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Marathe PN, Suckiel SA, Bonini KE, Kelly NR, Scarimbolo L, Insel BJ, Odgis JA, Sebastin M, Ramos MA, Di Biase M, Gallagher KM, Brown K, Rodriguez JE, Yelton N, Aguiñiga KL, Rodriguez MA, Maria E, Lopez J, Zinberg RE, Diaz GA, Greally JM, Abul-Husn NS, Bauman LJ, Gelb BD, Wasserstein MP, Kenny EE, Horowitz CR. Evaluating parental personal utility of pediatric genetic and genomic testing in a diverse, multilingual population. HGG ADVANCES 2024; 5:100321. [PMID: 38918948 PMCID: PMC11284555 DOI: 10.1016/j.xhgg.2024.100321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 06/21/2024] [Accepted: 06/21/2024] [Indexed: 06/27/2024] Open
Abstract
There is increasing evidence of the clinical utility of genetic and genomic testing (GT); however, factors influencing personal utility of GT, especially in diverse, multilingual populations, remain unclear. We explored these factors in a diverse cohort of parents/guardians (participants) whose children received clinical GT through the NYCKidSeq program. A total of 847 participants completed surveys at baseline, post-results disclosure, and 6 months (6m) post-results. The largest population groups were Hispanic/Latino(a) (48%), White/European American (24%), and Black/African American (16%). Personal utility was assessed using the Personal Utility (PrU) scale, adapted for pediatric populations and included on the surveys. Three PrU subscales were identified using factor analysis: practical, educational, and parental psychological utility. Overall personal utility summary score and the three subscales significantly decreased after receiving results and over time. Hispanic/Latino(a) participants identified greater overall personal utility than European American and African American participants at all time points (p < 0.001) as did participants whose children received positive/likely positive results compared with those with negative and uncertain results (post-results: p < 0.001 and p < 0.001; 6m post-results: p = 0.002 and p < 0.001, respectively). Post-results, higher subscale scores were associated with lower education levels (practical, parental psychological: p ≤ 0.02) and higher levels of trust in the healthcare system (practical, parental psychological: p ≤ 0.04). These findings help to understand the perspectives of diverse parents/guardians, which is critical to tailoring pre- and post-test counseling across a variety of populations and clinical settings.
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Affiliation(s)
- Priya N Marathe
- Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Sabrina A Suckiel
- Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Katherine E Bonini
- Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Nicole R Kelly
- Department of Pediatrics, Division of Pediatric Genetic Medicine, Children's Hospital at Montefiore/Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Laura Scarimbolo
- Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Beverly J Insel
- Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Jacqueline A Odgis
- Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Monisha Sebastin
- Department of Pediatrics, Division of Pediatric Genetic Medicine, Children's Hospital at Montefiore/Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Michelle A Ramos
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Miranda Di Biase
- Department of Pediatrics, Division of Pediatric Genetic Medicine, Children's Hospital at Montefiore/Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Katie M Gallagher
- Department of Pediatrics, Division of Pediatric Genetic Medicine, Children's Hospital at Montefiore/Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Kaitlyn Brown
- Department of Pediatrics, Division of Pediatric Genetic Medicine, Children's Hospital at Montefiore/Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Jessica E Rodriguez
- Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Nicole Yelton
- Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Karla Lopez Aguiñiga
- Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Michelle A Rodriguez
- Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Estefany Maria
- Department of Pediatrics, Division of Pediatric Genetic Medicine, Children's Hospital at Montefiore/Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Jessenia Lopez
- Department of Pediatrics, Division of Pediatric Genetic Medicine, Children's Hospital at Montefiore/Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Randi E Zinberg
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - George A Diaz
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - John M Greally
- Department of Pediatrics, Division of Pediatric Genetic Medicine, Children's Hospital at Montefiore/Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Noura S Abul-Husn
- Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Laurie J Bauman
- Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Bronx, NY 10461, USA; Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Bruce D Gelb
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Melissa P Wasserstein
- Department of Pediatrics, Division of Pediatric Genetic Medicine, Children's Hospital at Montefiore/Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Eimear E Kenny
- Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
| | - Carol R Horowitz
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
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2
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Harrington CN, Morales A, Bernstein JA, Calderwood L. Implications of Provider Specialty, Test Type, and Demographic Factors on Genetic Testing Outcomes for Patients with Autism Spectrum Disorder. J Autism Dev Disord 2024:10.1007/s10803-024-06423-1. [PMID: 38858309 DOI: 10.1007/s10803-024-06423-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2024] [Indexed: 06/12/2024]
Abstract
A minority of patients with autism spectrum disorder (ASD) are offered genetic testing by their providers or referred for genetics evaluation despite published guidelines and consensus statements supporting genetics-informed care for this population. This study aimed to investigate the ordering habits of providers of different specialties and to additionally assess the diagnostic utility of genetic testing by test type, patient sex, and race and ethnicity. We retrospectively analyzed data associated with orders for the indication of ASD from a large clinical laboratory over 6 years (2017-2022). Geneticists and neurologists were more likely than other specialists to order exome sequencing and neurodevelopmental (NDD) panel testing while other providers were more likely to order chromosomal microarray (CMA) and Fragile X testing. Exome had the highest diagnostic yield (24.5%), followed by NDD panel (6.4%), CMA (6.2%), and Fragile X testing (0.4%). Females were 1.4x (95% CI: 1.2-1.7) more likely than males to receive a genetic diagnosis. However, for Fragile X, males had a higher diagnostic yield than females (0.4% vs 0.2%). Our findings highlight the need to enable non-genetics providers to order comprehensive genetic testing or promote referral to genetics following negative CMA and/or Fragile X testing. Our data supports that ASD testing should include exome, CMA, and other clinically indicated tests, as first-tier tests, with the consideration of panel testing, in cases where exome sequencing is not an option. Lastly, our study helps to inform expectations for genetic testing yield by test type and patient presentation.
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Affiliation(s)
- Caitlin N Harrington
- Department of Pediatrics, Division of Medical Genetics, Stanford University School of Medicine, Stanford, CA, USA.
- Stanford Medicine Children's Health, Stanford, CA, USA.
| | - Ana Morales
- Translational Health Sciences Program, School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Jonathan A Bernstein
- Department of Pediatrics, Division of Medical Genetics, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Medicine Children's Health, Stanford, CA, USA
| | - Laurel Calderwood
- Department of Pediatrics, Division of Medical Genetics, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Medicine Children's Health, Stanford, CA, USA
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3
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Wynn J, Karlsen A, Huber B, Levine A, Salem A, White LC, Luby M, Bezborodko E, Xiao S, Chung WK, Klitzman RL, Appelbaum PS. Impact of a Genetic Diagnosis for a Child's Autism on Parental Perceptions. J Autism Dev Disord 2024:10.1007/s10803-024-06273-x. [PMID: 38578549 DOI: 10.1007/s10803-024-06273-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2024] [Indexed: 04/06/2024]
Abstract
Genetic testing is recommended as part of an autism assessment, and most parents support genetic testing for their minor children. However, the impact on parents of receiving a monogenetic/ copy number variant diagnosis for autism in their child is not well understood. To explore this, we surveyed and interviewed parents of children in the SPARK study, a study of autism that includes genetic testing. Surveys were administered one month before and one and 12 months after parents received their child's genetic result. Interviews were conducted approximately one month after results disclosure. A genetic diagnosis (GD) for their child appeared to reduce parents' sense of self-blame and feelings of guilt, and this impact was relatively stable. The data also indicate a modest impact on parents' actions related to the condition, perceptions of themselves, and some aspects of life planning for their child, as measured by quantitative instruments at one month and 12 months after receipt of results. Other measures of parental identity and expectations for their child, in contrast, showed little change following receipt of genetic findings. Overall, parents who were told that no GD was identified showed minimal changes in their responses over time. These results suggest a discernable but relatively limited impact of genetic test results on parents of children with autism. These results should be reassuring to clinicians caring for children with autism and are consistent with studies in other areas of medicine that have suggested that genetic results tend to have fewer effects-negative or positive-than were anticipated.
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Affiliation(s)
- Julia Wynn
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA.
| | - Anna Karlsen
- Columbia University Genetic Counseling Graduate Program, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Benjamin Huber
- Department of Epidemiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Alina Levine
- Department of Epidemiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Amanie Salem
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA
| | | | | | - Ekaterina Bezborodko
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA
| | | | - Wendy K Chung
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
- Simons Foundation, New York, NY, USA
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert L Klitzman
- Department of Psychiatry and Masters of Bioethics Program, and New York State Psychiatric Institute, Columbia University, New York, NY, USA
| | - Paul S Appelbaum
- Department of Psychiatry, and New York State Psychiatric Institute, Columbia University Irving Medical Center, New York, NY, USA
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4
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Dratch L, Azage M, Baldwin A, Johnson K, Paul RA, Bardakjian TM, Michon SC, Amado DA, Baer M, Deik AF, Elman LB, Gonzalez-Alegre P, Guo MH, Hamedani AG, Irwin DJ, Lasker A, Orthmann-Murphy J, Quinn C, Tropea TF, Scherer SS, Ellis CA. Genetic testing in adults with neurologic disorders: indications, approach, and clinical impacts. J Neurol 2024; 271:733-747. [PMID: 37891417 PMCID: PMC11095966 DOI: 10.1007/s00415-023-12058-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 10/29/2023]
Abstract
The role of genetic testing in neurologic clinical practice has increased dramatically in recent years, driven by research on genetic causes of neurologic disease and increased availability of genetic sequencing technology. Genetic testing is now indicated for adults with a wide range of common neurologic conditions. The potential clinical impacts of a genetic diagnosis are also rapidly expanding, with a growing list of gene-specific treatments and clinical trials, in addition to important implications for prognosis, surveillance, family planning, and diagnostic closure. The goals of this review are to provide practical guidance for clinicians about the role of genetics in their practice and to provide the neuroscience research community with a broad survey of current progress in this field. We aim to answer three questions for the neurologist in practice: Which of my patients need genetic testing? What testing should I order? And how will genetic testing help my patient? We focus on common neurologic disorders and presentations to the neurology clinic. For each condition, we review the most current guidelines and evidence regarding indications for genetic testing, expected diagnostic yield, and recommended testing approach. We also focus on clinical impacts of genetic diagnoses, highlighting a number of gene-specific therapies recently approved for clinical use, and a rapidly expanding landscape of gene-specific clinical trials, many using novel nucleotide-based therapeutic modalities like antisense oligonucleotides and gene transfer. We anticipate that more widespread use of genetic testing will help advance therapeutic development and improve the care, and outcomes, of patients with neurologic conditions.
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Affiliation(s)
- Laynie Dratch
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Meron Azage
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Aaron Baldwin
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Kelsey Johnson
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Rachel A Paul
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Tanya M Bardakjian
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
- Sarepta Therapeutics Inc, Cambridge, MA, 02142, USA
| | - Sara-Claude Michon
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Defne A Amado
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Michael Baer
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Andres F Deik
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Lauren B Elman
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Pedro Gonzalez-Alegre
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
- Spark Therapeutics Inc, Philadelphia, PA, 19104, USA
| | - Michael H Guo
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Ali G Hamedani
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - David J Irwin
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Aaron Lasker
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Jennifer Orthmann-Murphy
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Colin Quinn
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Thomas F Tropea
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Steven S Scherer
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA
| | - Colin A Ellis
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, 3 West Gates Building, Philadelphia, PA, 19104, USA.
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5
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D'Gama AM, Agrawal PB. Genomic medicine in neonatal care: progress and challenges. Eur J Hum Genet 2023; 31:1357-1363. [PMID: 37789085 PMCID: PMC10689757 DOI: 10.1038/s41431-023-01464-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 09/01/2023] [Accepted: 09/13/2023] [Indexed: 10/05/2023] Open
Abstract
During the neonatal period, many genetic disorders present and contribute to neonatal morbidity and mortality. Genomic medicine-the use of genomic information in clinical care- has the potential to significantly reduce morbidity and mortality in the neonatal period and improve outcomes for this population. Diagnostic genomic testing for symptomatic newborns, especially rapid testing, has been shown to be feasible and have diagnostic and clinical utility, particularly in the short-term. Ongoing studies are assessing the feasibility and utility, including personal utility, of implementation in diverse populations. Genomic screening for asymptomatic newborns has also been studied, and the acceptability and feasibility of such an approach remains an active area of investigation. Emerging precision therapies, with examples even at the "n-of-1" level, highlight the promise of precision diagnostics to lead to early intervention and improve outcomes. To sustainably implement genomic medicine in neonatal care in an ethical, effective, and equitable manner, we need to ensure access to genetics and genomics knowledge, access to genomic tests, which is currently limited by payors, feasible processes for ordering these tests, and access to follow up in the clinical and research realms. Future studies will provide further insight into enablers and barriers to optimize implementation strategies.
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Affiliation(s)
- Alissa M D'Gama
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
- Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, USA
| | - Pankaj B Agrawal
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, USA.
- The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA, USA.
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Holtz Children's Hospital, Jackson Health System, Miami, FL, USA.
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Hamilton JG, Shah IH, Salafia C, Schofield E, Garzon MG, Cadet K, Stadler ZK, Hay JL, Offit K, Robson ME. Development of a novel measure of advanced cancer patients' perceived utility of secondary germline findings from tumor genomic profiling. PEC INNOVATION 2023; 2:100124. [PMID: 37214538 PMCID: PMC10194097 DOI: 10.1016/j.pecinn.2023.100124] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/06/2023] [Accepted: 01/17/2023] [Indexed: 05/24/2023]
Abstract
Objective Tumor genomic profiling (TGP) can inform advanced cancer patients' treatment decisions, and also reveal secondary germline findings-information about inherited risks for cancer and other disorders. We sought to develop a measure of patient perceptions of the clinical and personal utility of secondary germline findings. Methods We developed a draft survey based on literature and patient interview data (n=40). We evaluated and refined the survey through cognitive interviews with advanced cancer patients who received secondary germline findings from TGP (n=10). The survey was psychometrically validated with data from two independent samples of advanced cancer patients undergoing TGP (total n=349). Results Cognitive interviews offered opportunities for survey refinement and confirmation of its comprehensible nature. Exploratory and confirmatory factor analysis of the survey identified 16 items across three subscales with strong internal consistency (Cronbach's alpha ≥0.79): perceived utility for others, perceived utility for self and health, and confidence in secondary findings. Conclusion We developed a novel valid scale with promise for measuring advanced cancer patients' perceptions of the utility of secondary germline findings. Innovation We offer a new patient-derived measure of perceived utility of and confidence in secondary germline findings with potential applications for precision oncology research and clinical communication.
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Affiliation(s)
- Jada G. Hamilton
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Psychiatry, Weill Cornell Medical College, Cornell University, New York, NY, USA
| | - Ibrahim H. Shah
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Caroline Salafia
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Human Development and Family Sciences, University of Connecticut, Storrs, CT, USA
| | - Elizabeth Schofield
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Margaux Genoff Garzon
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kechna Cadet
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Zsofia K. Stadler
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, Cornell University, New York, NY, USA
| | - Jennifer L. Hay
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Psychiatry, Weill Cornell Medical College, Cornell University, New York, NY, USA
| | - Kenneth Offit
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, Cornell University, New York, NY, USA
| | - Mark E. Robson
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, Cornell University, New York, NY, USA
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7
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Cole JJ, Aravamuthan BR. Current Practices in the Evaluation of Global Developmental Delay/Intellectual Disability: A Nationwide Survey of Child Neurologists. Neurol Clin Pract 2023; 13:e200192. [PMID: 37795501 PMCID: PMC10547469 DOI: 10.1212/cpj.0000000000200192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 07/07/2023] [Indexed: 10/06/2023]
Abstract
Background and Objectives Global developmental delay/intellectual disability (GDD/ID) are among the most common neurologic conditions evaluated by child neurologists in the United States. No recent neurology-specific guidelines for GDD/ID diagnostic evaluation exist, which could lead to practice variability. We assessed current practices in GDD/ID diagnostic evaluation among US child neurologists, including drivers of exome sequencing (ES). Methods A 19-item online anonymous survey was distributed between April 2021 and September 2021 to 953 eligible child neurologists by email and/or online platforms through the American Academy of Neurology and Child Neurology Society. Multinomial logistic regression was used to determine the predictors of sending ES as a part of GDD/ID diagnostic evaluation. Results Of 172 unique respondents, 69.2% reported almost always obtaining a chromosomal microarray while 10.5% reported almost always pursuing ES. However, 65.1% identified ES as a first-tier diagnostic test for GDD/ID. Clinical practice demographics independently associated with a higher likelihood of pursuit of ES were more years of experience (p = 0.002) and more people with GDD/ID in one's practice (p < 0.001). Inclusion of brain MRI, EEG, and metabolic laboratory values as part of GDD/ID diagnostic evaluation varied widely. Modalities to screen for treatable disorders (ES or metabolic laboratory values) were reported to be consistently used by only 24.8% of respondents. Respondents identified key barriers to the pursuit of ES including the need for genetics referral/genetic counseling and insurance coverage/out-of-pocket cost. Discussion Among US child neurologists, there is marked practice variability in GDD/ID diagnostic evaluation across multiple types of testing, raising concern for disparities in care. There is a widespread lack of screening for treatable causes of ID, which may lead to missed diagnoses and avoidable morbidity. Despite most respondents' support for ES as a first-tier diagnostic test for GDD/ID, only a small minority routinely pursue ES as a part of their evaluation. Provider-level factors (years of experience, percent of patients with GDD/ID) and system-level barriers (access to genetics expertise, lack of insurance coverage) were determinants of the frequency of use of ES. These findings suggest the need for updated consensus guidelines and advocacy/education to improve child neurologists' ability to pursue ES for GDD/ID.
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Affiliation(s)
- Jordan J Cole
- Department of Neurology, Washington University in St. Louis
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8
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McGill BC, Wakefield CE, Tucker KM, Daly RA, Donoghoe MW, Vetsch J, Warby M, Fuentes‐Bolanos NA, Barlow‐Stewart K, Kirk J, Courtney E, O’Brien TA, Marshall GM, Pinese M, Cowley MJ, Tyrrell V, Deyell RJ, Ziegler DS, Hetherington K. Parents' expectations, preferences, and recall of germline findings in a childhood cancer precision medicine trial. Cancer 2023; 129:3620-3632. [PMID: 37382186 PMCID: PMC10952780 DOI: 10.1002/cncr.34917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 04/17/2023] [Accepted: 05/15/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Germline genome sequencing in childhood cancer precision medicine trials may reveal pathogenic or likely pathogenic variants in cancer predisposition genes in more than 10% of children. These findings can have implications for diagnosis, treatment, and the child's and family's future cancer risk. Understanding parents' perspectives of germline genome sequencing is critical to successful clinical implementation. METHODS A total of 182 parents of 144 children (<18 years of age) with poor-prognosis cancers enrolled in the Precision Medicine for Children with Cancer trial completed a questionnaire at enrollment and after the return of their child's results, including clinically relevant germline findings (received by 13% of parents). Parents' expectations of germline genome sequencing, return of results preferences, and recall of results received were assessed. Forty-five parents (of 43 children) were interviewed in depth. RESULTS At trial enrollment, most parents (63%) believed it was at least "somewhat likely" that their child would receive a clinically relevant germline finding. Almost all expressed a preference to receive a broad range of germline genomic findings, including variants of uncertain significance (88%). Some (29%) inaccurately recalled receiving a clinically relevant germline finding. Qualitatively, parents expressed confusion and uncertainty after the return of their child's genome sequencing results by their child's clinician. CONCLUSIONS Many parents of children with poor-prognosis childhood cancer enrolled in a precision medicine trial expect their child may have an underlying cancer predisposition syndrome. They wish to receive a wide scope of information from germline genome sequencing but may feel confused by the reporting of trial results.
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Koh HY, Smith L, Wiltrout KN, Podury A, Chourasia N, D’Gama AM, Park M, Knight D, Sexton EL, Koh JJ, Oby B, Pinsky R, Shao DD, French CE, Shao W, Rockowitz S, Sliz P, Zhang B, Mahida S, Moufawad El Achkar C, Yuskaitis CJ, Olson HE, Sheidley BR, Poduri AH. Utility of Exome Sequencing for Diagnosis in Unexplained Pediatric-Onset Epilepsy. JAMA Netw Open 2023; 6:e2324380. [PMID: 37471090 PMCID: PMC10359957 DOI: 10.1001/jamanetworkopen.2023.24380] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/31/2023] [Indexed: 07/21/2023] Open
Abstract
Importance Genomic advances inform our understanding of epilepsy and can be translated to patients as precision diagnoses that influence clinical treatment, prognosis, and counseling. Objective To delineate the genetic landscape of pediatric epilepsy and clinical utility of genetic diagnoses for patients with epilepsy. Design, Setting, and Participants This cohort study used phenotypic data from medical records and treating clinicians at a pediatric hospital to identify patients with unexplained pediatric-onset epilepsy. Exome sequencing was performed for 522 patients and available biological parents, and sequencing data were analyzed for single nucleotide variants (SNVs) and copy number variants (CNVs). Variant pathogenicity was assessed, patients were provided with their diagnostic results, and clinical utility was evaluated. Patients were enrolled from August 2018 to October 2021, and data were analyzed through December 2022. Exposures Phenotypic features associated with diagnostic genetic results. Main Outcomes and Measures Main outcomes included diagnostic yield and clinical utility. Diagnostic findings included variants curated as pathogenic, likely pathogenic (PLP), or diagnostic variants of uncertain significance (VUS) with clinical features consistent with the involved gene's associated phenotype. The proportion of the cohort with diagnostic findings, the genes involved, and their clinical utility, defined as impact on clinical treatment, prognosis, or surveillance, are reported. Results A total of 522 children (269 [51.5%] male; mean [SD] age at seizure onset, 1.2 [1.4] years) were enrolled, including 142 children (27%) with developmental epileptic encephalopathy and 263 children (50.4%) with intellectual disability. Of these, 100 participants (19.2%) had identifiable genetic explanations for their seizures: 89 participants had SNVs (87 germline, 2 somatic mosaic) involving 69 genes, and 11 participants had CNVs. The likelihood of identifying a genetic diagnosis was highest in patients with intellectual disability (adjusted odds ratio [aOR], 2.44; 95% CI, 1.40-4.26), early onset seizures (aOR, 0.93; 95% CI, 0.88-0.98), and motor impairment (aOR, 2.19; 95% CI 1.34-3.58). Among 43 patients with apparently de novo variants, 2 were subsequently determined to have asymptomatic parents harboring mosaic variants. Of 71 patients who received diagnostic results and were followed clinically, 29 (41%) had documented clinical utility resulting from their genetic diagnoses. Conclusions and Relevance These findings suggest that pediatric-onset epilepsy is genetically heterogeneous and that some patients with previously unexplained pediatric-onset epilepsy had genetic diagnoses with direct clinical implications.
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Affiliation(s)
- Hyun Yong Koh
- Epilepsy Genetics Program, Boston Children’s Hospital, Boston, Massachusetts
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
- F.M. Kirby Neurobiology Center, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
- The Manton Center for Orphan Disease Research, Boston Children’s Hospital, Boston, Massachusetts
| | - Lacey Smith
- Epilepsy Genetics Program, Boston Children’s Hospital, Boston, Massachusetts
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
| | - Kimberly N. Wiltrout
- Epilepsy Genetics Program, Boston Children’s Hospital, Boston, Massachusetts
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | | | - Nitish Chourasia
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics and Neurology, University of Tennessee Health Science Center, Memphis
| | - Alissa M. D’Gama
- Epilepsy Genetics Program, Boston Children’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Division of Newborn Medicine, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Meredith Park
- Epilepsy Genetics Program, Boston Children’s Hospital, Boston, Massachusetts
| | - Devon Knight
- Epilepsy Genetics Program, Boston Children’s Hospital, Boston, Massachusetts
| | - Emma L. Sexton
- Epilepsy Genetics Program, Boston Children’s Hospital, Boston, Massachusetts
| | - Julia J. Koh
- Epilepsy Genetics Program, Boston Children’s Hospital, Boston, Massachusetts
| | - Brandon Oby
- Epilepsy Genetics Program, Boston Children’s Hospital, Boston, Massachusetts
| | - Rebecca Pinsky
- Epilepsy Genetics Program, Boston Children’s Hospital, Boston, Massachusetts
| | - Diane D. Shao
- Epilepsy Genetics Program, Boston Children’s Hospital, Boston, Massachusetts
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - Courtney E. French
- Research Computing, Department of Information Technology, Boston Children’s Hospital, Boston, Massachusetts
| | - Wanqing Shao
- Research Computing, Department of Information Technology, Boston Children’s Hospital, Boston, Massachusetts
| | - Shira Rockowitz
- The Manton Center for Orphan Disease Research, Boston Children’s Hospital, Boston, Massachusetts
- Research Computing, Department of Information Technology, Boston Children’s Hospital, Boston, Massachusetts
| | - Piotr Sliz
- The Manton Center for Orphan Disease Research, Boston Children’s Hospital, Boston, Massachusetts
- Research Computing, Department of Information Technology, Boston Children’s Hospital, Boston, Massachusetts
- Division of Molecular Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Bo Zhang
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
- Biostatistics and Research Design Center, Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, Massachusetts
| | - Sonal Mahida
- Epilepsy Genetics Program, Boston Children’s Hospital, Boston, Massachusetts
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
| | - Christelle Moufawad El Achkar
- Epilepsy Genetics Program, Boston Children’s Hospital, Boston, Massachusetts
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
- Biostatistics and Research Design Center, Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, Massachusetts
| | - Christopher J. Yuskaitis
- Epilepsy Genetics Program, Boston Children’s Hospital, Boston, Massachusetts
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
- F.M. Kirby Neurobiology Center, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - Heather E. Olson
- Epilepsy Genetics Program, Boston Children’s Hospital, Boston, Massachusetts
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
- F.M. Kirby Neurobiology Center, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - Beth Rosen Sheidley
- Epilepsy Genetics Program, Boston Children’s Hospital, Boston, Massachusetts
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
| | - Annapurna H. Poduri
- Epilepsy Genetics Program, Boston Children’s Hospital, Boston, Massachusetts
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
- F.M. Kirby Neurobiology Center, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts
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D'Gama AM, Agrawal PB. Role of genomic medicine and implementing equitable access for critically ill infants in neonatal intensive care units. J Perinatol 2023; 43:963-967. [PMID: 36774516 PMCID: PMC9918837 DOI: 10.1038/s41372-023-01630-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 01/27/2023] [Accepted: 01/31/2023] [Indexed: 02/13/2023]
Abstract
Genetic disorders are a leading cause of morbidity and mortality in infants admitted to neonatal intensive care units. This population has immense potential to benefit from genomic medicine, as early precision diagnosis is critical to early personalized management. However, the implementation of genomic medicine in neonatology thus far has arguably worsened health inequities, and strategies are urgently needed to achieve equitable access to genomics in neonatal care. In this perspective, we demonstrate the utility of genomic sequencing in critically ill infants and highlight three key recommendations to advance equitable access: recruitment of underrepresented populations, education of non-genetics providers to empower practice of genomic medicine, and development of innovative infrastructure to implement genomic medicine across diverse settings.
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Affiliation(s)
- Alissa M D'Gama
- Epilepsy Genetics Program, Division of Epilepsy and Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
- Neonatal Genomics Program, Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Pankaj B Agrawal
- Neonatal Genomics Program, Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA.
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
- The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA, USA.
- Broad Institute of MIT and Harvard, Cambridge, MA, USA.
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11
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Lantos JD. The Future of Newborn Genomic Testing. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1140. [PMID: 37508635 PMCID: PMC10378699 DOI: 10.3390/children10071140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/26/2023] [Accepted: 06/29/2023] [Indexed: 07/30/2023]
Abstract
Genome sequencing (GS) provides exciting opportunities to rapidly identify a diagnosis in critically ill newborns and children with rare genetic conditions. Nevertheless, there are reasons to remain cautious about the use of GS. Studies to date have been mostly in highly selected populations of babies with unusual clinical presentations. GS leads to diagnoses in many such infants. More rarely, it leads to beneficial changes in management. Parents and physicians whose babies meet these criteria and for whom GS is performed both find these results useful. The concern is this: we do not know how useful such testing will be in the general population. We can speculate that a number of problems will arise as the use of GS expands. First, the percentage of cases in which a valid molecular diagnosis is made will likely go down. The number of ambiguous results or false positives will rise. Genetic counseling will become more complex and challenging. We do not know the relative cost-effectiveness of whole genome, whole exome, or targeted panels in different populations. We do not know the relative contribution of a molecular diagnosis to the decision to withdraw life support. We will have to carefully evaluate the use of such testing in order to understand whether it truly improves outcome and survival or reduces symptoms in babies who are tested. Each of these concerns will require careful study of both the technology and the ethical issues to allow us to harness the potential of these new technologies while avoiding foreseeable problems. Studies are underway to see how the tests are used in general populations. These studies should generate important information to guide clinicians and policymakers. As part of informed consent, doctors should explain to parents that genetic results are not always straightforward. Sometimes, they confirm a diagnosis that was already suspected. Sometimes, they rule out a possible diagnosis. Sometimes, the results are ambiguous and difficult to interpret. Anticipatory discussions should try to give parents a realistic understanding of the likely impact of a genetic diagnosis. Diagnostic genomic testing for newborns is a science that is still in its infancy. More research is essential in order to establish how to personalize this promising but sometimes problematic tool.
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Affiliation(s)
- John D Lantos
- Department of Pediatrics, Mt Sinai School of Medicine, New York, NY 10029, USA
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12
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Lemke AA, Thompson ML, Gimpel EC, McNamara KC, Rich CA, Finnila CR, Cochran ME, Lawlor JMJ, East KM, Bowling KM, Latner DR, Hiatt SM, Amaral MD, Kelley WV, Greve V, Gray DE, Felker SA, Meddaugh H, Cannon A, Luedecke A, Jackson KE, Hendon LG, Janani HM, Johnston M, Merin LA, Deans SL, Tuura C, Hughes T, Williams H, Laborde K, Neu MB, Patrick-Esteve J, Hurst ACE, Kirmse BM, Savich R, Spedale SB, Knight SJ, Barsh GS, Korf BR, Cooper GM, Brothers KB. Parents' Perspectives on the Utility of Genomic Sequencing in the Neonatal Intensive Care Unit. J Pers Med 2023; 13:1026. [PMID: 37511639 PMCID: PMC10382030 DOI: 10.3390/jpm13071026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/08/2023] [Accepted: 06/16/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND It is critical to understand the wide-ranging clinical and non-clinical effects of genome sequencing (GS) for parents in the NICU context. We assessed parents' experiences with GS as a first-line diagnostic tool for infants with suspected genetic conditions in the NICU. METHODS Parents of newborns (N = 62) suspected of having a genetic condition were recruited across five hospitals in the southeast United States as part of the SouthSeq study. Semi-structured interviews (N = 78) were conducted after parents received their child's sequencing result (positive, negative, or variants of unknown significance). Thematic analysis was performed on all interviews. RESULTS Key themes included that (1) GS in infancy is important for reproductive decision making, preparing for the child's future care, ending the diagnostic odyssey, and sharing results with care providers; (2) the timing of disclosure was acceptable for most parents, although many reported the NICU environment was overwhelming; and (3) parents deny that receiving GS results during infancy exacerbated parent-infant bonding, and reported variable impact on their feelings of guilt. CONCLUSION Parents reported that GS during the neonatal period was useful because it provided a "backbone" for their child's care. Parents did not consistently endorse negative impacts like interference with parent-infant bonding.
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Affiliation(s)
- Amy A Lemke
- Department of Pediatrics, Norton Children's Research Institute, University of Louisville School of Medicine, Louisville, KY 40202, USA
| | | | - Emily C Gimpel
- Department of Pediatrics, Norton Children's Research Institute, University of Louisville School of Medicine, Louisville, KY 40202, USA
| | - Katelyn C McNamara
- Department of Pediatrics, Norton Children's Research Institute, University of Louisville School of Medicine, Louisville, KY 40202, USA
| | - Carla A Rich
- Department of Pediatrics, Norton Children's Research Institute, University of Louisville School of Medicine, Louisville, KY 40202, USA
| | | | - Meagan E Cochran
- HudsonAlpha Institute for Biotechnology, Huntsville, AL 35806, USA
| | - James M J Lawlor
- HudsonAlpha Institute for Biotechnology, Huntsville, AL 35806, USA
| | - Kelly M East
- HudsonAlpha Institute for Biotechnology, Huntsville, AL 35806, USA
| | - Kevin M Bowling
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Donald R Latner
- HudsonAlpha Institute for Biotechnology, Huntsville, AL 35806, USA
| | - Susan M Hiatt
- HudsonAlpha Institute for Biotechnology, Huntsville, AL 35806, USA
| | | | - Whitley V Kelley
- HudsonAlpha Institute for Biotechnology, Huntsville, AL 35806, USA
| | - Veronica Greve
- HudsonAlpha Institute for Biotechnology, Huntsville, AL 35806, USA
| | - David E Gray
- HudsonAlpha Institute for Biotechnology, Huntsville, AL 35806, USA
| | - Stephanie A Felker
- HudsonAlpha Institute for Biotechnology, Huntsville, AL 35806, USA
- Department of Biological Sciences, University of Alabama in Huntsville, Huntsville, AL 35899, USA
| | - Hannah Meddaugh
- Department of Genetics, Ochsner Health System, New Orleans, LA 70121, USA
| | - Ashley Cannon
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Amanda Luedecke
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Kelly E Jackson
- Division of Genetics, Norton Children's Genetics Center, University of Louisville School of Medicine, Louisville, KY 40202, USA
| | - Laura G Hendon
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Hillary M Janani
- Neonatal Intensive Care Unit, Woman's Hospital, Baton Rouge, LA 70817, USA
| | - Marla Johnston
- Department of Pediatrics, Children's Hospital New Orleans, New Orleans, LA 70118, USA
| | - Lee Ann Merin
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Sarah L Deans
- Department of Pediatrics, Norton Children's Research Institute, University of Louisville School of Medicine, Louisville, KY 40202, USA
| | - Carly Tuura
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Trent Hughes
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Heather Williams
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Kelly Laborde
- Neonatal Intensive Care Unit, Woman's Hospital, Baton Rouge, LA 70817, USA
| | - Matthew B Neu
- HudsonAlpha Institute for Biotechnology, Huntsville, AL 35806, USA
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | | | - Anna C E Hurst
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Brian M Kirmse
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Renate Savich
- Pediatrics Neonatology Division, University of New Mexico Health Sciences Center, Albuquerque, NM 87106, USA
| | - Steven B Spedale
- Neonatal Intensive Care Unit, Woman's Hospital, Baton Rouge, LA 70817, USA
| | - Sara J Knight
- Department of Internal Medicine, University of Utah, Salt Lake City, UT 84112, USA
| | - Gregory S Barsh
- HudsonAlpha Institute for Biotechnology, Huntsville, AL 35806, USA
| | - Bruce R Korf
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Gregory M Cooper
- HudsonAlpha Institute for Biotechnology, Huntsville, AL 35806, USA
| | - Kyle B Brothers
- Department of Pediatrics, Norton Children's Research Institute, University of Louisville School of Medicine, Louisville, KY 40202, USA
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Crellin E, Martyn M, McClaren B, Gaff C. What matters to parents? A scoping review of parents' service experiences and needs regarding genetic testing for rare diseases. Eur J Hum Genet 2023:10.1038/s41431-023-01376-y. [PMID: 37308600 PMCID: PMC10400618 DOI: 10.1038/s41431-023-01376-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/28/2023] [Accepted: 04/25/2023] [Indexed: 06/14/2023] Open
Abstract
Patient care experiences are key to promoting better outcomes and are an essential consideration for successful implementation of genomics in paediatric care. To understand parents' service experiences and needs regarding testing of their child for rare diseases, we conducted a scoping review. Five databases were searched (2000-2022), with 29 studies meeting the inclusion criteria. Experiences of care wholly delivered by genetic services were most commonly reported (n = 11). Results were synthesised by mapping extracted data to adapted Picker principles of person-centred care. Parents especially valued and emphasised the importance of feeling 'cared for', continuous relationships with clinicians, empathic communication, being kept informed while awaiting genetic test results, linkage with informational and psychosocial resources following results disclosure, and follow-up. Strategies were often proposed by authors to address long-standing unmet needs but evidence from the literature regarding their potential effectiveness was rarely provided. We conclude that 'what matters' to parents regarding genetic testing is not dissimilar to other aspects of care. Paediatric medical specialists have existing skill sets, trusted relationships and can apply familiar principles of 'good' care to enhance experiences of genetic testing. The lack of evidence for service improvement strategies highlights the pressing need to undertake rigorous design and testing of interventions alongside mainstreaming of genomics into paediatric care.
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Affiliation(s)
- Erin Crellin
- University of Melbourne, Melbourne, VIC, Australia
- Genomics in Society, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Melissa Martyn
- University of Melbourne, Melbourne, VIC, Australia
- Genomics in Society, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Melbourne Genomics Health Alliance, Walter and Eliza Hall Institute, Melbourne, VIC, Australia
| | - Belinda McClaren
- University of Melbourne, Melbourne, VIC, Australia
- Genomics in Society, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Melbourne Genomics Health Alliance, Walter and Eliza Hall Institute, Melbourne, VIC, Australia
| | - Clara Gaff
- University of Melbourne, Melbourne, VIC, Australia.
- Genomics in Society, Murdoch Children's Research Institute, Melbourne, VIC, Australia.
- Melbourne Genomics Health Alliance, Walter and Eliza Hall Institute, Melbourne, VIC, Australia.
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Ackerman SL, Brown JEH, Zamora A, Outram S. "I Have Fought for so Many Things": Disadvantaged families' Efforts to Obtain Community-Based Services for Their Child after Genomic Sequencing. AJOB Empir Bioeth 2023; 14:208-217. [PMID: 37162201 PMCID: PMC10615790 DOI: 10.1080/23294515.2023.2209747] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
BACKGROUND Families whose child has unexplained intellectual or developmental differences often hope that a genetic diagnosis will lower barriers to community-based therapeutic and support services. However, there is little known about efforts to mobilize genetic information outside the clinic or how socioeconomic disadvantage shapes and constrains outcomes. METHODS We conducted an ethnographic study with predominantly socioeconomically disadvantaged families enrolled in a multi-year genomics research study, including clinic observations and in-depth interviews in English and Spanish at multiple time points. Coding and thematic development were used to collaboratively interpret fieldnotes and transcripts. RESULTS Thirty-two families participated. Themes included familial expectations that a genetic diagnosis could be translated into information, understanding, and assistance to improve the quality of a child's day-to-day life. After sequencing, however, genetic information was not readily converted into improved access to services beyond the clinic, with families often struggling to use a genetic diagnosis to advocate for their child. CONCLUSION Families' ability to use a genetic diagnosis as an effective advocacy tool beyond the clinic was limited by the knowledge and resources available to them, and by the eligibility criteria used by therapeutic service providers' - which focused on clinical diagnosis and functional criteria more than etiologic information. All families undertaking genomic testing, particularly those who are disadvantaged, need additional support to understand the limits and potential benefits of genetic information beyond the clinic.
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Affiliation(s)
- Sara L Ackerman
- Program in Bioethics, University of California San Francisco, San Francisco, California, USA
- Department of Social & Behavioral Sciences, University of California San Francisco, San Francisco, California, USA
- Institute for Health & Aging, University of California San Francisco, San Francisco, California, USA
| | - Julia E H Brown
- Program in Bioethics, University of California San Francisco, San Francisco, California, USA
- Institute for Health & Aging, University of California San Francisco, San Francisco, California, USA
| | - Astrid Zamora
- Program in Bioethics, University of California San Francisco, San Francisco, California, USA
- Department of Nutritional Sciences, University of Michigan, Ann Arbor, Michigan, USA
| | - Simon Outram
- Program in Bioethics, University of California San Francisco, San Francisco, California, USA
- Department of Social & Behavioral Sciences, University of California San Francisco, San Francisco, California, USA
- Institute for Health & Aging, University of California San Francisco, San Francisco, California, USA
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Miller EG, Young JL, Rao A, Ward-Lev E, Halley MC. Demographic Characteristics Associated With Perceptions of Personal Utility in Genetic and Genomic Testing: A Systematic Review. JAMA Netw Open 2023; 6:e2310367. [PMID: 37145601 PMCID: PMC10163389 DOI: 10.1001/jamanetworkopen.2023.10367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/14/2023] [Indexed: 05/06/2023] Open
Abstract
Importance The expansion of genetic and genomic testing in health care has led to recognition that these tests provide personal as well as clinical utility to patients and families. However, available systematic reviews on this topic have not reported the demographic backgrounds of participants in studies of personal utility, leaving generalizability unclear. Objective To determine the demographic characteristics of participants in studies examining the personal utility of genetic and genomic testing in health care. Evidence Review For this systematic review, we utilized and updated the results of a highly cited 2017 systematic review on the personal utility of genetics and genomics, which identified relevant articles published between January 1, 2003, and August 4, 2016. We also used the original methods to update this bibliography with literature published subsequently up to January 1, 2022. Studies were screened for eligibility by 2 independent reviewers. Eligible studies reported empirical data on the perspectives of patients, family members, and/or the general public in the US on the personal utility of any type of health-related genetic or genomic test. We utilized a standardized codebook to extract study and participant characteristics. We summarized demographic characteristics descriptively across all studies and by subgroup based on study and participant characteristics. Findings We included 52 studies with 13 251 eligible participants. Sex or gender was the most frequently reported demographic characteristic (48 studies [92.3%]), followed by race and ethnicity (40 studies [76.9%]), education (38 studies [73.1%]), and income (26 studies [50.0%]). Across studies, participants disproportionately were women or female (mean [SD], 70.8% [20.5%]), were White (mean [SD], 76.1% [22.0%]), had a college degree or higher (mean [SD], 64.5% [19.9%]), and reported income above the US median (mean [SD], 67.4% [19.2%]). Examination of subgroups of results by study and participant characteristics evidenced only small shifts in demographic characteristics. Conclusions and Relevance This systematic review examined the demographic characteristics of individual participants in studies of the personal utility of health-related genetic and genomic testing in the US. The results suggest that participants in these studies were disproportionately White, college-educated women with above-average income. Understanding the perspectives of more diverse individuals regarding the personal utility of genetic and genomic testing may inform barriers to research recruitment and uptake of clinical testing in currently underrepresented populations.
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Affiliation(s)
- Emily G. Miller
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California
| | - Jennifer L. Young
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California
- Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Anoushka Rao
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California
| | - Eliana Ward-Lev
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California
| | - Meghan C. Halley
- Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California
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Rosenfeld LE, LeBlanc K, Nagy A, Ego BK, McCray AT. Participation in a national diagnostic research study: assessing the patient experience. Orphanet J Rare Dis 2023; 18:73. [PMID: 37032333 PMCID: PMC10084693 DOI: 10.1186/s13023-023-02695-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/02/2023] [Indexed: 04/11/2023] Open
Abstract
INTRODUCTION The Undiagnosed Diseases Network (UDN), a clinical research study funded by the National Institutes of Health, aims to provide answers for patients with undiagnosed conditions and generate knowledge about underlying disease mechanisms. UDN evaluations involve collaboration between clinicians and researchers and go beyond what is possible in clinical settings. While medical and research outcomes of UDN evaluations have been explored, this is the first formal assessment of the patient and caregiver experience. METHODS We invited UDN participants and caregivers to participate in focus groups via email, newsletter, and a private participant Facebook group. We developed focus group questions based on research team expertise, literature focused on patients with rare and undiagnosed conditions, and UDN participant and family member feedback. In March 2021, we conducted, recorded, and transcribed four 60-min focus groups via Zoom. Transcripts were evaluated using a thematic analysis approach. RESULTS The adult undiagnosed focus group described the UDN evaluation as validating and an avenue for access to medical providers. They also noted that the experience impacted professional choices and helped them rely on others for support. The adult diagnosed focus group described the healthcare system as not set up for rare disease. In the pediatric undiagnosed focus group, caregivers discussed a continued desire for information and gratitude for the UDN evaluation. They also described an ability to rule out information and coming to terms with not having answers. The pediatric diagnosed focus group discussed how the experience helped them focus on management and improved communication. Across focus groups, adults (undiagnosed/diagnosed) noted the comprehensiveness of the evaluation. Undiagnosed focus groups (adult/pediatric) discussed a desire for ongoing communication and care with the UDN. Diagnosed focus groups (adult/pediatric) highlighted the importance of the diagnosis they received in the UDN. The majority of the focus groups noted a positive future orientation after participation. CONCLUSION Our findings are consistent with prior literature focused on the patient experience of rare and undiagnosed conditions and highlight benefits from comprehensive evaluations, regardless of whether a diagnosis is obtained. Focus group themes also suggest areas for improvement and future research related to the diagnostic odyssey.
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Affiliation(s)
- Lindsay E Rosenfeld
- Department of Biomedical Informatics, Harvard Medical School, 10 Shattuck Street, Boston, MA, 02115, USA
- Heller School for Social Policy and Management, Institute for Child, Youth, and Family Policy, Brandeis University, 415 South St., Waltham, MA, 02453, USA
| | - Kimberly LeBlanc
- Department of Biomedical Informatics, Harvard Medical School, 10 Shattuck Street, Boston, MA, 02115, USA
| | - Anna Nagy
- Department of Biomedical Informatics, Harvard Medical School, 10 Shattuck Street, Boston, MA, 02115, USA
| | - Braeden K Ego
- Department of Biomedical Informatics, Harvard Medical School, 10 Shattuck Street, Boston, MA, 02115, USA
- Department of Genetics, Stanford University School of Medicine, 291 Campus Drive, Stanford, CA, 94305, USA
| | - Alexa T McCray
- Department of Biomedical Informatics, Harvard Medical School, 10 Shattuck Street, Boston, MA, 02115, USA.
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA.
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Whiwon L, Salma S, Daniel A, Stephanie L, Marc C, Cherith S, Abby T, Angela S, Robin H, Yvonne B. Patient-facing digital tools for delivering genetic services: a systematic review. J Med Genet 2023; 60:1-10. [PMID: 36137613 DOI: 10.1136/jmg-2022-108653] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 07/19/2022] [Indexed: 02/04/2023]
Abstract
This study systematically reviewed the literature on the impact of digital genetics tools on patient care and system efficiencies. MEDLINE and Embase were searched for articles published between January 2010 and March 2021. Studies evaluating the use of patient-facing digital tools in the context of genetic service delivery were included. Two reviewers screened and extracted patient-reported and system-focused outcomes from each study. Data were synthesised using a descriptive approach. Of 3226 unique studies identified, 87 were included. A total of 70 unique digital tools were identified. As a result of using digital tools, 84% of studies reported a positive outcome in at least one of the following patient outcomes: knowledge, psychosocial well-being, behavioural/management changes, family communication, decision-making or level of engagement. Digital tools improved workflow and efficiency for providers and reduced the amount of time they needed to spend with patients. However, we identified a misalignment between study purpose and patient-reported outcomes measured and a lack of tools that encompass the entire genetic counselling and testing trajectory. Given increased demand for genetic services and the shift towards virtual care, this review provides evidence that digital tools can be used to efficiently deliver patient-centred care. Future research should prioritise development, evaluation and implementation of digital tools that can support the entire patient trajectory across a range of clinical settings. PROSPERO registration numberCRD42020202862.
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Affiliation(s)
- Lee Whiwon
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Shickh Salma
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Assamad Daniel
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Luca Stephanie
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Clausen Marc
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Somerville Cherith
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Tafler Abby
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Shaw Angela
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Genomics Health Services Research Program, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Hayeems Robin
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Genomics Health Services Research Program, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Bombard Yvonne
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Genomics Health Services Research Program, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
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18
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Lacey HP, Lacey SC, Forest C, Blasi D, Dayal P. The role of emotional sensitivity to probability in the decision to choose genetic testing. J Genet Couns 2022; 31:677-688. [PMID: 34873773 DOI: 10.1002/jgc4.1534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/18/2021] [Accepted: 11/08/2021] [Indexed: 11/08/2022]
Abstract
While the availability of genetic testing is rapidly increasing, many opt out of testing. The decision to test or not is emotionally charged, and both clinical research and theoretical work in psychology show that in emotional decisions, people often struggle to interpret and utilize risk information. Clinical research on genetic testing uptake also shows that feeling overwhelmed by numeric information may be a deterrent to testing. However, recent psychological research indicates that some portion of the population has greater emotional sensitivity to probability, (i.e., the extent to which emotional reactions to risk depend on probabilities) than others. We hypothesize that participants high in emotional sensitivity to probability will be more interested in genetic testing as an opportunity to seek greater precision in risk estimates and that this relationship is moderated by the testing context itself. In an online survey of a nationally representative sample (not recruited as patients), participants were presented with a hypothetical scenario describing a suspected diagnosis with an option for genetic testing. The scenario experimentally varied the pre-test probability estimate of the diagnosis (low or high) and whether the test results would result in certainty (ruling in or ruling out the diagnosis), or reduced uncertainty (providing a more precise individual risk estimate). Results indicated that emotional sensitivity to probability was a strong predictor of intention to test, particularly when the test allowed participants to rule out a diagnosis, reducing an already low probability to zero. These results highlight the way patients' individual characteristics interact with the testing context to guide decision-making and provide important insight into the way patients integrate risk probability information into intensely emotional decisions.
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Affiliation(s)
- Heather P Lacey
- Department of Psychology, Bryant University, Smithfield, Rhode Island, USA
| | - Steven C Lacey
- Carroll School of Management, Boston College, Massachusetts, USA
| | - Caroline Forest
- Department of Psychology, Bryant University, Smithfield, Rhode Island, USA
| | - Dana Blasi
- Department of Psychology, Bryant University, Smithfield, Rhode Island, USA
| | - Prerna Dayal
- Department of Psychology, Bryant University, Smithfield, Rhode Island, USA
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Assessing Value in Child Health. CHILDREN 2021; 8:children8110972. [PMID: 34828684 PMCID: PMC8625247 DOI: 10.3390/children8110972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 10/25/2021] [Indexed: 11/17/2022]
Abstract
Assessing value in child health is increasingly important as health care systems face difficult choices with regard to what services and programs for children to fund and deliver [...]
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Lee W, Luca S, Costain G, Snell M, Marano M, Curtis M, Dunsmore K, Veenma D, Walker S, Cohn RD, Marshall CR, Cohen E, Meyn MS, Orkin J, Hayeems RZ. Genome sequencing among children with medical complexity: What constitutes value from parents' perspective? J Genet Couns 2021; 31:523-533. [PMID: 34674352 DOI: 10.1002/jgc4.1522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 10/02/2021] [Accepted: 10/08/2021] [Indexed: 11/06/2022]
Abstract
Genome sequencing (GS) has demonstrated high diagnostic yield in pediatric patients with complex, clinically heterogeneous presentations. Emerging evidence shows generally favorable experiences for patients and families receiving GS. As a result, implementation of GS in pediatrics is gaining momentum. To inform implementation, we conducted a qualitative study to explore the personal utility of GS for parents of children with medical complexity (CMC). GS was performed at an academic tertiary-care center for CMC for whom a genetic etiology was suspected. Following the return of GS results, semi-structured interviews were conducted with 14 parents about their child's diagnostic journey. Of the children whose parents were interviewed, six children received a diagnosis, two received a possible diagnosis, and six did not receive a diagnosis. A predominantly deductive thematic analysis approach to the interview data was used by applying Kohler's personal utility framework to understand affective, cognitive, behavioral and social impacts of GS. Both the diagnosed and undiagnosed groups experienced enhanced emotion-focused coping (affective). The diagnosed group experienced favorable utility related to knowledge of condition (cognitive) and communication with relatives (behavioral). A domain beyond Kohler's framework related to the presence or absence of GS impact on medical management was also described by parents. The deployment of GS late in the diagnostic odyssey and the limited knowledge available for the rare genetic disorders diagnosed in this cohort appeared to diminish the perceived utility of GS. As GS capabilities continue to evolve at a rapid pace and become available earlier in the diagnostic journey, it is important to consider the impact and timing of testing on parents of CMC.
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Affiliation(s)
- Whiwon Lee
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Stephanie Luca
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gregory Costain
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada.,The Centre for Applied Genomics and Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Genetics & Genome Biology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Meaghan Snell
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Maria Marano
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada.,Service de pédiatrie générale, CHU Sainte-Justine, Montreal, Québec, Canada
| | - Meredith Curtis
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kourtney Dunsmore
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Danielle Veenma
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics: Developmental and Genetics, Erasmus MC Sophia, Rotterdam, Netherlands
| | - Susan Walker
- The Centre for Applied Genomics and Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Genomics England, Queen Mary University of London, London, UK
| | - Ronald D Cohn
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Christian R Marshall
- The Centre for Applied Genomics and Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Eyal Cohen
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - M Stephen Meyn
- Center for Human Genomics and Precision Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA.,Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Julia Orkin
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Robin Z Hayeems
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, Ontario, Canada
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