To receive Nursing Contact Hours, you must complete the Genetics & Genomics evaluation.

1. Participants must attend the entire session in order to earn contact hour credit. Verification of participation will be noted by signature. No influential financial relationships have been disclosed by planners or presenters which would influence the planning of the activity. If any arise, an announcement will be made at the beginning of the session. No commercial support has influenced the planning of the educational objectives and content of the activity. Any commercial support will be used for events that are not CE related. There is no endorsement of any product by ANCC or DUHS associated with the session.

2. To receive Nursing Contact Hours, you must complete the Genetics & Genomics evaluation. The evaluation is a separate offering that you will launch from the Learning Management System.

3. Genetics & Genomics Kristi Wiggins MSN, RN,ANP-BC, AOCNP, CCRC Oncology Adult Nurse Practitioner Duke University Adult Stem Cell Transplant

4. This slide presentation is brought to you as part of the G2@Duke Project, part of the WVU MINC Project Expanding RN Scope of Practice: A Method for Introducing a New Competency (MINC) into Nursing Practice The primary aim of this research project is to establish and assess the outcomes of a Magnet Hospital Champion year-long intervention to improve the capacity of the institution to integrate genomic information into nursing healthcare delivery.

5. Objectives • Discuss basic concepts of genetics/genomics and how knowledge of these concepts impact personalized healthcare. • Name at least one advantage and one disadvantage to applying genetics to nursing practice. • Name at least 2 competencies for healthcare providers in genetics. • Obtain a family history to construct a 3-generation pedigree. • Define pharmacogenomics.

6. Genetics: Genetics is the study of genes & heredity - what is inherited from one’s predecessors • Genetics focuses primarily on the likelihood of developing disease • Genetic tests find mutations, not disease

7. Genomics: • Genomics is the study of how genes • interact and are expressed as a whole • Intricate look at a patient’s individual disease biology • Genomics & gene profiling focus on disease and can be used to determine: • Aggressiveness of the disease (prognosis) • Possible benefit from treatment (prediction)

8. Top 10 leading causes of mortality have a genetic/genomic component… • Heart disease, cancer, cerebrovascular disease, & diabetes represent the vast majority of mortalities in the US. • …nurses are intimately involved in the ongoing treatment and management of these conditions.

9. Where Do We Start? • “Our family’s past health history is key to our future wellbeing” ~ Geoffrey S. Ginsburg, MD, PhD Director, Center for Genomic Medicine Institute for Genome Sciences & Policy at Duke University

10. Similarities & Differences in Our Genes • We have 99.9% DNA in common with each other • We have 99% DNA on common with mice • 90% of genes associated with disease are identical in humans and mice. • Families share environment, diet, & habits that affect our genes • BUT…It’s the 0.1% that makes all the difference! (genetics) • Every person’s environmental exposures and genetic reactions are unique to the individual (genomics)

11. Basic Genetics: • Cells - Nuclear material • Chromosomes • DNA • DNA is the genetic material in a cell that contains genes. When DNA represents all of the genes for the species, it is referred to as the “genome.” • Genes • SNPs

12. Tightly supercoiled DNA condensed and packed into a chromosome structure. Figure from the National Human Genome Research Institute (NIH) Loosely coiled DNA

13. Chromosome:DNA that is tightly condensed & coiled into dense bodies that take up stain and are visible microscopy during metaphase. • Humans have 46 chromosomes (23 pairs). This number is known as the "diploid" number of chromosomes for humans. • These 46 chromosomes contain all the nuclear DNA of a human cell.

14. Karyotype:An organized arrangement of all of themetaphase chromosomes within one cell. • Chromosomes are collected into pairs (one from mom, one from dad), lined up according to size and centromere position. This is used to determine missing or extra Chromosomes, and some large structural rearrangements. • Euploid • Aneuploid

15. Allele:One of possible alternate forms of a gene for any trait or protein controlled by a single gene. • For blood type, there are 3 possible gene alleles: • A, B, and O. • However, each person only has two of these alleles that determine blood type (one copy from mom, the other from dad). • Some traits have even more than 3 possible gene alleles types, but each person only has 2.

16. Central Dogma of Molecular Genetics transcription translation DNA RNA Protein replication

17. The multi-step Process of Protein Synthesis Figure from the National Human Genome Research Institute (NIH)

18. SNP – Single NucleotidePolymorphism(s): A single nucleotide change within a gene, sometimes referred to as a “benign mutation” or a “normal variant.” (Such as the cytochrome p450 system alterations & “asparagus pee”)

19. What is Pharmacogenomics? • Study of how an individual's genetic make-up affects the body's response to drugs • Goal: tailor-made drugs, adapted to each person’s genetic makeup. • In addition to genetics, environment, diet, age, lifestyle, and state of health all can influence a person's response to treatments. • Combines traditional pharmaceutical sciences such as biochemistry with knowledge of genes, proteins, and SNPs. http://www.ornl.gov/sci/techresources/Human_Genome/medicine/pharma.shtml

20. Why Use Genetic Information in Nursing? • To be prepared for the incredible changes already occurring in health care related to genetics; closing the gap between research discoveries and healthcare to optimize health • To provide patients with genetic education and foster greater access for patients to receive genetic services • Identify patients at risk for genetic disorders, then … • Implement plans for prospective testing, screening, and/or treatment for those with a known or suspected genetic disorder, benefiting the future health of both the patient and their families • To educate patients on the rationale for targeted therapies • Be aware of genomic drug information to promote patient safety

21. Barriers to Using Genetic Information in Nursing • A large gap still exists between genetic knowledge and knowing how to apply this information in the clinical setting • Insufficient knowledge base to provide genetic-focused care in our current nursing care • Lack of systemic method for obtaining family history and screening for possible genetic abnormalities • Mutlifactorial emotional & ethical barriers to genetic testing • Fear of discrimination associated with genetic testing • Political and financial roadblocks to providing state-of-the-art genetic testing and treatment for patients regardless of demographics

22. Epigenetic Targets & Treatments Epigenetics: Study of heritable changes in gene expression that occur independent of changes in the primary DNA sequences. • Examples: Twins & animal behavior modification

23. Known Genetic Disorders • Down Syndrome • Cystic Fibrosis • Muscular Distrophy • Hemophilia • Sickle Cell disease • Turner Syndrome • Color Blindness • Polycystic Kidney disease • Hemochromatosis • Severe Combine Immune Deficiency (SCID) • Klinefelter Syndrome • Li-Fraumeni Syndrome

24. More Genetic Disorders • Nonpolyposis Colorectal Cancer • Cardiomyopathy (Noonan syndrome) • Celiac disease • Charcot-Marie-Tooth syndrome • Cowden Syndrome • Dwarfism • Di George’s Syndrome • Fragile X Syndrome • Huntington’s disease • Marfan Syndrome • Lynch Syndrome • Neurofibromatosis

25. Family History 101 • Collect information for at least three generations: • 1st patient & patient’s siblings • 2nd parents • 3rd grandparents • 4th children • (4th generation moving forward, important for health screening for future health concerns), and/or add great grandparents if information available

26. Family History - Continued • Name and Relationship to the patient • Date of Birth and/or Age • Gender • Family origin, heritage, race, or ethnicity • Any Diagnoses & Age Diagnosed • If Deceased, Cause of death & Age at death

29. DUKE HUMAN RESOURCES ”Health Assessment” http://www.hr.duke.edu/benefits/wellness/assessment/index.php

30. DUKE HUMAN RESOURCES ”Health Assessment” http://www.hr.duke.edu/benefits/wellness/assessment/index.php

31. Core Genetics Competencies Minimum Requirements of Healthcare Providers: • Identifying areas of strength and areas where professional development related to genetics and genomics would be beneficial. • Understand that health-related genetic information can have important social and psychological implications for individuals and families. • List essential family history elements and discuss their significance in clinical practice. • Identify ethical, cultural, legal, fiscal, ethnic, religious, and societal issues related to genetics/genomics information • Know how and when to make a referral to a genetics professional. www.nchpeg.org

32. The Future… • Understand the genetic basis for molecular pathways in our biology, allowing for knowledgeable patient & nursing education. • Recognize molecular targets for therapies used in novel treatments and diagnostic assays that we will administer and manage with our patients. • Enhance the management of our patient’s care with increased knowledge of genetic information and biomarkers to decrease toxicities, increase treatment accuracy, and improve disease outcomes.

33. Resources • Bennett, R.L., French, K.S., Resta, R.G., & Doyle, D.L. (2008). Standardized human pedigree nomenclature update and assessment of the recommendations of the National Society of Genetic Counselors. Journal of Geneitc Counseling [Springer]. 17doi:10.1007/s10897-008-9169-9. • http://www.ornl.gov/sci/techresources/Human_Genome/medicine/pharma.shtml • http://www.nature.com/bjc/journal/v100/n1/fig_tab/6604781f1.html#figure-title • Lee, H., et al., (2011). Lab Med Online. 2011 Jul;1(3):163-167. Published online 2011 July 05.  http://dx.doi.org/10.3343/lmo.2011.1.3.7, Laboratory Medicine Online • Nature Reviews Drug Discovery 3, 739-748 (September 2004) • National Human Genetics Research Institute • www.nhgri.gov • N Engl J Med 2009;360:753-764. • Oncology Nursing Society • www.ons.org • Paik et al. N Engl J Med. 2004;351: 2817-2826 • www.cancer.gov • http://www.cdc.gov/nchs/fastats/deaths.htm • www.cellulargenetix.com/pharmacogenomics.asp • www.genomics.gov • www.merriam-webster.com/ • www.nature.com/cancer/index.html • www.nci.gov • www.nchpeg.org Please proceed to the next slide.

34. To receive Nursing Contact Hours, you must complete the Genetics & Genomics evaluation. The evaluation is a separate offering that you will launch from the Learning Management System. To test your knowledge, please proceed to the next slide.

35. Genomics