Microsoft Word - 69 2017.docx


	
  

Vol	
  5,	
  No	
  1	
  (2017)	
  
ISSN	
  2167-­‐8677	
  (online)	
  

DOI	
  10.5195/d3000.2017.69	
  	
  

	
  

	
  

	
  

http://dentistry3000.pitt.edu	
  

	
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  articles	
  in	
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  Creative	
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  University	
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by	
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  Press.	
  

	
  

Potential	
  inheritance	
  patterns	
  of	
  a	
  prothrombin	
  gene	
  mutation	
  in	
  
a	
  23-­‐year-­‐old	
  female	
  and	
  ethical	
  considerations	
  of	
  a	
  positive	
  
diagnosis:	
  a	
  case	
  report	
  
Hannah	
  Brand1	
  
	
  
	
  1University	
  of	
  Pi.sburgh,	
  School	
  of	
  Dental	
  Medicine

Abstract	
  

Background:	
  Prothrombin,	
  also	
  called	
  Factor	
  II,	
  is	
  a	
  blood	
  clo4ng	
  protein	
  found	
  in	
  all	
  individuals	
  that	
  is	
  necessary	
  to	
  
form	
  blood	
  clots.	
  In	
  most	
  individuals,	
  a	
  balance	
  between	
  bleeding	
  and	
  blood	
  clot	
  forma7on	
  occurs.	
  However,	
  in	
  indi-­‐
viduals	
  with	
  a	
  muta-on	
  in	
  the	
  prothrombin	
  gene,	
  the	
  balance	
  is	
  disrupted	
  due	
  to	
  excess	
  produc-on	
  of	
  prothrombin	
  
which	
  leads	
  to	
  an	
  increase	
  in	
  blood	
  clot	
  forma2on	
  (1).	
   Inherited	
  predisposi2ons	
  to	
  blood	
  clot	
  forma2on	
  are	
  termed	
  
hereditary	
   thrombophilia.	
  Prothrombin	
  G20210A	
  muta2ons	
  are	
  one	
  of	
   the	
  most	
   common	
  hereditary	
   gene	
  associa-­‐
!ons.	
  Case	
  Descrip+on:	
  This	
  report	
  examines	
  the	
  case	
  of	
  a	
  23-­‐year-­‐old	
  female	
  who	
  has	
  tested	
  posi/ve	
  for	
  the	
  pro-­‐
thrombin	
   gene	
  muta.on.	
   The	
   individual	
   has	
   an	
   extensive	
   history	
   of	
   blood	
   clots	
   including	
   8	
   deep	
   vein	
   thromboses	
  
(DVTs),	
  4	
  pulmonary	
  embolisms	
  with	
  one	
  complete	
  infarc;on,	
  4	
  superficial	
  clots,	
  and	
  a	
  miscarried	
  pregnancy	
  a?ribut-­‐
ed	
  to	
  her	
  thrombophilia.	
  The	
  individual	
  has	
  a	
  significant	
  family	
  history	
  of	
  the	
  muta9on	
  and	
  takes	
  Coumadin	
  daily	
  for	
  
preven&on	
  of	
  further	
  clots.	
  Prac%cal	
  and	
  Ethical	
  Implica%ons:	
  Despite	
  a	
  strong	
  familial	
  history	
  of	
  blood	
  clots	
  and	
  re-­‐
lated	
  hospitaliza-ons,	
  the	
  parents	
  of	
  the	
  case	
  individual	
  do	
  not	
  want	
  to	
  get	
  their	
  other	
  children	
  tested	
  for	
  the	
  muta-­‐
!on	
  for	
  fear	
  that	
  the	
  children	
  will	
  be	
  denied	
  insurance	
  coverage	
  in	
  their	
  futures.	
  The	
  case	
  individual	
  will	
  likely	
  con!n-­‐
ue	
  to	
  be	
  on	
  blood	
  thinners	
  indefinitely.	
  This	
  will	
  affect	
  many	
  aspects	
  of	
  her	
  life,	
  including	
  dental	
  treatment,	
  as	
  she	
  will	
  
be	
  at	
  an	
  increased	
  risk	
  for	
  bleeding.	
  

	
  

Cita%on:	
  Brand,	
  H.	
   (2017)	
  Poten&al	
   inheritance	
  
pa#erns	
   of	
   a	
   prothrombin	
   gene	
   muta2on	
   in	
   a	
  
23-­‐year-­‐old	
  female	
  and	
  ethical	
  considera0ons	
  of	
  
a	
   posi've	
   diagnosis:	
   a	
   case	
   report.	
   Den$stry	
  
3000.	
  1:a001	
  doi:10.5195/d3000.2017.69	
  
Received:	
  	
  May	
  4,	
  2017	
  
Accepted:	
  	
  May	
  9,	
  2017	
  
Published:	
  	
  June	
  9,	
  2017	
  
Copyright:	
  ©2017	
  Brand,	
  H.	
  This	
   is	
  an	
  open	
  ac-­‐
cess	
  ar!cle	
   licensed	
  under	
  a	
  Crea!ve	
  Commons	
  
A"ribu%on	
  Work	
  4.0	
  United	
  States	
  License.	
  
Email:	
  hnb16@pi).edu

	
  

Introduction	
  

Having	
  a	
  mutation	
  in	
  a	
  
blood	
  clotting	
  gene	
  such	
  as	
  Pro-­‐
thrombin	
  G20210A,	
  means	
  that	
  an	
  
individual	
  has	
  a	
  higher	
  tendency	
  to	
  
form	
  blood	
  clots.	
  The	
  prothrombin	
  
mutation	
  is	
  found	
  in	
  approximate-­‐
ly	
  2%	
  of	
  Caucasians	
  in	
  the	
  United	
  
States	
  and	
  is	
  the	
  second	
  most	
  
common	
  inherited	
  form	
  of	
  throm-­‐
bophilia	
  (2-­‐4).	
  Given	
  the	
  rarity	
  of	
  
the	
  disease,	
  most	
  cases	
  are	
  inher-­‐
ited	
  as	
  heterozygous	
  prothrombin	
  
mutations	
  as	
  it	
  is	
  not	
  likely	
  that	
  
both	
  parents	
  would	
  possess	
  the	
  
mutation,	
  and	
  in	
  heterozygous	
  
cases,	
  only	
  one	
  copy	
  of	
  the	
  muta-­‐

tion	
  is	
  needed.	
  Homozygous	
  muta-­‐
tions	
  are	
  thought	
  to	
  be	
  more	
  se-­‐
vere	
  than	
  heterozygous.	
  Being	
  
heterozygous	
  for	
  the	
  mutation	
  in-­‐
creases	
  the	
  risk	
  of	
  a	
  blood	
  clot	
  by	
  
2-­‐3	
  times,	
  versus	
  homozygous	
  
where	
  the	
  risk	
  is	
  increased	
  by	
  as	
  
much	
  as	
  50	
  times	
  (3).	
  	
  

The	
  most	
  common	
  compli-­‐
cation	
  of	
  having	
  a	
  prothrombin	
  
gene	
  mutation	
  is	
  the	
  increased	
  risk	
  
for	
  formation	
  of	
  a	
  deep	
  venous	
  
thrombosis,	
  or	
  DVT.	
  	
  Typically,	
  
these	
  clots	
  form	
  in	
  the	
  leg,	
  but	
  
have	
  the	
  potential	
  of	
  traveling	
  
through	
  the	
  bloodstream	
  to	
  reach	
  
the	
  lungs,	
  known	
  as	
  a	
  pulmonary	
  

embolism,	
  or	
  to	
  the	
  brain,	
  a	
  cere-­‐
bral	
  embolism	
  (5).	
  	
  Women	
  with	
  
clotting	
  disorders	
  should	
  be	
  aware	
  
that	
  oral	
  contraceptives,	
  hormone	
  
therapy,	
  and	
  pregnancy	
  all	
  in-­‐
crease	
  the	
  risk	
  of	
  blood	
  clot	
  for-­‐
mation	
  (1).	
  The	
  prothrombin	
  mu-­‐
tation	
  has	
  been	
  suggested	
  to	
  lead	
  
to	
  increased	
  pregnancy	
  complica-­‐
tions	
  as	
  well,	
  including	
  preeclamp-­‐
sia,	
  placental	
  abruption,	
  pregnan-­‐
cy	
  loss	
  in	
  all	
  trimesters,	
  and	
  still-­‐
birth	
  (1).	
  Other	
  factors	
  that	
  in-­‐
crease	
  the	
  risk	
  of	
  clot	
  formation	
  
are	
  smoking,	
  being	
  overweight	
  or	
  
obese,	
  being	
  immobile	
  for	
  long	
  



	
  Poten&al	
  inheritance	
  pa+erns	
  of	
  a	
  prothrombin	
  gene	
  muta3on	
  in	
  a	
  23-­‐year-­‐old	
  female	
  and	
  ethical	
  considera0ons	
  of	
  a	
  posi0ve	
  diagnosis:	
  a	
  case	
  report	
  

Vol	
  5,	
  No	
  1	
  (2017)	
  	
  	
  	
  DOI	
  10.5195/d3000.2017.69	
  

	
  http://dentistry3000.pitt.edu	
  

periods	
  of	
  time,	
  and	
  infrequent	
  
exercise	
  habits	
  (3).	
  	
  

While	
  refraining	
  from	
  the	
  
aforementioned	
  risk	
  factors	
  can	
  
sometimes	
  be	
  enough	
  to	
  prevent	
  
the	
  formation	
  of	
  a	
  clot,	
  some	
  indi-­‐
viduals	
  with	
  the	
  prothrombin	
  mu-­‐
tation	
  still	
  develop	
  clots.	
  Warfarin,	
  
an	
  antiplatelet	
  agent,	
  is	
  commonly	
  
used	
  to	
  treat	
  these	
  patients.	
  War-­‐
farin	
  works	
  by	
  preventing	
  the	
  
proper	
  functioning	
  of	
  Vitamin	
  K	
  
during	
  the	
  formation	
  of	
  clots	
  (2,	
  
6).	
  It	
  is	
  important	
  for	
  health	
  care	
  
providers,	
  including	
  dentists,	
  to	
  
take	
  medications	
  such	
  as	
  Warfarin	
  
into	
  consideration	
  when	
  treating	
  
patients	
  as	
  they	
  may	
  be	
  at	
  an	
  in-­‐
creased	
  risk	
  for	
  bleeding	
  (7).	
  

The	
  goal	
  of	
  this	
  paper	
  is	
  to	
  
report	
  the	
  case	
  of	
  a	
  23-­‐year-­‐old	
  
female	
  with	
  an	
  extensive	
  history	
  
of	
  clotting	
  issues	
  stemming	
  from	
  a	
  
prothrombin	
  gene	
  mutation.	
  This	
  
paper	
  will	
  cover	
  the	
  biological	
  and	
  
ethical	
  concerns	
  related	
  to	
  a	
  posi-­‐
tive	
  diagnosis	
  of	
  a	
  clotting	
  disor-­‐
der.	
  

Case	
  Presentation:	
  

	
   This	
  report	
  examines	
  the	
  
case	
  of	
  a	
  23-­‐year-­‐old	
  female,	
  
“Anne”	
  (the	
  individual’s	
  name	
  has	
  
been	
  changed	
  to	
  protect	
  the	
  indi-­‐
vidual’s	
  identity).	
  Anne	
  has	
  a	
  per-­‐
sonal	
  and	
  familial	
  history	
  of	
  blood	
  
clots.	
  Anne	
  has	
  had	
  8	
  DVTs,	
  4	
  pul-­‐
monary	
  embolisms	
  with	
  one	
  com-­‐
plete	
  infarction,	
  4	
  superficial	
  clots,	
  
and	
  delivered	
  a	
  stillborn	
  baby	
  at	
  5	
  
months.	
  Doctors	
  attributed	
  the	
  
miscarriage	
  to	
  her	
  thrombophilia.	
  	
  

Anne’s	
  father	
  is	
  Caucasian	
  
and	
  her	
  mother	
  is	
  half	
  Japanese	
  
and	
  half	
  Caucasian.	
  Her	
  paternal	
  
grandmother	
  and	
  grandmother’s	
  
two	
  sisters	
  all	
  had	
  a	
  history	
  of	
  
hospitalizations	
  due	
  to	
  blood	
  clots.	
  
Her	
  father’s	
  sister	
  tested	
  positive	
  
as	
  having	
  the	
  mutation	
  and	
  has	
  
also	
  been	
  hospitalized	
  for	
  DVTs	
  
and	
  pulmonary	
  embolisms.	
  Anne	
  
reported	
  that	
  her	
  father	
  tested	
  
negative	
  for	
  the	
  mutation	
  and	
  that	
  
her	
  father	
  was	
  not	
  a	
  carrier,	
  but	
  it	
  
is	
  likely	
  that	
  he	
  was	
  a	
  heterozy-­‐
gous	
  carrier	
  for	
  the	
  trait.	
  Anne’s	
  

aunt	
  with	
  a	
  history	
  of	
  blood	
  clots	
  
and	
  Anne	
  herself	
  tested	
  positive	
  
as	
  homozygous	
  recessive	
  for	
  the	
  
trait.	
  Given	
  that	
  many	
  individuals	
  
who	
  are	
  heterozygous	
  for	
  the	
  trait	
  
never	
  form	
  blood	
  clots	
  and	
  that	
  
heterozygous	
  individuals	
  are	
  only	
  
at	
  2-­‐3	
  times	
  higher	
  risk,	
  it	
  is	
  plau-­‐
sible	
  to	
  think	
  that	
  Anne’s	
  parents	
  
are	
  carriers	
  of	
  the	
  trait.	
  The	
  exten-­‐
sive	
  history	
  of	
  blood	
  clots	
  and	
  em-­‐
bolisms	
  in	
  Anne’s	
  family	
  suggest	
  
that	
  Anne	
  is	
  homozygous	
  for	
  the	
  
trait,	
  as	
  increased	
  likelihood	
  of	
  
developing	
  clots,	
  up	
  to	
  50	
  times,	
  
and	
  increased	
  severity	
  are	
  report-­‐
ed	
  with	
  homozygous	
  cases	
  (3).	
  A	
  
hypothetical	
  pedigree	
  has	
  been	
  
proposed	
  (see	
  Figure	
  1).	
  

Discussion:	
  

Being	
  diagnosed	
  with	
  a	
  clotting	
  
disorder	
  like	
  a	
  prothrombin	
  muta-­‐
tion	
  has	
  many	
  implications	
  that	
  
can	
  last	
  a	
  lifetime.	
  Individuals	
  with	
  
such	
  mutations	
  are	
  at	
  increased	
  
risk	
  for	
  clotting	
  without	
  medica-­‐
tion,	
  and	
  are	
  at	
  increased	
  risk	
  for	
  
bleeding	
  if	
  on	
  blood	
  thinners	
  such	
  
as	
  Warfarin	
  (2).	
  Because	
  factors	
  
such	
  as	
  smoking	
  and	
  hormonal	
  
birth	
  control	
  significantly	
  increase	
  
one’s	
  risk	
  for	
  developing	
  a	
  clot,	
  it	
  
is	
  advised	
  that	
  individuals	
  with	
  
clotting	
  disorders	
  abstain	
  from	
  
them.	
  	
  

Anne	
  has	
  3	
  siblings	
  from	
  
the	
  same	
  parents.	
  It	
  is	
  possible	
  
that	
  her	
  siblings	
  may	
  also	
  carry	
  the	
  
mutation.	
  Anne	
  has	
  an	
  older	
  



	
  Poten&al	
  inheritance	
  pa+erns	
  of	
  a	
  prothrombin	
  gene	
  muta3on	
  in	
  a	
  23-­‐year-­‐old	
  female	
  and	
  ethical	
  considera0ons	
  of	
  a	
  posi0ve	
  diagnosis:	
  a	
  case	
  report	
  

Vol	
  5,	
  No	
  1	
  (2017)	
  	
  	
  	
  DOI	
  10.5195/d3000.2017.69	
  

	
  http://dentistry3000.pitt.edu	
  

brother,	
  26,	
  who	
  is	
  on	
  his	
  own	
  
health	
  insurance	
  plan.	
  Her	
  two	
  
younger	
  sisters,	
  16	
  and	
  12,	
  are	
  still	
  
on	
  their	
  parents’	
  health	
  insurance	
  
plan.	
  Anne’s	
  dad	
  is	
  unsure	
  wheth-­‐
er	
  he	
  wants	
  to	
  have	
  the	
  younger	
  
daughters	
  tested	
  for	
  the	
  mutation.	
  
While	
  he	
  feels	
  it	
  would	
  be	
  benefi-­‐
cial	
  to	
  know	
  if	
  they	
  have	
  the	
  muta-­‐
tion	
  to	
  better	
  watch	
  for	
  symptoms	
  
and	
  avoid	
  risk	
  factors,	
  he	
  fears	
  a	
  
positive	
  diagnosis	
  may	
  lead	
  to	
  a	
  
lifetime	
  of	
  insurance	
  denial	
  and	
  
anxiety	
  related	
  to	
  the	
  condition.	
  
The	
  Genetic	
  Information	
  Nondis-­‐
crimination	
  Act	
  (GINA)	
  prohibits	
  
employers	
  and	
  health	
  care	
  provid-­‐
ers	
  from	
  discriminating	
  against	
  
individuals	
  because	
  of	
  genetic	
  in-­‐
formation	
  (8).	
  It	
  is	
  unknown	
  if	
  the	
  
father	
  is	
  unaware	
  of	
  this	
  act,	
  is	
  
afraid	
  that	
  this	
  regulation	
  could	
  be	
  
overturned	
  in	
  the	
  future,	
  or	
  fears	
  
that	
  employers	
  and	
  providers	
  do	
  
not	
  always	
  abide	
  by	
  this	
  law.	
  	
  

When	
  seeking	
  medical	
  care	
  
and	
  attention,	
  patients	
  with	
  clot-­‐
ting	
  disorders	
  should	
  alert	
  their	
  
providers	
  of	
  their	
  condition	
  and	
  of	
  
the	
  medications	
  they	
  are	
  taking.	
  
Dentists	
  treating	
  patients	
  on	
  War-­‐
farin	
  should	
  be	
  careful	
  to	
  watch	
  
for	
  excessive	
  bleeding,	
  though	
  
medication	
  adjustments	
  are	
  rarely	
  
warranted	
  (2).	
  One	
  could	
  also	
  
raise	
  the	
  question	
  of	
  if	
  a	
  patient	
  
presents	
  to	
  a	
  dentist	
  with	
  a	
  clot-­‐
ting	
  disorder	
  and	
  a	
  positive	
  history	
  
of	
  smoking	
  and/or	
  hormonal	
  birth	
  
control,	
  is	
  it	
  the	
  obligation	
  of	
  the	
  

dentist	
  to	
  advise	
  the	
  patients	
  of	
  
the	
  risks	
  for	
  increased	
  clotting	
  
when	
  taking	
  such	
  substances?	
  
Based	
  on	
  current	
  literature	
  report-­‐
ing	
  the	
  significantly	
  heightened	
  
risks	
  of	
  clotting	
  with	
  these	
  agents,	
  
it	
  is	
  reasonable	
  to	
  think	
  that	
  a	
  
dentist	
  should	
  bare	
  this	
  responsi-­‐
bility.	
  The	
  dentist	
  should	
  also	
  
counsel	
  the	
  parents	
  on	
  the	
  pros	
  
and	
  cons	
  of	
  having	
  the	
  other	
  sib-­‐
lings	
  tested	
  given	
  the	
  potential	
  
severity	
  of	
  the	
  disease,	
  while	
  ulti-­‐
mately	
  leaving	
  the	
  decision	
  to	
  the	
  
family.	
  	
  

Conclusion	
  

	
   Anne’s	
  medical	
  and	
  familial	
  
history	
  of	
  blood	
  clots	
  show	
  the	
  
need	
  for	
  awareness	
  of	
  this	
  disor-­‐
der	
  and	
  the	
  importance	
  of	
  under-­‐
standing	
  modes	
  of	
  genetic	
  inher-­‐
itance	
  for	
  determining	
  the	
  risk	
  for	
  
other	
  family	
  members.	
  Individuals	
  
with	
  clotting	
  disorders	
  should	
  be	
  
advised	
  to	
  abstain	
  from	
  factors	
  
that	
  increase	
  the	
  risk	
  for	
  clotting,	
  
including	
  smoking	
  and	
  hormonal	
  
birth	
  control.	
  While	
  it	
  may	
  be	
  con-­‐
sidered	
  beneficial	
  to	
  know	
  one’s	
  
status	
  regarding	
  the	
  mutation	
  to	
  
increase	
  awareness	
  and	
  avoid	
  
triggering	
  factors,	
  the	
  current	
  
state	
  of	
  health	
  care	
  policy	
  in	
  the	
  
United	
  States	
  may	
  discourage	
  in-­‐
dividuals	
  from	
  getting	
  tested	
  for	
  
fear	
  of	
  insurance	
  denial	
  or	
  em-­‐
ployment	
  discrimination.	
  It	
  is	
  up	
  to	
  
the	
  individual	
  and	
  their	
  family	
  to	
  
make	
  these	
  decisions,	
  but	
  regard-­‐

less	
  of	
  the	
  decision	
  made,	
  dentists	
  
and	
  health	
  care	
  providers	
  have	
  
professional	
  and	
  ethical	
  obliga-­‐
tions	
  to	
  be	
  aware	
  of	
  and	
  prepared	
  
for	
  any	
  potential	
  complications	
  
that	
  may	
  arise	
  during	
  treatment.	
  

References	
  

1. Prothrombin	
  20210	
  Mutation	
  
(Factor	
  II	
  Mutation);	
  Varga	
  
EA,	
  Moll	
  S;	
  Circulation;	
  2004,	
  
July;110(3):e15-­‐8.	
  PMID:	
  
15262854.	
  

2. Yagiela,	
  Dowd,	
  Johnson,	
  et	
  al	
  
(2011)	
  Pharmacology	
  and	
  
Therapeutics	
  for	
  Dentistry.	
  
St.	
  Louis:	
  Mosby	
  Elsevier.	
  504	
  
p.	
  	
  

3. Lentz,	
  SR;	
  University	
  of	
  Iowa	
  
Hospitals	
  and	
  Clinics;	
  2005.	
  
[cited	
  2017	
  Mar	
  15].	
  Availa-­‐
ble	
  from	
  
https://www.healthcare.uio
wa.edu/labs/lentz/Informati
on_For_Patients/PDF/Prothr
om-­‐
bin%20Gene%20Mutation%
20Brochure.pdf	
  

4. Homozygotes	
  for	
  prothrom-­‐
bin	
  gene	
  20210	
  A	
  allele	
  in	
  a	
  
thrombophilic	
  family	
  without	
  
clinical	
  manifestations	
  of	
  ve-­‐
nous	
  thromboembolism;	
  Sou-­‐
to	
  JC,	
  Mateo	
  J,	
  Soria	
  JM,	
  et	
  al.;	
  
Haematologica;	
  1999;	
  
84(7):627-­‐32.	
  PMID:	
  
10406905.	
  

5. Genetics	
  Home	
  Reference;	
  
National	
  Institute	
  of	
  Health;	
  
U.S.	
  National	
  Library	
  of	
  Medi-­‐
cine;	
  2008.	
  [cited	
  2017	
  Mar	
  
26].	
  Available	
  from	
  
https://ghr.nlm.nih.gov/cond
ition/prothrombin-­‐
thrombophilia#inheritance	
  



	
  Poten&al	
  inheritance	
  pa+erns	
  of	
  a	
  prothrombin	
  gene	
  muta3on	
  in	
  a	
  23-­‐year-­‐old	
  female	
  and	
  ethical	
  considera0ons	
  of	
  a	
  posi0ve	
  diagnosis:	
  a	
  case	
  report	
  

Vol	
  5,	
  No	
  1	
  (2017)	
  	
  	
  	
  DOI	
  10.5195/d3000.2017.69	
  

	
  http://dentistry3000.pitt.edu	
  

6. Anticoagulants;	
  The	
  Johns	
  
Hopkins	
  Lupus	
  Center;	
  2017.	
  
[cited	
  2017	
  Mar	
  26].	
  Availa-­‐
ble	
  from	
  
https://www.hopkinslupus.o
rg/lupus-­‐
treatment/common-­‐
medications-­‐
conditions/anticoagulants/	
  

7. Anticoagulant	
  and	
  Antiplate-­‐
let	
  Medications	
  and	
  Dental	
  
Procedures;	
  The	
  American	
  
Dental	
  Association;	
  2015.	
  
[cited	
  2017	
  Mar	
  28]	
  Available	
  
from	
  
http://www.ada.org/en/me
mber-­‐center/oral-­‐health-­‐
topics/anticoagulant-­‐
antiplatelet-­‐medications-­‐
and-­‐dental-­‐	
  

8. Genetic	
  Information	
  Nondis-­‐
crimination	
  Act;	
  U.S.	
  Depart-­‐
ment	
  of	
  Health	
  and	
  Human	
  
Services;	
  2017.	
  [cited	
  2017	
  
Mar	
  28].	
  Available	
  from	
  
https://www.hhs.gov/hipaa/
for-­‐professionals/special-­‐
topics/genetic-­‐
information/index.html