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Ochoa-Morales A, Dávila-Ortiz de Montellano DJ, Chávez-Oliveros M, Rodríguez-Agudelo Y, Longoria-Ibarrola M, Sosa-Ortiz AL, Boll MC, Jara-Prado A, Yescas-Gómez P, Guerrero-Camacho J, Ramírez-García MÁ. Presymptomatic Testing for Huntington's Disease in Mexico: 28 Years of Experience. Arch Med Res 2024; 55:103004. [PMID: 38714041 DOI: 10.1016/j.arcmed.2024.103004] [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: 01/15/2024] [Revised: 04/09/2024] [Accepted: 04/23/2024] [Indexed: 05/09/2024]
Abstract
INTRODUCTION Huntington's disease (HD) is a genetic neurodegenerative disorder with dominant inheritance. Our center in Mexico City has offered presymptomatic testing (PT) since 1995. OBJECTIVE To describe the main clinical and demographic characteristics of at-risk HD individuals who applied to the PT program, the reasons for seeking it, and the molecular results. METHODS A cross-sectional study was conducted with sociodemographic and clinical data of all PT applicants from 1995-2023. Reasons for seeking PT were assessed using a modified questionnaire. In addition, anxiety, and depressive symptoms before and after PT were evaluated with Beck's instruments; cognitive impairment (CI) was assessed with the Mini-Mental State Examination (MMSE) and molecular results. RESULTS 214 people applied for PT (2.1% of the at-risk population identified in our center); 63% were women (mean age of 37.11 years). 204 (95.3%) were accepted and 190 received results. 70% indicated that the main reason for applying for PT was to inform their offspring about the risk of inheriting HD. Significant differences were observed in the reasons for seeking PT by age group. Although some subjects received treatment, Beck's instrument scores did not indicate special attention or pharmacological treatment. The MMSE showed probable CI in 20 subjects. Of those who received results, 37% were carriers of a full penetrance allele. CONCLUSION Our center has the only formal PT program for HD in Mexico. The reasons for seeking PT are varied and age-related. Although PT is offered to all subjects at risk for HD, uptake remains low.
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Affiliation(s)
- Adriana Ochoa-Morales
- Genetics Department, National Institute of Neurology and Neurosurgery, Manuel Velasco Suárez, Mexico City, Mexico
| | | | - Mireya Chávez-Oliveros
- Clinical Neuropsychology Laboratory, National Institute of Neurology and Neurosurgery, Manuel Velasco Suárez. Mexico City, Mexico
| | - Yaneth Rodríguez-Agudelo
- Clinical Neuropsychology Laboratory, National Institute of Neurology and Neurosurgery, Manuel Velasco Suárez. Mexico City, Mexico
| | - Mariana Longoria-Ibarrola
- Dementia Laboratory, National Institute of Neurology and Neurosurgery, Manuel Velasco Suárez, Mexico City, Mexico
| | - Ana Luisa Sosa-Ortiz
- Dementia Laboratory, National Institute of Neurology and Neurosurgery, Manuel Velasco Suárez, Mexico City, Mexico
| | - Marie-Catherine Boll
- Clinical Research Laboratory, National Institute of Neurology and Neurosurgery, Manuel Velasco Suárez, Mexico City, Mexico
| | - Aurelio Jara-Prado
- Genetics Department, National Institute of Neurology and Neurosurgery, Manuel Velasco Suárez, Mexico City, Mexico
| | - Petra Yescas-Gómez
- Genetics Department, National Institute of Neurology and Neurosurgery, Manuel Velasco Suárez, Mexico City, Mexico
| | - Jorge Guerrero-Camacho
- Genetics Department, National Institute of Neurology and Neurosurgery, Manuel Velasco Suárez, Mexico City, Mexico
| | - Miguel Ángel Ramírez-García
- Genetics Department, National Institute of Neurology and Neurosurgery, Manuel Velasco Suárez, Mexico City, Mexico.
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Van de Roovaart HJ, Nguyen N, Veenstra TD. Huntington's Disease Drug Development: A Phase 3 Pipeline Analysis. Pharmaceuticals (Basel) 2023; 16:1513. [PMID: 38004378 PMCID: PMC10674993 DOI: 10.3390/ph16111513] [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: 09/27/2023] [Revised: 10/12/2023] [Accepted: 10/20/2023] [Indexed: 11/26/2023] Open
Abstract
Huntington's Disease (HD) is a severely debilitating neurodegenerative disorder in which sufferers exhibit different combinations of movement disorders, dementia, and behavioral or psychiatric abnormalities. The disorder is a result of a trinucleotide repeat expansion mutation that is inherited in an autosomal dominant manner. While there is currently no treatment to alter the course of HD, there are medications that lessen abnormal movement and psychiatric symptoms. ClinicalTrials.gov was searched to identify drugs that are currently in or have completed phase III drug trials for the treatment of HD. The described phase III trials were further limited to interventional studies that were recruiting, active not recruiting, or completed. In addition, all studies must have posted an update within the past year. PubMed was used to gather further information on these interventional studies. Of the nine clinical trials that met these criteria, eight involved the following drugs: metformin, dextromethorphan/quinidine, deutetrabenazine, valbenazine, Cellavita HD, pridopidine, SAGE-718, and RO7234292 (RG6042). Of these drug treatments, four are already FDA approved. This systematic review provides a resource that summarizes the present therapies for treating this devastating condition that are currently in phase III clinical trials in the United States.
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Affiliation(s)
| | | | - Timothy D. Veenstra
- School of Pharmacy, Cedarville University, Cedarville, OH 45314, USA; (H.J.V.d.R.); (N.N.)
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3
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Nakamura K, Mukai S, Takezawa Y, Natori Y, Miyazaki A, Ide Y, Takebuchi M, Nanato K, Katoh M, Suzuki H, Sakyu A, Kojima T, Kise E, Hanafusa H, Kosho T, Kuwahara K, Sekijima Y. Clinical utility of urinary mulberry bodies/cells testing in the diagnosis of Fabry disease. Mol Genet Metab Rep 2023; 36:100983. [PMID: 37323223 PMCID: PMC10267638 DOI: 10.1016/j.ymgmr.2023.100983] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 05/30/2023] [Indexed: 06/17/2023] Open
Abstract
Introduction Variants in the galactosidase alpha (GLA) gene cause Fabry disease (FD), an X-linked lysosomal storage disorder caused by α-galactosidase A (α-GAL) deficiency. Recently, disease-modifying therapies have been developed, and simple diagnostic biomarkers for FD are required to initiate these therapies in the early stages of the disease. Detection of urinary mulberry bodies and cells (MBs/MCs) is beneficial for diagnosing FD. However, few studies have evaluated the diagnostic accuracy of urinary MBs/MCs in FD. Herein, we retrospectively evaluated the diagnostic ability of urinary MBs/MCs for FD. Methods We analyzed the medical records of 189 consecutive patients (125 males and 64 females) who underwent MBs/MCs testing. Out of these, two female patients had already been diagnosed with FD at the time of testing, and the remaining 187 patients were suspected of having FD and underwent both GLA gene sequencing and/or α-GalA enzymatic testing. Results Genetic testing did not confirm the diagnosis in 50 females (26.5%); hence, they were excluded from the evaluation. Two patients were previously diagnosed with FD, and sixteen were newly diagnosed. Among these 18 patients, 15, including two who had already developed HCM at diagnosis, remained undiagnosed until targeted genetic screening of at-risk family members of patients with FD was performed. The accuracy of urinary MBs/MCs testing exhibited a sensitivity of 0.944, specificity of 1, positive predictive value of 1, and negative predictive value of 0.992. Conclusions MBs/MCs testing is highly accurate in diagnosing FD and should be considered during the initial evaluation prior to genetic testing, particularly in female patients.
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Affiliation(s)
- Katsuya Nakamura
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
- Center for Medical Genetics, Shinshu University Hospital, Matsumoto, Japan
| | - Saki Mukai
- Department of Laboratory Medicine, Shinshu University Hospital, Matsumoto, Japan
| | - Yuka Takezawa
- Department of Laboratory Medicine, Shinshu University Hospital, Matsumoto, Japan
| | - Yuika Natori
- Department of Laboratory Medicine, Shinshu University Hospital, Matsumoto, Japan
| | - Akari Miyazaki
- Department of Laboratory Medicine, Shinshu University Hospital, Matsumoto, Japan
| | - Yuichiro Ide
- Department of Laboratory Medicine, Shinshu University Hospital, Matsumoto, Japan
| | - Mayu Takebuchi
- Department of Laboratory Medicine, Shinshu University Hospital, Matsumoto, Japan
| | - Kana Nanato
- Department of Laboratory Medicine, Shinshu University Hospital, Matsumoto, Japan
| | - Mizuki Katoh
- Department of Laboratory Medicine, Shinshu University Hospital, Matsumoto, Japan
| | - Harue Suzuki
- Department of Laboratory Medicine, Shinshu University Hospital, Matsumoto, Japan
| | - Akiko Sakyu
- Center for Medical Genetics, Shinshu University Hospital, Matsumoto, Japan
| | - Tomomi Kojima
- Center for Medical Genetics, Shinshu University Hospital, Matsumoto, Japan
| | - Emiko Kise
- Center for Medical Genetics, Shinshu University Hospital, Matsumoto, Japan
| | - Hiroaki Hanafusa
- Center for Medical Genetics, Shinshu University Hospital, Matsumoto, Japan
| | - Tomoki Kosho
- Center for Medical Genetics, Shinshu University Hospital, Matsumoto, Japan
- Department of Medical Genetics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Koichiro Kuwahara
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
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4
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Hubčíková K, Rakús T, Mühlbäck A, Benetin J, Bruncvik L, Petrášová Z, Bušková J, Brunovský M. Psychosocial Impact of Huntington's Disease and Incentives to Improve Care for Affected Families in the Underserved Region of the Slovak Republic. J Pers Med 2022; 12:jpm12121941. [PMID: 36556162 PMCID: PMC9783383 DOI: 10.3390/jpm12121941] [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: 08/17/2022] [Revised: 11/14/2022] [Accepted: 11/14/2022] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Huntington's disease (HD) is often on the margin of standard medical practice due to its low prevalence, the lack of causal treatment, and the typically long premanifest window prior to the onset of the symptoms, which contrasts with the long-lasting burden that the disease causes in affected families. METHODS To capture these socio-psychological aspects of HD and map the experiences of affected individuals, persons at risk of HD, and caregivers, we created a questionnaire using a qualitative research approach. The questionnaire containing 16 questions was conducted online for a period of three months through patient associations in Slovakia and their infrastructures. RESULTS In total, we received 30 responses. The survey results, in particular, indicate insufficient counselling by physicians with explicitly missing information about the possibility of preimplantation genetic diagnostic. There was also a necessity to improve comprehensive social and health care in the later stages of the disease, raise awareness of the disease in the general health community, and provide more information on ongoing clinical trials. CONCLUSION The psychosocial effects, as well as the burden, can be mitigated by comprehensive genetic counselling as well as reproductive and financial guidelines and subsequent therapeutic programs to actively support patients, caregivers, children, and adolescents growing up in affected families, preferably with the help of local HD community association. LIMITATIONS We have used online data collection to reach a wider HD community, but at the same time, we are aware that the quality of the data we would obtain through face-to-face interviews would be considerably better. Therefore, future studies need to be conducted to obtain more detailed information.
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Affiliation(s)
- Katarína Hubčíková
- Neuropsychiatric Department, Psychiatric Hospital of Philipp Pinel in Pezinok, 90201 Pezinok, Slovakia
- Third Faculty of Medicine, Charles University in Prague, 10000 Prague, Czech Republic
- Correspondence: ; Tel.: +421917111575; Fax: +421336482121
| | - Tomáš Rakús
- Neuropsychiatric Department, Psychiatric Hospital of Philipp Pinel in Pezinok, 90201 Pezinok, Slovakia
- Third Faculty of Medicine, Charles University in Prague, 10000 Prague, Czech Republic
- Department of Psychiatry, Slovac Medical University, 83303 Bratislava, Slovakia
| | - Alžbeta Mühlbäck
- Department of Neuropsychiatry, kbo-Isar-Amper-Klinikum, 84416 Taufkirchen (Vils), Germany
- Department of Neurology and Center of Clinical Neuroscience, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, 12821 Prague, Czech Republic
- Department of Neurology, University Hospital of Ulm, 89081 Ulm, Germany
| | - Ján Benetin
- Neuropsychiatric Department, Psychiatric Hospital of Philipp Pinel in Pezinok, 90201 Pezinok, Slovakia
| | - Lucia Bruncvik
- Third Faculty of Medicine, Charles University in Prague, 10000 Prague, Czech Republic
- Landesklinikum Hainburg, 2410 Hainburg an der Donau, Austria
| | - Zuzana Petrášová
- Neuropsychiatric Department, Psychiatric Hospital of Philipp Pinel in Pezinok, 90201 Pezinok, Slovakia
- Third Faculty of Medicine, Charles University in Prague, 10000 Prague, Czech Republic
| | - Jitka Bušková
- Third Faculty of Medicine, Charles University in Prague, 10000 Prague, Czech Republic
- National Institute of Mental Health, 25067 Klecany, Czech Republic
| | - Martin Brunovský
- Third Faculty of Medicine, Charles University in Prague, 10000 Prague, Czech Republic
- National Institute of Mental Health, 25067 Klecany, Czech Republic
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Goldman JS, Vallabh SM. Genetic counseling for prion disease: Updates and best practices. Genet Med 2022; 24:1993-2003. [PMID: 35819418 DOI: 10.1016/j.gim.2022.06.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/13/2022] [Accepted: 06/15/2022] [Indexed: 10/17/2022] Open
Abstract
Prion disease is a rare, fatal, and often rapidly progressive neurodegenerative disease. Ten to fifteen percent of cases are caused by autosomal dominant gain-of-function variants in the prion protein gene, PRNP. Rarity and phenotypic variability complicate diagnosis, often obscuring family history and leaving families unprepared for the genetic implications of an index case. Several recent developments inspire this update in best practices for prion disease genetic counseling. A new prion-detection assay has transformed symptomatic diagnosis. Meanwhile, penetrance, age of onset, and duration of illness have been systematically characterized across PRNP variants in a global cohort. Clinically, the traditional genotype-phenotype correlation has weakened over time, and the term genetic prion disease may now better serve providers than the historical subtypes Creutzfeldt-Jakob disease, fatal familial insomnia, and Gerstmann-Sträussler-Scheinker disease. Finally, in the age of genetically targeted therapies, clinical trials for prion disease are being envisaged, and healthy at-risk individuals may be best positioned to benefit. Such individuals need to be able to access clinical services for genetic counseling and testing. Thus, this update on the genetics of prion disease and best practices for genetic counseling for this disease aims to provide the information needed to expand genetic counseling services.
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Affiliation(s)
| | - Sonia M Vallabh
- Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA; Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA; Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Prion Alliance, Cambridge, MA.
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6
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Crook A, Jacobs C, Newton-John T, Richardson E, McEwen A. Patient and Relative Experiences and Decision-making About Genetic Testing and Counseling for Familial ALS and FTD: A Systematic Scoping Review. Alzheimer Dis Assoc Disord 2021; 35:374-385. [PMID: 34054018 DOI: 10.1097/wad.0000000000000458] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 04/13/2021] [Indexed: 11/25/2022]
Abstract
Genetic testing and counseling is an emerging part of care for patients with amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD) and their families. This scoping review aimed to map patients' and relatives' experiences of genetic testing and counseling for familial ALS and FTD and the factors influencing their decision to proceed with testing or counseling. Informed by the Joanna Briggs Institute methodology, 5 databases were systematically searched. Thirty studies from 39 references were included. A descriptive numerical summary analysis and narrative synthesis was conducted. Mostly positive diagnostic testing experiences were reported, but issues arose due to progressive disease and discordant results. Predictive testing impacted at-risk relatives, regardless of the result received, and psychosocial sequelae ranged from relief to guilt, worry or contemplating suicide. Four reproductive testing experiences were reported. Personal, familial and practical factors, and the lived experience of disease, informed decision-making. Greater uncertainty and complexity may be faced in familial ALS/FTD than in other late-onset neurodegenerative diseases due to clinical and genetic heterogeneity, and testing limitations. Genetic counseling models of care should consider this difference to ensure that individuals with, or at risk of, ALS/FTD are effectively managed. Implications for research and practice are discussed.
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Affiliation(s)
- Ashley Crook
- Graduate School of Health, University of Technology Sydney, Chippendale
- Department of Biomedical Science, Centre for MND Research
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - Chris Jacobs
- Graduate School of Health, University of Technology Sydney, Chippendale
| | - Toby Newton-John
- Graduate School of Health, University of Technology Sydney, Chippendale
| | - Ebony Richardson
- Graduate School of Health, University of Technology Sydney, Chippendale
| | - Alison McEwen
- Graduate School of Health, University of Technology Sydney, Chippendale
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Nakamura K, Sekijima Y. [Genetic counseling and predictive testing for hereditary neuromuscular diseases]. Rinsho Shinkeigaku 2021; 61:588-593. [PMID: 34433746 DOI: 10.5692/clinicalneurol.cn-001608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Recent progress in genetic analysis can provide a precision diagnosis for many hereditary neuromuscular diseases in daily practice. Moreover, disease-modifying therapies such as nucleic acid medicine for patients with several neuromuscular diseases (i.e., hereditary ATTR amyloidosis, spinal muscular atrophy, and Duchenne muscular dystrophy) have been approved in Japan. For all neurologists, knowledge and practical skills of genetic counseling, especially predictive testing, will increase in importance. To promote personalized medicine for patients with neuromuscular diseases and their families, it is necessary to develop of genetic counseling systems, including nurturing genetic professionals.
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Affiliation(s)
- Katsuya Nakamura
- Center for Medical Genetics, Shinshu University Hospital.,Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine
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8
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Ursin F, Timmermann C, Steger F. Ethical Implications of Alzheimer's Disease Prediction in Asymptomatic Individuals through Artificial Intelligence. Diagnostics (Basel) 2021; 11:diagnostics11030440. [PMID: 33806501 PMCID: PMC7998766 DOI: 10.3390/diagnostics11030440] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/09/2021] [Accepted: 02/25/2021] [Indexed: 11/25/2022] Open
Abstract
Biomarker-based predictive tests for subjectively asymptomatic Alzheimer’s disease (AD) are utilized in research today. Novel applications of artificial intelligence (AI) promise to predict the onset of AD several years in advance without determining biomarker thresholds. Until now, little attention has been paid to the new ethical challenges that AI brings to the early diagnosis in asymptomatic individuals, beyond contributing to research purposes, when we still lack adequate treatment. The aim of this paper is to explore the ethical arguments put forward for AI aided AD prediction in subjectively asymptomatic individuals and their ethical implications. The ethical assessment is based on a systematic literature search. Thematic analysis was conducted inductively of 18 included publications. The ethical framework includes the principles of autonomy, beneficence, non-maleficence, and justice. Reasons for offering predictive tests to asymptomatic individuals are the right to know, a positive balance of the risk-benefit assessment, and the opportunity for future planning. Reasons against are the lack of disease modifying treatment, the accuracy and explicability of AI aided prediction, the right not to know, and threats to social rights. We conclude that there are serious ethical concerns in offering early diagnosis to asymptomatic individuals and the issues raised by the application of AI add to the already known issues. Nevertheless, pre-symptomatic testing should only be offered on request to avoid inflicted harm. We recommend developing training for physicians in communicating AI aided prediction.
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9
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Genetic counseling and testing practices for late-onset neurodegenerative disease: a systematic review. J Neurol 2021; 269:676-692. [PMID: 33649871 PMCID: PMC7920548 DOI: 10.1007/s00415-021-10461-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/10/2021] [Accepted: 02/10/2021] [Indexed: 12/28/2022]
Abstract
Objective To understand contemporary genetic counseling and testing practices for late-onset neurodegenerative diseases (LONDs), and identify whether practices address the internationally accepted goals of genetic counseling: interpretation, counseling, education, and support. Methods Four databases were systematically searched for articles published from 2009 to 2020. Peer-reviewed research articles in English that reported research and clinical genetic counseling and testing practices for LONDs were included. A narrative synthesis was conducted to describe different practices and map genetic counseling activities to the goals. Risk of bias was assessed using the Qualsyst tool. The protocol was registered with PROSPERO (CRD42019121421). Results Sixty-one studies from 68 papers were included. Most papers focused on predictive testing (58/68) and Huntington’s disease (41/68). There was variation between papers in study design, study population, outcomes, interventions, and settings. Although there were commonalities, novel and inconsistent genetic counseling practices were identified. Eighteen papers addressed all four goals of genetic counseling. Conclusion Contemporary genetic counseling and testing practices for LONDs are varied and informed by regional differences and the presence of different health providers. A flexible, multidisciplinary, client- and family-centered care continues to emerge. As genetic testing becomes a routine part of care for patients (and their relatives), health providers must balance their limited time and resources with ensuring clients are safely and effectively counseled, and all four genetic counseling goals are addressed. Areas of further research include diagnostic and reproductive genetic counseling/testing practices, evaluations of novel approaches to care, and the role and use of different health providers in practice. Supplementary Information The online version contains supplementary material available at 10.1007/s00415-021-10461-5.
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10
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Koriath CAM, Kenny J, Ryan NS, Rohrer JD, Schott JM, Houlden H, Fox NC, Tabrizi SJ, Mead S. Genetic testing in dementia - utility and clinical strategies. Nat Rev Neurol 2021; 17:23-36. [PMID: 33168964 DOI: 10.1038/s41582-020-00416-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2020] [Indexed: 02/07/2023]
Abstract
Techniques for clinical genetic testing in dementia disorders have advanced rapidly but remain to be more widely implemented in practice. A positive genetic test offers a precise molecular diagnosis, can help members of an affected family to determine personal risk, provides a basis for reproductive choices and can offer options for clinical trials. The likelihood of identifying a specific genetic cause of dementia depends on the clinical condition, the age at onset and family history. Attempts to match phenotypes to single genes are mostly inadvisable owing to clinical overlap between the dementias, genetic heterogeneity, pleiotropy and concurrent mutations. Currently, the appropriate genetic test in most cases of dementia is a next-generation sequencing gene panel, though some conditions necessitate specific types of test such as repeat expansion testing. Whole-exome and whole-genome sequencing are becoming financially feasible but raise or exacerbate complex issues such as variants of uncertain significance, secondary findings and the potential for re-analysis in light of new information. However, the capacity for data analysis and counselling is already restricting the provision of genetic testing. Patients and their relatives need to be given reliable information to enable them to make informed choices about tests, treatments and data sharing; the ability of patients with dementia to make decisions must be considered when providing this information.
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Affiliation(s)
| | - Joanna Kenny
- South West Thames Regional Genetics Service, London, UK
| | - Natalie S Ryan
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, London, UK
- UK Dementia Research Institute, UCL Queen Square Institute of Neurology, London, UK
| | - Jonathan D Rohrer
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, London, UK
| | - Jonathan M Schott
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, London, UK
| | - Henry Houlden
- Neurogenetics Laboratory, National Hospital for Neurology and Neurosurgery, London, UK
| | - Nick C Fox
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, London, UK
- UK Dementia Research Institute, UCL Queen Square Institute of Neurology, London, UK
| | - Sarah J Tabrizi
- Huntington's Disease Centre, Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, London, UK
| | - Simon Mead
- MRC Prion Unit at UCL, UCL Institute of Prion Diseases, London, UK.
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11
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Sexton A, West K, Gill G, Wiseman A, Taylor J, Purvis R, Fahey M, Storey E, Walsh M, James P. Suicide in frontotemporal dementia and Huntington disease: analysis of family-reported pedigree data and implications for genetic healthcare for asymptomatic relatives. Psychol Health 2020; 36:1397-1402. [PMID: 33232178 DOI: 10.1080/08870446.2020.1849700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Genomic testing for early-onset dementia is becoming more accessible, along with predictive testing for at-risk relatives; however, complex counselling issues are important to address. The topic of suicide often has stigma associated, and thoughts or experiences may not be volunteered without prompting. Little has been published with consideration to suicide rates in the context of family experiences and their significance in genetic counselling for relatives of people with Huntington disease and frontotemporal dementia. DESIGN This study included pedigree information for 267 symptomatic individuals with frontotemporal dementia or Huntington disease, provided via genetic counselling clinics. MAIN OUTCOME MEASURES Descriptive statistics and suicide rate calculations based on family reported pedigree data. RESULTS The suicide rate was 2996 per 100,000 compared with the population rate of 10 per 100,000. Approximately one in 15 families reported suicide of an affected family member, and file notes indicated that one in five families had experienced suicide, suicidal thoughts or suicide attempts in one or more affected, unaffected or pre-symptomatic relative. CONCLUSION Health professional awareness of family experiences, including suicide of a relative, is vital in facilitating client decisions about genetic testing, and in providing adequate psychosocial support during the process of genetic testing and adaption to results.
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Affiliation(s)
- Adrienne Sexton
- Genomic Medicine, The Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine, The University of Melbourne, Parkville, Australia
| | - Kirsty West
- Genomic Medicine, The Royal Melbourne Hospital, Parkville, Australia
| | - Gulvir Gill
- Genomic Medicine, The Royal Melbourne Hospital, Parkville, Australia
| | - Allan Wiseman
- Genomic Medicine, The Royal Melbourne Hospital, Parkville, Australia
| | - Jessica Taylor
- Genomic Medicine, The Royal Melbourne Hospital, Parkville, Australia
| | - Rebecca Purvis
- Genomic Medicine, The Royal Melbourne Hospital, Parkville, Australia
| | - Michael Fahey
- Genomic Medicine, The Royal Melbourne Hospital, Parkville, Australia.,Department of Paediatrics, Monash University, Clayton, Australia
| | - Elsdon Storey
- Genomic Medicine, The Royal Melbourne Hospital, Parkville, Australia.,Central Clinical School, Monash University, Clayton, Australia
| | - Maie Walsh
- Genomic Medicine, The Royal Melbourne Hospital, Parkville, Australia
| | - Paul James
- Genomic Medicine, The Royal Melbourne Hospital, Parkville, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Australia
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12
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Goldman JS. Predictive Genetic Counseling for Neurodegenerative Diseases: Past, Present, and Future. Cold Spring Harb Perspect Med 2020; 10:cshperspect.a036525. [PMID: 31548223 DOI: 10.1101/cshperspect.a036525] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Predictive genetic counseling for neurodegenerative diseases commenced with Huntington's disease (HD). Because the psychological issues and outcomes have been best studied in HD, the HD genetic counseling and testing protocol is still accepted as the gold standard for genetic counseling for these diseases. Yet, advances in genomic technology have produced an abundance of new information about the genetics of diseases such as Alzheimer's disease, frontotemporal dementia, amyotrophic lateral sclerosis, and Parkinson's disease. The resulting expansion of genetic tests together with the availability of direct-to-consumer testing and clinical trials for treatment of these diseases present new ethical and practical issues requiring modifications to the protocol for HD counseling and new demands on both physicians and genetic counselors. This work reviews the history of genetic counseling for neurodegenerative diseases, its current practice, and the future direction of genetic counseling for these conditions.
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Affiliation(s)
- Jill S Goldman
- Taub Institute for Research on Alzheimer's Disease and the Aging Brain, Department of Neurology, Columbia University Vagelos College of Medicine, New York, New York 10032, USA
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13
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Ng KP, Richard-Devantoy S, Bertrand JA, Jiang L, Pascoal TA, Mathotaarachchi S, Therriault J, Yatawara C, Kandiah N, Greenwood CMT, Rosa-Neto P, Gauthier S. Suicidal ideation is common in autosomal dominant Alzheimer's disease at-risk persons. Int J Geriatr Psychiatry 2020; 35:60-68. [PMID: 31642105 PMCID: PMC7232741 DOI: 10.1002/gps.5215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 09/15/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To study the frequency of suicidal ideation and its association with clinical and neurobiological correlates among cognitively intact autosomal dominant Alzheimer's disease (ADAD) at-risk individuals. METHODS/DESIGN In a cross-sectional study of 183 ADAD at-risk individuals (91 mutation carriers and 92 noncarriers), we compared the frequency of suicidal ideation among carriers and noncarriers. Linear mixed-effects models with family-level random effects evaluated the relationships between geriatric depression scale (GDS), neuropsychiatric inventory-questionnaire (NPI-Q), and suicidal ideation scores among all ADAD at-risk individuals. An interaction term was added to the regression models to evaluate the interactions of suicidal ideation and mutation status on neuropsychiatric symptoms. RESULTS Twenty-six (14.20%) ADAD at-risk individuals (13 [14.28%] carriers and 13 [14.13%] noncarriers) had suicidal ideation. The frequency of suicidal ideation did not differ between carriers and noncarriers. Suicidal ideation was associated with higher GDS among all ADAD at-risk individuals. When stratified into mutation carrier status, noncarriers with suicidal ideation had higher GDS than carriers. There was no statistically significant association between suicidal ideation and NPI-Q among ADAD at-risk individuals. Awareness of mutation status, neuropsychological performances, and cerebrospinal fluid AD biomarkers were not associated with suicidal ideation among carriers and noncarriers. CONCLUSIONS Suicidal ideation is common among cognitively intact ADAD at-risk individuals. While ADAD at-risk individuals with suicidal ideation have greater depressive symptoms, noncarriers with suicidal ideation have higher GDS scores than carriers. Interestingly, awareness of the mutation status was not associated with suicidal ideation in our study. Early identification of suicidal thoughts can facilitate timely interventions to prevent suicidal behaviours. Keywords autosomal dominant Alzheimer's diseasedominantly inherited Alzheimer's networkneuropsychiatric symptomssuicidal ideation.
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Affiliation(s)
- Kok Pin Ng
- Alzheimer's Disease Research Unit, McGill Centre for Studies in Aging, McGill University, Québec, Canada
- Department of Neurology, National Neuroscience Institute, Singapore
- Translational Neuroimaging Laboratory, The McGill University Research Centre for Studies in Aging, Québec, Canada
| | - Stéphane Richard-Devantoy
- Department of Psychiatry & Douglas Mental Health University Institute, McGill Group for Suicide Studies, McGill University, Québec, Montréal, Canada
- CISSS des Laurentides, Quebec, Canada
| | - Josie-Anne Bertrand
- Douglas Research Center, Douglas Mental Health University Institute, Québec, Canada
| | - Lai Jiang
- Lady Davis Institute, McGill University, Québec, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Québec, Canada
| | - Tharick A Pascoal
- Alzheimer's Disease Research Unit, McGill Centre for Studies in Aging, McGill University, Québec, Canada
- Translational Neuroimaging Laboratory, The McGill University Research Centre for Studies in Aging, Québec, Canada
| | - Sulantha Mathotaarachchi
- Alzheimer's Disease Research Unit, McGill Centre for Studies in Aging, McGill University, Québec, Canada
- Translational Neuroimaging Laboratory, The McGill University Research Centre for Studies in Aging, Québec, Canada
| | - Joseph Therriault
- Alzheimer's Disease Research Unit, McGill Centre for Studies in Aging, McGill University, Québec, Canada
- Translational Neuroimaging Laboratory, The McGill University Research Centre for Studies in Aging, Québec, Canada
| | | | | | - Celia M T Greenwood
- Lady Davis Institute, McGill University, Québec, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Québec, Canada
| | - Pedro Rosa-Neto
- Alzheimer's Disease Research Unit, McGill Centre for Studies in Aging, McGill University, Québec, Canada
- Translational Neuroimaging Laboratory, The McGill University Research Centre for Studies in Aging, Québec, Canada
| | - Serge Gauthier
- Alzheimer's Disease Research Unit, McGill Centre for Studies in Aging, McGill University, Québec, Canada
- Translational Neuroimaging Laboratory, The McGill University Research Centre for Studies in Aging, Québec, Canada
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14
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Wesson M, Boileau NR, Perlmutter JS, Paulsen JS, Barton SK, McCormack MK, Carlozzi NE. Suicidal Ideation Assessment in Individuals with Premanifest and Manifest Huntington Disease. J Huntingtons Dis 2019; 7:239-249. [PMID: 30056431 DOI: 10.3233/jhd-180299] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Huntington disease (HD) is associated with increased risk of suicide. OBJECTIVE This study compares suicide ideation in HD to the general population, assesses factors associated with increased prevalence of suicidal thoughts, and compares clinician-rated to self-reported assessments of suicidal ideation. METHODS We examined 496 participants with premanifest or manifest HD. Clinician-rated suicidal ideation was measured using the Problem Behaviors Assessment - short form. Self-reported ideation was measured using two items from the HDQLIFE Concern with Death and Dying item bank. Independent sample t-tests were conducted to compare the prevalence of suicidal thoughts between our HD sample and the U.S. POPULATION Logistic regression analyses were used to determine characteristics associated with higher odds of clinically significant suicidal ideation. Kappa agreement coefficients were calculated to evaluate concurrence between clinician-rated and self-reported assessments. RESULTS Our sample had a significantly higher occurrence of suicidal ideation (19.76%) and suicidal plans (2.1%) than the general population (p < 0.0001). Odds of clinically significant suicidal ideation were 6.8 times higher in females (p = 0.04) on the clinician measure, and Hispanic/Latinos had 10.9 times higher odds than non-Hispanics (p = 0.025) on the self-report measure. Clinician-rated assessment had fair agreement (k = 0.2-0.4) with self-reported assessments, except in early stage HD where there was no overlap in the identification of participants with clinically significant suicidal ideation. DISCUSSION Assessment for suicidal ideation and clinically significant suicidal thoughts in HD with a multimodal approach that includes clinician-rated and self-report measures is critical at all stages of the disease.
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Affiliation(s)
- Melissa Wesson
- Department of Medical and Molecular Genetics, Indiana University, Indianapolis, IN, USA
| | - Nicholas R Boileau
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
| | - Joel S Perlmutter
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA.,Radiology, Neuroscience, Physical Therapy, Occupational Therapy, Washington University in St. Louis, St. Louis, MO, USA
| | - Jane S Paulsen
- Neurology, Psychiatry, Psychological and Brain Sciences, University of Iowa, Iowa City, IA, USA
| | - Stacey K Barton
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA
| | - Michael K McCormack
- Department of Pathology, Rowan University School of Medicine, Glassboro, NJ, USA.,Department of Psychiatry, Rutgers-RWJMS, Piscataway Township, NJ, USA
| | - Noelle E Carlozzi
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
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15
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Chu EMY, O'Neill M, Purkayastha DD, Knight C. Huntington's disease: a forensic risk factor in women. JOURNAL OF CLINICAL MOVEMENT DISORDERS 2019; 6:3. [PMID: 31367459 PMCID: PMC6657174 DOI: 10.1186/s40734-019-0078-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 07/14/2019] [Indexed: 11/10/2022]
Abstract
Background Huntington's disease (HD) is an autosomal dominant, neurodegenerative disorder. Associated cognitive deficits including impulsivity and disinhibition are the same factors that also predispose to forensic risk. Men tend to be perpetrators of more severe violent behaviours than women and women are less likely than men to be arrested for violence. This finding is not applicable in the case of women with Huntington's disease and explored in the three clinical cases of women with HD and their forensic histories that are subsequently described. Case presentation 'A' was admitted from court following a charge of arson and reckless behavior, with increasing severity and frequency of self-harm and attempted suicide. This case demonstrates someone who had previously presented to psychiatric services on multiple occasions for various reasons, culminating in a serious criminal charge of arson due to psychiatric symptoms associated with HD.'B' was arrested and imprisoned after having been charged with actual bodily harm (ABH) for assaulting her partner and young daughter then breaking her bail conditions. Although she was gene positive for HD she had no neurological symptoms of the disease. B was given leave but needed to be recalled to hospital by police. Six weeks later the medical recommendation for a court imposed hospital order was overturned as B presented and articulated her case so convincingly in court. This case demonstrates that even in the absence of psychiatric history or movement disorder there may be substantial forensic risk indicated by subtle underlying cognitive deficits due to changes in executive function affecting the frontal lobes.'C' was admitted to acute psychiatric services after being found wandering in traffic wanting to die. She had been diagnosed with HD in the previous year and had a long criminal record on a background of alcohol dependency. Following transfer to a specialist psychiatric unit, she engaged well with a neurobehavioural levels system which rewards desirable and appropriate behaviours and she responded well to a highly structured environment resulting in discharge to a community placement. Conclusions These three case studies aim to highlight the need to raise awareness of the increased forensic risk in women with HD. Although criminal behaviour is less frequently observed in women than men and usually violence is less severe in women, HD may cause or contribute to criminal behaviour that can be violent in nature in women who are gene carriers for HD even in the absence of movement disorder, psychiatric symptoms or overt cognitive deficits. Assessment and earlier treatment in appropriate hospital settings may successfully contain and modify behaviours leading to reduced levels of risk and recidivism in this vulnerable patient group.
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Affiliation(s)
- Elvina May-Yin Chu
- 1Huntington's Disease Centre, UCL Institute of Neurology, 2nd Floor Russell Square House, London, WC1B 5EH UK.,2Department of Psychiatry, Queen's University, Kingston, ON Canada
| | - Mari O'Neill
- Clinical Psychology, Priory Group, Melton Mowbray, UK
| | | | - Caroline Knight
- Elysium Neurological Services, Elysium Healthcare, St Neots Hospital, St Neots, Cambridgeshire UK.,The Oakleaf Group, Hartwell, Northamptonshire UK.,7School of Psychology, University of Leicester, Leicester, Leicestershire UK
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16
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Wurcel V, Cicchetti A, Garrison L, Kip M, Koffijberg H, Kolbe A, Leeflang M, Merlin T, Mestre-Ferrandiz J, Oortwijn W, Oosterwijk C, Tunis S, Zamora B. The Value of Diagnostic Information in Personalised Healthcare: A Comprehensive Concept to Facilitate Bringing This Technology into Healthcare Systems. Public Health Genomics 2019; 22:8-15. [DOI: 10.1159/000501832] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 07/01/2019] [Indexed: 11/19/2022] Open
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17
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Anderson KE, Eberly S, Marder KS, Oakes D, Kayson E, Young A, Shoulson I. The choice not to undergo genetic testing for Huntington disease: Results from the PHAROS study. Clin Genet 2019; 96:28-34. [DOI: 10.1111/cge.13529] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 01/30/2019] [Accepted: 02/02/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Karen E. Anderson
- Department of Psychiatry, Georgetown University Washington DC
- Department of Neurology, Georgetown University Washington DC
| | - Shirley Eberly
- Department of Biostatistics and Computational Biology, University of Rochester Rochester NY
| | - Karen S. Marder
- Department of Neurology, Columbia Vagelos College of Physicians and Surgeons, Columbia University New York NY
| | - David Oakes
- Department of Biostatistics and Computational Biology, University of Rochester Rochester NY
| | - Elise Kayson
- Center for Health + Technology/Clinical Trials Coordination Center, University of Rochester, NY
| | - Anne Young
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Ira Shoulson
- Department of Neurology, University of Rochester Rochester NY
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18
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Improving follow up after predictive testing in Huntington's disease: evaluating a genetic counselling narrative group session. J Community Genet 2019; 11:47-58. [PMID: 31001731 PMCID: PMC6962407 DOI: 10.1007/s12687-019-00416-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 03/11/2019] [Indexed: 11/21/2022] Open
Abstract
Recently updated Huntington’s disease (HD) predictive testing guidelines emphasise clinicians’ responsibility to facilitate emotional support following testing, regardless of the result. Yet models of post-test counselling support are poorly defined. Moreover, it is unclear how these might be best delivered. In this project, a genetic counsellor and clinical psychologist developed standalone group sessions using collective narrative practices for individuals post-predictive testing. Here we present an evaluation of the experiences of one group of six people who have tested mutation positive for HD and remain pre-symptomatic. Two partners also attended the session. Observations, evaluation forms and telephone interviews were used in data collection. Interview data was available from five mutation-positive individuals and one partner. Qualitative data were analysed using a thematic framework approach. Responses were overwhelmingly positive, emphasising the importance of a specifically arranged time and space to share experiences in a structured way. This was typically the first time participants had spoken openly with someone in their situation. Narrative facilitation of discussion encouraged participants to re-discover their strengths and resiliences, with similar experiences being discovered through connections with others. The evaluation was successful in implementing group narrative interventions as part of the predictive test counselling support for Huntington’s disease. Participants suggested that the approach could be extended and adopted for other genetic conditions.
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19
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Herzog–Krzywoszanska R, Krzywoszanski L. Sleep Disorders in Huntington's Disease. Front Psychiatry 2019; 10:221. [PMID: 31031659 PMCID: PMC6474183 DOI: 10.3389/fpsyt.2019.00221] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 03/26/2019] [Indexed: 12/13/2022] Open
Abstract
Huntington's chorea (Huntington's disease, HD) is a genetic disorder caused by autosomal dominant mutation, leading to progressive neurodegenerative changes in the central nervous system. Involuntary movements such as chorea occur typically in HD patients, accompanied by progressive cognitive and psychiatric disturbances. Other common symptoms of HD are circadian and sleep abnormalities, which are observed from the earliest stages of the disease or even before the occurrence of clinical symptoms. The most common sleep problems reported by HD patients include insomnia, difficulties in falling asleep, frequent nocturnal awakenings, and excessive daytime sleepiness. Also, specific changes in sleep architecture have been identified in HD. In this paper, we review studies on sleep and circadian rhythm disorders in HD. We outline findings concerning sleep patterns and disturbances of circadian rhythms in HD patients, as well as the role of psychiatric disorders and motor disorders in HD patients' sleep problems. We also discuss problems related to the different methods of diagnosing sleep disorders in HD. Furthermore, the adverse effects of medication used for the treatment of core HD symptoms as one of the sources of sleep disturbances in HD are emphasized. In conclusion, the diversity and complexity of the determinants of sleep and circadian rhythm disorders in HD are highlighted. Finally, the relevance of effective treatment to improve patients' functioning and quality of life as well as the potential relief of their cognitive and emotional symptoms is addressed.
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Affiliation(s)
| | - Lukasz Krzywoszanski
- Neurocognitive Psychology Unit, Chair of Psychology, Faculty of Pedagogy, Pedagogical University of Krakow, Krakow, Poland
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20
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Crook A, McEwen A, Fifita JA, Zhang K, Kwok JB, Halliday G, Blair IP, Rowe DB. The C9orf72 hexanucleotide repeat expansion presents a challenge for testing laboratories and genetic counseling. Amyotroph Lateral Scler Frontotemporal Degener 2019; 20:310-316. [PMID: 30907153 DOI: 10.1080/21678421.2019.1588904] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
C9orf72 hexanucleotide repeat expansions are the most common known cause of amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD). Genetic testing for C9orf72 expansions in patients with ALS and/or FTD and their relatives has become increasingly available since hexanucleotide repeat expansions were first reported in 2011. The repeat number is highly variable and the threshold at which repeat size leads to neurodegeneration remains unknown. We present the case of an ALS patient who underwent genetic testing through our Motor Neurone Disease Clinic. We highlight current limitations to analysing and interpreting C9orf72 expansion test results and describe how this resulted in discordant reports of pathogenicity between testing laboratories that confounded the genetic counselling process. We conclude that patients with ALS or FTD and their at-risk family members, need to be adequately counselled about the limitations of current knowledge to ensure they are making informed decisions about genetic testing for C9orf72. Greater collaboration between clinicians, testing laboratories and researchers is required to ensure risks to patients and their families are minimised.
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Affiliation(s)
- Ashley Crook
- a Department of Clinical Medicine, Faculty of Medicine and Health Sciences , Macquarie University , Sydney , Australia.,b Centre for MND Research, Department of Biomedical Science, Faculty of Medicine and Health Sciences , Macquarie University , Sydney , Australia.,c Graduate School of Health , University of Technology Sydney , Ultimo , Australia
| | - Alison McEwen
- c Graduate School of Health , University of Technology Sydney , Ultimo , Australia
| | - Jennifer A Fifita
- b Centre for MND Research, Department of Biomedical Science, Faculty of Medicine and Health Sciences , Macquarie University , Sydney , Australia
| | - Katharine Zhang
- b Centre for MND Research, Department of Biomedical Science, Faculty of Medicine and Health Sciences , Macquarie University , Sydney , Australia
| | - John B Kwok
- d Central Clinical School and Brain and Mind Centre , The University of Sydney , Sydney , Australia.,e School of Medical Sciences , University of New South Wales , Sydney , Australia
| | - Glenda Halliday
- d Central Clinical School and Brain and Mind Centre , The University of Sydney , Sydney , Australia
| | - Ian P Blair
- b Centre for MND Research, Department of Biomedical Science, Faculty of Medicine and Health Sciences , Macquarie University , Sydney , Australia
| | - Dominic B Rowe
- a Department of Clinical Medicine, Faculty of Medicine and Health Sciences , Macquarie University , Sydney , Australia.,b Centre for MND Research, Department of Biomedical Science, Faculty of Medicine and Health Sciences , Macquarie University , Sydney , Australia
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21
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McGarry A, McDermott MP, Kieburtz K, Fung WLA, McCusker E, Peng J, de Blieck EA, Cudkowicz M. Risk factors for suicidality in Huntington disease: An analysis of the 2CARE clinical trial. Neurology 2019; 92:e1643-e1651. [PMID: 30850442 DOI: 10.1212/wnl.0000000000007244] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 12/05/2018] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE Most suicidality literature in Huntington disease (HD) is based on natural history studies or retrospective reviews, but reports on risk factors from clinical trials are limited. METHODS We analyzed 609 participants from 2CARE, a randomized, double-blind, placebo-controlled clinical trial with up to 5 years of follow-up, for risk factors related to suicidality. The primary outcome variable was the time from randomization until the first occurrence of either suicidal ideation or attempt. We also considered time from randomization until the first suicide attempt as a secondary outcome variable. RESULTS Depression, anxiety, bipolar disorder, antidepressant or anxiolytic use, and prior suicide attempt at baseline were associated with time to ideation or attempt. Baseline employment status, marital status, CAG repeat length, tetrabenazine use, and treatment assignment (coenzyme Q10 or placebo) were not associated with suicidality. Time-dependent variables from the Unified Huntington's Disease Rating Scale Behavioral Assessment were associated with time to suicidal ideation or attempt, driven mainly by items related to depressed mood, low self-esteem/guilt, anxiety, suicidal thoughts, irritability, and compulsions. Variables associated with time to suicide attempt alone were generally similar. CONCLUSION These data suggest psychiatric comorbidities in HD are predictive of suicidal behavior while participating in clinical trials, reinforcing the importance of clinical surveillance and treatment towards lessening risk during participation and perhaps beyond. Designing a composite algorithm for early prediction of suicide attempts in HD may be of value, particularly given anticipated trials aimed at disease modification are likely to be long-term. CLINICALTRIALSGOV IDENTIFIER NCT00608881.
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Affiliation(s)
- Andrew McGarry
- From Cooper University Healthcare at Rowan University (A.M.), Camden, NJ; University of Rochester (M.P.M., K.K., E.A.d.B.), NY; North York General Hospital (W.L.A.F.), University of Toronto, Canada; Westmead Hospital (E.M.), Australia; The Ohio State University (J.P.), Columbus; and Harvard Medical School (M.C.), Boston, MA.
| | - Michael P McDermott
- From Cooper University Healthcare at Rowan University (A.M.), Camden, NJ; University of Rochester (M.P.M., K.K., E.A.d.B.), NY; North York General Hospital (W.L.A.F.), University of Toronto, Canada; Westmead Hospital (E.M.), Australia; The Ohio State University (J.P.), Columbus; and Harvard Medical School (M.C.), Boston, MA
| | - Karl Kieburtz
- From Cooper University Healthcare at Rowan University (A.M.), Camden, NJ; University of Rochester (M.P.M., K.K., E.A.d.B.), NY; North York General Hospital (W.L.A.F.), University of Toronto, Canada; Westmead Hospital (E.M.), Australia; The Ohio State University (J.P.), Columbus; and Harvard Medical School (M.C.), Boston, MA
| | - Wai Lun Alan Fung
- From Cooper University Healthcare at Rowan University (A.M.), Camden, NJ; University of Rochester (M.P.M., K.K., E.A.d.B.), NY; North York General Hospital (W.L.A.F.), University of Toronto, Canada; Westmead Hospital (E.M.), Australia; The Ohio State University (J.P.), Columbus; and Harvard Medical School (M.C.), Boston, MA
| | - Elizabeth McCusker
- From Cooper University Healthcare at Rowan University (A.M.), Camden, NJ; University of Rochester (M.P.M., K.K., E.A.d.B.), NY; North York General Hospital (W.L.A.F.), University of Toronto, Canada; Westmead Hospital (E.M.), Australia; The Ohio State University (J.P.), Columbus; and Harvard Medical School (M.C.), Boston, MA
| | - Jing Peng
- From Cooper University Healthcare at Rowan University (A.M.), Camden, NJ; University of Rochester (M.P.M., K.K., E.A.d.B.), NY; North York General Hospital (W.L.A.F.), University of Toronto, Canada; Westmead Hospital (E.M.), Australia; The Ohio State University (J.P.), Columbus; and Harvard Medical School (M.C.), Boston, MA
| | - Elisabeth A de Blieck
- From Cooper University Healthcare at Rowan University (A.M.), Camden, NJ; University of Rochester (M.P.M., K.K., E.A.d.B.), NY; North York General Hospital (W.L.A.F.), University of Toronto, Canada; Westmead Hospital (E.M.), Australia; The Ohio State University (J.P.), Columbus; and Harvard Medical School (M.C.), Boston, MA
| | - Merit Cudkowicz
- From Cooper University Healthcare at Rowan University (A.M.), Camden, NJ; University of Rochester (M.P.M., K.K., E.A.d.B.), NY; North York General Hospital (W.L.A.F.), University of Toronto, Canada; Westmead Hospital (E.M.), Australia; The Ohio State University (J.P.), Columbus; and Harvard Medical School (M.C.), Boston, MA
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22
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Testa CM, Jankovic J. Huntington disease: A quarter century of progress since the gene discovery. J Neurol Sci 2019; 396:52-68. [DOI: 10.1016/j.jns.2018.09.022] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 09/14/2018] [Accepted: 09/18/2018] [Indexed: 01/21/2023]
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23
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Presymptomatic testing of those at 25% risk of autosomal dominant neurodegenerative disease- testing team beware. Eur J Hum Genet 2018; 27:20-21. [PMID: 30291342 DOI: 10.1038/s41431-018-0280-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 09/14/2018] [Indexed: 11/08/2022] Open
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24
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Reverse pre-symptomatic testing for Huntington disease: double disclosure when 25% at-risk children reveal the genetic status to their parent. Eur J Hum Genet 2018; 27:22-27. [PMID: 30206353 DOI: 10.1038/s41431-018-0255-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 06/21/2018] [Accepted: 08/09/2018] [Indexed: 11/09/2022] Open
Abstract
Predictive testing for Huntington disease (HD) in 25% at-risk individuals is testing with full knowledge, and sometimes assuming, that the parent does not want to know his status. The goal of this study was to understand: (1) the differences in the motivation between 25% and 50% at-risk individuals to be tested and (2) the consequences of "double disclosure", including parental reactions. Test requests from 25% at-risk individuals were rare (155/1611, 10%). We compared their motivation with those of 1456 50% at-risk individuals. The principal motivation to have the test for both groups was "to know" (48% versus 58%, p = 0.049), but the desire to have children was more frequent in the 25% at-risk group (32% versus 17%, p < 0.001). Sixty percent of the 25% at-risk group went through the testing procedure: 15% (n = 14) were variant positive for HD. Testees reported four adverse reactions of their parent (22%): one committed suicide and three became depressed. This result highlights the impact of "double disclosure", a bad result for the person themselves and the transmitting parent. It is the responsibility of the team to anticipate this outcome with the 25% at-risk individuals: children revealing the genetic status to their parent. They should help the testees and their family to find a satisfactory solution to help prevent adverse reactions. This includes ensuring that the candidate is well-infomed abour the testing options and consequences to her/himself but also to her/his parent. The at-risk parent should be offered to discuss the implications of their child's testing.
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25
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What to Do with a Second Chance in Life? Long-Term Experiences of Non-carriers of Huntington’s Disease. J Genet Couns 2018; 27:1438-1446. [DOI: 10.1007/s10897-018-0257-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 03/26/2018] [Indexed: 10/17/2022]
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26
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Hartzell JW, Geary R, Gyure K, Chivukula VR, Haut MW. Completed suicide in an autopsy-confirmed case of early onset Alzheimer's disease. Neurodegener Dis Manag 2018; 8:81-88. [PMID: 29319406 PMCID: PMC6367712 DOI: 10.2217/nmt-2017-0045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
We report a case of a 57-year-old male with clinically diagnosed and autopsy-confirmed early onset Alzheimer's disease who completed suicide by gunshot wound to the chest. This case has several unique aspects that have not been discussed in previous case reports of completed suicide in Alzheimer's disease. In particular, our patient's death was highly planned with successful compensation for his cognitive deficits. After all firearms had been removed from the home as a safety precaution, he obtained a new weapon, hid it and left himself cues to find and use it. The case is discussed in the context of literature differentiating the neural circuitry propagating impulsive versus planned suicidal acts.
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Affiliation(s)
- Jennifer Wiener Hartzell
- Department of Supportive Oncology, Levine Cancer Institute, Carolinas HealthCare System, NC 28202, USA.,Department of Neuropsychology & Psychology, Carolinas Rehabilitation, Carolinas HealthCare System, NC 28203, USA
| | - Richard Geary
- Department of Psychiatry, Overlake Medical Center, WA 98004, USA
| | - Kymberly Gyure
- Department of Pathology, West Virginia University School of Medicine, WV 26506, USA.,Department of Neurology, West Virginia University School of Medicine, WV 26506, USA.,Department of Neurosurgery, West Virginia University School of Medicine, WV 26506, USA
| | - Venkata Ravi Chivukula
- Department of Behavioral Medicine & Psychiatry, West Virginia University School of Medicine, WV 26505, USA
| | - Marc W Haut
- Department of Neurology, West Virginia University School of Medicine, WV 26506, USA.,Department of Behavioral Medicine & Psychiatry, West Virginia University School of Medicine, WV 26505, USA.,Department of Radiology, West Virginia University School of Medicine, WV 26506, USA
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Orozco-Gutiérrez M, Cervantes-Aragón I, García-Cruz D. Consideraciones éticas en el diagnóstico presintomático de ataxias espinocerebelosas autosómico dominantes. Neurologia 2017; 32:469-475. [DOI: 10.1016/j.nrl.2015.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 04/01/2015] [Accepted: 06/01/2015] [Indexed: 12/28/2022] Open
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Orozco-Gutiérrez M, Cervantes-Aragón I, García-Cruz D. Ethical considerations in presymptomatic diagnosis of autosomal dominant spinocerebellar ataxias. NEUROLOGÍA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.nrleng.2015.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Crook A, Williams K, Adams L, Blair I, Rowe DB. Predictive genetic testing for amyotrophic lateral sclerosis and frontotemporal dementia: genetic counselling considerations. Amyotroph Lateral Scler Frontotemporal Degener 2017; 18:475-485. [PMID: 28585888 DOI: 10.1080/21678421.2017.1332079] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Once a gene mutation that is causal of amyotrophic lateral sclerosis (ALS) and/or frontotemporal dementia (FTD) is identified in a family, relatives may decide to undergo predictive genetic testing to determine whether they are at risk of developing disease. Recent advances in gene discovery have led to a pressing need to better understand the implications of predictive genetic testing. Here we review the uptake of genetic counselling, predictive and reproductive testing, and the factors that impact the decision to undergo testing, for consideration in clinical practice. The literature suggests that the factors impacting the decision to undergo testing are complex due to the nature of these diseases, absence of available preventative medical treatment and variable age of onset in mutation carriers. Gaining further insight into the decision-making process and the impact of testing is critical as we seek to develop best-practice guidelines for predictive testing for familial ALS and FTD.
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Affiliation(s)
- Ashley Crook
- a Department of Clinical Medicine, Faculty of Medicine and Health Sciences , Macquarie University , Sydney , New South Wales , Australia and
| | - Kelly Williams
- b Centre for MND Research , Department of Biomedical Science, Faculty of Medicine and Health Sciences , Macquarie University , Sydney , New South Wales , Australia
| | - Lorel Adams
- a Department of Clinical Medicine, Faculty of Medicine and Health Sciences , Macquarie University , Sydney , New South Wales , Australia and
| | - Ian Blair
- b Centre for MND Research , Department of Biomedical Science, Faculty of Medicine and Health Sciences , Macquarie University , Sydney , New South Wales , Australia
| | - Dominic B Rowe
- a Department of Clinical Medicine, Faculty of Medicine and Health Sciences , Macquarie University , Sydney , New South Wales , Australia and
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Quaid KA, Eberly SW, Kayson-Rubin E, Oakes D, Shoulson I. Factors related to genetic testing in adults at risk for Huntington disease: the prospective Huntington at-risk observational study (PHAROS). Clin Genet 2017; 91:824-831. [PMID: 27740685 PMCID: PMC5392180 DOI: 10.1111/cge.12893] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 10/07/2016] [Accepted: 10/11/2016] [Indexed: 11/30/2022]
Abstract
Huntington disease (HD) is a late onset ultimately fatal neurodegenerative disorder caused by a cytosine-adenine-guanine ( CAG) triplet repeat expansion in the Huntingtin gene which was discovered in 1993. The PHAROS study is a unique observational study of 1001 individuals at risk for HD who had not been previously tested for HD and who had no plans to do so. In this cohort, 104 (10%) individuals changed their minds and chose to be tested during the course of the study but outside of the study protocol. Baseline behavioral scores, especially apathy, were more strongly associated with later genetic testing than motor and chorea scores, particularly among subjects with expanded CAG repeat length. In the CAG expanded group, those choosing to be tested were older and had more chorea and higher scores on the behavioral section of the unified Huntington's disease rating scale at baseline than those not choosing to be tested. Following genetic testing, 56% of subjects with CAG < 37 had less depression when compared to prior to testing, but depression generally stayed the same or increased for 64% of subjects in the expanded group. This finding suggests that approaches to testing must continue to be cautious, with appropriate medical, psychological and social support.
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Affiliation(s)
- Kimberly A. Quaid
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN
| | - Shirley W. Eberly
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY
| | - Elise Kayson-Rubin
- Department of Neurology and CHET, University of Rochester Medical Center, Rochester, NY
| | - David Oakes
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY
| | - Ira Shoulson
- Department of Neurology and Program for Regulatory Science & Medicine (PRSM), Georgetown University, Washington, DC
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Nance MA. Genetic counseling and testing for Huntington's disease: A historical review. Am J Med Genet B Neuropsychiatr Genet 2017; 174:75-92. [PMID: 27174011 DOI: 10.1002/ajmg.b.32453] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 04/15/2016] [Indexed: 12/26/2022]
Abstract
This manuscript describes the ways in which genetic counseling has evolved since John Pearson and Sheldon Reed first promoted "a genetic education" in the 1950s as a voluntary, non-directive clinical tool for permitting individual decision making. It reviews how the emergence of Huntington's disease (HD) registries and patient support organizations, genetic testing, and the discovery of a disease-causing CAG repeat expansion changed the contours of genetic counseling for families with HD. It also reviews the guidelines, outcomes, ethical and laboratory challenges, and uptake of predictive, prenatal, and preimplantation testing, and it casts a vision for how clinicians can better make use of genetic counseling to reach a broader pool of families that may be affected by HD and to ensure that genetic counseling is associated with the best levels of care. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Martha A Nance
- Struthers Parkinson's Center, Golden Valley, Minnesota.,Hennepin County Medical Center, Minneapolis, Minnesota
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The highly anxious individual presenting for Huntington disease-predictive genetic testing: the psychiatrist's role in assessment and counseling. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/b978-0-12-801893-4.00008-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Lêdo S, Leite Â, Souto T, Dinis MA, Sequeiros J. Mid- and long-term anxiety levels associated with presymptomatic testing of Huntington's disease, Machado-Joseph disease, and familial amyloid polyneuropathy. ACTA ACUST UNITED AC 2016; 38:113-20. [PMID: 26870910 PMCID: PMC7111364 DOI: 10.1590/1516-4446-2014-1617] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 04/13/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To study anxiety as a variable of the mid- and long-term psychological impact of pre-symptomatic testing for three autosomal dominant late-onset disorders - Huntington's disease (HD), Machado-Joseph disease (MJD) and familial amyloid polyneuropathy (FAP) TTR V30M - in a Portuguese sample. METHODS This cross-sectional study included 203 participants: 170 (83.7%) underwent pre-symptomatic testing for FAP, 29 (14.3%) for HD, and 4 (2%) for MJD. Of the 203 participants, 73 (36.0%) were asymptomatic carriers, 29 (14.5%) were symptomatic carriers, 9 (4.5%) were diagnosed with FAP and had a liver transplant, and 89 (44.5%) were non-carriers. Most were women (58.1%) and married (66.5%). The anxiety variable was assessed using the Zung Self-Rating Anxiety Scale (SAS). RESULTS The anxiety scores were higher for symptomatic carriers and for those who underwent psychological support consultations over the years. For symptomatic carriers, the mean scores were superior to 40 points, which reflects clinical anxiety. CONCLUSION Although it was not possible to differentiate between the mid- and long-term psychological impacts, this study supports the conclusion that the proximity to the age of symptoms onset might be a trigger for anxiety.
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Affiliation(s)
- Susana Lêdo
- Centro de Genética Preditiva e Preventiva (CGPP), Instituto de Biologia Molecular e Celular (IBMC) do Instituto de Investigação e Inovação em Saúde (i3S), Porto , Portugal, Centro de Genética Preditiva e Preventiva (CGPP), Instituto de Biologia Molecular e Celular (IBMC) do Instituto de Investigação e Inovação em Saúde (i3S), Porto, Portugal.,Universidade do Porto, Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto , Portugal, Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
| | - Ângela Leite
- Centro de Genética Preditiva e Preventiva (CGPP), Instituto de Biologia Molecular e Celular (IBMC) do Instituto de Investigação e Inovação em Saúde (i3S), Porto , Portugal, Centro de Genética Preditiva e Preventiva (CGPP), Instituto de Biologia Molecular e Celular (IBMC) do Instituto de Investigação e Inovação em Saúde (i3S), Porto, Portugal.,Universidade Lusófona do Porto (ULP), Universidade Lusófona do Porto, Porto , Portugal, Universidade Lusófona do Porto (ULP), Porto, Portugal
| | - Teresa Souto
- Universidade Lusófona do Porto (ULP), Universidade Lusófona do Porto, Porto , Portugal, Universidade Lusófona do Porto (ULP), Porto, Portugal
| | - Maria A Dinis
- Universidade Fernando Pessoa (UFP), Unidade de Investigação em Energia, Ambiente e Saúde (FP-ENAS), Laboratório de Investigação em Energia, Ambiente e Saúde Ambiental e Pública (3ERL), Universidade Fernando Pessoa, Porto , Portugal, Unidade de Investigação em Energia, Ambiente e Saúde (FP-ENAS), Laboratório de Investigação em Energia, Ambiente e Saúde Ambiental e Pública (3ERL), Universidade Fernando Pessoa (UFP), Porto, Portugal
| | - Jorge Sequeiros
- Centro de Genética Preditiva e Preventiva (CGPP), Instituto de Biologia Molecular e Celular (IBMC) do Instituto de Investigação e Inovação em Saúde (i3S), Porto , Portugal, Centro de Genética Preditiva e Preventiva (CGPP), Instituto de Biologia Molecular e Celular (IBMC) do Instituto de Investigação e Inovação em Saúde (i3S), Porto, Portugal.,Universidade do Porto, Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto , Portugal, Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
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Bajestan S, Lockman J, Dunn LB. Ethical Considerations in Neuropsychiatric Disorders. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2016; 14:477-481. [PMID: 31975828 PMCID: PMC6519585 DOI: 10.1176/appi.focus.20160021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Sepideh Bajestan
- Dr. Bajestan, Dr. Lockman, and Dr. Dunn are with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA (e-mail: )
| | - Juliana Lockman
- Dr. Bajestan, Dr. Lockman, and Dr. Dunn are with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA (e-mail: )
| | - Laura B Dunn
- Dr. Bajestan, Dr. Lockman, and Dr. Dunn are with the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA (e-mail: )
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Su X, Kang PB, Russell JA, Simmons Z. Ethical issues in the evaluation of adults with suspected genetic neuromuscular disorders. Muscle Nerve 2016; 54:997-1006. [PMID: 27615030 DOI: 10.1002/mus.25400] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2016] [Indexed: 12/13/2022]
Abstract
Genetic testing is rapidly becoming an increasingly significant part of the diagnostic armamentarium of neuromuscular clinicians. Although technically easy to order, the results of such testing, whether positive or negative, have potentially enormous consequences for the individual tested and for family members. As a result, ethical considerations must be in the forefront of the physician's agenda when obtaining genetic testing. Informed consent is an important starting point for discussions between physicians and patients, but the counseling embedded in the informed consent process must be an ongoing part of subsequent interactions, including return of results and follow-up. Patient autonomy, including the right to know and right not-to-know results, must be respected. Considerations of capacity, physician beneficence and nonmaleficence, and privacy all play roles in the process. Muscle Nerve 54: 997-1006, 2016.
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Affiliation(s)
- Xiaowei Su
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Peter B Kang
- Division of Pediatric Neurology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - James A Russell
- Section of Neurology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Zachary Simmons
- Departments of Neurology and Humanities, Penn State Hershey Medical Center, 30 Hope Drive, Hershey, Pennsylvania, 17033, USA
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Abstract
BACKGROUND Concerns about suicide risk in people with dementia have been increasing in recent years along with a discourse about rational suicide and assisted suicide. METHODS A systematic narrative literature review of suicidal behavior and assisted suicide in persons with dementia. RESULTS Most studies that have examined the spectrum of suicidal ideation, attempted suicide and suicide in dementia have methodological limitations but the overall suicide risk does not appear to be increased. When suicidal behavior does occur, common themes include the presence of psychiatric comorbidity, mainly depression; occurrence early in the dementia course with preserved insight and capacity; and an increased risk in younger people. The emerging discourse on rational and assisted suicide has been spurred by early and pre-symptomatic diagnosis and poses a number of ethical challenges for clinicians including the role of proxy decision-makers. CONCLUSIONS Although dementia might not confer a significant overall risk for suicidal behavior, clinicians still need to consider the potential for suicide in vulnerable individuals particularly early in the dementia course.
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Abstract
Huntington disease (HD) is an autosomal dominant inherited neurodegenerative disease characterized by progressive motor, behavioral, and cognitive decline, culminating in death. It is caused by an expanded CAG repeat in the huntingtin gene. Even years before symptoms become overt, mutation carriers show subtle but progressive striatal and cerebral white matter atrophy by volumetric MRI. Although there is currently no direct treatment of HD, management options are available for several symptoms. A better understanding of HD pathogenesis, and more sophisticated clinical trials using newer biomarkers, may lead to meaningful treatments. This article reviews the current knowledge of HD pathogenesis and treatment.
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Affiliation(s)
- Praveen Dayalu
- Department of Neurology, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
| | - Roger L Albin
- Department of Neurology, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA; Neuroscience Research, Veterans Affairs Medical Center, 2215 Fuller Road, Ann Arbor, MI 48105, USA
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Clément S, Gargiulo M, Feingold J, Durr A. Guidelines for presymptomatic testing for Huntington's disease: past, present and future in France. Rev Neurol (Paris) 2015; 171:572-80. [PMID: 26002494 DOI: 10.1016/j.neurol.2015.02.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 01/22/2015] [Accepted: 02/04/2015] [Indexed: 11/30/2022]
Abstract
Huntington's disease was the first adult onset neurological disease for which presymptomatic genetic testing became possible. It served as a model for the approach which constituted a radical change in medical practice and provided an important framework for multi-step, multidisciplinary, counselling for at risk persons. We will review the historical context of guidelines and good clinical practices, the experiences of our team which covers more than 20 years of presymptomatic testing for Huntington's disease in France, and explore the impact of the new French legislation for the future of presymptomatic testing of diseases for which neither preventive measures nor curative treatments are yet available.
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Affiliation(s)
- S Clément
- EA1610, département de recherche en éthique, centre scientifique d'Orsay, université Paris Sud, bâtiment 407, 91405 Orsay cedex, France
| | - M Gargiulo
- EA 4056, laboratoire de psychologie clinique et psychopathologie, institut de psychologie, Sorbonne Paris Cité, université Paris Descartes, 71, avenue Édouard-Vaillant, 92774 Boulogne-Billancourt cedex, France; Département de génétique et cytogénétique, groupe hospitalier de la Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France; Institut de myologie, groupe hospitalier de la Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France
| | - J Feingold
- Département de génétique et cytogénétique, groupe hospitalier de la Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France
| | - A Durr
- Département de génétique et cytogénétique, groupe hospitalier de la Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France; Institut de myologie, groupe hospitalier de la Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France; Inserm U1127, CNRS UMR7225, UMR_S975, institut du cerveau et de la moelle épinière, hôpital de la Salpêtrière, UPMC - Paris VI, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France.
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Grubs RE, Parker LS, Hamilton R. Subtle Psychosocial Sequelae of Genetic Test Results. CURRENT GENETIC MEDICINE REPORTS 2014. [DOI: 10.1007/s40142-014-0053-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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41
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Genetics of Huntington's disease and related disorders. Drug Discov Today 2014; 19:985-9. [PMID: 24657309 DOI: 10.1016/j.drudis.2014.03.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Accepted: 03/07/2014] [Indexed: 02/05/2023]
Abstract
Huntington's disease is the most frequent form of the hereditary choreas and has a multifaceted phenotype including cognitive and psychiatric impairment. The disorder is due to a dynamic mutation, which also influences the onset age of the disorder. Other genetic modifiers of the HD phenotypes have been suggested but often not confirmed by independent studies. Several syndromes with similar presentation have different genetic backgrounds, including the neuroacanthocytoses, mainly choreoacanthocytosis and MacLeod syndrome as a result of mutations in chorein and Kell protein, respectively, but also benign hereditary chorea, owing to mutations in NKX-2-1, and paroxysmal kinesigenic dyskinesia, as a result of recently found mutations in the proline-rich transmembrane protein 2, PRRT2. Chorea can also be a major feature in other neurogenetic disorders, including the spinocerebellar ataxias and also in neurometabolic disorders.
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Importance of psychiatric examination in predictive genetic testing for Huntington disease. Neurol Neurochir Pol 2014; 47:534-41. [PMID: 24374998 DOI: 10.5114/ninp.2013.39070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND PURPOSE Huntington disease (HD) is an au-tosomal dominant hereditary neurodegenerative disease with multiplication of CAG triplet in the short arm of chromoso-me 4, manifested by motor symptoms, cognitive dysfunction progressing to dementia, and various types of neuropsychiat-ric disorders. The diagnosis of HD is confirmed by a gene-tic test, which may also be carried out presymptomatically. MATERIAL AND METHODS We studied differences in psychiatric examination and psychometric measures among the 52 people at risk of HD, who were recommended to postpone or to continue in the predictive protocol. In addition to the psychiatric examination, we administered the Eysenck Personality Questionnaire (EPQ-A), the Symptom Checklist 90 (SCL-90), and quality of life questionnaire (MANSA). RESULTS People at risk of HD with the recommended test postponement showed lower rate of neuroticism and EPQ-A lie score, higher values on the phobia and the so-called 'positive symptom distress index' in SCL-90 and lower quality of life than people at risk of HD with the recommendation to continue. CONCLUSIONS Our results indicate that the formalized testing does not bring significant information whereas the clinical psychiatric examination remains the main decisive factor in the recommendation to perform a predictive genetic test. The motivation of applicants is considered as the most important factor in the decision-making process.
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Sheffield L, Ayres SR. Predictive testing: more than just another test. Intern Med J 2013; 43:1261-2. [PMID: 24330359 DOI: 10.1111/imj.12312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 10/09/2013] [Indexed: 11/29/2022]
Affiliation(s)
- L Sheffield
- GenesFX Health Pty Ltd, Melbourne, Victoria, Australia
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Wedderburn S, Panegyres PK, Andrew S, Goldblatt J, Liebeck T, McGrath F, Wiltshire M, Pestell C, Lee J, Beilby J. Predictive gene testing for Huntington disease and other neurodegenerative disorders. Intern Med J 2013; 43:1272-9. [DOI: 10.1111/imj.12176] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Accepted: 03/18/2013] [Indexed: 11/26/2022]
Affiliation(s)
- S. Wedderburn
- Western Australian Department of Health; Neurosciences Unit; Perth Western Australia Australia
| | - P. K. Panegyres
- Western Australian Department of Health; Neurosciences Unit; Perth Western Australia Australia
- Neurodegenerative Disorders Research Pty Ltd; Perth Western Australia Australia
| | - S. Andrew
- Western Australian Department of Health; Neurosciences Unit; Perth Western Australia Australia
| | - J. Goldblatt
- King Edward Memorial Hospital; Perth Western Australia Australia
| | - T. Liebeck
- Western Australian Department of Health; Neurosciences Unit; Perth Western Australia Australia
| | - F. McGrath
- Western Australian Department of Health; Neurosciences Unit; Perth Western Australia Australia
| | - M. Wiltshire
- Western Australian Department of Health; Neurosciences Unit; Perth Western Australia Australia
| | - C. Pestell
- Western Australian Department of Health; Neurosciences Unit; Perth Western Australia Australia
| | - J. Lee
- Western Australian Department of Health; Neurosciences Unit; Perth Western Australia Australia
| | - J. Beilby
- Molecular Genetics; PathWest; Queen Elizabeth Medical Centre; Perth Western Australia Australia
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Paulsen JS, Nance M, Kim JI, Carlozzi NE, Panegyres PK, Erwin C, Goh A, McCusker E, Williams JK. A review of quality of life after predictive testing for and earlier identification of neurodegenerative diseases. Prog Neurobiol 2013; 110:2-28. [PMID: 24036231 PMCID: PMC3833259 DOI: 10.1016/j.pneurobio.2013.08.003] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 08/26/2013] [Accepted: 08/26/2013] [Indexed: 12/12/2022]
Abstract
The past decade has witnessed an explosion of evidence suggesting that many neurodegenerative diseases can be detected years, if not decades, earlier than previously thought. To date, these scientific advances have not provoked any parallel translational or clinical improvements. There is an urgency to capitalize on this momentum so earlier detection of disease can be more readily translated into improved health-related quality of life for families at risk for, or suffering with, neurodegenerative diseases. In this review, we discuss health-related quality of life (HRQOL) measurement in neurodegenerative diseases and the importance of these "patient reported outcomes" for all clinical research. Next, we address HRQOL following early identification or predictive genetic testing in some neurodegenerative diseases: Huntington disease, Alzheimer's disease, Parkinson's disease, Dementia with Lewy bodies, frontotemporal dementia, amyotrophic lateral sclerosis, prion diseases, hereditary ataxias, Dentatorubral-pallidoluysian atrophy and Wilson's disease. After a brief report of available direct-to-consumer genetic tests, we address the juxtaposition of earlier disease identification with assumed reluctance toward predictive genetic testing. Forty-one studies examining health-related outcomes following predictive genetic testing for neurodegenerative disease suggested that (a) extreme or catastrophic outcomes are rare; (b) consequences commonly include transiently increased anxiety and/or depression; (c) most participants report no regret; (d) many persons report extensive benefits to receiving genetic information; and (e) stigmatization and discrimination for genetic diseases are poorly understood and policy and laws are needed. Caution is appropriate for earlier identification of neurodegenerative diseases but findings suggest further progress is safe, feasible and likely to advance clinical care.
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Affiliation(s)
- Jane S Paulsen
- Department of Neurology, University of Iowa, Carver College of Medicine, Iowa City, IA, USA; Department of Psychiatry, University of Iowa, Carver College of Medicine, Iowa City, IA, USA; Department of Psychology, University of Iowa, Iowa City, IA, USA.
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Bechtel K, Geschwind MD. Ethics in prion disease. Prog Neurobiol 2013; 110:29-44. [PMID: 23906487 PMCID: PMC3818451 DOI: 10.1016/j.pneurobio.2013.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 07/05/2013] [Accepted: 07/06/2013] [Indexed: 12/13/2022]
Abstract
This paper is intended to discuss some of the scientific and ethical issues that are created by increased research efforts towards earlier diagnosis, as well as to treatment of, human prion diseases (and related dementias), including the resulting consequences for individuals, their families, and society. Most patients with prion disease currently are diagnosed when they are about 2/3 of the way through their disease course (Geschwind et al., 2010a; Paterson et al., 2012b), when the disease has progressed so far that even treatments that stop the disease process would probably have little benefit. Although there are currently no treatments available for prion diseases, we and others have realized that we must diagnose patients earlier and with greater accuracy so that future treatments have hope of success. As approximately 15% of prion diseases have a autosomal dominant genetic etiology, this further adds to the complexity of ethical issues, particularly regarding when to conduct genetic testing, release of genetic results, and when or if to implement experimental therapies. Human prion diseases are both infectious and transmissible; great care is required to balance the needs of the family and individual with both public health needs and strained hospital budgets. It is essential to proactively examine and address the ethical issues involved, as well as to define and in turn provide best standards of care.
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Affiliation(s)
- Kendra Bechtel
- Memory and Aging Center, University of California, San Francisco, United States
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López-Sendón Moreno JL, García de Yébenes J. Treatment options in Huntington's disease. Expert Opin Orphan Drugs 2013. [DOI: 10.1517/21678707.2013.851598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Hubers AAM, van Duijn E, Roos RAC, Craufurd D, Rickards H, Bernhard Landwehrmeyer G, van der Mast RC, Giltay EJ. Suicidal ideation in a European Huntington's disease population. J Affect Disord 2013; 151:248-58. [PMID: 23876196 DOI: 10.1016/j.jad.2013.06.001] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 05/31/2013] [Accepted: 06/01/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Previous studies indicate increased prevalences of suicidal ideation, suicide attempts, and completed suicide in Huntington's disease (HD) compared with the general population. This study investigates correlates and predictors of suicidal ideation in HD. METHODS The study cohort consisted of 2106 HD mutation carriers, all participating in the REGISTRY study of the European Huntington's Disease Network. Of the 1937 participants without suicidal ideation at baseline, 945 had one or more follow-up measurements. Participants were assessed for suicidal ideation by the behavioural subscale of the Unified Huntington's Disease Rating Scale (UHDRS). Correlates of suicidal ideation were analyzed using logistic regression analysis and predictors were analyzed using Cox regression analysis. RESULTS At baseline, 169 (8.0%) mutation carriers endorsed suicidal ideation. Disease duration (odds ratio [OR]=0.96; 95% confidence interval [CI]: 0.9-1.0), anxiety (OR=2.14; 95%CI: 1.4-3.3), aggression (OR=2.41; 95%CI: 1.5-3.8), a previous suicide attempt (OR=3.95; 95%CI: 2.4-6.6), and a depressed mood (OR=13.71; 95%CI: 6.7-28.0) were independently correlated to suicidal ideation at baseline. The 4-year cumulative incidence of suicidal ideation was 9.9%. Longitudinally, the presence of a depressed mood (hazard ratio [HR]=2.05; 95%CI: 1.1-4.0) and use of benzodiazepines (HR=2.44; 95%CI: 1.2-5.0) at baseline were independent predictors of incident suicidal ideation, whereas a previous suicide attempt was not predictive. LIMITATIONS As suicidal ideation was assessed by only one item, and participants were a selection of all HD mutation carriers, the prevalence of suicidal ideation was likely underestimated. CONCLUSIONS Suicidal ideation in HD frequently occurs. Assessment of suicidal ideation is a priority in mutation carriers with a depressed mood and in those using benzodiazepines.
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Affiliation(s)
- Anna A M Hubers
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands.
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The impact and desirability of news of risk for schizophrenia. PLoS One 2013; 8:e62904. [PMID: 23638164 PMCID: PMC3639267 DOI: 10.1371/journal.pone.0062904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Accepted: 03/26/2013] [Indexed: 11/19/2022] Open
Abstract
In studies of schizotypy, investigators seldom inform participants that they are engaged in research designed to shed light on risk for schizophrenia. Such nondisclosure is justified in part by the argument that disclosure of risk status may be harmful. However, there is little evidence that this is the case. Harm arising from disclosure of risk status was examined in two experiments. In the first, participants (n = 114 psychology undergraduates) were asked to anticipate their reactions to news of risk for schizophrenia, depression, cancer, and diabetes, and also to indicate whether they would want to know their schizophrenia risk status. Participants anticipated schizophrenia risk would have a negative impact that was significantly greater than depression or diabetes risk but similar to cancer risk. The anticipated impact of schizophrenia risk was predicted by expectations of stigmatization as well as confidence in the accuracy of biological screening. Although 81% indicated a preference for knowing their risk status, just 11% were prepared to undergo an assessment to find out. In the second, a between-subjects deception paradigm was used to inform participants (n = 144 psychology undergraduates) they had an enzyme deficiency that placed them at increased risk for schizophrenia, cancer, or depression. Impact was assessed using prospective self-report and salivary cortisol and retrospective self-report. Impact was modeled using measures of stigmatization and health locus of control. Retrospectively, schizophrenia, cancer, and depression risk had strong negative impacts relative to a control group, but there was no effect on prospective measures. Together, the findings suggest that news of risk for schizophrenia has the potential to engender distress, although participants’ anticipations and reflections of responses are not corroborated in prospectively measured outcomes.
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Roberts JS, Uhlmann WR. Genetic susceptibility testing for neurodegenerative diseases: ethical and practice issues. Prog Neurobiol 2013; 110:89-101. [PMID: 23583530 DOI: 10.1016/j.pneurobio.2013.02.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2012] [Revised: 01/22/2013] [Accepted: 02/25/2013] [Indexed: 12/12/2022]
Abstract
As the genetics of neurodegenerative disease become better understood, opportunities for genetic susceptibility testing for at-risk individuals will increase. Such testing raises important ethical and practice issues related to test access, informed consent, risk estimation and communication, return of results, and policies to prevent genetic discrimination. The advent of direct-to-consumer genetic susceptibility testing for various neurodegenerative disorders (including Alzheimer's disease (AD), Parkinson's disease, and certain prion diseases) means that ethical and practical challenges must be faced not only in traditional research and clinical settings, but also in broader society. This review addresses several topics relevant to the development and implementation of genetic susceptibility tests across research, clinical, and consumer settings; these include appropriate indications for testing, the implications of different methods for disclosing test results, clinical versus personal utility of risk information, psychological and behavioral responses to test results, testing of minors, genetic discrimination, and ethical dilemmas posed by whole-genome sequencing. We also identify future areas of likely growth in the field, including pharmacogenomics and genetic screening for individuals considering or engaged in activities that pose elevated risk of brain injury (e.g., football players, military personnel). APOE gene testing for risk of Alzheimer's disease is used throughout as an instructive case example, drawing upon the authors' experience as investigators in a series of multisite randomized clinical trials that have examined the impact of disclosing APOE genotype status to interested individuals (e.g., first-degree relatives of AD patients, persons with mild cognitive impairment).
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Affiliation(s)
- J Scott Roberts
- Department of Health Behavior & Health Education, University of Michigan School of Public Health, 1415 Washington Heights, SPH I Building, Room 3854, Ann Arbor, MI 48109, USA.
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