the importance of responsible implementation of NIPT within a national screening program.
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Affiliation(s)
- Karuna R M van der Meij
- Department of Clinical Genetics and Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Annabel Njio
- Department of Clinical Genetics and Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Linda Martin
- Department of Midwifery Science, AVAG, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Janneke T Gitsels-van der Wal
- Department of Midwifery Science, AVAG, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Mireille N Bekker
- Department of Obstetrics and Gynaecology, Utrecht University Medical Center, Utrecht, The Netherlands
| | | | | | - Adriana Kater-Kuipers
- Department of Clinical Genetics and Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Danielle R M Timmermans
- Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Erik A Sistermans
- Department of Clinical Genetics and Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Robert-Jan H Galjaard
- Department of Clinical Genetics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Lidewij Henneman
- Department of Clinical Genetics and Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
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