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Ewuoso C. Ubuntu philosophy and the consensus regarding incidental findings in genomic research: a heuristic approach. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2020; 23:433-444. [PMID: 32335796 DOI: 10.1007/s11019-020-09953-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
This study adopts a heuristic technique to argue the thesis that a set of norms rooted in the African philosophy of Ubuntu can usefully supplement current research guidelines for dealing with incidental findings discovered in genomic research. The consensus regarding incidental findings is that there is an ethical obligation to return individual genetic incidental findings that meet the threshold of analytic and clinical validity, have clinical utility, and are actionable, provided that research contributors have not opted out from receiving such information. This study outlines the hurdles that may hinder the integration of this consensus in mainstream clinical practice, and shows how an ethical theory from the global south may be used to address the same. This will advance the field of ethical, legal and social issues of personalized medicine by providing exposure to the under-represented African perspective on the ethical, legal, and social issues of genomics.
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Affiliation(s)
- Cornelius Ewuoso
- Department of Philosophy, University of Johannesburg, Johannesburg, South Africa.
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2
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Alahmad G, Alzahrany H, Almutairi AF. Returning Results of Stored Biological Samples and Biobanks: Perspectives of Saudi Arabian Biomedical Researchers. Biopreserv Biobank 2020; 18:395-402. [PMID: 32706976 DOI: 10.1089/bio.2020.0002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Scientific medical research involving human samples often leads to improved diagnosis, the discovery of treatment modalities, or the identification of possible risk factors for many diseases. Some findings, including incidental findings, may be important to donors, and some may require intervention. This study aimed to explore the perspectives of health care professionals in their use of stored biological samples for biomedical research regarding the concept of the research results and the challenges of informing donors regarding the results. This qualitative study involved 19 medical researchers doing research with stored biological samples and biobanks. The data were gathered during face-to-face interviews in English using a semistructured interview technique. The participants provided rich and illuminating experiences, framed in the following themes: the professional duty of researchers to return the research results and the right of donors to know; factors affecting informing donors of results (e.g., severity of disease; impact of the provided information; reliability of the research results; and donor approval); challenges to physically returning the results; and the nature of the informed consent, as well as the elements required in the informed consent documentation. Although the majority of researchers agree on the importance of returning research results, some have contradictory views such as that returning research results is not the researcher's responsibility. The study results also support the view that a number of elements should be included in the informed consent, such as the intention of informing the donors of the results as well as the benefits and risks.
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Affiliation(s)
- Ghiath Alahmad
- King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia
| | - Haneen Alzahrany
- King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia
| | - Adel F Almutairi
- King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia
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3
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Reid AE, Ferrer RA, Kadirvel S, Biesecker BB, Lewis KL, Biesecker LG, Klein WMP. Roles of attitudes and injunctive norms in decisional conflict and disclosure following receipt of genome sequencing results. Soc Sci Med 2020; 262:113147. [PMID: 32624263 DOI: 10.1016/j.socscimed.2020.113147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 05/05/2020] [Accepted: 06/13/2020] [Indexed: 10/24/2022]
Abstract
RATIONALE Individuals who choose to obtain genetic information may learn that their genetic profile confers health risks to themselves or offspring. Individuals may react more negatively to this information when personal attitudes, perceived norms, and/or the decision to receive results conflict with one another. OBJECTIVE We predicted that holding more negative attitudes (personal evaluations) or injunctive norms (perceptions of others' approval) toward obtaining genetic test results would prospectively predict greater conflict about the decision to undergo sequencing and less disclosure of sequencing results to family members. We also expected attitudes and norms to interact, such that attitudes would be negatively associated with decisional conflict and positively associated with disclosure when injunctive norms were positive, but weakly associated with outcomes when injunctive norms were negative. METHOD Participants (N=312) were enrolled in a genomic sequencing trial focused on identifying carrier genetic variants, reflecting a variant that might affect their biological children's or grandchildren's health. Participants reported attitudes and injunctive norms, underwent sequencing, and later received results indicating carrier status for at least one variant. Decisional conflict was assessed at immediate post-test, and 1- and 6-month follow-ups. Disclosure of results to children and siblings were assessed at 1 and 6 months. RESULTS In structural equation models with covariates, attitudes were negatively associated with post-test and 1-month decisional conflict. Injunctive norms were negatively associated with decisional conflict at 1 and 6 months and positively associated with disclosure to children and siblings at 1 month. The significant attitudes by injunctive norms interaction predicting post-test decisional conflict supported lower decisional conflict when attitudes, norms, and the decision to receive results were all aligned. Exploratory analyses supported indirect effects of attitudes and norms on 6-month sibling disclosure via 1- month decisional conflict. CONCLUSION Results support roles of psychosocial factors in decisional conflict and disclosure after receiving sequencing results.
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Affiliation(s)
- Allecia E Reid
- Department of Psychological and Brain Sciences, University of Massachusetts, Amherst, USA.
| | | | - Sanjana Kadirvel
- Department of Psychological and Brain Sciences, University of Massachusetts, Amherst, USA
| | | | - Katie L Lewis
- National Human Genome Research Institute, National Institutes of Health, USA
| | - Leslie G Biesecker
- National Human Genome Research Institute, National Institutes of Health, USA
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4
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Lantos JD. Ethical and Psychosocial Issues in Whole Genome Sequencing (WGS) for Newborns. Pediatrics 2019; 143:S1-S5. [PMID: 30600264 DOI: 10.1542/peds.2018-1099b] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/03/2018] [Indexed: 11/24/2022] Open
Abstract
In this article, I review some of the ethical issues that have arisen in the past when genetic testing has been done in newborns. I then suggest how whole genome sequencing may raise a new set of issues. Finally, I introduce a series of other articles in which the authors address different controversies that arise when whole genome sequencing is used in the newborn period.
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Affiliation(s)
- John D Lantos
- Bioethics Center, Children's Mercy Hospital and University of Missouri - Kansas City, Kansas City, Missouri
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5
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Reid AE, Taber JM, Ferrer RA, Biesecker BB, Lewis KL, Biesecker LG, Klein WMP. Associations of perceived norms with intentions to learn genomic sequencing results: Roles for attitudes and ambivalence. Health Psychol 2018; 37:553-561. [PMID: 29745680 PMCID: PMC5962407 DOI: 10.1037/hea0000579] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Genomic sequencing is becoming increasingly accessible, highlighting the need to understand the social and psychological factors that drive interest in receiving testing results. These decisions may depend on perceived descriptive norms (how most others behave) and injunctive norms (what is approved of by others). We predicted that descriptive norms would be directly associated with intentions to learn genomic sequencing results, whereas injunctive norms would be associated indirectly, via attitudes. These differential associations with intentions versus attitudes were hypothesized to be strongest when individuals held ambivalent attitudes toward obtaining results. METHOD Participants enrolled in a genomic sequencing trial (n = 372) reported intentions to learn medically actionable, nonmedically actionable, and carrier sequencing results. Descriptive norms items referenced other study participants. Injunctive norms were analyzed separately for close friends and family members. Attitudes, attitudinal ambivalence, and sociodemographic covariates were also assessed. RESULTS In structural equation models, both descriptive norms and friend injunctive norms were associated with intentions to receive all sequencing results (ps < .004). Attitudes consistently mediated all friend injunctive norms-intentions associations, but not the descriptive norms-intentions associations. Attitudinal ambivalence moderated the association between friend injunctive norms (p ≤ .001), but not descriptive norms (p = .16), and attitudes. Injunctive norms were significantly associated with attitudes when ambivalence was high, but were unrelated when ambivalence was low. Results replicated for family injunctive norms. CONCLUSIONS Descriptive and injunctive norms play roles in genomic sequencing decisions. Considering mediators and moderators of these processes enhances ability to optimize use of normative information to support informed decision making. (PsycINFO Database Record
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Affiliation(s)
| | | | | | | | - Katie L. Lewis
- National Human, Research Institute, National Institutes of Health
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6
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Pennington JW, Karavite DJ, Krause EM, Miller J, Bernhardt BA, Grundmeier RW. Genomic decision support needs in pediatric primary care. J Am Med Inform Assoc 2018; 24:851-856. [PMID: 28339689 DOI: 10.1093/jamia/ocw184] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 12/23/2016] [Indexed: 11/12/2022] Open
Abstract
Clinical genome and exome sequencing can diagnose pediatric patients with complex conditions that often require follow-up care with multiple specialties. The American Academy of Pediatrics emphasizes the role of the medical home and the primary care pediatrician in coordinating care for patients who need multidisciplinary support. In addition, the electronic health record (EHR) with embedded clinical decision support is recognized as an important component in providing care in this setting. We interviewed 6 clinicians to assess their experience caring for patients with complex and rare genetic findings and hear their opinions about how the EHR currently supports this role. Using these results, we designed a candidate EHR clinical decision support application mock-up and conducted formative exploratory user testing with 26 pediatric primary care providers to capture opinions on its utility in practice with respect to a specific clinical scenario. Our results indicate agreement that the functionality represented by the mock-up would effectively assist with care and warrants further development.
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Affiliation(s)
- Jeffrey W Pennington
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Dean J Karavite
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Edward M Krause
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jeffrey Miller
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Barbara A Bernhardt
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Robert W Grundmeier
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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7
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Zahed H, Sparks TN, Li B, Alsadah A, Shieh JTC. Potential Role of Genomic Sequencing in the Early Diagnosis of Treatable Genetic Conditions. J Pediatr 2017; 189:222-226.e1. [PMID: 28947054 PMCID: PMC6037534 DOI: 10.1016/j.jpeds.2017.06.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 04/02/2017] [Accepted: 06/15/2017] [Indexed: 12/18/2022]
Abstract
We present cases of 3 children diagnosed with the same genetic condition, Gitelman syndrome, at different stages using various genetic methods: panel testing, targeted single gene sequencing, and exome sequencing. We discuss the advantages and disadvantages of each method and review the potential of genomic sequencing for early disease detection.
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Affiliation(s)
- Hengameh Zahed
- Division of Medical Genetics, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Teresa N. Sparks
- Division of Medical Genetics, Department of Pediatrics, University of California San Francisco, San Francisco, CA
,Department of Obstetrics, Gynecology and Reproductive Medicine, University of California San Francisco, San Francisco, CA
| | - Ben Li
- Division of Medical Genetics, Department of Pediatrics, University of California San Francisco, San Francisco, CA
,Department of Obstetrics, Gynecology and Reproductive Medicine, University of California San Francisco, San Francisco, CA
| | - Adnan Alsadah
- Division of Medical Genetics, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Joseph T. C. Shieh
- Division of Medical Genetics, Department of Pediatrics, University of California San Francisco, San Francisco, CA
,Institute for Human Genetics, Benioff Children’s Hospital San Francisco, University of California San Francisco, San Francisco, CA
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Abstract
Information empowerment has been the greatest gain of genomics, yet it also poses serious threat to its survival, especially when the information is incidental. There may be an emerging consensus that actionable incidental findings be returned. But this has not been supported by any systematic review. Future directions are equally missing. These are significant gaps. To fill these gaps, an online search on PubMed and Genetics in Medicine website was conducted between 20th of August to 23rd of October, 2013; combining certain filters and phrases, such as ‘return incidental findings’. Nineteen (19) articles were selected from an avalanche of results, and reviewed. The review confirms a majority support for return of clinically actionable findings. The result also shows that the support represents views of Northern Americans. Critical contributions of Africans, Asians and Europeans are missing in this discourse. I recommended studies in this direction.
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Affiliation(s)
- Cornelius Ewuoso
- Department of Philosophy, Stellenbosch University, Stellenbosch, Western Cape, South Africa
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9
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Sénécal K, Thys K, Vears DF, Van Assche K, Knoppers BM, Borry P. Legal approaches regarding health-care decisions involving minors: implications for next-generation sequencing. Eur J Hum Genet 2016; 24:1559-1564. [PMID: 27302841 PMCID: PMC5110060 DOI: 10.1038/ejhg.2016.61] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/26/2016] [Accepted: 04/12/2016] [Indexed: 12/03/2022] Open
Abstract
The development of next-generation sequencing (NGS) technologies are revolutionizing medical practice, facilitating more accurate, sophisticated and cost-effective genetic testing. NGS is already being implemented in the clinic assisting diagnosis and management of disorders with a strong heritable component. Although considerable attention has been paid to issues regarding return of incidental or secondary findings, matters of consent are less well explored. This is particularly important for the use of NGS in minors. Recent guidelines addressing genomic testing and screening of children and adolescents have suggested that as 'young children' lack decision-making capacity, decisions about testing must be conducted by a surrogate, namely their parents. This prompts consideration of the age at which minors can provide lawful consent to health-care interventions, and consequently NGS performed for diagnostic purposes. Here, we describe the existing legal approaches regarding the rights of minors to consent to health-care interventions, including how laws in the 28 Member States of the European Union and in Canada consider competent minors, and then apply this to the context of NGS. There is considerable variation in the rights afforded to minors across countries. Many legal systems determine that minors would be allowed, or may even be required, to make decisions about interventions such as NGS. However, minors are often considered as one single homogeneous population who always require parental consent, rather than recognizing there are different categories of 'minors' and that capacity to consent or to be involved in discussions and decision-making process is a spectrum rather than a hurdle.
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Affiliation(s)
- Karine Sénécal
- Centre of Genomics and Policy, Department of Human Genetics, McGill University, Montreal, Quebec, Canada
| | - Kristof Thys
- Centre for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Danya F Vears
- Centre for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Kristof Van Assche
- Research Group on Personality Rights and Property Rights, Faculty of Law, University of Antwerp, Antwerp, Belgium
| | - Bartha M Knoppers
- Centre of Genomics and Policy, Department of Human Genetics, McGill University, Montreal, Quebec, Canada
| | - Pascal Borry
- Centre for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
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10
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Shearer AE, Smith RJH. Massively Parallel Sequencing for Genetic Diagnosis of Hearing Loss: The New Standard of Care. Otolaryngol Head Neck Surg 2015; 153:175-82. [PMID: 26084827 PMCID: PMC4743024 DOI: 10.1177/0194599815591156] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 05/22/2015] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To evaluate the use of new genetic sequencing techniques for comprehensive genetic testing for hearing loss. DATA SOURCES Articles were identified from PubMed and Google Scholar databases using pertinent search terms. REVIEW METHODS Literature search identified 30 studies as candidates that met search criteria. Three studies were excluded, and 8 studies were found to be case reports. Twenty studies were included for review analysis, including 7 studies that evaluated controls and 16 studies that evaluated patients with unknown causes of hearing loss; 3 studies evaluated both controls and patients. CONCLUSIONS In the 20 studies included in the review analysis, 426 control samples and 603 patients with unknown causes of hearing loss underwent comprehensive genetic diagnosis for hearing loss using massively parallel sequencing. Control analysis showed a sensitivity and specificity >99%, sufficient for clinical use of these tests. The overall diagnostic rate was 41% (range, 10%-83%) and varied based on several factors, including inheritance and prescreening prior to comprehensive testing. There were significant differences in platforms available with regard to the number and type of genes included and whether copy number variations were examined. Based on these results, comprehensive genetic testing should form the cornerstone of a tiered approach to clinical evaluation of patients with hearing loss along with history, physical examination, and audiometry and can determine further testing that may be required, if any. IMPLICATIONS FOR PRACTICE Comprehensive genetic testing has become the new standard of care for genetic testing for patients with sensorineural hearing loss.
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Affiliation(s)
- A Eliot Shearer
- Department of Otolaryngology-Head and Neck Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Richard J H Smith
- Department of Otolaryngology-Head and Neck Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA Interdepartmental PhD Program in Genetics, University of Iowa, Iowa City, Iowa, USA Department of Molecular Physiology & Biophysics, University of Iowa College of Medicine, Iowa City, Iowa, USA
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11
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Day E, Kearns PK, Taylor CJ, Bradley JA. Transplantation Between Monozygotic Twins. Transplantation 2014; 98:485-9. [DOI: 10.1097/tp.0000000000000274] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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12
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Córdoba M, González Morón D, Rodríguez-Quiroga SA, Kauffman MA. Neurología genómica personalizada: el futuro es ahora. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.neuarg.2014.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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13
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Strong KA, Zusevics KL, Bick D, Veith R. Views of primary care providers regarding the return of genome sequencing incidental findings. Clin Genet 2014; 86:461-8. [PMID: 24673592 DOI: 10.1111/cge.12390] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 02/13/2014] [Accepted: 03/25/2014] [Indexed: 01/18/2023]
Abstract
Sequencing of the entire exome or genome is increasingly used in clinical practice. Debate continues, however, regarding which incidental findings (IFs) should be returned and who should be involved in those decisions. Previous empirical research regarding stakeholder attitudes to the return of IFs has primarily involved genetics professionals; non-genetics health professionals have not been widely surveyed. Given this, a survey regarding return of IFs was administered at the Best Practices in Pediatrics Conference following an educational presentation on genetics terminology and genetic condition examples. A total of 258 participants completed the survey. Of particular note, respondents who were positively disposed to sequencing did not always report wanting to learn about IFs, even if actionable. This is noteworthy given recent American College of Medical Genetics and Genomics guidelines recommending particular actionable IF be returned 'without reference to patient preference'. This study's findings are important because they provide insight regarding the attitudes to the return of genome sequencing results for an important professional group, primary care providers. Ultimately, as likely gatekeepers to referrals for this technology, their opinions about the test will be key to its successful deployment.
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Affiliation(s)
- K A Strong
- Program in Genomics and Ethics, Center for Bioethics and Medical Humanities, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI, USA; Human and Molecular Genetics Center, Medical College of Wisconsin, Milwaukee, WI, USA
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14
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Solomon BD. Obstacles and opportunities for the future of genomic medicine. Mol Genet Genomic Med 2014; 2:205-9. [PMID: 24936509 PMCID: PMC4049360 DOI: 10.1002/mgg3.78] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 03/25/2014] [Indexed: 12/15/2022] Open
Affiliation(s)
- Benjamin D Solomon
- Division of Medical Genomics, Inova Translational Medicine Institute, Inova Health System Falls Church, Virginia ; Department of Pediatrics, Inova Children's Hospital, Inova Health System Falls Church, Virginia
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15
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Solomon BD. Enhancing the incidental pipeline in genomic sequencing. Mol Syndromol 2014; 5:47-50. [PMID: 24715850 DOI: 10.1159/000357929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2013] [Indexed: 11/19/2022] Open
Affiliation(s)
- B D Solomon
- Division of Medical Genomics, Inova Translational Medicine Institute, Inova Health System, and Department of Pediatrics, Inova Children's Hospital, Falls Church, Va., USA
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16
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Whole-genome sequencing in health care: recommendations of the European Society of Human Genetics. Eur J Hum Genet 2013; 21:580-4. [PMID: 23676617 DOI: 10.1038/ejhg.2013.46] [Citation(s) in RCA: 250] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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17
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Abstract
The development of novel technologies for high-throughput DNA sequencing is having a major impact on our ability to measure and define normal and pathologic variation in humans. This review discusses advances in DNA sequencing that have been applied to benign hematologic disorders, including those affecting the red blood cell, the neutrophil, and other white blood cell lineages. Relevant examples of how these approaches have been used for disease diagnosis, gene discovery, and studying complex traits are provided. High-throughput DNA sequencing technology holds significant promise for impacting clinical care. This includes development of improved disease detection and diagnosis, better understanding of disease progression and stratification of risk of disease-specific complications, and development of improved therapeutic strategies, particularly patient-specific pharmacogenomics-based therapy, with monitoring of therapy by genomic biomarkers.
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18
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Abstract
Whole genome/exome sequencing (WGS/WES) integration into medicine will yield a new disease paradigm moving from clinical to molecular diagnosis. This paradigm will present significant challenges in the interpretation of sequence data and clinicians will face dilemmas about if, when and how to offer information to patients. Sequencing will ultimately reshape psychiatry in predicting disease risk and lead to greater understanding of aetiology, prognosis and/or treatment response. This commentary on the ethics of returning WGS/WES results describes the nature of the data as a dynamic health resource, the importance of understanding participant motivations, determinations of personal utility and potential effects of WGS/WES on self-concept and well-being. As this technology unfurls, ethical challenges will not be novel but they will be compounded by the volume and scope of the data. Research into participant/patient perceptions, preferences and outcomes will identify areas of caution and prepare psychiatrists for eventual integration into clinical care.
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Affiliation(s)
- Barbara Bowles Biesecker
- Social and Behavioral Research Branch, National Human Genome Research Institute, Bethesda, MD 20892, USA.
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19
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Schiffman JD, Geller JI, Mundt E, Means A, Means L, Means V. Update on pediatric cancer predisposition syndromes. Pediatr Blood Cancer 2013; 60:1247-52. [PMID: 23625733 DOI: 10.1002/pbc.24555] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 03/08/2013] [Indexed: 12/21/2022]
Abstract
Hereditary cancer syndromes in children and adolescents are becoming more recognized in the field of pediatric hematology/oncology. A recent workshop held at the American Society of Pediatric Hematology/Oncology (ASPHO) 2012 Annual Meeting included several interactive sessions related to specific familial cancer syndromes, genetic testing and screening, and ethical issues in caring for families with inherited cancer risk. This review highlights the workshop presentations, including a brief background about pediatric cancer predisposition syndromes and the importance of learning about them for the practicing pediatric hematologists/oncologists. This is followed by a brief summary of the newly described cancer predisposition syndromes including Rhabdoid Tumor Predisposition Syndrome, Hereditary Paragangliomas and Pheochromocytoma Syndrome, and Familial Pleuropulmonaryblastoma Tumor Predisposition (DICER1) Syndrome. The next section covers genetic testing and screening for pediatric cancer predisposition syndromes. Ethical issues are also discussed including preimplantation genetic diagnosis or testing (PGD/PGT), suspicious lesions found on tumor screening, and incidental mutations discovered by whole genome sequencing. Finally, the perspective of a family with Li-Fraumeni Syndrome is shared.
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Affiliation(s)
- Joshua D Schiffman
- Center for Children's Cancer Research and Department of Pediatrics, University of Utah, Salt Lake City, Utah 84112, USA.
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20
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Wade CH, Tarini BA, Wilfond BS. Growing up in the genomic era: implications of whole-genome sequencing for children, families, and pediatric practice. Annu Rev Genomics Hum Genet 2013; 14:535-55. [PMID: 23875800 DOI: 10.1146/annurev-genom-091212-153425] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Whole-genome sequencing (WGS) has advanced to a point where it is beginning to be integrated into pediatric practice. With little consensus on how to maximize the benefits of WGS for children, there is a growing need for focused efforts that connect researchers, clinicians, and families to chart a path forward. To illustrate relevant concerns, two contrasting applications of pediatric WGS are explored: clinical use with children who have undiagnosed conditions, and population-based screening. Specific challenges for health care services, policy development, and the well-being of children are discussed in light of current research. In the interest of ensuring evidence-based pediatric WGS, strategies are identified for advancing our understanding of what it means for children to grow up with WGS results guiding their health care.
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Affiliation(s)
- Christopher H Wade
- Nursing and Health Studies Program, University of Washington Bothell, Bothell, Washington 98011;
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21
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van El CG, Cornel MC, Borry P, Hastings RJ, Fellmann F, Hodgson SV, Howard HC, Cambon-Thomsen A, Knoppers BM, Meijers-Heijboer H, Scheffer H, Tranebjaerg L, Dondorp W, de Wert GMWR. Whole-genome sequencing in health care. Recommendations of the European Society of Human Genetics. Eur J Hum Genet 2013; 21 Suppl 1:S1-S5. [PMID: 23819146 PMCID: PMC3660957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
Affiliation(s)
- Carla G van El
- Section Community Genetics, Department of Clinical Genetics and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
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Wright GEB, Koornhof PGJ, Adeyemo AA, Tiffin N. Ethical and legal implications of whole genome and whole exome sequencing in African populations. BMC Med Ethics 2013; 14:21. [PMID: 23714101 PMCID: PMC3668248 DOI: 10.1186/1472-6939-14-21] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Accepted: 05/20/2013] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Rapid advances in high throughput genomic technologies and next generation sequencing are making medical genomic research more readily accessible and affordable, including the sequencing of patient and control whole genomes and exomes in order to elucidate genetic factors underlying disease. Over the next five years, the Human Heredity and Health in Africa (H3Africa) Initiative, funded by the Wellcome Trust (United Kingdom) and the National Institutes of Health (United States of America), will contribute greatly towards sequencing of numerous African samples for biomedical research. DISCUSSION Funding agencies and journals often require submission of genomic data from research participants to databases that allow open or controlled data access for all investigators. Access to such genotype-phenotype and pedigree data, however, needs careful control in order to prevent identification of individuals or families. This is particularly the case in Africa, where many researchers and their patients are inexperienced in the ethical issues accompanying whole genome and exome research; and where an historical unidirectional flow of samples and data out of Africa has created a sense of exploitation and distrust. In the current study, we analysed the implications of the anticipated surge of next generation sequencing data in Africa and the subsequent data sharing concepts on the protection of privacy of research subjects. We performed a retrospective analysis of the informed consent process for the continent and the rest-of-the-world and examined relevant legislation, both current and proposed. We investigated the following issues: (i) informed consent, including guidelines for performing culturally-sensitive next generation sequencing research in Africa and availability of suitable informed consent documents; (ii) data security and subject privacy whilst practicing data sharing; (iii) conveying the implications of such concepts to research participants in resource limited settings. SUMMARY We conclude that, in order to meet the unique requirements of performing next generation sequencing-related research in African populations, novel approaches to the informed consent process are required. This will help to avoid infringement of privacy of individual subjects as well as to ensure that informed consent adheres to acceptable data protection levels with regard to use and transfer of such information.
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Affiliation(s)
- Galen EB Wright
- South African National Bioinformatics Institute, University of the Western Cape, Bellville, South Africa
| | - Pieter GJ Koornhof
- Department of Mercantile and Labour Law, University of the Western Cape, Bellville, South Africa
| | - Adebowale A Adeyemo
- Center for Research on Genomics and Global Health, National Institutes of Health/National Human Genome Research Institute, Bethesda, MD, USA
| | - Nicki Tiffin
- South African National Bioinformatics Institute, University of the Western Cape, Bellville, South Africa
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Abstract
Technological advances have greatly increased the availability of human genomic sequencing. However, the capacity to analyze genomic data in a clinically meaningful way lags behind the ability to generate such data. To help address this obstacle, we reviewed all conditions with genetic causes and constructed the Clinical Genomic Database (CGD) (http://research.nhgri.nih.gov/CGD/), a searchable, freely Web-accessible database of conditions based on the clinical utility of genetic diagnosis and the availability of specific medical interventions. The CGD currently includes a total of 2,616 genes organized clinically by affected organ systems and interventions (including preventive measures, disease surveillance, and medical or surgical interventions) that could be reasonably warranted by the identification of pathogenic mutations. To aid independent analysis and optimize new data incorporation, the CGD also includes all genetic conditions for which genetic knowledge may affect the selection of supportive care, informed medical decision-making, prognostic considerations, reproductive decisions, and allow avoidance of unnecessary testing, but for which specific interventions are not otherwise currently available. For each entry, the CGD includes the gene symbol, conditions, allelic conditions, clinical categorization (for both manifestations and interventions), mode of inheritance, affected age group, description of interventions/rationale, links to other complementary databases, including databases of variants and presumed pathogenic mutations, and links to PubMed references (>20,000). The CGD will be regularly maintained and updated to keep pace with scientific discovery. Further content-based expert opinions are actively solicited. Eventually, the CGD may assist the rapid curation of individual genomes as part of active medical care.
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Yu JH, Jamal SM, Tabor HK, Bamshad MJ. Self-guided management of exome and whole-genome sequencing results: changing the results return model. Genet Med 2013; 15:684-90. [PMID: 23619276 DOI: 10.1038/gim.2013.35] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Accepted: 02/19/2013] [Indexed: 02/04/2023] Open
Abstract
Researchers and clinicians face the practical and ethical challenge of if and how to offer for return the wide and varied scope of results available from individual exome sequencing and whole-genome sequencing. We argue that rather than viewing individual exome sequencing and whole-genome sequencing as a test for which results need to be "returned," that the technology should instead be framed as a dynamic resource of information from which results should be "managed" over the lifetime of an individual. We further suggest that individual exome sequencing and whole-genome sequencing results management is optimized using a self-guided approach that enables individuals to self-select among results offered for return in a convenient, confidential, personalized context that is responsive to their value system. This approach respects autonomy, allows individuals to maximize potential benefits of genomic information (beneficence) and minimize potential harms (nonmaleficence), and also preserves their right to an open future to the extent they desire or think is appropriate. We describe key challenges and advantages of such a self-guided management system and offer guidance on implementation using an information systems approach.
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Affiliation(s)
- Joon-Ho Yu
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
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Clayton EW, Haga S, Kuszler P, Bane E, Shutske K, Burke W. Managing incidental genomic findings: legal obligations of clinicians. Genet Med 2013; 15:624-9. [PMID: 23448723 DOI: 10.1038/gim.2013.7] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 01/10/2013] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Clinical whole-exome and whole-genome sequencing will result in a broad range of incidental findings, but clinicians' obligations to identify and disclose such findings are a matter of debate. We sought legal cases that could offer insights into clinicians' legal liability. METHODS We searched for cases in which incidental findings were related to the cause of action, using the search engines WestLaw, WestLaw Next, Lexis, and Lexis Advance. RESULTS We found no case law related to incidental findings from genetic testing but identified eight cases involving incidental findings in medical imaging. These cases suggest that clinicians may face liability for failing to disclose incidental findings that would have offered an opportunity for interventions to improve health outcome, if under the applicable standard of care, they fail to identify or appreciate the significance of the incidental finding or they negligently fail to notify other clinicians and/or the patient of the identified incidental finding. Other cases support liability for failure to refer appropriately to a clinician with greater expertise. CONCLUSIONS Clinicians may face liability if they fail to disclose incidental information that could inform interventions to improve health outcome; information lacking clinical actionability is likely to have less import.
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Affiliation(s)
- Ellen Wright Clayton
- Center for Biomedical Ethics and Society, Vanderbilt University, Nashville, Tennessee, USA
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Costain G, Bassett AS. Incomplete knowledge of the clinical context as a barrier to interpreting incidental genetic research findings. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2013; 13:58-60. [PMID: 23391068 PMCID: PMC4459859 DOI: 10.1080/15265161.2012.754063] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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Hughes IA, Morel Y, McElreavey K, Rogol A. Biological assessment of abnormal genitalia. J Pediatr Urol 2012; 8:592-6. [PMID: 23168057 DOI: 10.1016/j.jpurol.2012.10.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Accepted: 10/02/2012] [Indexed: 01/26/2023]
Abstract
Biological assessment of abnormal genitalia is based on an ordered sequence of endocrine and genetic investigations that are predicated on knowledge obtained from a suitable history and detailed examination of the external genital anatomy. Investigations are particularly relevant in 46,XY DSD where the diagnostic yield is less successful than in the 46,XX counterpart. Advantage should be taken of spontaneous activity of the pituitary-gonadal axis in early infancy rendering measurements of gonadotrophins and sex steroids by sensitive, validated assays key to assessing testicular function. Allied measurement of serum anti-Müllerian hormone completes a comprehensive testis profile of Leydig and Sertoli cell function. Genetic assessment is dominated by analysis of a plethora of genes that attempts to delineate a cause for gonadal dysgenesis. In essence, this is successful in up to 20% of cases from analysis of SRY and SF1 (NR5A1) genes. In contrast, gene mutation analysis is highly successful in 46,XY DSD due to defects in androgen synthesis or action. The era of next generation sequencing is increasingly being applied to investigate complex medical conditions of unknown cause, including DSD. The challenge for health professionals will lie in integrating vast amounts of genetic information with phenotypes and counselling families appropriately. How tissues respond to hormones is apposite to assessing the range of genital phenotypes that characterise DSD, particularly for syndromes associated with androgen resistance. In vitro methods are available to undertake quantitative and qualitative analysis of hormone action. The in vivo equivalent is some assessment of the degree of under-masculinisation in the male, such as an external masculinisation score, and measurement of the ano-genital distance. This anthropometric marker is effectively a postnatal readout of the effects of prenatal androgens acting during the masculinisation programming window. For investigation of the newborn with abnormal genitalia, a pragmatic approach can be taken to guide the clinician using appropriate algorithms.
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Affiliation(s)
- I A Hughes
- Human Developmental Genetics, Institut Pasteur, Paris, France.
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Intentions to receive individual results from whole-genome sequencing among participants in the ClinSeq study. Eur J Hum Genet 2012; 21:261-5. [PMID: 22892536 DOI: 10.1038/ejhg.2012.179] [Citation(s) in RCA: 144] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Genome sequencing has been rapidly integrated into clinical research and is currently marketed to health-care practitioners and consumers alike. The volume of sequencing data generated for a single individual and the wide range of findings from whole-genome sequencing raise critical questions about the return of results and their potential value for end-users. We conducted a mixed-methods study of 311 sequential participants in the NIH ClinSeq study to assess general preferences and specific attitudes toward learning results. We tested how these variables predicted intentions to receive results within four categories of findings ranging from medically actionable to variants of unknown significance. Two hundred and ninety-four participants indicated a preference to learn their genome sequencing results. Most often, participants cited disease prevention as their reason, including intention to change their lifestyle behaviors. Participants held positive attitudes, strongly perceived social norms and strong intentions to learn results, although there were significant mean differences among four categories of findings (P<0.01). Attitudes and social norms for medically actionable and carrier results were most similar and rated the highest. Participants distinguished among the types and quality of information they may receive, despite strong intentions to learn all results presented. These intentions were motivated by confidence in their ability to use the information to prevent future disease and a belief in the value of even uninterpretable information. It behooves investigators to facilitate participants' desire to learn a range of information from genomic sequencing while promoting realistic expectations for its clinical and personal utility.
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Solomon BD, Pineda-Alvarez DE, Bear KA, Mullikin JC, Evans JP. Applying Genomic Analysis to Newborn Screening. Mol Syndromol 2012; 3:59-67. [PMID: 23112750 DOI: 10.1159/000341253] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2012] [Indexed: 01/30/2023] Open
Abstract
Large-scale genomic analysis such as whole-exome and whole-genome sequencing is becoming increasingly prevalent in the research arena. Clinically, many potential uses of this technology have been proposed. One such application is the extension or augmentation of newborn screening. In order to explore this application, we examined data from 3 children with normal newborn screens who underwent whole-exome sequencing as part of research participation. We analyzed sequence information for 151 selected genes associated with conditions ascertained by newborn screening. We compared findings with publicly available databases and results from over 500 individuals who underwent whole-exome sequencing at the same facility. Novel variants were confirmed through bidirectional dideoxynucleotide sequencing. High-density microarrays (Illumina Omni1-Quad) were also performed to detect potential copy number variations affecting these genes. We detected an average of 87 genetic variants per individual. After excluding artifacts, 96% of the variants were found to be reported in public databases and have no evidence of pathogenicity. No variants were identified that would predict disease in the tested individuals, which is in accordance with their normal newborn screens. However, we identified 6 previously reported variants and 2 novel variants that, according to published literature, could result in affected offspring if the reproductive partner were also a mutation carrier; other specific molecular findings highlight additional means by which genomic testing could augment newborn screening.
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Affiliation(s)
- B D Solomon
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Md., USA
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30
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Donley G, Hull SC, Berkman BE. Prenatal whole genome sequencing: just because we can, should we? Hastings Cent Rep 2012; 42:28-40. [PMID: 22777977 DOI: 10.1002/hast.50] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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