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Kalkman S, Dondorp W. The case for screening in early life for 'non-treatable' disorders: ethics, evidence and proportionality. A report from the Health Council of the Netherlands. Eur J Hum Genet 2022; 30:1155-1158. [PMID: 35132176 PMCID: PMC9554018 DOI: 10.1038/s41431-022-01055-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/25/2021] [Accepted: 01/20/2022] [Indexed: 12/15/2022] Open
Abstract
In the Netherlands, the call to add 'non-treatable' disorders to the newborn bloodspot screening programme has found a sympathetic ear with the Government. In 2019, the Health Council of the Netherlands was formally asked for advice on the conditions under which bloodspot screening for such disorders might be offered. Here we present the reasoning and the recommendations of the resulting report, and briefly discuss its reception. The report holds on to the classical view that screening must benefit the child, but argues for a wider account of child benefit than only in terms of substantial health gains. However, screening for 'non-treatable' disorders would still require evidence of a favourable benefits to harm ratio. The report presents a framework for such screening, but concludes that apart perhaps from Duchenne Muscular Dystrophy (DMD), no or only very few 'non-treatable' disorders would at present meet its criteria. Setting up a screening programme that might benefit only a small percentage of families struggling with uncertainty about their child's diagnosis would not seem proportional. Instead, the Government is advised to invest in a better infrastructure for early referral, testing and care. The reaction to the report from proponents of such screening shows that the dividing line in the debate is not about whether screening neonates for 'non-treatable' disorders is acceptable in itself. It is rather whether such screening should be regarded as catering to a parental 'right to know', or as a public health service that should be subject to standards of evidence and proportionality.
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Affiliation(s)
- Shona Kalkman
- Health Council of the Netherlands, The Hague, the Netherlands
| | - Wybo Dondorp
- Dept of Health, Ethics & Society, School for Public Health & Primary Care (CAPHRI), Maastricht University, Maastricht, the Netherlands.
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Rajan-Babu IS, Phang GP, Law HY, Lee CG, Chong SS. High-Throughput Methylation-Specific Triplet-Primed PCR and Melting Curve Analysis for Selective and Reliable Identification of Actionable FMR1 Genotypes. J Mol Diagn 2022; 24:241-252. [PMID: 35038595 DOI: 10.1016/j.jmoldx.2021.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/26/2021] [Accepted: 11/23/2021] [Indexed: 11/17/2022] Open
Abstract
Methylated FMR1 full-mutation expansions cause fragile X syndrome. FMR1 premutation carriers are susceptible to other late-onset conditions, and women with premutation are at risk of transmitting a fully expanded FMR1 allele to offspring. Identification of individuals with actionable FMR1 genotypes (full-mutation males and females, and premutation females at risk for primary ovarian insufficiency and/or having fragile X-affected offspring) can enable timely access to intervention services and genetic counseling. This study presents a rapid, first-tier test based on melting curve analysis of methylation-specific triplet-primed PCR amplicons (msTP-PCR MCA) for concurrent detection of FMR1 CGG-repeat expansions and their methylation status. The msTP-PCR MCA assay was optimized on 20 fragile X reference samples, and its performance was evaluated on 111 peripheral blood-derived DNA samples from patients who have undergone prior molecular testing with PCR and/or Southern blot analysis. The msTP-PCR MCA assay detected all samples with a methylated FMR1 CGG-repeat expansion, and had sensitivity, specificity, positive predictive value, and negative predictive values of 100%, 92.06%, 91.1%, and 100%, respectively. The msTP-PCR MCA assay identified premutation/full-mutation mosaicism down to 1%, detected skewed inactivation in females with FMR1 expansions, and enabled selective identification of all individuals with an actionable FMR1 genotype. The msTP-PCR MCA assay may aid in fragile X screening of at-risk populations and newborns and voluntary carrier screening of women of reproductive age.
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Affiliation(s)
- Indhu-Shree Rajan-Babu
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Medical Genetics, University of British Columbia, and Children's and Women's Hospital, Vancouver, British Columbia, Canada.
| | - Gui-Ping Phang
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Hai-Yang Law
- Department of Pediatric Medicine, KK Women's and Children's Hospital, Singapore
| | - Caroline G Lee
- Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Cellular and Molecular Research, Humphrey Oei Institute of Cancer Research, National Cancer Centre Singapore, Singapore; Cancer and Stem Cell Biology Program, Duke-NUS Medical School, Singapore
| | - Samuel S Chong
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Obstetrics and Gynecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Laboratory Medicine, National University Hospital, Singapore.
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3
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Lisi EC, Ali N. Opinions of adults affected with later-onset lysosomal storage diseases regarding newborn screening: A qualitative study. J Genet Couns 2021; 30:1544-1558. [PMID: 33938615 DOI: 10.1002/jgc4.1421] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 03/09/2021] [Accepted: 03/13/2021] [Indexed: 12/23/2022]
Abstract
Lysosomal storage diseases (LSDs) are a heterogeneous group of conditions causing substrate accumulation leading to progressive organ damage. Newborn screening (NBS) for several LSDs has become available in recent years due to advances in technology and treatment availability. While early initiation of treatment is lifesaving for those with infantile presentations, controversy continues regarding diagnosis of milder, later-onset diseases in infancy, including creation of pre-symptomatic populations of 'patients-in-waiting', the potential for medicalization, stigmatization, and/or discrimination. In-depth interviews were conducted with 36 adults [11 with Fabry disease (FD), 8 with Gaucher disease (GD), and 17 with late-onset Pompe disease (LOPD)], to determine their perspectives on NBS for their respective conditions. Thirty-four of 36 participants were in favor of NBS; both participants not in favor had GD1. Emergent themes influencing participants favorably toward NBS included earlier age of onset, a long diagnostic odyssey, less efficacious treatment, and the desire to have made different life decisions (e.g., relationships, career, or lifestyle) with the knowledge of their diagnosis. Concerns about insurance discrimination and psychological or physical burdens were associated with less favorable opinions of NBS. The ability for parents to make future reproductive decisions based their child's NBS result was considered favorably by some participants and unfavorably by others. Participants' specific condition (GD1, FD, or LOPD) contributed to these experiences differently. Participants with LOPD and FD favored NBS to initiate earlier treatment and prevent irreversible organ damage, whereas fewer patients with GD1 mentioned this benefit. Participants with LOPD had the longest diagnostic odyssey, while those with FD were more likely to report feeling misunderstood and experiencing accusations of malingering, both contributing to favorable views of NBS. Results expand prior quantitative findings by illuminating how participants' lived experiences can shape opinions about NBS. By understanding how currently affected individuals perceive the lifelong impact of a NBS result, genetic counselors can provide better anticipatory guidance to the parents of individuals diagnosed with a later-onset LSD by NBS.
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Affiliation(s)
- Emily C Lisi
- Department of Human Genetics, Emory University, Atlanta, GA, USA.,Graduate School for Arts and Sciences- Biomedical Sciences Division, Wake Forest University, Winston-Salem, NC, USA
| | - Nadia Ali
- Department of Human Genetics, Emory University, Atlanta, GA, USA
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4
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Lee S, Taylor JL, Redmond C, Hadd AG, Kemppainen JA, Haynes BC, Shone S, Bailey DB, Latham GJ. Validation of Fragile X Screening in the Newborn Population Using a Fit-for-Purpose FMR1 PCR Assay System. J Mol Diagn 2020; 22:346-354. [PMID: 31866572 PMCID: PMC7103763 DOI: 10.1016/j.jmoldx.2019.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 10/25/2019] [Accepted: 11/18/2019] [Indexed: 12/11/2022] Open
Abstract
Newborn screening is designed for presymptomatic identification of serious conditions with effective early interventions. Clinical laboratories must perform prospective pilot studies to ensure that the analytical performance and workflow for a given screening test are appropriate. We assessed the potential to screen newborns for fragile X syndrome, a monogenic neurodevelopmental disorder, by establishing a customized, high-throughput PCR and analysis software system designed to detect fragile X mental retardation 1 gene repeat expansions from dried blood spots (DBSs). Assay precision, accuracy, sensitivity, and specificity were characterized across the categorical range of repeat expansions. The assay consistently resolved genotypes within three CGG repeats of reference values up to at least 137 repeats and within six repeats for larger expansions up to 200 repeats. Accuracy testing results were concordant with reference results. Full and premutation alleles were detected from subnanogram DNA inputs eluted from DBSs and from mixtures with down to 1% relative abundance of the respective expansion. Analysis of 963 deidentified newborn DBS samples identified 957 normal and 6 premutation specimens, consistent with previously published prevalence estimates. These studies demonstrate that the assay system can support high-throughput newborn screening programs.
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Affiliation(s)
- Stacey Lee
- Center for Newborn Screening, Ethics, and Disability Studies, RTI International, Research Triangle Park, North Carolina
| | - Jennifer L Taylor
- Center for Newborn Screening, Ethics, and Disability Studies, RTI International, Research Triangle Park, North Carolina.
| | | | | | | | | | - Scott Shone
- Center for Newborn Screening, Ethics, and Disability Studies, RTI International, Research Triangle Park, North Carolina
| | - Donald B Bailey
- Center for Newborn Screening, Ethics, and Disability Studies, RTI International, Research Triangle Park, North Carolina.
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Gabis LV, Shefer S, Raas-Rothschild A. Ethical Dilemmas Linked to Fragile X Testing of Minors—a Preliminary Survey Among Professionals. J Mol Neurosci 2020; 70:254-259. [DOI: 10.1007/s12031-019-01445-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 11/13/2019] [Indexed: 11/29/2022]
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Consumer Satisfaction with Newborn Pulse Oximetry Screening in a Midwifery-Led Maternity Setting. Int J Neonatal Screen 2018; 4:38. [PMID: 33072958 PMCID: PMC7548887 DOI: 10.3390/ijns4040038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 11/30/2018] [Indexed: 11/23/2022] Open
Abstract
Pulse oximetry screening to detect hypoxaemia in newborn infants was introduced at birthing facilities in New Zealand during a feasibility study determining barriers and enablers to universal screening in a midwifery-led maternity system focused on community values and partnership with, and participation by, consumers. During the 2-year study period, parents of infants who underwent pulse oximetry screening were invited to complete a written survey to investigate consumer satisfaction. Respondents ranked their satisfaction with the test and with information resources on a five-level Likert scale. Additional comments were added in a free text space. Participation was voluntary and anonymous. A total of 657 surveys were included for analysis. Consumers were satisfied with the screening procedure; 94% either agreed or strongly agreed that it is an important health check. Although the quality of information sources was deemed good, a third of participants indicated a wish to obtain more information. Some participants stated that retention of information was an issue, reporting that they were fatigued following the birth. Consumers are receptive to pulse oximetry screening. Sharing information (while considering the receptivity of parents) and engaging the parents of newborn infants are factors that are paramount to the success of newborn screening initiatives.
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Shen MD, Piven J. Brain and behavior development in autism from birth through infancy. DIALOGUES IN CLINICAL NEUROSCIENCE 2018. [PMID: 29398928 PMCID: PMC5789210 DOI: 10.31887/dcns.2017.19.4/mshen] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Autism spectrum disorder (ASD) is a heterogeneous condition that affects 1 in 68 children. Diagnosis is based on the presence of characteristic behavioral impairments that emerge in the second year of life and thus is not typically made until 3 to 4 years of age. Recent studies of early brain and behavior development have provided important new insights into the nature of this condition. Autism-specific brain imaging features have been identified as early as 6 months of age, and age-specific brain and behavior changes have been demonstrated across the first 2 years of life, highlighting the developmental nature of ASD. New findings demonstrate that early brain imaging in the first year of life holds great promise for presymptomatic prediction of ASD. There is a general understanding in medicine that earlier treatment has better outcomes than later treatment, and in autism, there is an emerging consensus that earlier intervention results in more successful outcomes for the child. Examining early brain and behavior trajectories also has the potential to parse the etiologic heterogeneity in ASD, a well-recognized impediment to developing targeted, mechanistic treatments. This review highlights the current state of the science in the pursuit of early brain and behavioral markers of autism during infancy and examines the potential implications of these findings for treatment of this condition.
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Affiliation(s)
- Mark D Shen
- Carolina Institute for Developmental Disabilities and Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Joseph Piven
- Carolina Institute for Developmental Disabilities and Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
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Including ELSI research questions in newborn screening pilot studies. Genet Med 2018; 21:525-533. [PMID: 30100612 DOI: 10.1038/s41436-018-0101-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Accepted: 06/13/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The evidence review processes for adding new conditions to state newborn screening (NBS) panels rely on data from pilot studies aimed at assessing the potential benefits and harms of screening. However, the consideration of ethical, legal, and social implications (ELSI) of screening within this research has been limited. This paper outlines important ELSI issues related to newborn screening policy and practices as a resource to help researchers integrate ELSI into NBS pilot studies. APPROACH Members of the Bioethics and Legal Workgroup for the Newborn Screening Translational Research Network facilitated a series of professional and public discussions aimed at engaging NBS stakeholders to identify important existing and emerging ELSI challenges accompanying NBS. RESULTS Through these engagement activities, we identified a set of key ELSI questions related to (1) the types of results parents may receive through newborn screening and (2) the initiation and implementation of NBS for a condition within the NBS system. CONCLUSION Integrating ELSI questions into pilot studies will help NBS programs to better understand the potential impact of screening for a new condition on newborns and families, and make crucial policy decisions aimed at maximized benefits and mitigating the potential negative medical or social implications of screening.
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Boardman FK, Sadler C, Young PJ. Newborn genetic screening for spinal muscular atrophy in the UK: The views of the general population. Mol Genet Genomic Med 2017; 6:99-108. [PMID: 29169204 PMCID: PMC5823674 DOI: 10.1002/mgg3.353] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 10/12/2017] [Accepted: 10/26/2017] [Indexed: 12/16/2022] Open
Abstract
Background Spinal muscular atrophy (SMA) is an inherited neuromuscular disorder and a leading genetic cause of infant death worldwide. However, there is no routine screening program for SMA in the UK. Lack of treatments and the inability of screening tests to accurately predict disease severity are among the key reasons implementation of screening has faltered in the UK. With the recent release of the first therapy for SMA (Nusinersen), calls are being made for a reconsideration of this stance; however, very little is known about the views of the general public. Methods An online survey was administered to 232 individuals with no prior relationship with SMA to assess their attitudes toward a newborn screening program for it. Results are compared with previously gathered data on the views of SMA‐affected families toward screening. Results Eighty‐four percent of participants were in favor of newborn screening. Key reasons for support were a belief that it would lead to better healthcare and life expectancy for affected infants and facilitate informed decision‐making for future pregnancies. Key reasons for nonsupport were a belief in the potential for significant negative impact on the family unit in terms of bonding and stress. Conclusions Public acceptability is a key component in the evaluation of any potential screening program in the UK. This study demonstrates that newborn screening for SMA is viewed largely positively by people unfamiliar with the condition. The importance of early identification overrode all other social and ethical concerns about screening for the majority of participants.
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Affiliation(s)
- Felicity K Boardman
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Chloe Sadler
- School of Life Sciences, University of Warwick, Coventry, UK
| | - Philip J Young
- School of Life Sciences, University of Warwick, Coventry, UK
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Riley C, Wheeler A. Assessing the Fragile X Syndrome Newborn Screening Landscape. Pediatrics 2017; 139:S207-S215. [PMID: 28814541 PMCID: PMC5599128 DOI: 10.1542/peds.2016-1159g] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/24/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Fragile X syndrome (FXS) is the most common known inherited form of intellectual disability. Early identification is an important step in linking FXS individuals with appropriate and timely medical and social services. Newborn screening (NBS) is 1 approach that has been used for other conditions to facilitate early identification. METHODS A literature review was conducted to identify issues, barriers, challenges, and approaches to addressing challenges related to NBS for FXS. Search terms included: fragile X syndrome, FMR1, newborn screening, screening, and genetic testing. To supplement the literature review, 9 key informant interviews were conducted. Information gathered through these interviews supplemented what was identified in the literature. Information from both the literature review and supplemental interviews was reviewed by 3 researchers who discussed and came to consensus on thematic areas and categorization of issues. RESULTS The barriers and challenges related to NBS for FXS identified in the literature and by experts and stakeholders are categorized into 5 thematic areas: public health burden, treatment, timing, screening/testing methodologies, and translating results. Summaries of these issues and barriers are provided, along with potential approaches to addressing them. CONCLUSIONS The issues and barriers described in this article highlight limited areas of knowledge that need be addressed to improve our understanding of FXS and the potential benefit of NBS. The landscape of NBS for FXS could be influenced by a series of research findings over time or a larger breakthrough that demonstrates an effective targeted treatment that has to be implemented early in life.
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Affiliation(s)
- Catharine Riley
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anne Wheeler
- RTI International, Research Triangle Park, North Carolina
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Bailey DB, Berry-Kravis E, Gane LW, Guarda S, Hagerman R, Powell CM, Tassone F, Wheeler A. Fragile X Newborn Screening: Lessons Learned From a Multisite Screening Study. Pediatrics 2017; 139:S216-S225. [PMID: 28814542 DOI: 10.1542/peds.2016-1159h] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/24/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Delays in the diagnosis of children with fragile X syndrome (FXS) suggest the possibility of newborn screening as a way to identify children earlier. However, FXS does not have a proven treatment that must be provided early, and ethical concerns have been raised about the detection of infants who are carriers. This article summarizes major findings from a multisite, prospective, longitudinal pilot screening study. METHODS Investigators in North Carolina, California, and Illinois collaborated on a study in which voluntary screening for FXS was offered to parents in 3 birthing hospitals. FXS newborn screening was offered to >28 000 families to assess public acceptance and determine whether identification of babies resulted in any measurable harms or adverse events. Secondary goals were to determine the prevalence of FMR1 carrier gene expansions, study the consent process, and describe early development and behavior of identified children. RESULTS A number of publications have resulted from the project. This article summarizes 10 "lessons learned" about the consent process, reasons for accepting and declining screening, development and evaluation of a decision aid, prevalence of carriers, father participation in consent, family follow-up, and maternal reactions to screening. CONCLUSIONS The project documented public acceptance of screening as well as the challenges inherent in obtaining consent in the hospital shortly after birth. Collectively, the study provides answers to a number of questions that now set the stage for a next generation of research to determine the benefits of earlier identification for children and families.
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Affiliation(s)
- Donald B Bailey
- Center for Newborn Screening, Ethics, and Disability Studies, RTI International, Research Triangle Park, North Carolina;
| | | | - Louise W Gane
- MIND Institute, University of California at Davis, Sacramento, California; and
| | - Sonia Guarda
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Randi Hagerman
- MIND Institute, University of California at Davis, Sacramento, California; and
| | - Cynthia M Powell
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Flora Tassone
- MIND Institute, University of California at Davis, Sacramento, California; and
| | - Anne Wheeler
- Center for Newborn Screening, Ethics, and Disability Studies, RTI International, Research Triangle Park, North Carolina
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Movaghar A, Mailick M, Sterling A, Greenberg J, Saha K. Automated screening for Fragile X premutation carriers based on linguistic and cognitive computational phenotypes. Sci Rep 2017; 7:2674. [PMID: 28572606 PMCID: PMC5454004 DOI: 10.1038/s41598-017-02682-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 04/18/2017] [Indexed: 01/03/2023] Open
Abstract
Millions of people globally are at high risk for neurodegenerative disorders, infertility or having children with a disability as a result of the Fragile X (FX) premutation, a genetic abnormality in FMR1 that is underdiagnosed. Despite the high prevalence of the FX premutation and its effect on public health and family planning, most FX premutation carriers are unaware of their condition. Since genetic testing for the premutation is resource intensive, it is not practical to screen individuals for FX premutation status using genetic testing. In a novel approach to phenotyping, we have utilized audio recordings and cognitive profiling assessed via self-administered questionnaires on 200 females. Machine-learning methods were developed to discriminate FX premutation carriers from mothers of children with autism spectrum disorders, the comparison group. By using a random forest classifier, FX premutation carriers could be identified in an automated fashion with high precision and recall (0.81 F1 score). Linguistic and cognitive phenotypes that were highly associated with FX premutation carriers were high language dysfluency, poor ability to organize material, and low self-monitoring. Our framework sets the foundation for computational phenotyping strategies to pre-screen large populations for this genetic variant with nominal costs.
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Affiliation(s)
- Arezoo Movaghar
- Waisman Center, University of Wisconsin-Madison, Madison, WI, USA
- Wisconsin Institute for Discovery, University of Wisconsin-Madison, Madison, WI, USA
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Marsha Mailick
- Waisman Center, University of Wisconsin-Madison, Madison, WI, USA.
| | - Audra Sterling
- Waisman Center, University of Wisconsin-Madison, Madison, WI, USA.
- Department of Communication Sciences and Disorders, University of Wisconsin-Madison, Madison, WI, USA.
| | - Jan Greenberg
- Department of Social Work, University of Wisconsin-Madison, Madison, WI, USA
| | - Krishanu Saha
- Waisman Center, University of Wisconsin-Madison, Madison, WI, USA.
- Wisconsin Institute for Discovery, University of Wisconsin-Madison, Madison, WI, USA.
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, USA.
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Healthcare professionals' and parents' experiences of the confirmatory testing period: a qualitative study of the UK expanded newborn screening pilot. BMC Pediatr 2017; 17:121. [PMID: 28482885 PMCID: PMC5422997 DOI: 10.1186/s12887-017-0873-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 04/25/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND With further expansion of the number of conditions for which newborn screening can be undertaken, it is timely to consider the impact of positive screening results and the confirmatory testing period on the families involved. This study was undertaken as part of a larger programme of work to evaluate the Expanded Newborn Screening (ENBS) programme in the United Kingdom (UK). It was aimed to determine the views and experiences of healthcare professionals (HCPs) and parents on communication and interaction during the period of confirmatory testing following a positive screening result. METHODS Semi-structured interviews were undertaken with parents of children who had received a positive ENBS result and HCPs who had been involved with the diagnosis and support of parents. Ten parents and 11 healthcare professionals took part in the in-depth interviews. Questions considered the journey from the positive screening result through confirmatory testing to a confirmed diagnosis and the communication and interaction between the parents and HCPs that they had been experienced. Key themes were identified through thematic analysis. RESULTS The results point to a number of elements within the path through confirmatory testing that are difficult for parents and could be further developed to improve the experience. These include the way in which the results are communicated to parents, rapid turnaround of results, offering a consistent approach, exploring interventions to support family relationships and reviewing the workload and scheduling implications for healthcare professionals. CONCLUSIONS As technology enables newborn screening of a larger number of conditions, there is an increasing need to consider and mediate the potentially negative effects on families. The findings from this study point to a number of elements within the path through confirmatory testing that are difficult for parents and could be further developed to benefit the family experience.
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Jansen ME, Lister KJ, van Kranen HJ, Cornel MC. Policy Making in Newborn Screening Needs a Structured and Transparent Approach. Front Public Health 2017; 5:53. [PMID: 28377917 PMCID: PMC5359248 DOI: 10.3389/fpubh.2017.00053] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 03/01/2017] [Indexed: 01/21/2023] Open
Abstract
PURPOSE Newborn bloodspot screening (NBS) programs have expanded significantly in the past years and are expected to expand further with the emergence of genetic technologies. Historically, NBS expansion has often occurred following ad hoc consideration of conditions, instead of a structured and transparent approach. In this review, we explore issues pertinent to NBS policy making, through the lens of the policy cycle: (a) agenda setting, (b) policy advice, (c) policy decision, (d) implementation, and (e) evaluation. METHODS A literature search was conducted to gather information on the elements specific to NBS and its policy making process. RESULTS The review highlighted two approaches to nominate a condition: a structured approach through horizon scanning; and an ad hoc process. For assessment of a condition, there was unanimous support for a robust process based on criteria. While the need to assess harms and benefits was a repeated theme in the articles, there is no agreed-upon threshold for benefit in decision-making. Furthermore, the literature was consistent in its recommendation for an overarching, independent, multidisciplinary group providing recommendations to government. An implementation plan focusing on the different levels on which NBS operates and the information needed on each level is essential for successful implementation. Continuously monitoring, and improving a program is vital, particularly following the implementation of screening for a new condition. An advisory committee could advise on implementation, development, review, modification, and cessation of (parts of) NBS. CONCLUSION The results highlight that there are a wave of issues facing NBS programs that policy makers must take into account when developing policy processes. What conditions to screen, and the technologies used in NBS, are both up for debate.
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Affiliation(s)
- Marleen E Jansen
- Section Community Genetics, Department of Clinical Genetics, Amsterdam Public Health Research Institute, Amsterdam, Netherlands; Institute for Public Health Genomics, School for Oncology and Developmental Biology (GROW), Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Karla J Lister
- Screening Policy Section, Office of Population Health Genomics, Department of Health, Government of Western Australia , Perth, WA , Australia
| | - Henk J van Kranen
- Institute for Public Health Genomics, School for Oncology and Developmental Biology (GROW), Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, Netherlands; Center for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment, Bilthoven, Netherlands
| | - Martina C Cornel
- Section Community Genetics, Department of Clinical Genetics, Amsterdam Public Health Research Institute , Amsterdam , Netherlands
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Berg JS, Agrawal PB, Bailey DB, Beggs AH, Brenner SE, Brower AM, Cakici JA, Ceyhan-Birsoy O, Chan K, Chen F, Currier RJ, Dukhovny D, Green RC, Harris-Wai J, Holm IA, Iglesias B, Joseph G, Kingsmore SF, Koenig BA, Kwok PY, Lantos J, Leeder SJ, Lewis MA, McGuire AL, Milko LV, Mooney SD, Parad RB, Pereira S, Petrikin J, Powell BC, Powell CM, Puck JM, Rehm HL, Risch N, Roche M, Shieh JT, Veeraraghavan N, Watson MS, Willig L, Yu TW, Urv T, Wise AL. Newborn Sequencing in Genomic Medicine and Public Health. Pediatrics 2017; 139:e20162252. [PMID: 28096516 PMCID: PMC5260149 DOI: 10.1542/peds.2016-2252] [Citation(s) in RCA: 140] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2016] [Indexed: 12/20/2022] Open
Abstract
The rapid development of genomic sequencing technologies has decreased the cost of genetic analysis to the extent that it seems plausible that genome-scale sequencing could have widespread availability in pediatric care. Genomic sequencing provides a powerful diagnostic modality for patients who manifest symptoms of monogenic disease and an opportunity to detect health conditions before their development. However, many technical, clinical, ethical, and societal challenges should be addressed before such technology is widely deployed in pediatric practice. This article provides an overview of the Newborn Sequencing in Genomic Medicine and Public Health Consortium, which is investigating the application of genome-scale sequencing in newborns for both diagnosis and screening.
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Affiliation(s)
| | - Pankaj B Agrawal
- Divisions of Newborn Medicine and
- Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Alan H Beggs
- Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Amy M Brower
- American College of Medical Genetics and Genomics, Bethesda, Maryland
| | - Julie A Cakici
- Rady Children's Institute for Genomic Medicine, San Diego, California
| | | | - Kee Chan
- Chicago School of Public Health, University of Illinois, Chicago, Illinois
| | | | - Robert J Currier
- Genetic Disease Screening Program, California Department of Public Health, Sacramento, California
| | - Dmitry Dukhovny
- Department of Pediatrics and Division of Neonatology, Oregon Health & Science University, Portland, Oregon
| | | | | | - Ingrid A Holm
- Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Galen Joseph
- Department of Anthropology, History, and Social Medicine
| | | | | | - Pui-Yan Kwok
- Institute for Human Genetics
- Cardiovascular Research Institute, and Department of Dermatology
| | - John Lantos
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
| | - Steven J Leeder
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
| | - Megan A Lewis
- RTI International, Research Triangle Park, North Carolina
| | - Amy L McGuire
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas; and
| | | | | | - Richard B Parad
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stacey Pereira
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas; and
| | - Joshua Petrikin
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
| | | | - Cynthia M Powell
- Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
| | - Jennifer M Puck
- Department of Pediatrics, University of California, San Francisco, California
| | | | | | - Myra Roche
- Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
| | - Joseph T Shieh
- Institute for Human Genetics
- Department of Pediatrics, Benioff Children's Hospital, and
| | | | - Michael S Watson
- American College of Medical Genetics and Genomics, Bethesda, Maryland
| | - Laurel Willig
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
| | - Timothy W Yu
- Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tiina Urv
- National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, Maryland
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Abstract
Fragile X syndrome (FXS) is the first of 3 syndromes identified as a health condition related to fragile X mental retardation (FMR1) gene dysfunction. The other 2 syndromes are fragile X-associated primary ovarian insufficiency syndrome (FXPOI) and fragile X-associated tremor/ataxia syndrome (FXTAS), which together are referred to as fragile X-associated disorders (FXDs). Collectively, this group comprises the 3 faces of fragile X. Even though the 3 conditions share a common genetic defect, each one is a separate health condition that results in a variety of body function impairments such as motor delay, musculoskeletal issues related to low muscle tone, coordination limitations, ataxia, tremor, undefined muscle aches and pains, and, for FXTAS, a late-onset neurodegeneration. Although each FXD condition may benefit from physical therapy intervention, available evidence as to the efficacy of intervention appropriate to FXDs is lacking. This perspective article will discuss the genetic basis of FMR1 gene dysfunction and describe health conditions related to this mutation, which have a range of expressions within a family. Physical therapy concerns and possible assessment and intervention strategies will be introduced. Understanding the intergenerational effect of the FMR1 mutation with potential life-span expression is a key component to identifying and treating the health conditions related to this specific genetic condition.
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Molecular Correlates and Recent Advancements in the Diagnosis and Screening of FMR1-Related Disorders. Genes (Basel) 2016; 7:genes7100087. [PMID: 27754417 PMCID: PMC5083926 DOI: 10.3390/genes7100087] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 10/06/2016] [Accepted: 10/08/2016] [Indexed: 12/12/2022] Open
Abstract
Fragile X syndrome (FXS) is the most common monogenic cause of intellectual disability and autism. Molecular diagnostic testing of FXS and related disorders (fragile X-associated primary ovarian insufficiency (FXPOI) and fragile X-associated tremor/ataxia syndrome (FXTAS)) relies on a combination of polymerase chain reaction (PCR) and Southern blot (SB) for the fragile X mental retardation 1 (FMR1) CGG-repeat expansion and methylation analyses. Recent advancements in PCR-based technologies have enabled the characterization of the complete spectrum of CGG-repeat mutation, with or without methylation assessment, and, as a result, have reduced our reliance on the labor- and time-intensive SB, which is the gold standard FXS diagnostic test. The newer and more robust triplet-primed PCR or TP-PCR assays allow the mapping of AGG interruptions and enable the predictive analysis of the risks of unstable CGG expansion during mother-to-child transmission. In this review, we have summarized the correlation between several molecular elements, including CGG-repeat size, methylation, mosaicism and skewed X-chromosome inactivation, and the extent of clinical involvement in patients with FMR1-related disorders, and reviewed key developments in PCR-based methodologies for the molecular diagnosis of FXS, FXTAS and FXPOI, and large-scale (CGG)n expansion screening in newborns, women of reproductive age and high-risk populations.
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Paquin RS, Peay HL, Gehtland LM, Lewis MA, Bailey DB. Parental intentions to enroll children in a voluntary expanded newborn screening program. Soc Sci Med 2016; 166:17-24. [PMID: 27526258 DOI: 10.1016/j.socscimed.2016.07.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 07/16/2016] [Accepted: 07/26/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND OBJECTIVES Nearly all babies in the United States are tested at birth for rare, serious, and treatable disorders through mandatory state newborn screening (NBS). Recently, there have been calls for an expanded, voluntary model to facilitate early diagnosis and treatment of a wider range of disorders. We applied the reasoned action framework to examine parental intentions to participate in voluntary expanded screening. METHODS We recruited a national cohort of recent and expectant parents living in the U.S. who completed a self-administered online survey (N = 1001). Using a mixed-level fractional factorial experiment, we studied parental participation intentions and preferences for timing of consent, cost, consent format, and testing options. RESULTS We conducted a hierarchical regression analysis assessing parental intentions to participate in voluntary expanded NBS. Attitudes, perceived normative influence, and perceived behavioral control explained substantial variance in intention, with perceived normative influence emerging as the strongest predictor. We found no evidence that the manipulated program features altered mean levels of intention, but timing of parental permission, cost, and permission format moderated the relative importance of reasoned action constructs on intention. CONCLUSION Program design features may impact the psychological mechanisms underlying parental decision making for voluntary expanded screening. These results have important implications for parent education, outreach, and informed parental permission procedures.
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Affiliation(s)
- Ryan S Paquin
- Center for Communication Science, RTI International, Research Triangle Park, NC, United States.
| | - Holly L Peay
- Center for P-12 Education, RTI International, Research Triangle Park, NC, United States
| | - Lisa M Gehtland
- Center for P-12 Education, RTI International, Research Triangle Park, NC, United States
| | - Megan A Lewis
- Center for Communication Science, RTI International, Research Triangle Park, NC, United States
| | - Donald B Bailey
- Education and Workforce Development, RTI International, Research Triangle Park, NC, United States
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Gammon BL, Kraft SA, Michie M, Allyse M. "I think we've got too many tests!": Prenatal providers' reflections on ethical and clinical challenges in the practice integration of cell-free DNA screening. ACTA ACUST UNITED AC 2016; 2:334-342. [PMID: 28180146 DOI: 10.1016/j.jemep.2016.07.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The recent introduction of cell-free DNA-based non-invasive prenatal screening (cfDNA screening) into clinical practice was expected to revolutionize prenatal testing. cfDNA screening for fetal aneuploidy has demonstrated higher test sensitivity and specificity for some conditions than conventional serum screening and can be conducted early in the pregnancy. However, it is not clear whether and how clinical practices are assimilating this new type of testing into their informed consent and counselling processes. Since the introduction of cfDNA screening into practice in 2011, the uptake and scope have increased dramatically. Prenatal care providers are under pressure to stay up to date with rapidly changing cfDNA screening panels, manage increasing patient demands, and keep up with changing test costs, all while attempting to use the technology responsibly and ethically. While clinical literature on cfDNA screening has shown benefits for specific patient populations, it has also identified significant misunderstandings among providers and patients alike about the power of the technology. The unique features of cfDNA screening, in comparison to established prenatal testing technologies, have implications for informed decision-making and genetic counselling that must be addressed to ensure ethical practice. OBJECTIVES This study explored the experiences of prenatal care providers at the forefront of non-invasive genetic screening in the United States to understand how this testing changes the practice of prenatal medicine. We aimed to learn how the experience of providing and offering this testing differs from established prenatal testing methodologies. These differences may necessitate changes to patient education and consent procedures to maintain ethical practice. METHODS We used the online American Congress of Obstetricians and Gynecologists Physician Directory to identify a systematic sample of five prenatal care providers in each U.S. state and the District of Columbia. Beginning with the lowest zip code in each state, we took every fifth name from the directory, excluding providers who were retired, did not currently practice in the state in which they were listed, or were not involved in a prenatal specialty. After repeating this step twice and sending a total of 461 invitations, 37 providers expressed interest in participating, and we completed telephone interviews with 21 providers (4.6%). We developed a semi-structured interview guide including questions about providers' use of and attitudes toward cfDNA screening. A single interviewer conducted and audio-recorded all interviews by telephone, and the interviews lasted approximately 30 minutes each. We collaboratively developed a codebook through an iterative process of transcript review and code application, and a primary coder coded all transcripts. RESULTS Prenatal care providers have varying perspectives on the advantages of cfDNA screening and express a range of concerns regarding the implementation of cfDNA screening in practice. While providers agreed on several advantages of cfDNA, including increased accuracy, earlier return of results, and decreased risk of complications, many expressed concern that there is not enough time to adequately counsel and educate patients on their prenatal screening and testing options. Providers also agreed that demand for cfDNA screening has increased and expressed a desire for more information from professional societies, labs, and publications. Providers disagreed about the healthcare implications and future of cfDNA screening. Some providers anticipated that cfDNA screening would decrease healthcare costs when implemented widely and expressed optimism for expanded cfDNA screening panels. Others were concerned that cfDNA screening would increase costs over time and questioned whether the expansion to include microdeletions could be done ethically. CONCLUSIONS The perspectives and experiences of the providers in this study allow insight into the clinical benefit, burden on prenatal practice, and potential future of cfDNA screening in clinical practice. Given the likelihood that the scope and uptake of cfDNA screening will continue to increase, it is essential to consider how these changes will affect frontline prenatal care providers and, in turn, patients. Providers' requests for additional guidance and data as well as their concerns with the lack of time available to explain screening and testing options indicate significant potential issues with patient care. It is important to ensure that the clinical integration of cfDNA screening is managed responsibly and ethically before it expands further, exacerbating pre-existing issues. As prenatal screening evolves, so should informed consent and the resources available to women making decisions. The field must take steps to maximize the advantages of cfDNA screening and responsibly manage its ethical issues.
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Affiliation(s)
- B L Gammon
- Biomedical Ethics Program, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - S A Kraft
- Stanford University Center for Biomedical Ethics, 1215 Welch Road, Modular A, Stanford, CA 94305, USA
| | - M Michie
- UCSF School of Nursing, 3333 Calif. Street, Laurel Heights, San Francisco, CA 94118, USA
| | - M Allyse
- Biomedical Ethics Program, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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20
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Kwon JM, Abdel-Hamid HZ, Al-Zaidy SA, Mendell JR, Kennedy A, Kinnett K, Cwik VA, Street N, Bolen J, Day JW, Connolly AM. Clinical Follow-Up for Duchenne Muscular Dystrophy Newborn Screening: A Proposal. Muscle Nerve 2016; 54:186-91. [PMID: 27170260 DOI: 10.1002/mus.25185] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 04/28/2016] [Accepted: 05/06/2016] [Indexed: 01/16/2023]
Abstract
New developments in the rapid diagnosis and treatment of boys with Duchenne muscular dystrophy (DMD) have led to growing enthusiasm for instituting DMD newborn screening (NBS) in the United States. Our group has been interested in developing clinical guidance to be implemented consistently in specialty care clinics charged with the care of presymptomatically identified newborns referred after DMD-NBS. We reviewed the existing literature covering patient-centered clinical follow-up after NBS, educational material from public health and advocacy sites, and federal recommendations on effective NBS follow-up. We discussed the review as a group and added our own experience to develop materials suitable for initial parent and primary care provider education. These materials and a series of templates for subspecialist encounters could be used to provide consistent care across centers and serve as the basis for ongoing quality improvement. Muscle Nerve 54: 186-191, 2016.
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Affiliation(s)
- Jennifer M Kwon
- Departments of Neurology and Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Hoda Z Abdel-Hamid
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Samiah A Al-Zaidy
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Jerry R Mendell
- Department of Pediatrics, The Ohio State University and Center for Gene Therapy, Nationwide Children's Hospital, Columbus, Ohio
| | - Annie Kennedy
- Parent Project Muscular Dystrophy, Headquarters, Hackensack, New Jersey
| | | | | | - Natalie Street
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Julie Bolen
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - John W Day
- Department of Neurology, Stanford University, Stanford, California
| | - Anne M Connolly
- Departments of Neurology and Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, Missouri
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21
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Family Communication and Cascade Testing for Fragile X Syndrome. J Genet Couns 2016; 25:1075-84. [DOI: 10.1007/s10897-016-9940-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 02/18/2016] [Indexed: 10/22/2022]
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Balobaid A, Qari A, Al-Zaidan H. Genetic counselors' scope of practice and challenges in genetic counseling services in Saudi Arabia. Int J Pediatr Adolesc Med 2016; 3:1-6. [PMID: 30805460 PMCID: PMC6372413 DOI: 10.1016/j.ijpam.2015.12.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 12/17/2015] [Indexed: 12/18/2022]
Abstract
Genetic counseling is an evolving field in Saudi Arabia. In 2015, genetic counseling was recognized as a Master's program by the Saudi Commission for Health Specialties. Our genetic counselors combine their knowledge of genetics, counseling theory and interpersonal communication to serve Saudi and non-Saudi patients affected with a range of genetic conditions and/or birth defects. Most patients are referred to the clinic from different clinics at King Faisal Specialist Hospital and Research Centre (KFSHRC) and outside of KFSHRC for various indications. Carrier testing and preventative reproduction options rank highly on the reasons for referral to our clinics. The Saudi population has unique customs and beliefs, such as consanguinity and the evil eye. Challenges that are routinely encountered in our genetic counseling clinics include, but are not limited to, preventative reproductive options and termination of pregnancy, manifesting carriers, stigmatization of women and approaches to complex molecular findings. Working with families from different backgrounds and beliefs undoubtedly requires professionals with a distinctive set of skills and a structured clinical setting. This review article presents the scope of genetic counseling practice and tackles some of the challenges faced in providing genetic counseling in Saudi Arabia.
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Affiliation(s)
- Ameera Balobaid
- Department of Medical Genetics, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia.,College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Alya Qari
- Department of Medical Genetics, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia.,College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Hamad Al-Zaidan
- Department of Medical Genetics, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia.,College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
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23
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Char DS. How should whole-genome sequencing be implemented in children? A consideration of the current limitations. Per Med 2016; 13:33-42. [DOI: 10.2217/pme.15.44] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
In children, whole-genome sequencing (WGS) is envisioned as a tool to improve diagnosis of undiagnosed diseases and to improve population-based screening. Pilot applications have shown benefits: genomic information has been used as a diagnostic aid; pharmacogenomics can reduce medicine-related adverse events; advanced knowledge of the potential for later-onset disease can target tests and appropriate therapies. However, emerging technical, conceptual and ethical challenges may limit WGS from fulfilling the current vision for future applications. WGS platforms still struggle with reliability and accuracy. The role of the genome in long-term organismal function and disease is still being established. Ethical implications of WGS in both undiagnosed disease and population screening, particularly potential impacts of testing on children and their families are still unresolved.
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Affiliation(s)
- Danton S Char
- Department of Anesthesiology, Stanford University School of Medicine, Division of Pediatric Cardiac Anesthesia, H3580, Stanford University Medical Center, 300 Pasteur Drive, Stanford, CA 94305, USA
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24
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Berg JS, Powell CM. Potential Uses and Inherent Challenges of Using Genome-Scale Sequencing to Augment Current Newborn Screening. Cold Spring Harb Perspect Med 2015; 5:cshperspect.a023150. [PMID: 26438605 DOI: 10.1101/cshperspect.a023150] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Since newborn screening (NBS) began in the 1960s, technological advances have enabled its expansion to include an increasing number of disorders. Recent developments now make it possible to sequence an infant's genome relatively quickly and economically. Clinical application of whole-exome and whole-genome sequencing is expanding at a rapid pace but presents many challenges. Its utility in NBS has yet to be demonstrated and its application in the pediatric population requires examination, not only for potential clinical benefits, but also for the unique ethical challenges it presents.
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Affiliation(s)
- Jonathan S Berg
- Department of Genetics, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7264
| | - Cynthia M Powell
- Departments of Pediatrics and Genetics, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7264
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Bailey DB, Wheeler A, Berry-Kravis E, Hagerman R, Tassone F, Powell CM, Roche M, Gane LW, Sideris J. Maternal Consequences of the Detection of Fragile X Carriers in Newborn Screening. Pediatrics 2015; 136:e433-40. [PMID: 26169437 PMCID: PMC4516945 DOI: 10.1542/peds.2015-0414] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The possibility of newborn screening for fragile X syndrome is complicated by the potential for identifying premutation carriers. Although knowing the child's carrier status has potential benefits, the possibility of late-onset disorders in carrier children and their parents raises concerns about whether such information would be distressing to parents and potentially more harmful than helpful. This study sought to answer this question by offering voluntary fragile X screening to new parents and returning results for both the full mutation and premutation FMR1 gene expansions. We tested the assumption that such information could lead to adverse mental health outcomes or decision regret. We also wanted to know if child age and spousal support were associated with the outcomes of interest. METHODS Eighteen mothers of screen-positive infants with the premutation and 15 comparison mothers completed a battery of assessments of maternal anxiety, postpartum depression, stress, family quality of life, decision regret, and spousal support. The study was longitudinal, with an average of 3 assessments per mother. RESULTS The premutation group was not statistically different from the comparison group on measures of anxiety, depression, stress, or quality of life. A subset of mothers experienced clinically significant anxiety and decision regret, but factors associated with these outcomes could not be identified. Greater spousal support was generally associated with more positive outcomes. CONCLUSIONS Although we did not find evidence of significant adverse events, disclosure of newborn carrier status remains an important consideration in newborn screening policy.
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Affiliation(s)
- Donald B Bailey
- Social, Statistical, and Environmental Sciences, RTI International, Research Triangle Park, North Carolina;
| | - Anne Wheeler
- Social, Statistical, and Environmental Sciences, RTI International, Research Triangle Park, North Carolina
| | - Elizabeth Berry-Kravis
- Departments of Pediatrics and Neurologic Sciences, Rush University Medical Center, Chicago, Illinois
| | - Randi Hagerman
- Department of Pediatrics, M.I.N.D. Institute, University of California at Davis Medical Center, Sacramento, California
| | - Flora Tassone
- Department of Pediatrics, M.I.N.D. Institute, University of California at Davis Medical Center, Sacramento, California
| | - Cynthia M Powell
- Department of Pediatrics and Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Myra Roche
- Department of Pediatrics and Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Louise W Gane
- M.I.N.D. Institute, University of California at Davis Medical Center, Sacramento, California
| | - John Sideris
- Frank Porter Graham Child Development Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Hayeems RZ, Miller FA, Bombard Y, Avard D, Carroll J, Wilson B, Little J, Chakraborty P, Bytautas J, Giguere Y, Allanson J, Axler R. Expectations and values about expanded newborn screening: a public engagement study. Health Expect 2015; 18:419-29. [PMID: 23369110 PMCID: PMC5060787 DOI: 10.1111/hex.12047] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2012] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES Newborn bloodspot screening (NBS) panels have expanded to include conditions for which treatment effects are less certain, creating debate about population-based screening criteria. We investigated Canadian public expectations and values regarding the types of conditions that should be included in NBS and whether parents should provide consent. METHODS Eight focus groups (FG; n = 60) included education, deliberative discussion and pre-/post-questionnaires. Data were analysed quantitatively and qualitatively. RESULTS Quantitatively, the majority supported NBS for serious disorders for which treatment is not available (95-98, 82%). A majority endorsed screening without explicit consent (77-88%) for treatable disorders, but 62% supported unpressured choice for screening for untreatable disorders. Qualitatively, participants valued treatment-related benefits for infants and informational benefits for families. Concern for anxiety, stigma and unwanted knowledge depended upon disease context and strength of countervailing benefits. CONCLUSIONS Anticipated benefits of expanded infant screening were prioritized over harms, with information provision perceived as a mechanism for mitigating harms and enabling choice. However, we urge caution around the potential for public enthusiasm to foster unlimited uptake of infant screening technologies.
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Affiliation(s)
- Robin Z Hayeems
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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Barajas M, Ross LF. Pediatric Professionals' Attitudes about Secondary Findings in Genomic Sequencing of Children. J Pediatr 2015; 166:1276-1282.e7. [PMID: 25726921 DOI: 10.1016/j.jpeds.2015.01.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 12/01/2014] [Accepted: 01/20/2015] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To evaluate the attitudes of pediatric professionals towards the March 2013 statement of the American College of Medical Genetics and Genomics that whenever genomic sequencing is ordered, the laboratory must look for 56 genes known to be highly penetrant in high-risk groups, and these results must be reported to the clinician regardless of patient age or consent. STUDY DESIGN E-mail and postal survey sent to 332 members of the American Academy of Pediatrics (AAP) Section on Bioethics (SOB) (n=183), Section on Genetics and Birth Defects (n=148), and 1 member of both groups regarding the mandatory search and reporting of secondary findings from genomic sequencing performed on children. RESULTS Of 332 potential participants, 12 asked to be excluded and 181 partially or completely responded (181/320, or 56.6%). Two were subsequently excluded (179). More than 80% believed that patients and parents (guardians) should have the right to refuse to be informed of secondary findings. Only 34.7% of AAP SOB members supported the American College of Medical Genetics and Genomics proposed mandatory search policy in contrast with 70.8% of Section of Genetics and Birth Defects members (P<.01). Approximately 30% of both groups thought that parents should not have access to information about adult-onset conditions in their children. AAP SOB members were less likely to support testing a child for parental benefit (34.5% vs 79.7%, P<.01). CONCLUSIONS There is broad consensus that parents should have the right to opt out of receiving secondary findings. There is no consensus about the ethics of justifying disclosure on the basis of parental benefit.
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Affiliation(s)
- Miguel Barajas
- University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Lainie Friedman Ross
- Department of Pediatrics, University of Chicago, Chicago, IL; MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL.
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28
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Char D. Preventive Genomic Sequencing and Care of the Individual Patient. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2015; 15:32-33. [PMID: 26147263 DOI: 10.1080/15265161.2015.1039725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Nicholls SG, Wilson BJ, Etchegary H, Brehaut JC, Potter BK, Hayeems R, Chakraborty P, Milburn J, Pullman D, Turner L, Carroll JC. Benefits and burdens of newborn screening: public understanding and decision-making. Per Med 2014; 11:593-607. [PMID: 29758802 DOI: 10.2217/pme.14.46] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In this article we review the literature regarding the public understanding of the potential benefits and burdens of expanded newborn bloodspot screening. We draw attention to broadened notions of benefit that go beyond early identification of asymptomatic individuals and interventions to reduce morbidity or mortality, and include benefits gained by families through knowledge that may facilitate life choices, as well as gains generated by avoiding diagnostic delays. We also reflect on burdens such as increasing false-positive results and parental anxiety, together with risks of overdiagnosis when the natural history of a condition is poorly understood. We conclude that expanded notions of benefit and burden bring with them implications for parental consent and confidentiality and the secondary use of bloodspots.
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Affiliation(s)
- Stuart G Nicholls
- Department of Epidemiology & Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Brenda J Wilson
- Department of Epidemiology & Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Holly Etchegary
- Clinical Epidemiology, Memorial University, St John's, Newfoundland and Labrador, Canada
| | - Jamie C Brehaut
- Department of Epidemiology & Community Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Centre for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Beth K Potter
- Department of Epidemiology & Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Robin Hayeems
- Hospital for Sick Children Research Institute, Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada.,Institute of Health Policy Management & Evaluation, University of Toronto, Canada
| | - Pranesh Chakraborty
- Newborn Screening Ontario, Children's Hospital of Eastern Ontario (CHEO), Ottawa, Ontario, Canada
| | - Jennifer Milburn
- Better Outcomes Registry & Network (BORN), Children's Hospital of Eastern Ontario (CHEO), Ottawa, Ontario, Canada
| | - Daryl Pullman
- Faculty of Medicine, Memorial University, St Johns, Newfoundland & Labrador, Canada
| | - Lesley Turner
- Eastern Health, St John's, Newfoundland & Labrador, Canada
| | - June C Carroll
- Department of Family & Community Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Canada
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30
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Hall A, Chowdhury S, Hallowell N, Pashayan N, Dent T, Pharoah P, Burton H. Implementing risk-stratified screening for common cancers: a review of potential ethical, legal and social issues. J Public Health (Oxf) 2014; 36:285-91. [PMID: 23986542 PMCID: PMC4041100 DOI: 10.1093/pubmed/fdt078] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The identification of common genetic variants associated with common cancers including breast, prostate and ovarian cancers would allow population stratification by genotype to effectively target screening and treatment. As scientific, clinical and economic evidence mounts there will be increasing pressure for risk-stratified screening programmes to be implemented. METHODS This paper reviews some of the main ethical, legal and social issues (ELSI) raised by the introduction of genotyping into risk-stratified screening programmes, in terms of Beauchamp and Childress's four principles of biomedical ethics--respect for autonomy, non-maleficence, beneficence and justice. Two alternative approaches to data collection, storage, communication and consent are used to exemplify the ELSI issues that are likely to be raised. RESULTS Ultimately, the provision of risk-stratified screening using genotyping raises fundamental questions about respective roles of individuals, healthcare providers and the state in organizing or mandating such programmes, and the principles, which underpin their provision, particularly the requirement for distributive justice. CONCLUSIONS The scope and breadth of these issues suggest that ELSI relating to risk-stratified screening will become increasingly important for policy-makers, healthcare professionals and a wide diversity of stakeholders.
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Affiliation(s)
- A.E. Hall
- PHG Foundation (Foundation for Genomics and Population Health), 2 Worts Causeway, Cambridge CB1 8RN, UK
| | - S. Chowdhury
- PHG Foundation (Foundation for Genomics and Population Health), 2 Worts Causeway, Cambridge CB1 8RN, UK
| | - N. Hallowell
- PHG Foundation (Foundation for Genomics and Population Health), 2 Worts Causeway, Cambridge CB1 8RN, UK
| | - N. Pashayan
- UCL Department of Applied Health Research, University College London, 1-19 Torrington Place, London WC1E 6BT, UK
| | - T. Dent
- PHG Foundation (Foundation for Genomics and Population Health), 2 Worts Causeway, Cambridge CB1 8RN, UK
| | - P. Pharoah
- Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, University Forvie Site, Robinson Way, Cambridge CB2 OSR, UK
- Department of Oncology, University of Cambridge, Cambridge CB2 2QQ, UK
| | - H. Burton
- PHG Foundation (Foundation for Genomics and Population Health), 2 Worts Causeway, Cambridge CB1 8RN, UK
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31
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Li J, Huang W, Luo S, Lin Y, Duan R. Attitude of medical school students in China towards genetic testing and counseling issues in FXS. J Genet Couns 2013; 22:733-40. [PMID: 23955144 DOI: 10.1007/s10897-013-9634-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2012] [Accepted: 07/25/2013] [Indexed: 12/01/2022]
Abstract
Fragile X syndrome (FXS) is the most common form of inherited intellectual disability. However, genetic testing protocols and genetic counseling guidelines for FXS are not yet established in mainland China. In the present study, we conducted a comprehensive analysis using a self-administered questionnaire among students at the Xiangya medical school to investigate their attitude towards genetic testing and counseling issues of FXS. We have gained a general understanding of the attitudes of medical students towards these FXS issues in China. This information is of immense importance to develop appropriate genetic tests and to train counselors for FXS. As the medical school students surveyed are prospective physicians who will be a part of the Chinese health system, our survey was focused on the basic knowledge of FXS, population-based FXS screening, confidentiality and reproductive options for mutation carriers. The study demonstrated that only less than one third of the participants had heard about FXS. 94.6 % of participants were in favor of FXS screening for women in their reproductive age who had a genetic history of FXS. Furthermore, only half of the participants would inform their families about their genetic status in case of positive test results, and more than half of the participants supported natural conception and prenatal diagnosis for FXS mutation carriers. Additional findings and research implications are also discussed. This survey targeting potential doctors provides important information for the development of FXS genetic test and counselor training for the Chinese health system.
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Affiliation(s)
- Jia Li
- State Key Laboratory of Medical Genetics, Central South University, Changsha, Hunan, 410078, China
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32
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LaFauci G, Adayev T, Kascsak R, Kascsak R, Nolin S, Mehta P, Brown WT, Dobkin C. Fragile X Screening by Quantification of FMRP in Dried Blood Spots by a Luminex Immunoassay. J Mol Diagn 2013; 15:508-17. [DOI: 10.1016/j.jmoldx.2013.02.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 02/11/2013] [Accepted: 02/20/2013] [Indexed: 02/03/2023] Open
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Tonnsen BL, Malone PS, Hatton DD, Roberts JE. Early negative affect predicts anxiety, not autism, in preschool boys with fragile X syndrome. JOURNAL OF ABNORMAL CHILD PSYCHOLOGY 2013; 41:267-80. [PMID: 23011214 DOI: 10.1007/s10802-012-9671-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Children with fragile X syndrome (FXS) face high risk for anxiety disorders, yet no studies have explored FXS as a high-risk sample for investigating early manifestations of anxiety outcomes. Negative affect is one of the most salient predictors of problem behaviors and has been associated with both anxiety and autistic outcomes in clinical and non-clinical pediatric samples. In light of the high comorbidity between autism and anxiety within FXS, the present study investigates the relationship between longitudinal trajectories of negative affect (between 8 and 71 months) and severity of anxiety and autistic outcomes in young males with FXS (n = 25). Multilevel models indicated associations between elevated anxiety and higher fear and sadness, lower soothability, and steeper longitudinal increases in approach. Autistic outcomes were unrelated to negative affect. These findings suggest early negative affect differentially predicts anxiety, not autistic symptoms, within FXS. Future research is warranted to determine the specificity of the relationship between negative affect and anxiety, as well as to explore potential moderators. Characterizing the relationship between early negative affect and anxiety within FXS may inform etiology and treatment considerations specific to children with FXS, as well as lend insight into precursors of anxiety disorders in other clinical groups and community samples.
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Affiliation(s)
- Bridgette L Tonnsen
- Department of Psychology, University of South Carolina, 1512 Pendleton St., Columbia, SC 29208, USA
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34
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Acharya K, Schindler A. Developmental and behavioral pediatricians' attitudes toward screening for fragile X. AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES 2013; 118:284-93. [PMID: 23937370 PMCID: PMC3744113 DOI: 10.1352/1944-7558-188.4.284] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Developmental and behavioral pediatricians (DBP) diagnose and care for children with fragile X syndrome. Their attitudes toward FMR1 newborn screening (NBS) and FMR1 carrier testing in childhood could highlight potential pitfalls with FMR1 NBS. We conducted a cross-sectional survey with an adjusted response rate of 61%. Among DBP, 74% supported universal FMR1 NBS, preferring to identify both full mutations and premutations. DBP also support FMR1 testing of asymptomatic siblings. Although DBP support testing for premutations at various points in the lifespan, DBP are not familiar with the array of fragile X-associated disorders (FXAD). Targeted educational interventions are needed to ensure that all health care providers have the knowledge and competence to consent and to counsel families on FXAD.
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35
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Waggoner DJ, Tan CA. Expanding newborn screening for lysosomal disorders: opportunities and challenges. ACTA ACUST UNITED AC 2013; 17:9-14. [PMID: 22447749 DOI: 10.1002/ddrr.132] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Newborn screening (NBS), since its implementation in the 1960s, has traditionally been successful in reducing mortality and disability in children with a range of different conditions. Lysosomal storage disorders (LSD) are a heterogeneous group of inherited metabolic diseases that result from lysosomal dysfunction. Based on available treatment and suitable screening methods, the LSDs that are considered for NBS generally include Fabry, Gaucher, Krabbe, MPSI, MPSII, MPSV, Metachromatic leukodystrophy, Niemann-Pick, and Pompe. Utilizing traditional and expanded criteria for consideration of NBS leads to a set of fundamental questions that need to be explored when considering the opportunities and challenges of adding LSDs to NBS panels.
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Affiliation(s)
- Darrel J Waggoner
- Department of Human Genetics, University of Chicago, Chicago, IL 60637, USA.
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36
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Christie L, Wotton T, Bennetts B, Wiley V, Wilcken B, Rogers C, Boyle J, Turner C, Hansen J, Hunter M, Goel H, Field M. Maternal attitudes to newborn screening for fragile X syndrome. Am J Med Genet A 2013; 161A:301-11. [DOI: 10.1002/ajmg.a.35752] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Accepted: 10/11/2012] [Indexed: 01/19/2023]
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37
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Nelson DK, Skinner D, Guarda S, Choudhury S, Sideris J, Barnum L, Ten Haagen K, Heyward Q, Bailey DB. Obtaining consent from both parents for pediatric research: what does "reasonably available" mean? Pediatrics 2013; 131:e223-9. [PMID: 23266920 PMCID: PMC3529951 DOI: 10.1542/peds.2012-1278] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Circumstances surrounding parental availability and decision-making were examined in the setting of a research protocol involving newborn screening (NBS) for fragile X syndrome, in which the institutional review board (IRB) had determined that consent (permission) was required from both parents. METHODS A survey was conducted with 3001 families who were approached to participate in optional NBS. In addition to basic demographics, observational notes detailed the reasons why fathers were not present or deemed "not reasonably available" (per IRB regulations), and content analysis identified the factors for this lack of availability. Logistic regression models estimated the likelihood that both parents would agree to enroll their infant in the screening project. RESULTS Fathers were not present in 589 cases, including 158 in which fathers were ultimately determined to be not reasonably available. Primary reasons for father's unavailability were deployment with the military, incarceration, living out of state, or not involved in the mother's life. In cases in which both parents were available, 64% agreed to enroll in the NBS study. Criteria to guide researchers in making required determinations were developed from consultations with IRB officials and legal counsel. CONCLUSIONS In a large-scale population-based study, 19.6% of fathers were absent for the consent process. Scenarios encountered underscore the complexity of parental relations and their implications for obtaining consent for research involving children. The algorithm developed may serve as a useful tool for others in applying the regulatory requirements for dual parental permission.
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Affiliation(s)
- Daniel K. Nelson
- Departments of Social Medicine and Pediatrics,,Center for Genomics and Society
| | - Debra Skinner
- Center for Genomics and Society,,FPG Child Development Institute, and
| | - Sonia Guarda
- Center for Genomics and Society,,FPG Child Development Institute, and
| | - Summer Choudhury
- Division of Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and
| | | | | | | | | | - Donald B. Bailey
- Center for Genomics and Society,,RTI International, Research Triangle Park, North Carolina
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38
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Downing NR, Williams JK, Daack-Hirsch S, Driessnack M, Simon CM. Genetics specialists' perspectives on disclosure of genomic incidental findings in the clinical setting. PATIENT EDUCATION AND COUNSELING 2013; 90:133-8. [PMID: 23068909 PMCID: PMC3522795 DOI: 10.1016/j.pec.2012.09.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Revised: 08/31/2012] [Accepted: 09/23/2012] [Indexed: 05/26/2023]
Abstract
OBJECTIVE Evidence documenting management of incidental findings (IFs) from clinical genomic testing is limited. The aim of this study was to examine genetics specialists' perspectives regarding current and preferred disclosure of clinical genomic IFs. METHODS 50 genetics specialists, including medical geneticists, laboratory professionals, genetic counselors, and nurses participated in structured telephone interviews. Data were analyzed using qualitative content analysis and descriptive statistics. RESULTS Most specialists had encountered IFs, but definitions of IFs varied. They discussed challenges with informing patients about the prospect of IFs and disclosing IFs to patients. Causing psychological harm to patients was a concern. Participants were divided on whether IFs needed to be clinically significant and/or actionable in order to be disclosed to patients. Creating formal disclosure guidelines was considered useful, but only if they were flexible. Additional counseling, more interdisciplinary communication, maintaining contact with patients, and a centralized database to interpret IFs were also proposed. CONCLUSION Genetics specialists offer insights into the challenges of defining IFs, knowing when and how to disclose them, and the potential need for flexible disclosure guidelines. PRACTICE IMPLICATIONS Further discussion between practicing genetics specialists is needed to develop consensus on the development of best-practice guidelines for IF management.
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Affiliation(s)
- Nancy R Downing
- College of Nursing, The University of Iowa, Iowa City, IA, USA.
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39
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Sorensen PL, Gane LW, Yarborough M, Hagerman RJ, Tassone F. Newborn screening and cascade testing for FMR1 mutations. Am J Med Genet A 2012; 161A:59-69. [PMID: 23239591 DOI: 10.1002/ajmg.a.35680] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 08/20/2012] [Indexed: 12/12/2022]
Abstract
We describe an ongoing pilot project in which newborn screening (NBS) for FMR1 mutations and subsequent cascade testing are performed by the MIND Institute at the University of California, Davis Medical Center (UCDMC). To date, out of 3,042 newborns initially screened, 44 extended family members have been screened by cascade testing of extended family members once a newborn is identified. Fourteen newborns (7 males and 7 females) and 27 extended family members (5 males and 22 females) have been identified with FMR1 mutations. Three family histories are discussed in detail, each demonstrating some benefits and risks of NBS and cascade testing for FMR1 mutations in extended family members. While we acknowledge inherent risks, we propose that with genetic counseling, clinical follow-up of identified individuals and cascade testing, NBS has significant benefits. Treatment for individuals in the extended family who would otherwise not have received treatment can be beneficial. In addition, knowledge of carrier status can lead to lifestyle changes and prophylactic interventions that are likely to reduce the risk of late onset neurological or psychiatric problems in carriers. Also with identification of carrier family members through NBS, reproductive choices become available to those who would not have known that they were at risk to have offspring with fragile X syndrome.
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Affiliation(s)
- Page L Sorensen
- University of California Davis Medical Center, Sacramento, CA, USA
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40
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Abrams L, Cronister A, Brown WT, Tassone F, Sherman SL, Finucane B, McConkie-Rosell A, Hagerman R, Kaufmann WE, Picker J, Coffey S, Skinner D, Johnson V, Miller R, Berry-Kravis E. Newborn, carrier, and early childhood screening recommendations for fragile X. Pediatrics 2012; 130:1126-35. [PMID: 23129072 DOI: 10.1542/peds.2012-0693] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Fragile X syndrome, diagnosed by Fragile X Mental Retardation 1 (FMR1) DNA testing, is the most common single-gene cause of inherited intellectual disability. The expanded CGG mutation in the FMR1 gene, once thought to have clinical significance limited to fragile X syndrome, is now well established as the cause for other fragile X-associated disorders including fragile X-associated primary ovarian insufficiency and fragile X-associated tremor ataxia syndrome in individuals with the premutation (carriers). The importance of early diagnostic and management issues, in conjunction with the identification of family members at risk for or affected by FMR1 mutations, has led to intense discussion about the appropriate timing for early identification of FMR1 mutations. This review includes an overview of the fragile X-associated disorders and screening efforts to date, and discussion of the advantages and barriers to FMR1 screening in newborns, during childhood, and in women of reproductive age. Comparison with screening programs for other common genetic conditions is discussed to arrive at action steps to increase the identification of families affected by FMR1 mutations.
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Affiliation(s)
- Liane Abrams
- National Fragile X Foundation, Walnut Creek, CA 94596, USA.
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41
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Allyse M, Sayres LC, King JS, Norton ME, Cho MK. Cell-free fetal DNA testing for fetal aneuploidy and beyond: clinical integration challenges in the US context. Hum Reprod 2012; 27:3123-31. [PMID: 22863603 PMCID: PMC3472618 DOI: 10.1093/humrep/des286] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The recent release of new, non-invasive prenatal tests for fetal aneuploidy using cell-free fetal DNA (cffDNA) has been hailed as a revolution in prenatal testing and has triggered significant commercial interest in the field. Ongoing research portends the arrival of a wide range of cffDNA tests. However, it is not yet clear how these tests will be integrated into well-established prenatal testing strategies in the USA, as the timing of such testing and the degree to which new non-invasive tests will supplement or replace existing screening and diagnostic tools remain uncertain. We argue that there is an urgent need for policy-makers, regulators and professional societies to provide guidance on the most efficient and ethical manner for such tests to be introduced into clinical practice in the USA.
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Affiliation(s)
- Megan Allyse
- Stanford Center for Biomedical Ethics, Stanford, CA 94305-5417, USA.
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42
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Can a decision aid enable informed decisions in neonatal nursery recruitment for a fragile X newborn screening study? Genet Med 2012; 15:299-306. [PMID: 23100013 DOI: 10.1038/gim.2012.135] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To determine whether a brochure based on principles of informed decision making improved attention to study materials or altered decisions made by parents invited to participate in a fragile X syndrome newborn screening study. METHODS A total of 1,323 families were invited to participate in a newborn screening study to identify infants with fragile X syndrome as well as premutation carrier infants. Of these families, 716 received the original project brochure and 607 were given a new decision aid brochure. RESULTS Families were more likely to look at the new decision aid and mothers were more likely to read it completely, but the proportion of mothers who read the entire decision aid was only 14%. Families were more likely to rate the decision aid as very helpful. Consistent with informed decision making theory and research, participants receiving the decision aid brochure were less likely to agree to participate. CONCLUSION The decision aid increased attention to and perceived helpfulness of educational information about the study, but most families did not read it completely. The study suggests that even well-designed study materials are not fully reviewed in the context of in-hospital postpartum study recruitment and may need to be accompanied by a research recruiter to obtain informed consent.
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43
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Bailey DB, Lewis MA, Harris SL, Grant T, Bann C, Bishop E, Roche M, Guarda S, Barnum L, Powell C, Therrell BL. Design and evaluation of a decision aid for inviting parents to participate in a fragile X newborn screening pilot study. J Genet Couns 2012; 22:108-17. [PMID: 22736213 DOI: 10.1007/s10897-012-9511-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Accepted: 05/20/2012] [Indexed: 12/19/2022]
Abstract
The major objectives of this project were to develop and evaluate a brochure to help parents make an informed decision about participation in a fragile X newborn screening study. We used an iterative development process that drew on principles of Informed Decision Making (IDM), stakeholder input, design expertise, and expert evaluation. A simulation study with 118 women examined response to the brochure. An independent review rated the brochure high on informational content, guidance, and values. Mothers took an average of 6.5 min to read it and scored an average of 91.1 % correct on a knowledge test. Most women rated the brochure as high quality and trustworthy. When asked to make a hypothetical decision about study participation, 61.9 % would agree to screening. Structural equation modeling showed that agreement to screening and decisional confidence were associated with perceived quality and trust in the brochure. Minority and white mothers did not differ in perceptions of quality or trust. We demonstrate the application of IDM in developing a study brochure. The brochure was highly rated by experts and consumers, met high standards for IDM, and achieved stated goals in a simulation study. The IDM provides a model for consent in research disclosing complicated genetic information of uncertain value.
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Affiliation(s)
- Donald B Bailey
- RTI International, Research Triangle Park, 3040 Cornwallis Road, NC 27709, USA.
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44
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Teo CRL, Law HY, Lee CG, Chong SS. Screening for CGG Repeat Expansion in the FMR1 Gene by Melting Curve Analysis of Combined 5′ and 3′ Direct Triplet-Primed PCRs. Clin Chem 2012; 58:568-79. [DOI: 10.1373/clinchem.2011.174615] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Abstract
BACKGROUND
CGG repeat expansions in the FMR1 (fragile X mental retardation 1) gene are associated with fragile X syndrome, fragile X–associated tremor/ataxia syndrome, and fragile X–associated primary ovarian insufficiency. We evaluated the use of melting curve analysis (MCA) of triplet-primed PCR (TP-PCR) assays as a rapid screening tool for the positive identification of expanded FMR1 alleles in men and women.
METHODS
Both 5′- and 3′-weighted direct TP-PCRs (dTP-PCRs) were evaluated on 29 cell line–derived DNA samples and 44 blinded clinical samples. The presence of expansions was identified by the melting curve profiles generated automatically through MCA on the LightCycler 480 Real-Time PCR System. All samples were also analyzed by capillary electrophoresis to confirm the identities of the PCR fragments that gave rise to the observed melt peak profiles.
RESULTS
The presence of expanded alleles in samples from both males and females produced melt peak profiles that were distinct from those of individuals with the normal allelic form. In the blinded test, positive and negative calls for the presence of an expanded allele corroborated with previously determined genotype classifications for all samples.
CONCLUSIONS
The approach of dTP-PCR plus MCA offers a single-step strategy with high diagnostic sensitivity and specificity for rapid screening detection of FMR1 CGG repeat expansions, regardless of sex. The combined use of 5′- and 3′-weighted dTP-PCR assays minimizes the incidence of false-negative results arising from repeat-flanking deletions.
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Affiliation(s)
- Clara R L Teo
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Hai-Yang Law
- Department of Pediatric Medicine, KK Women's and Children's Hospital, Singapore
| | - Caroline G Lee
- Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Medical Sciences, National Cancer Center, Singapore
- Duke-NUS Graduate Medical School, Singapore
| | - Samuel S Chong
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- University Children's Medical Institute and
- Department of Laboratory Medicine, National University Hospital, Singapore
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45
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Henderson GE, Juengst ET, King NMP, Kuczynski K, Michie M. What research ethics should learn from genomics and society research: lessons from the ELSI Congress of 2011. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2012; 40:1008-24. [PMID: 23289702 PMCID: PMC4103651 DOI: 10.1111/j.1748-720x.2012.00728.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Research on the ethical, legal, and social implications (ELSI) of human genomics has devoted significant attention to the research ethics issues that arise from genomic science as it moves through the translational process. Given the prominence of these issues in today's debates over the state of research ethics overall, these studies are well positioned to contribute important data, contextual considerations, and policy arguments to the wider research ethics community's deliberations, and ultimately to develop a research ethics that can help guide biomedicine's future. In this essay, we illustrate this thesis through an analytic summary of the research presented at the 2011 ELSI Congress, an international meeting of genomics and society researchers. We identify three pivotal factors currently shaping genomic research, its clinical translation, and its societal implications: (1) the increasingly blurred boundary between research and treatment; (2) uncertainty--that is, the indefinite, indeterminate, and incomplete nature of much genomic information and the challenges that arise from making meaning and use of it; and (3) the role of negotiations between multiple scientific and non-scientific stakeholders in setting the priorities for and direction of biomedical research, as it is increasingly conducted "in the public square."
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Affiliation(s)
- Gail E Henderson
- Department of Social Medicine, School of Medicine, Center for Genomics and Society, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
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46
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Din ES, Brown CJ, Grosse SD, Wang C, Bialek SR, Ross DS, Cannon MJ. Attitudes toward newborn screening for cytomegalovirus infection. Pediatrics 2011; 128:e1434-42. [PMID: 22084323 DOI: 10.1542/peds.2011-1444] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Newborns are not routinely screened for cytomegalovirus (CMV), the leading infectious cause of developmental disability. Congenital CMV satisfies a number of criteria for inclusion in newborn screening, and screening potentially offers benefits. Screening could also introduce harms such as anxiety and unnecessary costs for the families of the substantial proportion of CMV-infected children who never develop CMV-related disabilities. Our objective was to assess attitudes toward newborn screening for CMV. METHODS We analyzed responses to 5 statements about CMV and newborn screening from 3922 participants in the 2009 HealthStyles survey, a national mail survey designed to include a group similar to the US population with respect to gender, age, race/ethnicity, income, and household size. Two-step cluster analysis was performed to identify clusters of parental attitudes. RESULTS The majority of respondents strongly or somewhat agreed that they would want to have their newborn tested for CMV even if it was not performed routinely (84%), they had to pay $20 (87%), or CMV-related problems never developed (84%). Nearly half (47%) of them "would worry that the CMV test would lead to unneeded doctor visits and expenses," and 32% "think CMV problems are too rare to worry about." Three clusters of parent respondents were identified on the basis of their attitudes toward CMV screening: "strongly in favor" (31%), "moderately in favor" (49%), and "weakly opposed" (20%). CONCLUSIONS Among most parents, costs, worry, and anxiety associated with newborn screening for CMV would be acceptable. Although attitudes were generally favorable, a minority of the parents were weakly opposed to newborn screening for CMV.
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Affiliation(s)
- Erica S Din
- Centers for Disease Control and Prevention, Atlanta, GA, USA
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Abstract
PURPOSE We sought to determine caregiver perceptions about population screening for fragile X and to examine factors potentially associated with support for screening. METHODS We asked 1,099 caregivers of a child with fragile X syndrome or a fragile X carrier to rate whether free, voluntary screening should be offered preconception, prenatally, neonatally, or when problems occur. Caregivers chose a preferred time for screening, reported whether screening would affect parent-child bonding, indicated preferences for carrier detection, and gave reasons for their choices. RESULTS Caregivers endorsed all forms of screening, but prenatal screening was less strongly endorsed than preconception or postnatal screening. Most (79%) preferred preconception carrier testing, allowing more options when making reproductive decisions. Most thought that screening should also disclose carrier status and believed a positive screen would not negatively affect parent-child bonding. Maternal education, caregiver depression, family impact, and severity of disability were not associated with screening opinions, but parents who only had carrier children were less likely to endorse prenatal screening. CONCLUSION Caregivers of children with fragile X widely endorse screening. However, because different parents will make different choices, screening may need to be offered at multiple times with careful consideration of consent and informed decision-making.
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Abstract
BACKGROUND An increasing array of rare inherited conditions can be detected as part of the universal newborn screening programme. The introduction and evaluation of these service developments require consideration of the ethical issues involved and appropriate mechanisms for informing parents and gaining consent if required. Exploration of parental views is needed to inform the debate and specifically consider whether more flexible protocols are needed to fit with the public perception of new developments in this context. OBJECTIVE This study has been undertaken to explore perceptions and attitudes of parents and future parents to an expanded newborn screening programme in the United Kingdom and the necessary information provision and consent processes. DESIGN AND PARTICIPANTS A mixed methods study involving focus groups (n = 29) and a web-survey (n = 142) undertaken with parents and future parents. RESULTS AND CONCLUSIONS Parents want guaranteed information provision with clear decision-making powers and an awareness of the choices available to them. The difference between existing screening provision and expanded screening was not considered to be significant enough by participants to warrant formal written, informed consent for expanded screening. It is argued that the ethical review processes need to be more flexible towards the provision of information and consent processes for service developments in newborn screening.
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Affiliation(s)
- Louise Moody
- Department of Industrial Design, Coventry University, UK.
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Skinner D, Choudhury S, Sideris J, Guarda S, Buansi A, Roche M, Powell C, Bailey DB. Parents' decisions to screen newborns for FMR1 gene expansions in a pilot research project. Pediatrics 2011; 127:e1455-63. [PMID: 21624881 PMCID: PMC3103273 DOI: 10.1542/peds.2010-3078] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE The goal of this study was to document rates of parental consent in a pilot study of newborn screening for FMR1 gene expansions, examine demographic characteristics of mothers who consented or declined, describe the reasons for their decision, and discuss ethical and social aspects of the consent process. METHODS A brief survey was used to record basic demographic data from mothers and an open-ended question was used to elicit parents' reasons for accepting or declining screening. A descriptive analysis was conducted on the number of mothers who consented to or declined screening, and a logistic regression model predicted mothers' likelihood to agree to screening based on demographic characteristics. Reasons for decisions were analyzed using content analysis. The study was conducted at University of North Carolina Hospitals. A total of 2137 mothers were approached. RESULTS The uptake rate for couples was 63%. Acceptance rates varied by race/ethnicity, with black respondents being less likely to accept screening. Primary reasons for accepting were "to know," "belief in research," and "the test was minimal/no risk." Reasons for declining included not wanting to know or worry, not being a good time, and issues with testing children or with genetic tests. CONCLUSIONS Findings demonstrate that a majority of parents accepted newborn screening for FMR1 gene expansions, but decision rates and reasons for accepting or declining varied in part as a function of race/ethnicity and in part as a function of what parents most valued or feared in their assessment of risks and benefits.
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Affiliation(s)
- Debra Skinner
- FPG Child Development Institute, University of North Carolina at Chapel Hill, Carrboro, NC 27510, USA.
| | | | | | | | | | - Myra Roche
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and
| | - Cynthia Powell
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and
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Abstract
UNLABELLED Diagnosis of Klinefelter syndrome (KS) allows for timely beneficial interventions across the lifespan. Most cases currently remain undiagnosed because of low awareness of KS amongst health professionals, the hesitancy of men to seek medical attention and its variable clinical presentation. Given these barriers, population-based genetic screening provides an approach to comprehensive and early detection. We examine current evidence regarding risks and benefits of diagnosing KS at different ages. CONCLUSION There is a lack of evidence regarding the influence of age at diagnosis on adult outcomes that can only be obtained through a pilot screening programme.
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Affiliation(s)
- Amy S Herlihy
- Murdoch Childrens Research Institute, Parkville, Vic., Australia.
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