"I think we've got too many tests!": Prenatal providers' reflections on ethical and clinical challenges in the practice integration of cell-free DNA screening.

BACKGROUND: The recent introduction of cell-free DNA-based non-invasive prenatal screening (cfDNA screening) into clinical practice was expected to revolutionize prenatal testing. cfDNA screening for fetal aneuploidy has demonstrated higher test sensitivity and specificity for some conditions than conventional serum screening and can be conducted early in the pregnancy. However, it is not clear whether and how clinical practices are assimilating this new type of testing into their informed consent and counselling processes. Since the introduction of cfDNA screening into practice in 2011, the uptake and scope have increased dramatically. Prenatal care providers are under pressure to stay up to date with rapidly changing cfDNA screening panels, manage increasing patient demands, and keep up with changing test costs, all while attempting to use the technology responsibly and ethically. While clinical literature on cfDNA screening has shown benefits for specific patient populations, it has also identified significant misunderstandings among providers and patients alike about the power of the technology. The unique features of cfDNA screening, in comparison to established prenatal testing technologies, have implications for informed decision-making and genetic counselling that must be addressed to ensure ethical practice. OBJECTIVES: This study explored the experiences of prenatal care providers at the forefront of non-invasive genetic screening in the United States to understand how this testing changes the practice of prenatal medicine. We aimed to learn how the experience of providing and offering this testing differs from established prenatal testing methodologies. These differences may necessitate changes to patient education and consent procedures to maintain ethical practice. METHODS: We used the online American Congress of Obstetricians and Gynecologists Physician Directory to identify a systematic sample of five prenatal care providers in each U.S. state and the District of Columbia. Beginning with the lowest zip code in each state, we took every fifth name from the directory, excluding providers who were retired, did not currently practice in the state in which they were listed, or were not involved in a prenatal specialty. After repeating this step twice and sending a total of 461 invitations, 37 providers expressed interest in participating, and we completed telephone interviews with 21 providers (4.6%). We developed a semi-structured interview guide including questions about providers' use of and attitudes toward cfDNA screening. A single interviewer conducted and audio-recorded all interviews by telephone, and the interviews lasted approximately 30 minutes each. We collaboratively developed a codebook through an iterative process of transcript review and code application, and a primary coder coded all transcripts. RESULTS: Prenatal care providers have varying perspectives on the advantages of cfDNA screening and express a range of concerns regarding the implementation of cfDNA screening in practice. While providers agreed on several advantages of cfDNA, including increased accuracy, earlier return of results, and decreased risk of complications, many expressed concern that there is not enough time to adequately counsel and educate patients on their prenatal screening and testing options. Providers also agreed that demand for cfDNA screening has increased and expressed a desire for more information from professional societies, labs, and publications. Providers disagreed about the healthcare implications and future of cfDNA screening. Some providers anticipated that cfDNA screening would decrease healthcare costs when implemented widely and expressed optimism for expanded cfDNA screening panels. Others were concerned that cfDNA screening would increase costs over time and questioned whether the expansion to include microdeletions could be done ethically. CONCLUSIONS: The perspectives and experiences of the providers in this study allow insight into the clinical benefit, burden on prenatal practice, and potential future of cfDNA screening in clinical practice. Given the likelihood that the scope and uptake of cfDNA screening will continue to increase, it is essential to consider how these changes will affect frontline prenatal care providers and, in turn, patients. Providers' requests for additional guidance and data as well as their concerns with the lack of time available to explain screening and testing options indicate significant potential issues with patient care. It is important to ensure that the clinical integration of cfDNA screening is managed responsibly and ethically before it expands further, exacerbating pre-existing issues. As prenatal screening evolves, so should informed consent and the resources available to women making decisions. The field must take steps to maximize the advantages of cfDNA screening and responsibly manage its ethical issues.

CONTEXTE: L'introduction récente du dépistage prénatal non invasif (dépistage cfDNA) exempt de cellules à base d'ADN dans la pratique clinique devait révolutionner le dépistage prénatal. Le dépistage cfDNA de l'aneuploïdie fœtale a démontré une meilleure sensibilité et spécificité que le dépistage sérique classique et peut être effectué au début de la grossesse. Cependant, on ne sait pas si et comment les pratiques cliniques assimilent ce nouveau type de test dans leurs processus de consentement et de conseil éclairés. Depuis l'introduction du dépistage cfDNA dans la pratique en 2011, l'absorption et la portée ont augmenté de façon spectaculaire. Les professionnels sont sous pression pour rester à jour avec l'évolution rapide des échantillons cfDNA, gérer la demande croissante des patients, et suivre l'évolution des coûts de test, tout en essayant d'utiliser la technologie de manière responsable et éthique. Bien que la littérature clinique sur le dépistage cfDNA a montré des avantages pour les populations de patients spécifiques, elle a également identifié des malentendus importants entre les professionnels et les patients sur le pouvoir de la technologie. Les caractéristiques uniques du dépistage cfDNA, par rapport aux technologies de dépistage prénatal établies, ont des implications pour la prise de décisions éclairées et le conseil génétique qui rentrent en compte pour assurer une pratique éthique. OBJECTIFS: Cette étude a exploré les expériences des professionnels à la pointe du dépistage génétique non invasif aux États-Unis pour comprendre comment ce test modifie la pratique de la médecine prénatale. Nous avons cherché à savoir comment l'expérience de fournir et d'offrir ce test diffère des méthodes plus anciennes de dépistage prénatal. Ces différences peuvent nécessiter des changements dans l'éducation du patient et les procédures de consentement pour maintenir une pratique éthique. MÉTHODES: Nous avons utilisé l'annuaire en ligne du Congrès américain des médecins obstétriciens et gynécologues pour identifier un échantillon systématique de cinq fournisseurs de soins prénatals dans chaque État américain et le District de Columbia. En commençant par le code postal le plus bas dans chaque état, nous avons pris tous les cinquièmes noms de l'annuaire, à l'exclusion des prestataires qui étaient à la retraite, ne pratiquait pas actuellement dans l'état dans lequel ils ont été énumérés, ou ne sont pas impliqués dans une spécialité prénatale. Après avoir répété cette étape deux fois et l'envoi d'un total de 461 invitations, 37 professionnels ont exprimé leur intérêt à participer, et nous avons réalisé des entrevues téléphoniques avec 21 fournisseurs (4,6 %). Nous avons développé un entretien semi-dirigé comprenant des questions sur l'utilisation de fournisseurs de dépistage et les attitudes envers le cfDNA. Un seul intervieweur a mené et enregistré toutes les interviews par téléphone, les entretiens ont duré environ 30 minutes chacun. Nous avons développé en collaboration un dictionnaire par un processus itératif d'examen de la transcription et de l'application du code, et un codeur primaire a codé toutes les transcriptions. RÉSULTATS: Les professionnels de soins prénataux ont des points de vue variés sur les avantages du dépistage cfDNA et expriment une gamme de préoccupations concernant la mise en œuvre du dépistage cfDNA dans la pratique. S'ils ont convenu de plusieurs avantages de cfDNA, y compris une précision accrue, un retour plus rapide des résultats et une diminution de risque de complications, une préoccupation exprimée est qu'il n'y a pas suffisamment pour conseiller et éduquer les patients sur les options de dépistage et de dépistage prénatal. Les professionnels ont également convenu que la demande pour le dépistage cfDNA a augmenté et ont souhaité plus d'informations émanant des sociétés professionnelles, des laboratoires et des publications. Les fournisseurs étaient en désaccord au sujet des implications sur la santé et sur l'avenir du dépistage cfDNA. Certains fournisseurs prévoyaient que le dépistage cfDNA diminuerait les coûts des soins de santé lorsqu'ils seront appliqués largement et a exprimé son optimisme pour l'élargissement des échantillons de dépistage cfDNA. D'autres craignaient que le dépistage cfDNA augmenterait les coûts au fil du temps et se sont demandé si la possibilité d'y inclure les microdélétions pourrait être fait sur le plan éthique. CONCLUSIONS: Les perspectives et les expériences des fournisseurs dans cette étude permettent d'avoir un aperçu de l'avantage clinique, de la charge sur la pratique prénatale, et du futur potentiel du dépistage cfDNA dans la pratique clinique. Compte tenu de la probabilité que la portée et l'acceptation du dépistage cfDNA vont continuer à augmenter, il est essentiel d'examiner comment ces changements auront une incidence sur les fournisseurs de soins prénataux de première ligne et sur les patients. Les demandes de professionnels pour obtenir des conseils et des données supplémentaires ainsi que leurs préoccupations sur le manque de temps disponible pour expliquer aux patients les options de dépistage et de tests indiquent des problèmes potentiellement lourds. Il est important de veiller à ce que l'intégration clinique du dépistage cfDNA soit gérée de façon responsable et éthique avant qu'il ne se développe davantage, aggravant les problèmes préexistants. Comme le dépistage prénatal évolue, de même devrait évoluer le consentement éclairé et les ressources disponibles pour que les femmes puissent prendre leur décision. La discipline doit prendre des mesures pour maximiser les avantages du dépistage cfDNA et gérer de façon responsable les questions éthiques qui s'y rapportent.

Fluorescence in situ hybridization for ambiguous melanocytic tumors.

The large majority of melanocytic lesions can be reliably classified as either benign or malignant based upon morphology alone, but a minority of lesions remains difficult to classify by traditional histologic methods. Recently, a panel of fluorescence in situ hybridization (FISH) probes targeting loci on chromosomes 6 and 11 has emerged as a powerful tool to discriminate melanoma from nevi. This has been validated in numerous difficult diagnostic scenarios. In addition, this same FISH panel has been shown to provide independent prognostic information in traditional melanomas. There is accumulating evidence that FISH targeting these loci as well as several other key chromosomal loci such as 9p21 and 8q24 can provide valuable prognostic information in histologically ambiguous melanocytic tumors. However, since the vast majority of atypical spitz tumors have an indolent course, larger studies including adequate numbers of cases with adverse events is necessary to provide sufficient proof of its role in clinically relevant cases. In this review, we discuss the current literature and studies to date on this topic.

Increased 5-year mortality in the migrant South Asian stroke patients with diabetes mellitus in the United Kingdom: the West Birmingham Stroke Project.

BACKGROUND: Stroke is a major cause of premature mortality in Britain, but its burden is markedly greater amongst South Asians. Because of the paucity of data in this area, we investigated the magnitude and impact of risk from cardiovascular comorbidities on survival amongst South Asian stroke patients. METHODS: We reviewed hospital case records of consecutive first in life time ischaemic stroke patients [self reported ethnicity and International Classification of Disease (ICD) 10th revision, codes 430-438] admitted to an inner city hospital in the UK between 1997 and 2001. In-hospital mortality data and CVD risk factors were analysed. Five-year mortality data was obtained from the National Health Tracing Services. RESULTS: Of 1474 ischaemic stroke patients, 242 (16%) were South Asian of whom, 143 (59.1%) were male. The prevalence of hypertension was 70.2%, followed by diabetes 56.2%, hyperlipidaemia 7% and myocardial infarction 10.3%. At 5 years follow-up, 40.5% had died. Cumulative event-free survival at 5 years was significantly poorer in patients with diabetes (log-rank test, p=0.009). On Cox regression analysis, incorporating age, gender and other CVD risk factors, diabetes mellitus was an independent predictor of mortality odds ratio=1.65 (1.02-2.6, p=0.039). Hypertension and dyslipidaemia did not discriminate survival amongst South Asian patients. CONCLUSION: Stroke mortality in South Asians is associated with presence of diabetes mellitus. This highlights the significance of early and intensive CVD risk modification strategies in ethnic minorities particularly in patients with diabetes. Further research is warranted in South Asians to examine the underlying basis and related pathophysiological abnormalities.

Accumulation of [3H]-inositol into inositol polyphosphates during development of Dictyostelium.

Inositol hexakisphosphate (InsP6) is present in large amounts during the development of Dictyostelium discoideum although its function is unknown. We have investigated the accumulation of [3H]-labelled inositol into both InsP6 and a more highly charged inositol species called InsPY during development of amoebae on filters. We report that the pattern of [3H]-labelled inositol incorporation into InsP6 and InsPY differs markedly from the pattern seen for inositol phospholipids and inositol(1,4,5)trisphosphate. Incorporation into PtdIns, PtdInsP, PtdInsP2 and Ins(1,4,5)P3 reached plateau values within 4 h. In contrast, incorporation into InsP6 continued in an approximately linear manner for the first eight hours of development. No incorporation into InsPY was seen during the first three hours of development at which time accumulation of [3H] continued linearly in a similar manner as for InsP6. Because the total cell concentration of InsP6 (measured by chemical assay) changes very little during development it seems probable that incorporation of label into InsPY after 3 h is due to a developmentally controlled metabolic switch rather than a requirement for a threshold level of its probable precursor, InsP6.

Signal transduction for chemotaxis in Dictyostelium amoebae.

The signal for chemotaxis in D. discoideum is cyclic AMP. This molecule binds to cell surface receptors and triggers the production of inositol (1,4,5)trisphosphate which releases Ca2+ from non-mitochondrial stores. The subsequent chain of signal transduction events brings about the polymerization of cytoskeletal actin (associated with pseudopodium formation) within five seconds and the formation of a peak of cyclic GMP within 10 s. Evidence from streamer F mutants indicates that the cyclic GMP regulates the association of myosin with the cytoskeleton that occurs at 25-50 s and that this phenomenon is concerned with elongation of the amoebae during chemotactic movement.

Inositol tris- and polyphosphate formation during chemotaxis of Dictyostelium.

Using the technique of HPLC with Partisil SAX columns, we have found that stimulation of amoebae of Dictyostelium discoideum with the chemoattractant cyclic AMP induces the rapid accumulation of inositol 1,4,5-trisphosphate (Ins(1,4,5)P3), with a peak at 5 s. A smaller HPLC peak (designated P3) that elutes just after the Ins(1,4,5)P3 peak accumulates more slowly to a maximum at 20 s. In control studies, the changes in Ins(1,4,5)P3 were shown not to be due to varying recovery from the cell extracts and a comparison of reverse-phase and Partisil SAX HPLC columns showed similar values for determinations by either method. The involvement of a G-protein in this chemotactic system was confirmed by the finding that accumulation of Ins(1,4,5)P3 was elicited by the addition of GTP gamma S (5'-[gamma-thio]triphosphate) to saponin-permeabilized amoebae. A study of the changes in the lipid-soluble phosphatidyl inositol phosphates demonstrated that cyclic AMP also stimulated a rapid loss of radioactivity from 32P-labelled phosphatidylinositol 4,5-bisphosphate (PtdIns(4,5)P2), which corresponded in its timing to the rise in Ins(1,4,5)P3, indicating that a phosphoinositidase C (phospholipase C) is present that can be stimulated by occupation of the cell surface cyclic AMP receptors.