1
|
Raper AC, Weathers BL, Drivas TG, Ellis CA, Kripke CM, Oyer RA, Owens AT, Verma A, Wileyto PE, Wollack CC, Zhou W, Ritchie MD, Schnoll RA, Nathanson KL. Protocol for a type 3 hybrid implementation cluster randomized clinical trial to evaluate the effect of patient and clinician nudges to advance the use of genomic medicine across a diverse health system. Implement Sci 2024; 19:61. [PMID: 39160614 PMCID: PMC11331805 DOI: 10.1186/s13012-024-01385-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 07/14/2024] [Indexed: 08/21/2024] Open
Abstract
BACKGROUND Germline genetic testing is recommended for an increasing number of conditions with underlying genetic etiologies, the results of which impact medical management. However, genetic testing is underutilized in clinics due to system, clinician, and patient level barriers. Behavioral economics provides a framework to create implementation strategies, such as nudges, to address these multi-level barriers and increase the uptake of genetic testing for conditions where the results impact medical management. METHODS Patients meeting eligibility for germline genetic testing for a group of conditions will be identified using electronic phenotyping algorithms. A pragmatic, type 3 hybrid cluster randomization study will test nudges to patients and/or clinicians, or neither. Clinicians who receive nudges will be prompted to either refer their patient to genetics or order genetic testing themselves. We will use rapid cycle approaches informed by clinician and patient experiences, health equity, and behavioral economics to optimize these nudges before trial initiation. The primary implementation outcome is uptake of germline genetic testing for the pre-selected health conditions. Patient data collected through the electronic health record (e.g. demographics, geocoded address) will be examined as moderators of the effect of nudges. DISCUSSION This study will be one of the first randomized trials to examine the effects of patient- and clinician-directed nudges informed by behavioral economics on uptake of genetic testing. The pragmatic design will facilitate a large and diverse patient sample, allow for the assessment of genetic testing uptake, and provide comparison of the effect of different nudge combinations. This trial also involves optimization of patient identification, test selection, ordering, and result reporting in an electronic health record-based infrastructure to further address clinician-level barriers to utilizing genomic medicine. The findings may help determine the impact of low-cost, sustainable implementation strategies that can be integrated into health care systems to improve the use of genomic medicine. TRIAL REGISTRATION ClinicalTrials.gov. NCT06377033. Registered on March 31, 2024. https://clinicaltrials.gov/study/NCT06377033?term=NCT06377033&rank=1.
Collapse
Affiliation(s)
- Anna C Raper
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Benita L Weathers
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Theodore G Drivas
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Colin A Ellis
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Colleen Morse Kripke
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Randall A Oyer
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anjali T Owens
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anurag Verma
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Paul E Wileyto
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Colin C Wollack
- Information Services Applications, Penn Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Wenting Zhou
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Marylyn D Ritchie
- Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert A Schnoll
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Interdisciplinary Research on Nicotine Addiction, University of Pennsylvania, Philadelphia, PA, USA
| | - Katherine L Nathanson
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| |
Collapse
|
2
|
Lempel N, Shelly S, Chorin O, Rock R, Eliyahu A, Finezilber Y, Poran H, Feinstein-Goren N, Segev M, Reznik-Wolf H, Barel O, Orion D, Anis S, Regev M, Yonath H, Dominissini D, Blatt I, Hassin-Baer S, Dori A, Pras E, Greenbaum L. The yield of genetic workup for middle-aged and elderly patients with neurological disorders in a real-world setting. J Neurol Sci 2024; 463:123074. [PMID: 38968664 DOI: 10.1016/j.jns.2024.123074] [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: 11/07/2023] [Revised: 04/25/2024] [Accepted: 05/29/2024] [Indexed: 07/07/2024]
Abstract
Genetic workup is becoming increasingly common in the clinical assessment of neurological disorders. We evaluated its yield among middle-aged and elderly neurological patients, in a real-world context. This retrospective study included 368 consecutive Israeli patients aged 50 years and older (202 [54.9%] males), who were referred to a single neurogenetics clinic between 2017 and mid-2023. All had neurological disorders, without a previous molecular diagnosis. Demographic, clinical and genetic data were collected from medical records. The mean age at first genetic counseling at the clinic was 62.3 ± 7.8 years (range 50-85 years), and the main indications for referral were neuromuscular, movement and cerebrovascular disorders, as well as cognitive impairment and dementia. Out of the 368 patients, 245 (66.6%) underwent genetic testing that included exome sequencing (ES), analysis of nucleotide repeat expansions, detection of specific mutations, targeted gene panel sequencing or chromosomal microarray analysis. Overall, 80 patients (21.7%) received a molecular diagnosis due to 36 conditions, accounting for 32.7% of the patients who performed genetic testing. The diagnostic rates were highest for neuromuscular (58/186 patients [31.2%] in this group, 39.2% of 148 tested individuals) and movement disorders (14/79 [17.7%] patients, 29.2% of 48 tested), but lower for other disorders. Testing of nucleotide repeat expansions and ES provided a diagnosis to 28/73 (38.4%) and 19/132 (14.4%) individuals, respectively. Based on our findings, genetic workup and testing are useful in the diagnostic process of neurological patients aged ≥50 years, in particular for those with neuromuscular and movement disorders.
Collapse
Affiliation(s)
- Noga Lempel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shahar Shelly
- Department of Neurology, Rambam Medical Center, Haifa, Israel; Rappaport Faculty of Medicine, Technion, Haifa, Israel; Department of Neurology, Mayo Clinic, Rochester, MN, United States of America
| | - Odelia Chorin
- The Danek Gertner Institute of Human Genetics, Sheba Medical Center, Tel Hashomer, Israel
| | - Rachel Rock
- The Danek Gertner Institute of Human Genetics, Sheba Medical Center, Tel Hashomer, Israel
| | - Aviva Eliyahu
- The Danek Gertner Institute of Human Genetics, Sheba Medical Center, Tel Hashomer, Israel
| | - Yael Finezilber
- The Danek Gertner Institute of Human Genetics, Sheba Medical Center, Tel Hashomer, Israel
| | - Hana Poran
- The Danek Gertner Institute of Human Genetics, Sheba Medical Center, Tel Hashomer, Israel
| | - Neta Feinstein-Goren
- The Danek Gertner Institute of Human Genetics, Sheba Medical Center, Tel Hashomer, Israel
| | - Meirav Segev
- The Danek Gertner Institute of Human Genetics, Sheba Medical Center, Tel Hashomer, Israel
| | - Haike Reznik-Wolf
- The Danek Gertner Institute of Human Genetics, Sheba Medical Center, Tel Hashomer, Israel
| | - Ortal Barel
- The Genomics Unit, Sheba Cancer Research Center, Sheba Medical Center, Tel Hashomer, Israel
| | - David Orion
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Neurology, Sheba Medical Center, Tel Hashomer, Israel
| | - Saar Anis
- Department of Neurology, Sheba Medical Center, Tel Hashomer, Israel; Movement Disorders Institute, Sheba Medical Center, Tel Hashomer, Israel
| | - Miriam Regev
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; The Danek Gertner Institute of Human Genetics, Sheba Medical Center, Tel Hashomer, Israel
| | - Hagith Yonath
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; The Danek Gertner Institute of Human Genetics, Sheba Medical Center, Tel Hashomer, Israel; Department of Internal Medicine A, Sheba Medical Center, Tel Hashomer, Israel
| | - Dan Dominissini
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; The Genomics Unit, Sheba Cancer Research Center, Sheba Medical Center, Tel Hashomer, Israel; The Wohl Institute for Translational Medicine, Sheba Cancer Research Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Ilan Blatt
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sharon Hassin-Baer
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Neurology, Sheba Medical Center, Tel Hashomer, Israel; Movement Disorders Institute, Sheba Medical Center, Tel Hashomer, Israel
| | - Amir Dori
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Neurology, Sheba Medical Center, Tel Hashomer, Israel
| | - Elon Pras
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; The Danek Gertner Institute of Human Genetics, Sheba Medical Center, Tel Hashomer, Israel
| | - Lior Greenbaum
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; The Danek Gertner Institute of Human Genetics, Sheba Medical Center, Tel Hashomer, Israel; The Joseph Sagol Neuroscience Center, Sheba Medical Center, Tel Hashomer, Israel.
| |
Collapse
|
3
|
Watson S, Ngo KJ, Stevens HA, Wong DY, Kim J, Song Y, Han B, Hyun SI, Khang R, Ryu SW, Lee E, Seo G, Lee H, Lajonchere C, Fogel BL. Cross-Sectional Analysis of Exome Sequencing Diagnosis in Patients With Neurologic Phenotypes Facing Barriers to Clinical Testing. Neurol Genet 2024; 10:e200133. [PMID: 38617022 PMCID: PMC11010248 DOI: 10.1212/nxg.0000000000200133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/19/2024] [Indexed: 04/16/2024]
Abstract
Background and Objectives Exome sequencing (ES) demonstrates a 20-50 percent diagnostic yield for patients with a suspected monogenic neurologic disease. Despite the proven efficacy in achieving a diagnosis for such patients, multiple barriers for obtaining exome sequencing remain. This study set out to assess the efficacy of ES in patients with primary neurologic phenotypes who were appropriate candidates for testing but had been unable to pursue clinical testing. Methods A total of 297 patients were identified from the UCLA Clinical Neurogenomics Research Center Biobank, and ES was performed, including bioinformatic assessment of copy number variation and repeat expansions. Information regarding demographics, clinical indication for ES, and reason for not pursuing ES clinically were recorded. To assess diagnostic efficacy, variants were interpreted by a multidisciplinary team of clinicians, bioinformaticians, and genetic counselors in accordance with the American College of Medical Genetics and Genomics variant classification guidelines. We next examined the specific barriers to testing for these patients, including how frequently insurance-related barriers such as coverage denials and inadequate coverage of cost were obstacles to pursuing exome sequencing. Results The cohort primarily consisted of patients with sporadic conditions (n = 126, 42.4%) of adult-onset (n = 239, 80.5%). Cerebellar ataxia (n = 225, 75.8%) was the most common presenting neurologic phenotype. Our study found that in this population of mostly adult patients with primary neurologic phenotypes that were unable to pursue exome sequencing clinically, 47 (15.8%) had diagnostic results while an additional 24 patients (8.1%) had uncertain results. Of the 297 patients, 206 were initially recommended for clinical exome but 88 (42.7%) could not pursue ES because of insurance barriers, of whom 14 (15.9%) had diagnostic findings, representing 29.8% of all patients with diagnostic findings. In addition, the incorporation of bioinformatic repeat expansion testing was valuable, identifying a total of 8 pathogenic repeat expansions (17.0% of all diagnostic findings) including 3 of the common spinocerebellar ataxias and 2 patients with Huntington disease. Discussion These findings underscore the importance and value of clinical ES as a diagnostic tool for neurogenetic disease and highlight key barriers that prevent patients from receiving important clinical information with potential treatment and psychosocial implications for patients and family members.
Collapse
Affiliation(s)
- Sonya Watson
- From the Department of Neurology (S.W., K.J.N., H.A.S., D.Y.W., C.L., B.L.F.), the Clinical Neurogenomics Research Center (S.W., H.A.S., D.Y.W., C.L., B.L.F.), the Institute for Precision Health (S.W., C.L., B.L.F.), and the Department of Human Genetics (S.W., B.L.F.), David Geffen School of Medicine, University of California at Los Angeles (UCLA); 3billion, Inc. (J.K., Y.S., B.H., S.-I.H., R.K., S.W.R., E.L., G.S., H.L.)
| | - Kathie J Ngo
- From the Department of Neurology (S.W., K.J.N., H.A.S., D.Y.W., C.L., B.L.F.), the Clinical Neurogenomics Research Center (S.W., H.A.S., D.Y.W., C.L., B.L.F.), the Institute for Precision Health (S.W., C.L., B.L.F.), and the Department of Human Genetics (S.W., B.L.F.), David Geffen School of Medicine, University of California at Los Angeles (UCLA); 3billion, Inc. (J.K., Y.S., B.H., S.-I.H., R.K., S.W.R., E.L., G.S., H.L.)
| | - Hannah A Stevens
- From the Department of Neurology (S.W., K.J.N., H.A.S., D.Y.W., C.L., B.L.F.), the Clinical Neurogenomics Research Center (S.W., H.A.S., D.Y.W., C.L., B.L.F.), the Institute for Precision Health (S.W., C.L., B.L.F.), and the Department of Human Genetics (S.W., B.L.F.), David Geffen School of Medicine, University of California at Los Angeles (UCLA); 3billion, Inc. (J.K., Y.S., B.H., S.-I.H., R.K., S.W.R., E.L., G.S., H.L.)
| | - Darice Y Wong
- From the Department of Neurology (S.W., K.J.N., H.A.S., D.Y.W., C.L., B.L.F.), the Clinical Neurogenomics Research Center (S.W., H.A.S., D.Y.W., C.L., B.L.F.), the Institute for Precision Health (S.W., C.L., B.L.F.), and the Department of Human Genetics (S.W., B.L.F.), David Geffen School of Medicine, University of California at Los Angeles (UCLA); 3billion, Inc. (J.K., Y.S., B.H., S.-I.H., R.K., S.W.R., E.L., G.S., H.L.)
| | - Jihye Kim
- From the Department of Neurology (S.W., K.J.N., H.A.S., D.Y.W., C.L., B.L.F.), the Clinical Neurogenomics Research Center (S.W., H.A.S., D.Y.W., C.L., B.L.F.), the Institute for Precision Health (S.W., C.L., B.L.F.), and the Department of Human Genetics (S.W., B.L.F.), David Geffen School of Medicine, University of California at Los Angeles (UCLA); 3billion, Inc. (J.K., Y.S., B.H., S.-I.H., R.K., S.W.R., E.L., G.S., H.L.)
| | - Yongjun Song
- From the Department of Neurology (S.W., K.J.N., H.A.S., D.Y.W., C.L., B.L.F.), the Clinical Neurogenomics Research Center (S.W., H.A.S., D.Y.W., C.L., B.L.F.), the Institute for Precision Health (S.W., C.L., B.L.F.), and the Department of Human Genetics (S.W., B.L.F.), David Geffen School of Medicine, University of California at Los Angeles (UCLA); 3billion, Inc. (J.K., Y.S., B.H., S.-I.H., R.K., S.W.R., E.L., G.S., H.L.)
| | - Beomman Han
- From the Department of Neurology (S.W., K.J.N., H.A.S., D.Y.W., C.L., B.L.F.), the Clinical Neurogenomics Research Center (S.W., H.A.S., D.Y.W., C.L., B.L.F.), the Institute for Precision Health (S.W., C.L., B.L.F.), and the Department of Human Genetics (S.W., B.L.F.), David Geffen School of Medicine, University of California at Los Angeles (UCLA); 3billion, Inc. (J.K., Y.S., B.H., S.-I.H., R.K., S.W.R., E.L., G.S., H.L.)
| | - Seong-In Hyun
- From the Department of Neurology (S.W., K.J.N., H.A.S., D.Y.W., C.L., B.L.F.), the Clinical Neurogenomics Research Center (S.W., H.A.S., D.Y.W., C.L., B.L.F.), the Institute for Precision Health (S.W., C.L., B.L.F.), and the Department of Human Genetics (S.W., B.L.F.), David Geffen School of Medicine, University of California at Los Angeles (UCLA); 3billion, Inc. (J.K., Y.S., B.H., S.-I.H., R.K., S.W.R., E.L., G.S., H.L.)
| | - Rin Khang
- From the Department of Neurology (S.W., K.J.N., H.A.S., D.Y.W., C.L., B.L.F.), the Clinical Neurogenomics Research Center (S.W., H.A.S., D.Y.W., C.L., B.L.F.), the Institute for Precision Health (S.W., C.L., B.L.F.), and the Department of Human Genetics (S.W., B.L.F.), David Geffen School of Medicine, University of California at Los Angeles (UCLA); 3billion, Inc. (J.K., Y.S., B.H., S.-I.H., R.K., S.W.R., E.L., G.S., H.L.)
| | - Seung Woo Ryu
- From the Department of Neurology (S.W., K.J.N., H.A.S., D.Y.W., C.L., B.L.F.), the Clinical Neurogenomics Research Center (S.W., H.A.S., D.Y.W., C.L., B.L.F.), the Institute for Precision Health (S.W., C.L., B.L.F.), and the Department of Human Genetics (S.W., B.L.F.), David Geffen School of Medicine, University of California at Los Angeles (UCLA); 3billion, Inc. (J.K., Y.S., B.H., S.-I.H., R.K., S.W.R., E.L., G.S., H.L.)
| | - Eugene Lee
- From the Department of Neurology (S.W., K.J.N., H.A.S., D.Y.W., C.L., B.L.F.), the Clinical Neurogenomics Research Center (S.W., H.A.S., D.Y.W., C.L., B.L.F.), the Institute for Precision Health (S.W., C.L., B.L.F.), and the Department of Human Genetics (S.W., B.L.F.), David Geffen School of Medicine, University of California at Los Angeles (UCLA); 3billion, Inc. (J.K., Y.S., B.H., S.-I.H., R.K., S.W.R., E.L., G.S., H.L.)
| | - Gohun Seo
- From the Department of Neurology (S.W., K.J.N., H.A.S., D.Y.W., C.L., B.L.F.), the Clinical Neurogenomics Research Center (S.W., H.A.S., D.Y.W., C.L., B.L.F.), the Institute for Precision Health (S.W., C.L., B.L.F.), and the Department of Human Genetics (S.W., B.L.F.), David Geffen School of Medicine, University of California at Los Angeles (UCLA); 3billion, Inc. (J.K., Y.S., B.H., S.-I.H., R.K., S.W.R., E.L., G.S., H.L.)
| | - Hane Lee
- From the Department of Neurology (S.W., K.J.N., H.A.S., D.Y.W., C.L., B.L.F.), the Clinical Neurogenomics Research Center (S.W., H.A.S., D.Y.W., C.L., B.L.F.), the Institute for Precision Health (S.W., C.L., B.L.F.), and the Department of Human Genetics (S.W., B.L.F.), David Geffen School of Medicine, University of California at Los Angeles (UCLA); 3billion, Inc. (J.K., Y.S., B.H., S.-I.H., R.K., S.W.R., E.L., G.S., H.L.)
| | - Clara Lajonchere
- From the Department of Neurology (S.W., K.J.N., H.A.S., D.Y.W., C.L., B.L.F.), the Clinical Neurogenomics Research Center (S.W., H.A.S., D.Y.W., C.L., B.L.F.), the Institute for Precision Health (S.W., C.L., B.L.F.), and the Department of Human Genetics (S.W., B.L.F.), David Geffen School of Medicine, University of California at Los Angeles (UCLA); 3billion, Inc. (J.K., Y.S., B.H., S.-I.H., R.K., S.W.R., E.L., G.S., H.L.)
| | - Brent L Fogel
- From the Department of Neurology (S.W., K.J.N., H.A.S., D.Y.W., C.L., B.L.F.), the Clinical Neurogenomics Research Center (S.W., H.A.S., D.Y.W., C.L., B.L.F.), the Institute for Precision Health (S.W., C.L., B.L.F.), and the Department of Human Genetics (S.W., B.L.F.), David Geffen School of Medicine, University of California at Los Angeles (UCLA); 3billion, Inc. (J.K., Y.S., B.H., S.-I.H., R.K., S.W.R., E.L., G.S., H.L.)
| |
Collapse
|
4
|
Baldwin A, Copeland J, Azage M, Dratch L, Johnson K, Paul RA, Amado DA, Baer M, Deik A, Elman LB, Guo M, Hamedani AG, Irwin DJ, Lasker A, Orthmann-Murphy J, Quinn CC, Tropea TF, Scherer SS, Shinohara RT, Hamilton RH, Ellis CA. Disparities in Genetic Testing for Neurologic Disorders. Neurology 2024; 102:e209161. [PMID: 38447117 PMCID: PMC11383874 DOI: 10.1212/wnl.0000000000209161] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 12/01/2023] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Genetic testing is now the standard of care for many neurologic conditions. Health care disparities are unfortunately widespread in the US health care system, but disparities in the utilization of genetic testing for neurologic conditions have not been studied. We tested the hypothesis that access to and results of genetic testing vary according to race, ethnicity, sex, socioeconomic status, and insurance status for adults with neurologic conditions. METHODS We analyzed retrospective data from patients who underwent genetic evaluation and testing through our institution's neurogenetics program. We tested for differences between demographic groups in 3 steps of a genetic evaluation pathway: (1) attending a neurogenetic evaluation, (2) completing genetic testing, and (3) receiving a diagnostic result. We compared patients on this genetic evaluation pathway with the population of all neurology outpatients at our institution, using univariate and multivariable logistic regression analyses. RESULTS Between 2015 and 2022, a total of 128,440 patients were seen in our outpatient neurology clinics and 2,540 patients underwent genetic evaluation. Black patients were less than half as likely as White patients to be evaluated (odds ratio [OR] 0.49, p < 0.001), and this disparity was similar after controlling for other demographic factors in multivariable analysis. Patients from the least wealthy quartile of zip codes were also less likely to be evaluated (OR 0.67, p < 0.001). Among patients who underwent evaluation, there were no disparities in the likelihood of completing genetic testing, nor in the likelihood of a diagnostic result after adjusting for age. Analyses restricted to specific indications for genetic testing supported these findings. DISCUSSION We observed unequal utilization of our clinical neurogenetics program for patients from marginalized and minoritized demographic groups, especially Black patients. Among patients who do undergo evaluation, all groups benefit similarly from genetic testing when it is indicated. Understanding and removing barriers to accessing genetic testing will be essential to health care equity and optimal care for all patients with neurologic disorders.
Collapse
Affiliation(s)
- Aaron Baldwin
- From the Department of Neurology (A.B., J.C., M.A., L.D., K.J., R.A.P., D.A.A., M.B., A.D., L.B.E., M.G., A.G.H., D.J.I., A.L., J.O.-M., C.C.Q., T.F.T., S.S.S., R.H.H., C.A.E.), Penn Statistics in Imaging and Visualization Center (PennSIVE) (R.T.S.), Department of Biostatistics, Epidemiology, and Informatics, and Center for Biomedical Image Computing and Analytics (R.T.S.), Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Juliette Copeland
- From the Department of Neurology (A.B., J.C., M.A., L.D., K.J., R.A.P., D.A.A., M.B., A.D., L.B.E., M.G., A.G.H., D.J.I., A.L., J.O.-M., C.C.Q., T.F.T., S.S.S., R.H.H., C.A.E.), Penn Statistics in Imaging and Visualization Center (PennSIVE) (R.T.S.), Department of Biostatistics, Epidemiology, and Informatics, and Center for Biomedical Image Computing and Analytics (R.T.S.), Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Meron Azage
- From the Department of Neurology (A.B., J.C., M.A., L.D., K.J., R.A.P., D.A.A., M.B., A.D., L.B.E., M.G., A.G.H., D.J.I., A.L., J.O.-M., C.C.Q., T.F.T., S.S.S., R.H.H., C.A.E.), Penn Statistics in Imaging and Visualization Center (PennSIVE) (R.T.S.), Department of Biostatistics, Epidemiology, and Informatics, and Center for Biomedical Image Computing and Analytics (R.T.S.), Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Laynie Dratch
- From the Department of Neurology (A.B., J.C., M.A., L.D., K.J., R.A.P., D.A.A., M.B., A.D., L.B.E., M.G., A.G.H., D.J.I., A.L., J.O.-M., C.C.Q., T.F.T., S.S.S., R.H.H., C.A.E.), Penn Statistics in Imaging and Visualization Center (PennSIVE) (R.T.S.), Department of Biostatistics, Epidemiology, and Informatics, and Center for Biomedical Image Computing and Analytics (R.T.S.), Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Kelsey Johnson
- From the Department of Neurology (A.B., J.C., M.A., L.D., K.J., R.A.P., D.A.A., M.B., A.D., L.B.E., M.G., A.G.H., D.J.I., A.L., J.O.-M., C.C.Q., T.F.T., S.S.S., R.H.H., C.A.E.), Penn Statistics in Imaging and Visualization Center (PennSIVE) (R.T.S.), Department of Biostatistics, Epidemiology, and Informatics, and Center for Biomedical Image Computing and Analytics (R.T.S.), Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Rachel A Paul
- From the Department of Neurology (A.B., J.C., M.A., L.D., K.J., R.A.P., D.A.A., M.B., A.D., L.B.E., M.G., A.G.H., D.J.I., A.L., J.O.-M., C.C.Q., T.F.T., S.S.S., R.H.H., C.A.E.), Penn Statistics in Imaging and Visualization Center (PennSIVE) (R.T.S.), Department of Biostatistics, Epidemiology, and Informatics, and Center for Biomedical Image Computing and Analytics (R.T.S.), Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Defne A Amado
- From the Department of Neurology (A.B., J.C., M.A., L.D., K.J., R.A.P., D.A.A., M.B., A.D., L.B.E., M.G., A.G.H., D.J.I., A.L., J.O.-M., C.C.Q., T.F.T., S.S.S., R.H.H., C.A.E.), Penn Statistics in Imaging and Visualization Center (PennSIVE) (R.T.S.), Department of Biostatistics, Epidemiology, and Informatics, and Center for Biomedical Image Computing and Analytics (R.T.S.), Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Michael Baer
- From the Department of Neurology (A.B., J.C., M.A., L.D., K.J., R.A.P., D.A.A., M.B., A.D., L.B.E., M.G., A.G.H., D.J.I., A.L., J.O.-M., C.C.Q., T.F.T., S.S.S., R.H.H., C.A.E.), Penn Statistics in Imaging and Visualization Center (PennSIVE) (R.T.S.), Department of Biostatistics, Epidemiology, and Informatics, and Center for Biomedical Image Computing and Analytics (R.T.S.), Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Andres Deik
- From the Department of Neurology (A.B., J.C., M.A., L.D., K.J., R.A.P., D.A.A., M.B., A.D., L.B.E., M.G., A.G.H., D.J.I., A.L., J.O.-M., C.C.Q., T.F.T., S.S.S., R.H.H., C.A.E.), Penn Statistics in Imaging and Visualization Center (PennSIVE) (R.T.S.), Department of Biostatistics, Epidemiology, and Informatics, and Center for Biomedical Image Computing and Analytics (R.T.S.), Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Lauren B Elman
- From the Department of Neurology (A.B., J.C., M.A., L.D., K.J., R.A.P., D.A.A., M.B., A.D., L.B.E., M.G., A.G.H., D.J.I., A.L., J.O.-M., C.C.Q., T.F.T., S.S.S., R.H.H., C.A.E.), Penn Statistics in Imaging and Visualization Center (PennSIVE) (R.T.S.), Department of Biostatistics, Epidemiology, and Informatics, and Center for Biomedical Image Computing and Analytics (R.T.S.), Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Michael Guo
- From the Department of Neurology (A.B., J.C., M.A., L.D., K.J., R.A.P., D.A.A., M.B., A.D., L.B.E., M.G., A.G.H., D.J.I., A.L., J.O.-M., C.C.Q., T.F.T., S.S.S., R.H.H., C.A.E.), Penn Statistics in Imaging and Visualization Center (PennSIVE) (R.T.S.), Department of Biostatistics, Epidemiology, and Informatics, and Center for Biomedical Image Computing and Analytics (R.T.S.), Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Ali G Hamedani
- From the Department of Neurology (A.B., J.C., M.A., L.D., K.J., R.A.P., D.A.A., M.B., A.D., L.B.E., M.G., A.G.H., D.J.I., A.L., J.O.-M., C.C.Q., T.F.T., S.S.S., R.H.H., C.A.E.), Penn Statistics in Imaging and Visualization Center (PennSIVE) (R.T.S.), Department of Biostatistics, Epidemiology, and Informatics, and Center for Biomedical Image Computing and Analytics (R.T.S.), Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - David J Irwin
- From the Department of Neurology (A.B., J.C., M.A., L.D., K.J., R.A.P., D.A.A., M.B., A.D., L.B.E., M.G., A.G.H., D.J.I., A.L., J.O.-M., C.C.Q., T.F.T., S.S.S., R.H.H., C.A.E.), Penn Statistics in Imaging and Visualization Center (PennSIVE) (R.T.S.), Department of Biostatistics, Epidemiology, and Informatics, and Center for Biomedical Image Computing and Analytics (R.T.S.), Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Aaron Lasker
- From the Department of Neurology (A.B., J.C., M.A., L.D., K.J., R.A.P., D.A.A., M.B., A.D., L.B.E., M.G., A.G.H., D.J.I., A.L., J.O.-M., C.C.Q., T.F.T., S.S.S., R.H.H., C.A.E.), Penn Statistics in Imaging and Visualization Center (PennSIVE) (R.T.S.), Department of Biostatistics, Epidemiology, and Informatics, and Center for Biomedical Image Computing and Analytics (R.T.S.), Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jennifer Orthmann-Murphy
- From the Department of Neurology (A.B., J.C., M.A., L.D., K.J., R.A.P., D.A.A., M.B., A.D., L.B.E., M.G., A.G.H., D.J.I., A.L., J.O.-M., C.C.Q., T.F.T., S.S.S., R.H.H., C.A.E.), Penn Statistics in Imaging and Visualization Center (PennSIVE) (R.T.S.), Department of Biostatistics, Epidemiology, and Informatics, and Center for Biomedical Image Computing and Analytics (R.T.S.), Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Colin C Quinn
- From the Department of Neurology (A.B., J.C., M.A., L.D., K.J., R.A.P., D.A.A., M.B., A.D., L.B.E., M.G., A.G.H., D.J.I., A.L., J.O.-M., C.C.Q., T.F.T., S.S.S., R.H.H., C.A.E.), Penn Statistics in Imaging and Visualization Center (PennSIVE) (R.T.S.), Department of Biostatistics, Epidemiology, and Informatics, and Center for Biomedical Image Computing and Analytics (R.T.S.), Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Thomas F Tropea
- From the Department of Neurology (A.B., J.C., M.A., L.D., K.J., R.A.P., D.A.A., M.B., A.D., L.B.E., M.G., A.G.H., D.J.I., A.L., J.O.-M., C.C.Q., T.F.T., S.S.S., R.H.H., C.A.E.), Penn Statistics in Imaging and Visualization Center (PennSIVE) (R.T.S.), Department of Biostatistics, Epidemiology, and Informatics, and Center for Biomedical Image Computing and Analytics (R.T.S.), Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Steven S Scherer
- From the Department of Neurology (A.B., J.C., M.A., L.D., K.J., R.A.P., D.A.A., M.B., A.D., L.B.E., M.G., A.G.H., D.J.I., A.L., J.O.-M., C.C.Q., T.F.T., S.S.S., R.H.H., C.A.E.), Penn Statistics in Imaging and Visualization Center (PennSIVE) (R.T.S.), Department of Biostatistics, Epidemiology, and Informatics, and Center for Biomedical Image Computing and Analytics (R.T.S.), Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Russell T Shinohara
- From the Department of Neurology (A.B., J.C., M.A., L.D., K.J., R.A.P., D.A.A., M.B., A.D., L.B.E., M.G., A.G.H., D.J.I., A.L., J.O.-M., C.C.Q., T.F.T., S.S.S., R.H.H., C.A.E.), Penn Statistics in Imaging and Visualization Center (PennSIVE) (R.T.S.), Department of Biostatistics, Epidemiology, and Informatics, and Center for Biomedical Image Computing and Analytics (R.T.S.), Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Roy H Hamilton
- From the Department of Neurology (A.B., J.C., M.A., L.D., K.J., R.A.P., D.A.A., M.B., A.D., L.B.E., M.G., A.G.H., D.J.I., A.L., J.O.-M., C.C.Q., T.F.T., S.S.S., R.H.H., C.A.E.), Penn Statistics in Imaging and Visualization Center (PennSIVE) (R.T.S.), Department of Biostatistics, Epidemiology, and Informatics, and Center for Biomedical Image Computing and Analytics (R.T.S.), Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Colin A Ellis
- From the Department of Neurology (A.B., J.C., M.A., L.D., K.J., R.A.P., D.A.A., M.B., A.D., L.B.E., M.G., A.G.H., D.J.I., A.L., J.O.-M., C.C.Q., T.F.T., S.S.S., R.H.H., C.A.E.), Penn Statistics in Imaging and Visualization Center (PennSIVE) (R.T.S.), Department of Biostatistics, Epidemiology, and Informatics, and Center for Biomedical Image Computing and Analytics (R.T.S.), Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| |
Collapse
|
5
|
Stavros K. Genetic Myelopathies. Continuum (Minneap Minn) 2024; 30:119-132. [PMID: 38330475 DOI: 10.1212/con.0000000000001377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
OBJECTIVE This article provides an overview of genetic myelopathies, a diverse group of inherited, degenerative conditions that may be broadly categorized as motor neuron disorders, disorders of spinocerebellar degeneration, leukodystrophies, and hereditary spastic paraplegia. Clinical examples from each category are provided to illustrate the spectrum of genetic myelopathies and their distinguishing features that aid in differentiating genetic myelopathies from potentially treatable acquired causes of myelopathy. LATEST DEVELOPMENTS Advances in genetic testing have vastly enhanced current knowledge of genetic myelopathies and the ability to diagnose and provide appropriate counseling to patients and their families. However, potential health care disparities in access to genetic testing is a topic that must be further explored. Although treatment for most of these conditions is typically supportive, there have been recent therapeutic breakthroughs in treatments for amyotrophic lateral sclerosis, spinal muscular atrophy, and Friedreich ataxia. ESSENTIAL POINTS Genetic myelopathies may present with chronic and progressive symptoms, a family history of similar symptoms, and involvement of other structures outside of the spinal cord. Imaging often shows spinal cord atrophy, but cord signal change is rare. Exclusion of reversible causes of myelopathy is a key step in the diagnosis. There are many different causes of genetic myelopathies, and in some cases, symptoms may overlap, which underscores the utility of genetic testing in confirming the precise underlying neurologic condition.
Collapse
|
6
|
Beuschel JJ, Ng GI, Abaraoha JC, Fortuna RJ. Traumatic Self-Inflicted Ventricular Laceration: A Case of Smith-Lemli-Opitz Syndrome in an Adult. Cureus 2024; 16:e53613. [PMID: 38449995 PMCID: PMC10916526 DOI: 10.7759/cureus.53613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 01/21/2024] [Indexed: 03/08/2024] Open
Abstract
Adults with intellectual and developmental disabilities (IDD) are increasingly living into adulthood, highlighting the need for adult clinicians to expand their familiarity with congenital conditions. Smith-Lemli-Opitz syndrome (SLOS) is a rare autosomal recessive inborn error of cholesterol synthesis. SLOS is commonly diagnosed in childhood, but a number of adults with IDD progress into adulthood without a formal diagnosis. We present an 18-year-old male with a history of IDD and altered pain sensation who was hospitalized following a self-inflicted knife injury resulting in a traumatic ventricular septal defect. Over the following 15 years, the patient continued to exhibit self-injurious behaviors. At the age of 33, caregivers consented to further work-up of his intellectual disability, and whole-exome genetic sequencing revealed a diagnosis of SLOS. The clinical course of this patient represents a unique presentation of altered pain sensation, a delayed diagnosis of SLOS into adulthood, and the challenges of providing care to an adult with IDD. The case further highlights the importance of understanding the typical workup and management of genetic and congenital conditions arising in childhood.
Collapse
Affiliation(s)
- Jennifer J Beuschel
- Internal Medicine and Pediatrics, University of Rochester Medical Center, Rochester, USA
| | - Grace I Ng
- Internal Medicine and Pediatrics, University of Rochester Medical Center, Rochester, USA
| | - Joanna C Abaraoha
- Internal Medicine and Pediatrics, University of Rochester Medical Center, Rochester, USA
| | - Robert J Fortuna
- Internal Medicine and Pediatrics, University of Rochester Medical Center, Rochester, USA
| |
Collapse
|
7
|
Paul RA, Baldwin A, Johnson K, Manning Peskin S, Tropea TF, Azage M, Bardakjian T, Dratch L. Preimplantation Genetic Testing for Adult-Onset Neurodegenerative Disease: Considerations for Access, Utilization, and Counseling. Neurology 2023; 101:836-841. [PMID: 37596038 PMCID: PMC10663009 DOI: 10.1212/wnl.0000000000207736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 06/20/2023] [Indexed: 08/20/2023] Open
Abstract
Preimplantation genetic testing for monogenic conditions (PGT-M), formerly called preimplantation genetic diagnosis, is a specialized assisted reproduction technique that aims to reduce the risk of a pregnancy inheriting a monogenic condition. Despite calls to increase awareness and prepare neurologists for discussing PGT-M with patients and their families, no guidelines currently exist. When introducing PGT-M to those who may be interested in using it, there are major factors for discussion, including (1) genetic considerations (e.g., requirement for a confirmed genetic diagnosis; timing of genetic test results); (2) practical considerations (e.g., access to PGT-M and genetic services); (3) technical considerations (e.g., factors that can affect the success rate of PGT-M); and (4) psychosocial and ethical considerations (e.g., predictive testing for asymptomatic family members; family dynamics and values). Here, our team of neurologists and specialized genetic counselors discusses the current state of genetic characterization in adult-onset neurodegenerative conditions and highlights the major factors that should be considered when discussing PGT-M with families.
Collapse
Affiliation(s)
- Rachel A Paul
- From the Department of Neurology (R.A.P., A.B., K.J., S.M.P., T.F.T., M.A., L.D.), University of Pennsylvania, Philadelphia; and Sarepta Therapeutics (T.B.), Cambridge, MA.
| | - Aaron Baldwin
- From the Department of Neurology (R.A.P., A.B., K.J., S.M.P., T.F.T., M.A., L.D.), University of Pennsylvania, Philadelphia; and Sarepta Therapeutics (T.B.), Cambridge, MA
| | - Kelsey Johnson
- From the Department of Neurology (R.A.P., A.B., K.J., S.M.P., T.F.T., M.A., L.D.), University of Pennsylvania, Philadelphia; and Sarepta Therapeutics (T.B.), Cambridge, MA
| | - Sara Manning Peskin
- From the Department of Neurology (R.A.P., A.B., K.J., S.M.P., T.F.T., M.A., L.D.), University of Pennsylvania, Philadelphia; and Sarepta Therapeutics (T.B.), Cambridge, MA
| | - Thomas F Tropea
- From the Department of Neurology (R.A.P., A.B., K.J., S.M.P., T.F.T., M.A., L.D.), University of Pennsylvania, Philadelphia; and Sarepta Therapeutics (T.B.), Cambridge, MA
| | - Meron Azage
- From the Department of Neurology (R.A.P., A.B., K.J., S.M.P., T.F.T., M.A., L.D.), University of Pennsylvania, Philadelphia; and Sarepta Therapeutics (T.B.), Cambridge, MA
| | - Tanya Bardakjian
- From the Department of Neurology (R.A.P., A.B., K.J., S.M.P., T.F.T., M.A., L.D.), University of Pennsylvania, Philadelphia; and Sarepta Therapeutics (T.B.), Cambridge, MA
| | - Laynie Dratch
- From the Department of Neurology (R.A.P., A.B., K.J., S.M.P., T.F.T., M.A., L.D.), University of Pennsylvania, Philadelphia; and Sarepta Therapeutics (T.B.), Cambridge, MA
| |
Collapse
|
8
|
Jain V, Irving R, Williams A. Genomic testing in neurology. Pract Neurol 2023; 23:420-429. [PMID: 37468300 DOI: 10.1136/pn-2023-003735] [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] [Accepted: 06/11/2023] [Indexed: 07/21/2023]
Abstract
Genomic testing has been available for neurological conditions for decades. However, in recent years, there has been a significant change in its availability, range and cost, as well as improvements in the technology and knowledge that underpin how the genome is interrogated. Neurologists can encounter a wide range of genetic conditions, and so their understanding of genomic testing is fundamental to modern clinical practice.
Collapse
Affiliation(s)
- Vani Jain
- All Wales Medical Genomics Service, University Hospital of Wales Healthcare NHS Trust, Cardiff, UK
| | - Rachel Irving
- All Wales Medical Genomics Service, University Hospital of Wales Healthcare NHS Trust, Cardiff, UK
| | - Angharad Williams
- All Wales Medical Genomics Service, University Hospital of Wales Healthcare NHS Trust, Cardiff, UK
| |
Collapse
|
9
|
Chung CCY, Hue SPY, Ng NYT, Doong PHL, Chu ATW, Chung BHY. Meta-analysis of the diagnostic and clinical utility of exome and genome sequencing in pediatric and adult patients with rare diseases across diverse populations. Genet Med 2023; 25:100896. [PMID: 37191093 DOI: 10.1016/j.gim.2023.100896] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 05/07/2023] [Accepted: 05/10/2023] [Indexed: 05/17/2023] Open
Abstract
PURPOSE This meta-analysis aims to compare the diagnostic and clinical utility of exome sequencing (ES) vs genome sequencing (GS) in pediatric and adult patients with rare diseases across diverse populations. METHODS A meta-analysis was conducted to identify studies from 2011 to 2021. RESULTS One hundred sixty-one studies across 31 countries/regions were eligible, featuring 50,417 probands of diverse populations. Diagnostic rates of ES (0.38, 95% CI 0.36-0.40) and GS (0.34, 95% CI 0.30-0.38) were similar (P = .1). Within-cohort comparison illustrated 1.2-times odds of diagnosis by GS over ES (95% CI 0.79-1.83, P = .38). GS studies discovered a higher range of novel genes than ES studies; yet, the rate of variant of unknown significance did not differ (P = .78). Among high-quality studies, clinical utility of GS (0.77, 95% CI 0.64-0.90) was higher than that of ES (0.44, 95% CI 0.30-0.58) (P < .01). CONCLUSION This meta-analysis provides an important update to demonstrate the similar diagnostic rates between ES and GS and the higher clinical utility of GS over ES. With the newly published recommendations for clinical interpretation of variants found in noncoding regions of the genome and the trend of decreasing variant of unknown significance and GS cost, it is expected that GS will be more widely used in clinical settings.
Collapse
Affiliation(s)
| | - Shirley P Y Hue
- Hong Kong Genome Institute, Hong Kong Special Administrative Region
| | - Nicole Y T Ng
- Department of Paediatrics and Adolescent Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region
| | - Phoenix H L Doong
- Department of Paediatrics and Adolescent Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region
| | - Annie T W Chu
- Hong Kong Genome Institute, Hong Kong Special Administrative Region.
| | - Brian H Y Chung
- Hong Kong Genome Institute, Hong Kong Special Administrative Region; Department of Paediatrics and Adolescent Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region.
| |
Collapse
|
10
|
Fellner A, Goldberg Y, Basel-Salmon L. Ordering genetic testing by neurologists: points to consider. J Neurol 2023:10.1007/s00415-023-11758-3. [PMID: 37154893 DOI: 10.1007/s00415-023-11758-3] [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: 04/11/2023] [Revised: 04/28/2023] [Accepted: 04/29/2023] [Indexed: 05/10/2023]
Abstract
A significant challenge limiting the comprehensive utilization of genomic medicine is the lack of timely access to genetics specialists. Although neurologists see patients for whom genetic testing should be considered, the knowledge regarding the choice of the optimal genetic test for each case and the management of the test results are out of the scope of their everyday practice. In this review, we provide a step-by-step guide for non-geneticist physicians through the decision-making process when ordering diagnostic genetic testing for monogenic neurological diseases and when dealing with their results.
Collapse
Affiliation(s)
- Avi Fellner
- The Neurogenetics Clinic, Raphael Recanati Genetics Institute, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel.
| | - Yael Goldberg
- Raphael Recanati Genetics Institute, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Lina Basel-Salmon
- Raphael Recanati Genetics Institute, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Felsenstein Medical Research Center, Tel-Aviv University, Tel-Aviv, Israel
| |
Collapse
|
11
|
Mainali A, Athey T, Bahl S, Hung C, Caluseriu O, Chan A, Eaton A, Ghai SJ, Kannu P, MacPherson M, Niederhoffer KY, Siriwardena K, Mercimek-Andrews S. Diagnostic yield of clinical exome sequencing in adulthood in medical genetics clinics. Am J Med Genet A 2023; 191:510-517. [PMID: 36401557 DOI: 10.1002/ajmg.a.63053] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/11/2022] [Accepted: 11/08/2022] [Indexed: 11/21/2022]
Abstract
Clinical exome sequencing (ES) is the most comprehensive genomic test to identify underlying genetic diseases in Canada. We performed this retrospective cohort study to investigate the diagnostic yield of clinical ES in adulthood. Inclusion criteria were: (1) Adult patients ≥18 years old; (2) Patients underwent clinical ES between January 1 and December 31, 2021; (3) Patients were seen in the Department of Medical Genetics. We reviewed patient charts. We applied American College of Medical Genetics and Genomics and the Association for Molecular Pathology variant classification guidelines for interpretation of variants. Non-parametric Fisher's exact statistical test was used. Seventy-seven patients underwent clinical ES. Fourteen different genetic diseases were confirmed in 15 patients: FBXO11, MYH7, MED13L, NSD2, ANKRD11 (n = 2), SHANK3, RHOBTB2, CDKL5, TRIO, TCF4, SCN1, SMAD3, POGZ, and EIF2B3 diseases. The diagnostic yield of clinical ES was 19.5%. Patients with a genetic diagnosis had a significantly higher frequency of neurodevelopmental disorders than those with no genetic diagnosis (p = 0.00339). The diagnostic yield of clinical ES was the highest in patients with seizures (35.7%), and with progressive neurodegenerative diseases (33.3%). Clinical ES is a helpful genomic test to provide genetic diagnoses to the patients who are referred to medical genetic clinics due to suspected genetic diseases in adulthood to end their diagnostic odyssey. Targeted next generation sequencing panels for specific phenotypes may decrease the cost of genomic test in adulthood.
Collapse
Affiliation(s)
- Apurba Mainali
- Department of Medical Genetics, Faculty of Medicine and Dentistry, University of Alberta, Alberta Health Services, Edmonton Zone, Edmonton, Alberta, Canada
| | - Taryn Athey
- Department of Medical Genetics, Faculty of Medicine and Dentistry, University of Alberta, Alberta Health Services, Edmonton Zone, Edmonton, Alberta, Canada
| | - Shalini Bahl
- Department of Medical Genetics, Faculty of Medicine and Dentistry, University of Alberta, Alberta Health Services, Edmonton Zone, Edmonton, Alberta, Canada.,Princess Margaret Cancer Centre, Toronto, Ontario, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Clara Hung
- Department of Medical Genetics, Faculty of Medicine and Dentistry, University of Alberta, Alberta Health Services, Edmonton Zone, Edmonton, Alberta, Canada
| | - Oana Caluseriu
- Department of Medical Genetics, Faculty of Medicine and Dentistry, University of Alberta, Alberta Health Services, Edmonton Zone, Edmonton, Alberta, Canada
| | - Alicia Chan
- Department of Medical Genetics, Faculty of Medicine and Dentistry, University of Alberta, Alberta Health Services, Edmonton Zone, Edmonton, Alberta, Canada
| | - Alison Eaton
- Department of Medical Genetics, Faculty of Medicine and Dentistry, University of Alberta, Alberta Health Services, Edmonton Zone, Edmonton, Alberta, Canada
| | - Shailly Jain Ghai
- Department of Medical Genetics, Faculty of Medicine and Dentistry, University of Alberta, Alberta Health Services, Edmonton Zone, Edmonton, Alberta, Canada
| | - Peter Kannu
- Department of Medical Genetics, Faculty of Medicine and Dentistry, University of Alberta, Alberta Health Services, Edmonton Zone, Edmonton, Alberta, Canada
| | - Melissa MacPherson
- Department of Medical Genetics, Faculty of Medicine and Dentistry, University of Alberta, Alberta Health Services, Edmonton Zone, Edmonton, Alberta, Canada
| | - Karen Y Niederhoffer
- Department of Medical Genetics, Faculty of Medicine and Dentistry, University of Alberta, Alberta Health Services, Edmonton Zone, Edmonton, Alberta, Canada
| | - Komudi Siriwardena
- Department of Medical Genetics, Faculty of Medicine and Dentistry, University of Alberta, Alberta Health Services, Edmonton Zone, Edmonton, Alberta, Canada
| | - Saadet Mercimek-Andrews
- Department of Medical Genetics, Faculty of Medicine and Dentistry, University of Alberta, Alberta Health Services, Edmonton Zone, Edmonton, Alberta, Canada.,Women and Children's Health Research Institute, University of Alberta, Edmonton, Alberta, Canada.,Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
12
|
Félix TM, Fischinger Moura de Souza C, Oliveira JB, Rico-Restrepo M, Zanoteli E, Zatz M, Giugliani R. Challenges and recommendations to increasing the use of exome sequencing and whole genome sequencing for diagnosing rare diseases in Brazil: an expert perspective. Int J Equity Health 2023; 22:11. [PMID: 36639662 PMCID: PMC9837951 DOI: 10.1186/s12939-022-01809-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 12/14/2022] [Indexed: 01/15/2023] Open
Abstract
Early diagnosis of genetic rare diseases is an unmet need in Brazil, where an estimated 10-13 million people live with these conditions. Increased use of chromosome microarray assays, exome sequencing, and whole genome sequencing as first-tier testing techniques in suitable indications can shorten the diagnostic odyssey, eliminate unnecessary tests, procedures, and treatments, and lower healthcare expenditures. A selected panel of Brazilian experts in fields related to rare diseases was provided with a series of relevant questions to address before a multi-day conference. Within this conference, each narrative was discussed and edited through numerous rounds of discussion until agreement was achieved. The widespread adoption of exome sequencing and whole genome sequencing in Brazil is limited by various factors: cost and lack of funding, reimbursement, awareness and education, specialist shortages, and policy issues. To reduce the burden of rare diseases and increase early diagnosis, the Brazilian healthcare authorities/government must address the barriers to equitable access to early diagnostic methods for these conditions. Recommendations are provided, including broadening approved testing indications, increasing awareness and education efforts, increasing specialist training opportunities, and ensuring sufficient funding for genetic testing.
Collapse
Affiliation(s)
- Têmis Maria Félix
- grid.414449.80000 0001 0125 3761Medical Genetics Service, Hospital de Clinicas de Porto Alegre, Rua Ramiro Barcelos, 2350, Porto Alegre, 90,035–903 Brazil
| | - Carolina Fischinger Moura de Souza
- grid.414449.80000 0001 0125 3761Medical Genetics Service, Hospital de Clinicas de Porto Alegre, Rua Ramiro Barcelos, 2350, Porto Alegre, 90,035–903 Brazil
| | - João Bosco Oliveira
- grid.413562.70000 0001 0385 1941Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Edmar Zanoteli
- grid.11899.380000 0004 1937 0722Faculdade de Medicina, Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Mayana Zatz
- grid.11899.380000 0004 1937 0722Human Genome and Stem-cell Research Center, Institute of Biosciences, University of São Paulo, São Paulo, Brazil
| | - Roberto Giugliani
- grid.414449.80000 0001 0125 3761Medical Genetics Service, Hospital de Clinicas de Porto Alegre, Rua Ramiro Barcelos, 2350, Porto Alegre, 90,035–903 Brazil ,House of Rares, Porto Alegre, Rio Grande do Sul Brazil
| |
Collapse
|
13
|
Rojnueangnit K, Anthanont P, Khetkham T, Puttamanee S, Ittiwut C. Genetic diagnosis for adult patients at a genetic clinic. Cold Spring Harb Mol Case Stud 2022; 8:a006235. [PMID: 36265913 PMCID: PMC9808555 DOI: 10.1101/mcs.a006235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 10/04/2022] [Indexed: 01/31/2023] Open
Abstract
Clinical utility of genetic testing has rapidly increased in the past decade to identify the definitive diagnosis, etiology, and specific management. The majority of patients receiving testing are children. There are several barriers for genetic tests in adult patients; barriers may arise from either patients or clinicians. Our study aims to realize the detection rate and the benefits of genetic tests in adults. We conducted a prospective study of 10 adult patients who were referred to a genetic clinic. Exome sequencing (ES) was pursued in all cases, and chromosomal microarray (CMA) was performed for six cases. Our result is impressive; six cases (60%) received likely pathogenic and pathogenic variants. Four definitive diagnosis cases had known pathogenic variants in KCNJ2, TGFBR1, SCN1A, and FBN1, whereas another two cases revealed novel likely pathogenic and pathogenic variants in GNB1 and DNAH9. Our study demonstrates the success in genetic diagnosis in adult patients: four cases with definitive, two cases with possible, and one case with partial diagnosis. The advantage of diagnosis is beyond obtaining the diagnosis itself, but also relieving any doubt for the patient regarding any previous questionable diagnosis, guide for management, and recurrence risk in their children or family members. Therefore, this supports the value of genetic testing in adult patients.
Collapse
Affiliation(s)
- Kitiwan Rojnueangnit
- Department of Pediatrics, Faculty of Medicine, Thammasat University, Pathumthani, 12120 Thailand
| | - Pimjai Anthanont
- Department of Medicine, Faculty of Medicine, Thammasat University, Pathumthani, 12120 Thailand
| | - Thanitchet Khetkham
- Division of Forensic Medicine, Thammasat University Hospital, 12120 Thailand
| | - Sukita Puttamanee
- Faculty of Medicine, Thammasat University, Pathumthani, 12120 Thailand
| | - Chupong Ittiwut
- Center of Excellence for Medical Genomics, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330 Thailand
- Excellence Center for Genomics and Precision Medicine, King Chulalongkorn Memorial Hospital, the Thai Red Cross Society, Bangkok, 10330 Thailand
| |
Collapse
|
14
|
Guerrini R, Balestrini S, Wirrell EC, Walker MC. Monogenic Epilepsies: Disease Mechanisms, Clinical Phenotypes, and Targeted Therapies. Neurology 2021; 97:817-831. [PMID: 34493617 PMCID: PMC10336826 DOI: 10.1212/wnl.0000000000012744] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 08/18/2021] [Indexed: 02/05/2023] Open
Abstract
A monogenic etiology can be identified in up to 40% of people with severe epilepsy. To address earlier and more appropriate treatment strategies, clinicians are required to know the implications that specific genetic causes might have on pathophysiology, natural history, comorbidities, and treatment choices. In this narrative review, we summarize concepts on the genetic epilepsies based on the underlying pathophysiologic mechanisms and present the current knowledge on treatment options based on evidence provided by controlled trials or studies with lower classification of evidence. Overall, evidence robust enough to guide antiseizure medication (ASM) choices in genetic epilepsies remains limited to the more frequent conditions for which controlled trials and observational studies have been possible. Most monogenic disorders are very rare and ASM choices for them are still based on inferences drawn from observational studies and early, often anecdotal, experiences with precision therapies. Precision medicine remains applicable to only a narrow number of patients with monogenic epilepsies and may target only part of the actual functional defects. Phenotypic heterogeneity is remarkable, and some genetic mutations activate epileptogenesis through their developmental effects, which may not be reversed postnatally. Other genes seem to have pure functional consequences on excitability, acting through either loss- or gain-of-function effects, and these may have opposite treatment implications. In addition, the functional consequences of missense mutations may be difficult to predict, making precision treatment approaches considerably more complex than estimated by deterministic interpretations. Knowledge of genetic etiologies can influence the approach to surgical treatment of focal epilepsies. Identification of germline mutations in specific genes contraindicates surgery while mutations in other genes do not. Identification, quantification, and functional characterization of specific somatic mutations before surgery using CSF liquid biopsy or after surgery in brain specimens will likely be integrated in planning surgical strategies and reintervention after a first unsuccessful surgery as initial evidence suggests that mutational load may correlate with the epileptogenic zone. Promising future directions include gene manipulation by DNA or mRNA targeting; although most are still far from clinical use, some are in early phase clinical development.
Collapse
Affiliation(s)
- Renzo Guerrini
- From the Neuroscience Department (R.G., S.B.), Meyer Children's Hospital-University of Florence, Italy; Department of Clinical and Experimental Epilepsy (S.B., M.C.W.), UCL Queen Square Institute of Neurology, London; Chalfont Centre for Epilepsy (S.B.), Buckinghamshire, UK; and Divisions of Child and Adolescent Neurology and Epilepsy (E.C.W.), Department of Neurology, Mayo Clinic, Rochester, MN.
| | - Simona Balestrini
- From the Neuroscience Department (R.G., S.B.), Meyer Children's Hospital-University of Florence, Italy; Department of Clinical and Experimental Epilepsy (S.B., M.C.W.), UCL Queen Square Institute of Neurology, London; Chalfont Centre for Epilepsy (S.B.), Buckinghamshire, UK; and Divisions of Child and Adolescent Neurology and Epilepsy (E.C.W.), Department of Neurology, Mayo Clinic, Rochester, MN
| | - Elaine C Wirrell
- From the Neuroscience Department (R.G., S.B.), Meyer Children's Hospital-University of Florence, Italy; Department of Clinical and Experimental Epilepsy (S.B., M.C.W.), UCL Queen Square Institute of Neurology, London; Chalfont Centre for Epilepsy (S.B.), Buckinghamshire, UK; and Divisions of Child and Adolescent Neurology and Epilepsy (E.C.W.), Department of Neurology, Mayo Clinic, Rochester, MN
| | - Matthew C Walker
- From the Neuroscience Department (R.G., S.B.), Meyer Children's Hospital-University of Florence, Italy; Department of Clinical and Experimental Epilepsy (S.B., M.C.W.), UCL Queen Square Institute of Neurology, London; Chalfont Centre for Epilepsy (S.B.), Buckinghamshire, UK; and Divisions of Child and Adolescent Neurology and Epilepsy (E.C.W.), Department of Neurology, Mayo Clinic, Rochester, MN
| |
Collapse
|