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Andersen SK, Vincent G, Butler RA, Brown EHP, Maloney D, Khalid S, Oanesa R, Yun J, Pidro C, Davis VN, Resick J, Richardson A, Rak K, Barnes J, Bezak KB, Thurston A, Reitschuler-Cross E, King LA, Barbash I, Al-Khafaji A, Brant E, Bishop J, McComb J, Chang CCH, Seaman J, Temel JS, Angus DC, Arnold R, Schenker Y, White DB. ProPACC: Protocol for a Trial of Integrated Specialty Palliative Care for Critically Ill Older Adults. J Pain Symptom Manage 2022; 63:e601-e610. [PMID: 35595373 PMCID: PMC9299559 DOI: 10.1016/j.jpainsymman.2022.02.344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Each year, approximately one million older adults die in American intensive care units (ICUs) or survive with significant functional impairment. Inadequate symptom management, surrogates' psychological distress and inappropriate healthcare use are major concerns. Pioneering work by Dr. J. Randall Curtis paved the way for integrating palliative care (PC) specialists to address these needs, but convincing proof of efficacy has not yet been demonstrated. DESIGN We will conduct a multicenter patient-randomized efficacy trial of integrated specialty PC (SPC) vs. usual care for 500 high-risk ICU patients over age 60 and their surrogate decision-makers from five hospitals in Pennsylvania. INTERVENTION The intervention will follow recommended best practices for inpatient PC consultation. Patients will receive care from a multidisciplinary SPC team within 24 hours of enrollment that continues until hospital discharge or death. SPC clinicians will meet with patients, families, and the ICU team every weekday. SPC and ICU clinicians will jointly participate in proactive family meetings according to a predefined schedule. Patients in the control arm will receive routine ICU care. OUTCOMES Our primary outcome is patient-centeredness of care, measured using the modified Patient Perceived Patient-Centeredness of Care scale. Secondary outcomes include surrogates' psychological symptom burden and health resource utilization. Other outcomes include patient survival, as well as interprofessional collaboration. We will also conduct prespecified subgroup analyses using variables such as PC needs, measured by the Needs of Social Nature, Existential Concerns, Symptoms, and Therapeutic Interaction scale. CONCLUSIONS This trial will provide robust evidence about the impact of integrating SPC with critical care on patient, family, and health system outcomes.
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Affiliation(s)
- Sarah K Andersen
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Grace Vincent
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Rachel A Butler
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Elke H P Brown
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Dave Maloney
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Sana Khalid
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Rae Oanesa
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - James Yun
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Carrie Pidro
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Valerie N Davis
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Judith Resick
- Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics (J.R., K.B.B., R.A., Y.S.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Aaron Richardson
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kimberly Rak
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jackie Barnes
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Karl B Bezak
- Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics (J.R., K.B.B., R.A., Y.S.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Andrew Thurston
- Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Eva Reitschuler-Cross
- Department of Medicine, Division of General Internal Medicine (E.R.-C., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Linda A King
- Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ian Barbash
- Department of Critical Care Medicine (I.B., A.-K., E.B., J.B.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Department of Medicine, Division of Pulmonary, Allergy and Critical Care (I.B., J.M.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ali Al-Khafaji
- Department of Critical Care Medicine (I.B., A.-K., E.B., J.B.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Emily Brant
- Department of Critical Care Medicine (I.B., A.-K., E.B., J.B.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jonathan Bishop
- Department of Critical Care Medicine (I.B., A.-K., E.B., J.B.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jennifer McComb
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care (I.B., J.M.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Chung-Chou H Chang
- Department of Medicine, Division of General Internal Medicine (E.R.-C., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jennifer Seaman
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Acute and Tertiary Care (J.S.), University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA
| | - Jennifer S Temel
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston (J.S.T.), Massachusetts, USA
| | - Derek C Angus
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Robert Arnold
- Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA; The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Yael Schenker
- Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics (J.R., K.B.B., R.A., Y.S.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Douglas B White
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
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Cohen M, Althouse A, Chu E, Resick J, Rosenzweig MQ, Smith K, White DB, Schenker Y. The impact of primary palliative care on advance care planning in advanced cancer. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.12030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
12030 Background: Palliative care specialists are experts in conducting advance care planning (ACP), but are a limited resource. We sought to determine the impact of a nurse-led primary palliative care intervention on ACP completion among patients with advanced cancer. Methods: We performed a secondary analysis of a cluster randomized controlled trial looking at the impact of nurse-based primary palliative care at community cancer centers. In the parent trial, patients with advanced cancer received either monthly primary palliative care visits with trained nurses within their cancer center or usual care. Nurses in the intervention arm received special training in addressing symptom management and ACP. ACP uptake was assessed at enrollment and 3 months later via validated questionnaire in the forms of an end-of-life conversation (EOLC) with one’s oncologist or completion of an advance directive (AD). The present analyses were restricted to patients without ACP at baseline. Multivariable logistic regression tested differences in ACP uptake by treatment arm when adjusting for age, religious importance, education, time with current oncologist, and ECOG. Results: Of 672 patients enrolled, 182/336 in the intervention arm and 196/336 in usual care lacked an EOLC at baseline and completed three-month assessments. Of those, 82/182 (45.1%) in the intervention arm and 29/196 (14.8%) in the usual care arm reported having an EOLC at three months (Table). Similarly, 111/336 in the intervention arm and 105/336 in usual care lacked an AD at baseline and completed the three-month assessments. Of those, 48/111 (43.2%) in the intervention arm and 19/105 (18.1%) in usual care completed an AD over the study period (Table). For both types of ACP, the treatment effect suggested increased uptake of new ACP in the intervention arm after controlling for variables known to be associated with ACP (Table) Conclusions: Nurse-led primary palliative care increased the uptake of ACP among patients with advanced cancer. Training oncology nurses embedded within community cancer centers may represent a feasible mechanism to improve access to primary palliative care and uptake of advance care planning. Clinical trial information: NCT02712229. [Table: see text]
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Affiliation(s)
- Michael Cohen
- UPMC Cancer Center - Magee-Womens Hospital, Pittsburgh, PA
| | | | - Edward Chu
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | | | - Kenneth Smith
- University of Pittsburgh Medical Center, Department of Medicine, Pittsburgh, PA
| | | | - Yael Schenker
- Palliative Research Center (PaRC) and Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA
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Rodenbach R, Kavalieratos D, Tamber A, Tapper C, Resick J, Arnold R, Childers J. Coaching Palliative Care Conversations: Evaluating the Impact on Resident Preparedness and Goals-of-Care Conversations. J Palliat Med 2019; 23:220-225. [PMID: 31460823 DOI: 10.1089/jpm.2019.0165] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: There is increasing need for nonspecialty physicians to deliver palliative care (PC) services to meet patient needs, but many physicians feel inadequately prepared. Objective: We aimed to improve the PC skills of resident physicians through a learner-centered, just-in-time coaching intervention. Design: Our quality improvement initiative consisted of two didactics and brief thrice-weekly coaching sessions that focused on real-time PC questions. Upper level internal medicine residents participated during an inpatient hospitalist rotation. Measurements: Residents completed pre/postrotation surveys of their preparedness in discussing PC topics. Electronic medical record data of documentation of goals-of-care (GOC) discussions and Physician Orders for Life-Sustaining Treatment (POLST) completion in at-risk hospitalized patients (age >65 with two or more hospitalizations in the past six months, or age >90) were obtained and compared with before hospitalization. These data were also compared with data from patients on the same resident hospitalist service during the six-month period before the intervention began. Results: During the 14-month intervention period, 42 residents cared for 232 at-risk patients. Among at-risk patients, 12.9% had a documented GOC discussion before hospitalization, which rose to 57.3% before discharge. Among at-risk patients preintervention, these rates were 5.2% and 25.0%, respectively. Residents reported their preparedness increased across many elements of GOC discussions and rated coaching sessions as useful and relevant to their training. Rates of POLST completion did not differ between preintervention and intervention groups. Conclusions: Brief coaching sessions can integrate PC education into a busy clinical service, improve residents' primary PC skills, and improve GOC documentation.
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Affiliation(s)
- Rachel Rodenbach
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dio Kavalieratos
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anoo Tamber
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Corey Tapper
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Judith Resick
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert Arnold
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Julie Childers
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Schenker Y, Park SY, Jeong K, Pruskowski J, Kavalieratos D, Resick J, Abernethy A, Kutner JS. Associations Between Polypharmacy, Symptom Burden, and Quality of Life in Patients with Advanced, Life-Limiting Illness. J Gen Intern Med 2019; 34:559-566. [PMID: 30719645 PMCID: PMC6445911 DOI: 10.1007/s11606-019-04837-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 09/13/2018] [Accepted: 12/19/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND Polypharmacy may be particularly burdensome near the end of life, as patients "accumulate" medications to treat and prevent multiple diseases. OBJECTIVE To evaluate associations between polypharmacy, symptom burden, and quality of life (QOL) in patients with advanced, life-limiting illness (clinician-estimated, 1 month-1 year). DESIGN Secondary analysis of baseline data from a trial of statin discontinuation. PARTICIPANTS Adults with advanced, life-limiting illness. MAIN MEASURES Polypharmacy was assessed by summing the number of non-statin medications taken regularly or as needed. Symptom burden was assessed using the Edmonton Symptom Assessment Scale (range 0-90; higher scores indicating greater symptom burden) and QOL was assessed using the McGill QOL Questionnaire (range 0-10; higher scores indicating better QOL). Linear regression models assessed associations between polypharmacy, symptom burden, and QOL. KEY RESULTS Among 372 participants, 47% were age 75 or older and 35% were enrolled in hospice. The mean symptom score was 27.0 (standard deviation (SD) 16.1) and the mean QOL score was 7.0 (SD 1.3). The average number of non-statin medications was 11.6 (SD 5.0); one-third of participants took ≥ 14 medications. In adjusted models, higher polypharmacy was associated with higher symptom burden (coefficient 0.81; p < .001) and lower QOL (coefficient - .06; p = .001). Adjusting for symptom burden weakened the association between polypharmacy and QOL (coefficient - .03; p = .045) without a significant interaction, suggesting that worse quality of life associated with polypharmacy may be related to medication-associated symptoms. CONCLUSIONS Among adults with advanced illness, taking more medications is associated with higher symptom burden and lower QOL. Attention to medication-related symptoms and shared decision-making regarding deprescribing are warranted in this setting. NIH TRIAL REGISTRY NUMBER ClinicalTrials.gov Identifier for Parent Study - NCT01415934.
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Affiliation(s)
- Yael Schenker
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, 230 McKee Place, Suite 600, Pittsburgh, PA, 15213, USA.
| | - Seo Young Park
- Center for Research on Healthcare Data Center, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kwonho Jeong
- Center for Research on Healthcare Data Center, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jennifer Pruskowski
- Department of Pharmacy and Therapeutics, UPMC Palliative and Supportive Institute, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Dio Kavalieratos
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, 230 McKee Place, Suite 600, Pittsburgh, PA, 15213, USA
| | - Judith Resick
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, 230 McKee Place, Suite 600, Pittsburgh, PA, 15213, USA
| | | | - Jean S Kutner
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Leslie E, Liu H, Carlson J, Shaffer J, Feingold E, Wehby G, Laurie C, Jain D, Laurie C, Doheny K, McHenry T, Resick J, Sanchez C, Jacobs J, Emanuele B, Vieira A, Neiswanger K, Standley J, Czeizel A, Deleyiannis F, Christensen K, Munger R, Lie R, Wilcox A, Romitti P, Field L, Padilla C, Cutiongco-de la Paz E, Lidral A, Valencia-Ramirez L, Lopez-Palacio A, Valencia D, Arcos-Burgos M, Castilla E, Mereb J, Poletta F, Orioli I, Carvalho F, Hecht J, Blanton S, Buxó C, Butali A, Mossey P, Adeyemo W, James O, Braimah R, Aregbesola B, Eshete M, Deribew M, Koruyucu M, Seymen F, Ma L, de Salamanca J, Weinberg S, Moreno L, Cornell R, Murray J, Marazita M. A Genome-wide Association Study of Nonsyndromic Cleft Palate Identifies an Etiologic Missense Variant in GRHL3. Am J Hum Genet 2016; 98:744-54. [PMID: 27018472 DOI: 10.1016/j.ajhg.2016.02.014] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 02/17/2016] [Indexed: 10/22/2022] Open
Abstract
Cleft palate (CP) is a common birth defect occurring in 1 in 2,500 live births. Approximately half of infants with CP have a syndromic form, exhibiting other physical and cognitive disabilities. The other half have nonsyndromic CP, and to date, few genes associated with risk for nonsyndromic CP have been characterized. To identify such risk factors, we performed a genome-wide association study of this disorder. We discovered a genome-wide significant association with a missense variant in GRHL3 (p.Thr454Met [c.1361C>T]; rs41268753; p = 4.08 × 10(-9)) and replicated the result in an independent sample of case and control subjects. In both the discovery and replication samples, rs41268753 conferred increased risk for CP (OR = 8.3, 95% CI 4.1-16.8; OR = 2.16, 95% CI 1.43-3.27, respectively). In luciferase transactivation assays, p.Thr454Met had about one-third of the activity of wild-type GRHL3, and in zebrafish embryos, perturbed periderm development. We conclude that this mutation is an etiologic variant for nonsyndromic CP and is one of few functional variants identified to date for nonsyndromic orofacial clefting. This finding advances our understanding of the genetic basis of craniofacial development and might ultimately lead to improvements in recurrence risk prediction, treatment, and prognosis.
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Leslie EJ, Carlson JC, Shaffer JR, Feingold E, Wehby G, Laurie CA, Jain D, Laurie CC, Doheny KF, McHenry T, Resick J, Sanchez C, Jacobs J, Emanuele B, Vieira AR, Neiswanger K, Lidral AC, Valencia-Ramirez LC, Lopez-Palacio AM, Valencia DR, Arcos-Burgos M, Czeizel AE, Field LL, Padilla CD, Cutiongco-de la Paz EMC, Deleyiannis F, Christensen K, Munger RG, Lie RT, Wilcox A, Romitti PA, Castilla EE, Mereb JC, Poletta FA, Orioli IM, Carvalho FM, Hecht JT, Blanton SH, Buxó CJ, Butali A, Mossey PA, Adeyemo WL, James O, Braimah RO, Aregbesola BS, Eshete MA, Abate F, Koruyucu M, Seymen F, Ma L, de Salamanca JE, Weinberg SM, Moreno L, Murray JC, Marazita ML. A multi-ethnic genome-wide association study identifies novel loci for non-syndromic cleft lip with or without cleft palate on 2p24.2, 17q23 and 19q13. Hum Mol Genet 2016; 25:2862-2872. [PMID: 27033726 DOI: 10.1093/hmg/ddw104] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 03/04/2016] [Accepted: 03/24/2016] [Indexed: 12/27/2022] Open
Abstract
Orofacial clefts (OFCs), which include non-syndromic cleft lip with or without cleft palate (CL/P), are among the most common birth defects in humans, affecting approximately 1 in 700 newborns. CL/P is phenotypically heterogeneous and has a complex etiology caused by genetic and environmental factors. Previous genome-wide association studies (GWASs) have identified at least 15 risk loci for CL/P. As these loci do not account for all of the genetic variance of CL/P, we hypothesized the existence of additional risk loci. We conducted a multiethnic GWAS in 6480 participants (823 unrelated cases, 1700 unrelated controls and 1319 case-parent trios) with European, Asian, African and Central and South American ancestry. Our GWAS revealed novel associations on 2p24 near FAM49A, a gene of unknown function (P = 4.22 × 10-8), and 19q13 near RHPN2, a gene involved in organizing the actin cytoskeleton (P = 4.17 × 10-8). Other regions reaching genome-wide significance were 1p36 (PAX7), 1p22 (ARHGAP29), 1q32 (IRF6), 8q24 and 17p13 (NTN1), all reported in previous GWASs. Stratification by ancestry group revealed a novel association with a region on 17q23 (P = 2.92 × 10-8) among individuals with European ancestry. This region included several promising candidates including TANC2, an oncogene required for development, and DCAF7, a scaffolding protein required for craniofacial development. In the Central and South American ancestry group, significant associations with loci previously identified in Asian or European ancestry groups reflected their admixed ancestry. In summary, we have identified novel CL/P risk loci and suggest new genes involved in craniofacial development, confirming the highly heterogeneous etiology of OFCs.
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Affiliation(s)
- Elizabeth J Leslie
- Department of Oral Biology, Center for Craniofacial and Dental Genetics, School of Dental Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA
| | - Jenna C Carlson
- Department of Oral Biology, Center for Craniofacial and Dental Genetics, School of Dental Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA.,Department of Biostatistics
| | - John R Shaffer
- Department of Oral Biology, Center for Craniofacial and Dental Genetics, School of Dental Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA.,Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Eleanor Feingold
- Department of Oral Biology, Center for Craniofacial and Dental Genetics, School of Dental Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA.,Department of Biostatistics.,Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - George Wehby
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, IA 52246, USA
| | - Cecelia A Laurie
- Department of Biostatistics, Genetic Coordinating Center, University of Washington, Seattle, WA 98195, USA
| | - Deepti Jain
- Department of Biostatistics, Genetic Coordinating Center, University of Washington, Seattle, WA 98195, USA
| | - Cathy C Laurie
- Department of Biostatistics, Genetic Coordinating Center, University of Washington, Seattle, WA 98195, USA
| | - Kimberly F Doheny
- Center for Inherited Disease Research, Johns Hopkins University, Baltimore, MD 21224, USA
| | - Toby McHenry
- Department of Oral Biology, Center for Craniofacial and Dental Genetics, School of Dental Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA
| | - Judith Resick
- Department of Oral Biology, Center for Craniofacial and Dental Genetics, School of Dental Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA
| | - Carla Sanchez
- Department of Oral Biology, Center for Craniofacial and Dental Genetics, School of Dental Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA
| | - Jennifer Jacobs
- Department of Oral Biology, Center for Craniofacial and Dental Genetics, School of Dental Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA
| | - Beth Emanuele
- Department of Oral Biology, Center for Craniofacial and Dental Genetics, School of Dental Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA
| | - Alexandre R Vieira
- Department of Oral Biology, Center for Craniofacial and Dental Genetics, School of Dental Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA.,Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Katherine Neiswanger
- Department of Oral Biology, Center for Craniofacial and Dental Genetics, School of Dental Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA
| | | | | | | | - Dora Rivera Valencia
- Population Genetics and Mutacarcinogenesis Group, University of Antioquia, Medellin 050001, Colombia
| | - Mauricio Arcos-Burgos
- Genomics and Predictive Medicine, Genome Biology Department, John Curtin School of Medical Research, ANU College of Medicine, Biology & Environment, The Australian National University, Canberra, ACT 0200, Australia
| | - Andrew E Czeizel
- Foundation for the Community Control of Hereditary Diseases, Budapest 1051, Hungary
| | - L Leigh Field
- Department of Medical Genetics, University of British Columbia, Vancouver V6H 3N1, Canada
| | - Carmencita D Padilla
- Department of Pediatrics, College of Medicine; and Institute of Human Genetics, National Institutes of Health; University of the Philippines Manila, Manilla, The Philippines 1000.,Philippine Genome Center, University of the Philippines System, Manilla, The Philippines 1101
| | - Eva Maria C Cutiongco-de la Paz
- Department of Pediatrics, College of Medicine; and Institute of Human Genetics, National Institutes of Health; University of the Philippines Manila, Manilla, The Philippines 1000.,Philippine Genome Center, University of the Philippines System, Manilla, The Philippines 1101
| | - Frederic Deleyiannis
- Department of Surgery, Plastic and Reconstructive Surgery, University of Colorado School of Medicine, Denver, CO 80045, USA
| | - Kaare Christensen
- Department of Epidemiology, Institute of Public Health, University of Southern Denmark, Odense DK-5230 Denmark
| | - Ronald G Munger
- Department of Nutrition, Dietetics, and Food Sciences, Utah State University, Logan, UT 84322, USA
| | - Rolv T Lie
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, NO-5020 Norway
| | - Allen Wilcox
- Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, NC 27709, USA
| | | | - Eduardo E Castilla
- CEMIC: Center for Medical Education and Clinical Research, Buenos Aires 1431, Argentina.,Laboratory of Congenital Malformation Epidemiology, Oswaldo Cruz Institute, FIOCRUZ, Rio de Janeiro 21040-360, Brazil.,ECLAMC (Latin American Collaborative Study of Congenital Malformations) at INAGEMP (National Institute of Population Medical Genetics)
| | - Juan C Mereb
- ECLAMC (Latin American Collaborative Study of Congenital Malformations) at Hospital de Area, El Bolson 8430, Argentina
| | - Fernando A Poletta
- CEMIC: Center for Medical Education and Clinical Research, Buenos Aires 1431, Argentina.,Laboratory of Congenital Malformation Epidemiology, Oswaldo Cruz Institute, FIOCRUZ, Rio de Janeiro 21040-360, Brazil.,ECLAMC (Latin American Collaborative Study of Congenital Malformations) at INAGEMP (National Institute of Population Medical Genetics)
| | - Iêda M Orioli
- ECLAMC (Latin American Collaborative Study of Congenital Malformations) at INAGEMP (National Institute of Population Medical Genetics).,Department of Genetics, Institute of Biology, Federal University of Rio de Janeiro, Rio de Janeiro 21941-617, Brazil
| | - Flavia M Carvalho
- Laboratory of Congenital Malformation Epidemiology, Oswaldo Cruz Institute, FIOCRUZ, Rio de Janeiro 21040-360, Brazil.,ECLAMC (Latin American Collaborative Study of Congenital Malformations) at INAGEMP (National Institute of Population Medical Genetics)
| | - Jacqueline T Hecht
- Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Susan H Blanton
- Dr. John T. Macdonald Foundation Department of Human Genetics, Hussman Institute for Human Genomics, Mailman School of Medicine, University of Miami, Miami, FL 33124, USA
| | - Carmen J Buxó
- School of Dental Medicine, University of Puerto Rico, San Juan, Puerto Rico 00936
| | - Azeez Butali
- Department of Oral Pathology, Radiology and Medicine, Dows Institute for Dental Research, College of Dentistry
| | - Peter A Mossey
- Department of Orthodontics, University of Dundee, Dundee DD1 4HN, Scotland
| | - Wasiu L Adeyemo
- Department of Oral and Maxillofacial Surgery. College of Medicine, University of Lagos, Lagos P.M.B. 12003, Nigeria
| | - Olutayo James
- Department of Oral and Maxillofacial Surgery. College of Medicine, University of Lagos, Lagos P.M.B. 12003, Nigeria
| | - Ramat O Braimah
- Department of Oral and Maxillofacial Surgery, Obafemi Awolowo University, Ife-Ife P.M.B. 13, Nigeria
| | - Babatunde S Aregbesola
- Department of Oral and Maxillofacial Surgery, Obafemi Awolowo University, Ife-Ife P.M.B. 13, Nigeria
| | - Mekonen A Eshete
- Surgical Department, School of Medicine, Addis Ababa University, Addis Ababa, P.O. Box 26493, Ethiopia
| | - Fikre Abate
- Surgical Department, School of Medicine, Addis Ababa University, Addis Ababa, P.O. Box 26493, Ethiopia
| | - Mine Koruyucu
- Department of Pedodontics, Istanbul University, Istanbul 34116, Turkey
| | - Figen Seymen
- Department of Pedodontics, Istanbul University, Istanbul 34116, Turkey
| | - Lian Ma
- Peking University, School of Stomatology, Beijing 100081, China
| | | | - Seth M Weinberg
- Department of Oral Biology, Center for Craniofacial and Dental Genetics, School of Dental Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA
| | | | - Jeffrey C Murray
- Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
| | - Mary L Marazita
- Department of Oral Biology, Center for Craniofacial and Dental Genetics, School of Dental Medicine, University of Pittsburgh, Pittsburgh, PA 15219, USA .,Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 15261, USA.,Clinical and Translational Science, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
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