1
|
Roopnarain K, Klein C. Genetic Testing for GBA and LRRK2 Mutations: Is it Time for Routine Use? Mov Disord Clin Pract 2023; 10:S26-S31. [PMID: 37637988 PMCID: PMC10448120 DOI: 10.1002/mdc3.13619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/27/2022] [Accepted: 07/04/2022] [Indexed: 08/29/2023] Open
Affiliation(s)
- Karisha Roopnarain
- Institute of NeurogeneticsUniversity of Luebeck and University Hospital Schleswig‐HolsteinLuebeckGermany
- Faculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - Christine Klein
- Institute of NeurogeneticsUniversity of Luebeck and University Hospital Schleswig‐HolsteinLuebeckGermany
| |
Collapse
|
2
|
Pal G, Cook L, Schulze J, Verbrugge J, Alcalay RN, Merello M, Sue CM, Bardien S, Bonifati V, Chung SJ, Foroud T, Gatto E, Hall A, Hattori N, Lynch T, Marder K, Mascalzoni D, Novaković I, Thaler A, Raymond D, Salari M, Shalash A, Suchowersky O, Mencacci NE, Simuni T, Saunders‐Pullman R, Klein C. Genetic Testing in Parkinson's Disease. Mov Disord 2023; 38:1384-1396. [PMID: 37365908 PMCID: PMC10946878 DOI: 10.1002/mds.29500] [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: 10/31/2022] [Revised: 02/28/2023] [Accepted: 05/24/2023] [Indexed: 06/28/2023] Open
Abstract
Genetic testing for persons with Parkinson's disease is becoming increasingly common. Significant gains have been made regarding genetic testing methods, and testing is becoming more readily available in clinical, research, and direct-to-consumer settings. Although the potential utility of clinical testing is expanding, there are currently no proven gene-targeted therapies, but clinical trials are underway. Furthermore, genetic testing practices vary widely, as do knowledge and attitudes of relevant stakeholders. The specter of testing mandates financial, ethical, and physician engagement, and there is a need for guidelines to help navigate the myriad of challenges. However, to develop guidelines, gaps and controversies need to be clearly identified and analyzed. To this end, we first reviewed recent literature and subsequently identified gaps and controversies, some of which were partially addressed in the literature, but many of which are not well delineated or researched. Key gaps and controversies include: (1) Is genetic testing appropriate in symptomatic and asymptomatic individuals without medical actionability? (2) How, if at all, should testing vary based on ethnicity? (3) What are the long-term outcomes of consumer- and research-based genetic testing in presymptomatic PD? (4) What resources are needed for clinical genetic testing, and how is this impacted by models of care and cost-benefit considerations? Addressing these issues will help facilitate the development of consensus and guidelines regarding the approach and access to genetic testing and counseling. This is also needed to guide a multidisciplinary approach that accounts for cultural, geographic, and socioeconomic factors in developing testing guidelines. © 2023 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
Collapse
Affiliation(s)
- Gian Pal
- Department of NeurologyRutgers‐Robert Wood Johnson Medical SchoolNew BrunswickNew JerseyUSA
| | - Lola Cook
- Department of Medical and Molecular GeneticsIndiana University School of MedicineIndianapolisIndianaUSA
| | - Jeanine Schulze
- Department of Medical and Molecular GeneticsIndiana University School of MedicineIndianapolisIndianaUSA
| | - Jennifer Verbrugge
- Department of Medical and Molecular GeneticsIndiana University School of MedicineIndianapolisIndianaUSA
| | - Roy N. Alcalay
- Department of NeurologyColumbia University Irving Medical CenterNew YorkNew YorkUSA
- Movement Disorders Division, Neurological InstituteTel Aviv Sourasky Medical CenterTel AvivIsrael
| | - Marcelo Merello
- Neuroscience Department FleniCONICET, Catholic University of Buenos AiresBuenos AiresArgentina
| | - Carolyn M. Sue
- Department of NeurologyRoyal North Shore HospitalSt LeonardsNew South WalesAustralia
- Department of Neurogenetics, Kolling Institute, Faculty of Medicine and HealthUniversity of SydneySt LeonardsNew South WalesAustralia
| | - Soraya Bardien
- Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
- South African Medical Research Council/Stellenbosch University Genomics of Brain Disorders Research UnitStellenbosch UniversityCape TownSouth Africa
| | - Vincenzo Bonifati
- Department of Clinical Genetics, Erasmus MCUniversity Medical Center RotterdamRotterdamthe Netherlands
| | - Sun Ju Chung
- Department of Neurology, Asan Medical CenterUniversity of Ulsan College of MedicineSeoulSouth Korea
| | - Tatiana Foroud
- Department of Medical and Molecular GeneticsIndiana University School of MedicineIndianapolisIndianaUSA
| | - Emilia Gatto
- Instituto de Neurociencias Buenos AiresAffiliated Buenos Aires UniversityBuenos AiresArgentina
| | - Anne Hall
- Parkinson's FoundationNew YorkNew YorkUSA
| | - Nobutaka Hattori
- Research Institute of Disease of Old Age, Graduate School of MedicineJuntendo UniversityTokyoJapan
- Department of NeurologyJuntendo University School of MedicineTokyoJapan
- Neurodegenerative Disorders Collaborative LaboratoryRIKEN Center for Brain ScienceSaitamaJapan
| | - Tim Lynch
- Dublin Neurological Institute at the Mater Misericordiae University HospitalDublinIreland
| | - Karen Marder
- Department of NeurologyColumbia University Irving Medical CenterNew YorkNew YorkUSA
| | - Deborah Mascalzoni
- Institute for Biomedicine, Eurac ResearchAffiliated Institute of the University of LübeckBolzanoItaly
- Center for Research Ethics and Bioethics, Department of Public Health and Caring SciencesUppsala UniversityUppsalaSweden
| | - Ivana Novaković
- Institute of Human Genetics, Faculty of MedicineUniversity of BelgradeBelgradeSerbia
| | - Avner Thaler
- Movement Disorders Unit, Neurological InstituteTel‐Aviv Medical CenterTel AvivIsrael
- Sackler School of MedicineTel‐Aviv UniversityTel AvivIsrael
- Sagol School of NeuroscienceTel‐Aviv UniversityTel AvivIsrael
- Laboratory of Early Markers of Neurodegeneration, Neurological InstituteTel‐Aviv Medical CenterTel AvivIsrael
| | - Deborah Raymond
- Department of NeurologyMount Sinai Beth Israel and Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Mehri Salari
- Functional Neurosurgery Research Center, Shohada‐e Tajrish Comprehensive Neurosurgical Center of ExcellenceShahid Beheshti University of Medical SciencesTehranIran
| | - Ali Shalash
- Department of Neurology, Faculty of MedicineAin Shams UniversityCairoEgypt
| | - Oksana Suchowersky
- Department of Medicine (Neurology), Medical Genetics and PediatricsUniversity of AlbertaEdmontonAlbertaCanada
| | - Niccolò E. Mencacci
- Ken and Ruth Davee Department of Neurology and Simpson Querrey Center for NeurogeneticsNorthwestern University, Feinberg School of MedicineChicagoIllinoisUSA
- Parkinson's Disease and Movement Disorders CenterNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Tanya Simuni
- Parkinson's Disease and Movement Disorders CenterNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Rachel Saunders‐Pullman
- Department of NeurologyMount Sinai Beth Israel and Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Christine Klein
- Institute of NeurogeneticsUniversity of Lübeck and University Hospital Schleswig‐HolsteinLübeckGermany
| |
Collapse
|
3
|
Mighton C, Shickh S, Aguda V, Krishnapillai S, Adi-Wauran E, Bombard Y. From the patient to the population: Use of genomics for population screening. Front Genet 2022; 13:893832. [PMID: 36353115 PMCID: PMC9637971 DOI: 10.3389/fgene.2022.893832] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 09/26/2022] [Indexed: 10/22/2023] Open
Abstract
Genomic medicine is expanding from a focus on diagnosis at the patient level to prevention at the population level given the ongoing under-ascertainment of high-risk and actionable genetic conditions using current strategies, particularly hereditary breast and ovarian cancer (HBOC), Lynch Syndrome (LS) and familial hypercholesterolemia (FH). The availability of large-scale next-generation sequencing strategies and preventive options for these conditions makes it increasingly feasible to screen pre-symptomatic individuals through public health-based approaches, rather than restricting testing to high-risk groups. This raises anew, and with urgency, questions about the limits of screening as well as the moral authority and capacity to screen for genetic conditions at a population level. We aimed to answer some of these critical questions by using the WHO Wilson and Jungner criteria to guide a synthesis of current evidence on population genomic screening for HBOC, LS, and FH.
Collapse
Affiliation(s)
- Chloe Mighton
- Genomics Health Services Research Program, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Salma Shickh
- Genomics Health Services Research Program, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Vernie Aguda
- Genomics Health Services Research Program, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
- Centre for Medical Education, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Suvetha Krishnapillai
- Genomics Health Services Research Program, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Ella Adi-Wauran
- Genomics Health Services Research Program, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Yvonne Bombard
- Genomics Health Services Research Program, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
4
|
Biancolella M, Ouédraogo NLM, Zongo N, Zohoncon TM, Testa B, Rizzacasa B, Latini A, Conte C, Compaore TR, Ouedraogo CMRN, Traore SS, Simpore J, Novelli G. Breast cancer in West Africa: molecular analysis of BRCA genes in early-onset breast cancer patients in Burkina Faso. Hum Genomics 2021; 15:65. [PMID: 34717758 PMCID: PMC8557567 DOI: 10.1186/s40246-021-00365-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 10/17/2021] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Breast cancer (BC) is the most commonly diagnosed cancer and the second leading cause of cancer-related deaths among women in Africa after cervical cancer. Even if the epidemiological data are now aligned with those relating to industrialized countries, the knowledge concerning breast cancer in Africa, particularly in Western Africa, still lack clinical data, medical treatments, and the evaluation of genetic and non-genetic factors implicated in the etiology of the disease. The early onset and the aggressiveness of diagnosed breast cancers in patients of African ancestry strongly suggest that the genetic risk factor may be a key component, but so far, very few studies on the impact of germ line mutations in breast cancer in Africa have been conducted, with negative consequences on prevention, awareness and patient management. Through Next Generation sequencing (NGS), we analyzed all of the coding regions and the exon-intron junctions of BRCA1 and BRCA2 genes-the two most important genes in hereditary breast cancer-in fifty-one women from Burkina Faso with early onset of breast cancer with or without a family history. RESULTS We identified six different pathogenic mutations (three in BRCA1, three in BRCA2), two of which were recurrent in eight unrelated women. Furthermore, we identified, in four other patients, two variants of uncertain clinical significance (VUS) and two variants never previously described in literature, although one of them is present in the dbSNP database. CONCLUSIONS This is the first study in which the entire coding sequence of BRCA genes has been analyzed through Next Generation Sequencing in Burkinabe young women with breast cancer. Our data support the importance of genetic risk factors in the etiology of breast cancer in this population and suggest the necessity to improve the genetic cancer risk assessment. Furthermore, the identification of the most frequent mutations of BRCA1 and BRCA2 in the population of Burkina Faso will allow the development of an inexpensive genetic test for the identification of subjects at high genetic cancer risk, which could be used to design personalized therapeutic protocols.
Collapse
Affiliation(s)
- Michela Biancolella
- Department of Biology, University of Rome “Tor Vergata”, 00133 Rome, Italy
- Medical Genetics Laboratory, Tor Vergata Hospital, Rome, Italy
| | - Nabonswindé Lamoussa Marie Ouédraogo
- University Saint Thomas d’Aquin of Ouagadougou, Saint Camille Hospital, 06 BP: 10212, Ouagadougou 06, Burkina Faso
- Research Centre (CERBA), P.O. Box 364, Ouagadougou 01, Burkina Faso
| | - Nayi Zongo
- Department of Visceral Surgery of Yalgado, Ouédraogo University Hospital (CHUYO), Joseph KI ZERBO University of Ouagadougou, Ouagadougou, Burkina Faso
| | - Théodora Mahoukèdè Zohoncon
- University Saint Thomas d’Aquin of Ouagadougou, Saint Camille Hospital, 06 BP: 10212, Ouagadougou 06, Burkina Faso
- Research Centre (CERBA), P.O. Box 364, Ouagadougou 01, Burkina Faso
| | - Barbara Testa
- Department of Biomedicine and Prevention, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Barbara Rizzacasa
- Department of Biomedicine and Prevention, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Andrea Latini
- Department of Biomedicine and Prevention, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Chiara Conte
- Medical Genetics Laboratory, Tor Vergata Hospital, Rome, Italy
| | | | - Charlemagne Marie Rayang-Newendé Ouedraogo
- University Saint Thomas d’Aquin of Ouagadougou, Saint Camille Hospital, 06 BP: 10212, Ouagadougou 06, Burkina Faso
- Department of the Gynecology of Bogodogo University Hospital, Joseph KI ZERBO University of Ouagadougou, 04 BP 8201, Ouagadougou 04, Burkina Faso
| | - Si Simon Traore
- University Saint Thomas d’Aquin of Ouagadougou, Saint Camille Hospital, 06 BP: 10212, Ouagadougou 06, Burkina Faso
| | - Jacques Simpore
- University Saint Thomas d’Aquin of Ouagadougou, Saint Camille Hospital, 06 BP: 10212, Ouagadougou 06, Burkina Faso
- Research Centre (CERBA), P.O. Box 364, Ouagadougou 01, Burkina Faso
| | - Giuseppe Novelli
- Medical Genetics Laboratory, Tor Vergata Hospital, Rome, Italy
- Department of Biomedicine and Prevention, University of Rome “Tor Vergata”, 00133 Rome, Italy
- IRCCS Neuromed, Pozzilli, IS Italy
- Department of Pharmacology, School of Medicine, University of Nevada, Reno, NV 89557 USA
| |
Collapse
|
5
|
Feinstein MA, Sharp RR, Sandness DJ, Feemster JC, Junna M, Kotagal S, Lipford MC, Tippmann-Peikert M, Boeve BF, Silber MH, St Louis EK. Physician and patient determinants of prognostic counseling in idiopathic REM sleep-behavior disorder. Sleep Med 2019; 62:80-85. [PMID: 31581066 DOI: 10.1016/j.sleep.2019.03.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 03/11/2019] [Accepted: 03/12/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES/BACKGROUND Prognostic counseling about the risk for developing overt neurodegenerative disorders for patients with idiopathic REM sleep-behavior disorder (iRBD) and isolated REM sleep without atonia (iRSWA) is difficult, given lack of disease-modifying interventions and uncertainty in accurate prognostication for individuals. We aimed to analyze patient and physician characteristics associated with documented prognostic discussions for patients with iRBD and iRSWA. PATIENTS/METHODS We retrospectively reviewed the medical records for 138 (112 iRBD and 26 iRSWA) patients seen at the Mayo Clinic between 2012 and 2015. We analyzed physician and patient demographics, initial complaint, and other information discussed during office visits. We then comparatively analyzed the impact of physician and patient characteristics on documented prognostic discussions using Chi Square or Fischer's exact test. RESULTS Mean iRBD patient age was 65.0 ± 13.0, and mean iRSWA age was 58 ± 15 years. Seventy-eight (69.6%) iRBD and 22 (84.6%) iRSWA patients were men. Sixty-two (55%) iRBD and three (12%) iRSWA patients received prognostic counseling about phenoconversion risk. iRBD was a secondary complaint in 67 (59.8%). Patients over age 60 years and those having iRBD as a chief complaint more frequently received prognostic discussions than those with opposite characteristics (all p < 0.05). Patient sex and antidepressant use were not associated with counseling. Sleep neurologists disclosed prognostic information most frequently, with male more likely than female clinicians to disclose prognoses. CONCLUSIONS Several patient and physician characteristics appear to influence documented prognostic counseling for iRBD/RSWA patients. Future studies of iRBD/RSWA patients' preferences are needed to clarify ethically appropriate physician-patient communication concerning prognosis.
Collapse
Affiliation(s)
- Max A Feinstein
- Mayo Center for Sleep Medicine, Department of Medicine, USA; Biomedical Ethics Research Program, USA; University of California San Francisco School of Medicine, USA
| | - Richard R Sharp
- Biomedical Ethics Research Program, USA; Mayo Clinic College of Medicine, Rochester, MN, USA
| | - David J Sandness
- Mayo Center for Sleep Medicine, Department of Medicine, USA; Department of Neurology, USA
| | - John C Feemster
- Mayo Center for Sleep Medicine, Department of Medicine, USA; Department of Neurology, USA
| | - Mithri Junna
- Department of Neurology, USA; Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Suresh Kotagal
- Department of Neurology, USA; Mayo Clinic College of Medicine, Rochester, MN, USA; Department of Pediatrics and Adolescent Medicine, USA
| | - Melissa C Lipford
- Mayo Center for Sleep Medicine, Department of Medicine, USA; Department of Neurology, USA; Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Maja Tippmann-Peikert
- Mayo Center for Sleep Medicine, Department of Medicine, USA; Department of Neurology, USA; Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Bradley F Boeve
- Mayo Center for Sleep Medicine, Department of Medicine, USA; Department of Neurology, USA; Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Michael H Silber
- Mayo Center for Sleep Medicine, Department of Medicine, USA; Department of Neurology, USA; Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Erik K St Louis
- Mayo Center for Sleep Medicine, Department of Medicine, USA; Biomedical Ethics Research Program, USA; Department of Neurology, USA; Mayo Clinic College of Medicine, Rochester, MN, USA.
| |
Collapse
|
6
|
Sokol LL, Young MJ, Jankovic J. Counseling At-Risk Parkinson’s Disease Cohorts: Integrating Emerging Evidence. CURRENT GENETIC MEDICINE REPORTS 2017. [DOI: 10.1007/s40142-017-0116-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
7
|
Population screening for BRCA1/BRCA2 mutations: lessons from qualitative analysis of the screening experience. Genet Med 2016; 19:628-634. [PMID: 27906198 DOI: 10.1038/gim.2016.175] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 09/21/2016] [Indexed: 12/28/2022] Open
Abstract
PURPOSE Population screening for BRCA1/BRCA2. mutations is being considered for Ashkenazi Jews (AJ) because 2.5% carry recurrent deleterious mutations and effective cancer prevention exists. This study aimed to provide a qualitative focus on perspectives of individuals, particularly carriers, who were tested through a screening trial. In this trial, the pretest process included only written information. METHODS Interviews were performed with 26 carriers and 10 noncarriers who participated in a BRCA population screening trial for AJ. RESULTS Attitudes toward screening were generally positive. The main motivator for testing was knowledge of BRCA status to enable cancer risk reduction. Knowledge of carrier status, although challenging, was thus viewed as health-empowering. The screening paradigm was sensed as increasing awareness and as overcoming access, referral, and familial barriers. Streamlining the pretest process was positively perceived as offering gradual, stepwise knowledge commensurate with test results. Participants were concerned that health systems provide the necessary conceptual and infrastructural framework and that individual autonomy be maintained. CONCLUSIONS BRCA screening in AJ is viewed favorably, even by carriers. Stepwise acquisition of knowledge based on test results was viewed as most relevant to the screening context. Screening program development should account for safeguarding autonomy and providing requisite post-test services.Genet Med advance online publication 01 December 2016.
Collapse
|
8
|
Buhat DML, Tan EK. Genetic testing of LRRK2 in Parkinson's disease: is there a clinical role? Parkinsonism Relat Disord 2014; 20 Suppl 1:S54-6. [PMID: 24262189 DOI: 10.1016/s1353-8020(13)70015-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Genetic testing has played an important role for the diagnosis of many rare monogenic disorders. However, the role and limitations of genetic testing have generated considerable debate in the medical community. In recent years, the identification of several monogenic genes in Parkinson's disease (PD), a common neurodegenerative disorder, has led to calls for genetic testing guidelines for this disorder. Genetic testing of LRRK2 provides an excellent platform to highlight some of the pertinent issues (generic and specific) related to genetic testing in PD. The identification of a common recurrent mutation (G2019S) worldwide provides an opportunity for developing guidelines that are applicable internationally. However, the incomplete penetrance of the mutation and the lack of clarity of the pathogenicity of many other reported LRRK2 mutations call for cautious implementation of genetic testing programs. The clinical utility of genetic testing is compounded by easy accessibility of Direct to Consumer genetic services and the relative lack of regulation on reliability of service providers in internet advertisements. Based on current literature, genetic testing of LRRK2 (particularly for G2019S) certainly has a clinical role, though it is applicable primarily in select scenarios and in certain at-risk populations.
Collapse
|