Selected birth defects data from population-based birth defects surveillance programs in the United States, 2006 to 2010: featuring trisomy conditions

Cases of trisomy 21 and trisomy 18 among historic and prehistoric individuals discovered from ancient DNA

Aneuploidies, and in particular, trisomies represent the most common genetic aberrations observed in human genetics today. To explore the presence of trisomies in historic and prehistoric populations we screen nearly 10,000 ancient human individuals for the presence of three copies of any of the target autosomes. We find clear genetic evidence for six cases of trisomy 21 (Down syndrome) and one case of trisomy 18 (Edwards syndrome), and all cases are present in infant or perinatal burials. We perform comparative osteological examinations of the skeletal remains and find overlapping skeletal markers, many of which are consistent with these syndromes. Interestingly, three cases of trisomy 21, and the case of trisomy 18 were detected in two contemporaneous sites in early Iron Age Spain (800-400 BCE), potentially suggesting a higher frequency of burials of trisomy carriers in those societies. Notably, the care with which the burials were conducted, and the items found with these individuals indicate that ancient societies likely acknowledged these individuals with trisomy 18 and 21 as members of their communities, from the perspective of burial practice.

Contemporary Trends in Cardiac Surgical Care for Trisomy 13 and 18 Patients Admitted to Hospitals in the United States

OBJECTIVE

To assess rates of cardiac surgery and the clinical and demographic features that influence surgical vs nonsurgical treatment of congenital heart disease (CHD) in patients with trisomy 13 (T13) and trisomy 18 (T18) in the United States.

STUDY DESIGN

A retrospective study was performed using the Pediatric Health Information System. All hospital admissions of children (<18 years of age) with T13 and T18 in the United States were identified from 2003 through 2022. International Classifications of Disease (ICD) codes were used to identify presence of CHD, extracardiac comorbidities/malformations, and performance of cardiac surgery.

RESULTS

Seven thousand one hundred thirteen patients were identified. CHD was present in 62% (1625/2610) of patients with T13 and 73% (3288/4503) of patients with T18. The most common CHD morphologies were isolated atrial/ventricular septal defects (T13 40%, T18 42%) and aortic hypoplasia/coarctation (T13 21%, T18 23%). Single-ventricle morphologies comprised 6% (100/1625) of the T13 and 5% (167/3288) of the T18 CHD cohorts. Surgery was performed in 12% of patients with T13 plus CHD and 17% of patients with T18 plus CHD. For all cardiac diagnoses, <50% of patients received surgery. Nonsurgical patients were more likely to be born prematurely (P < .05 for T13 and T18). The number of extracardiac comorbidities was similar between surgical/nonsurgical patients with T13 (median 2 vs 2, P = .215) and greater in surgical vs nonsurgical patients with T18 (median 3 vs 2, P < .001). Hospital mortality was <10% for both surgical cohorts.

CONCLUSIONS

Patients with T13 or T18 and CHD receive surgical palliation, but at a low prevalence (≤17%) nationally. Given operative mortality <10%, opportunity exists perhaps for quality improvement in the performance of cardiac surgery for these vulnerable patient populations.

12-Year Trends of Orofacial Clefts in the United States: Highlighting Racial/Ethnic Differences in Prevalence of Cleft Lip and Cleft Palate

OBJECTIVE

Discrepancies in prevalence among infants with orofacial clefts are public health research priorities. Our objective was to calculate updated estimated prevalence of orofacial clefts in the United States, with sub-analyses by racial/ethnic group.

DESIGN

The National Birth Defect Prevention Network database was used to evaluate trends in cases with orofacial cleft in the United States from 2006 to 2018. Cases with cleft lip with and without cleft palate (CL ± P) and cleft palate (CP) alone were sub-stratified by racial/ethnic category. Estimated prevalence was calculated using the total live births reported in each maternal racial/ethnic group. The odds ratio (OR) was calculated to measure the strength of association between racial/ethnic group and risk of orofacial clefts.

RESULTS

Estimated prevalence rates show that maternally-reported Native American/Alaskan Native individuals were 43.8% (p < 0.0001) and 36.0% (p < 0.0001) more likely to have CL ± P and CP alone, respectively, compared to maternally-reported non-Hispanic White individuals. Estimated prevalence of CL ± P in maternally-reported non-Hispanic Black individuals (OR = 0.64) and maternally-reported Asians/Pacific Islander individuals were significantly lower than in maternally-reported non-Hispanic White individuals (OR = 0.63, p < 0.0001). Estimated prevalence of CP alone was significantly lower in maternally-reported non-Hispanic Black individuals (OR = 0.64, p < 0.0001), maternally-reported Asians/Pacific Islander individuals (OR = 0.69, p < 0.0001), and maternally-reported Hispanic individuals (OR = 0.81, p < 0.0001).

CONCLUSIONS

Across the total population, there was no significant change in estimated orofacial cleft prevalence. However, there were significant disproportions in estimated orofacial cleft prevalence across racial/ethnic groups, which may guide further discussion among craniofacial health care providers and centers and their patients regarding differences in cleft risk factors.

Louis AM, Agopian AJ. Scientific impact of the National Birth Defects Prevention Network multistate collaborative publications

BACKGROUND

Given the lack of a national, population-based birth defects surveillance program in the United States, the National Birth Defects Prevention Network (NBDPN) has facilitated important studies on surveillance, research, and prevention of major birth defects. We sought to summarize NBDPN peer-reviewed publications and their impact.

METHODS

We obtained and reviewed a curated list of 49 NBDPN multistate collaborative publications during 2000-2022, as of December 31, 2022. Each publication was reviewed and classified by type (e.g., risk factor association analysis). Key characteristics of study populations and analytic approaches used, along with publication impact (e.g., number of citations), were tabulated.

RESULTS

NBDPN publications focused on prevalence estimates (N = 17), surveillance methods (N = 11), risk factor associations (N = 10), mortality and other outcomes among affected individuals (N = 6), and descriptive epidemiology of various birth defects (N = 5). The most cited publications were those that reported on prevalence estimates for a spectrum of defects and those that assessed changes in neural tube defects (NTD) prevalence following mandatory folic acid fortification in the United States.

CONCLUSIONS

Results from multistate NBDPN publications have provided critical information not available through other sources, including US prevalence estimates of major birth defects, folic acid fortification and NTD prevention, and improved understanding of defect trends and surveillance efforts. Until a national birth defects surveillance program is established in the United States, NBDPN collaborative publications remain an important resource for investigating birth defects and informing decisions related to health services planning of secondary disabilities prevention and care.

Validation of ICD-9-CM codes for major genitourinary birth defects in Military Health System administrative data, 2006-2014

BACKGROUND

The Department of Defense Birth and Infant Health Research program is dedicated to birth defects research and surveillance among military families. Here, we assess and refine the validity of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for selected genitourinary birth defects in the Military Health System (MHS). We additionally outline methods for the calculation of positive predictive value (PPV) and negative predictive value (NPV), sensitivity, and specificity using a stratified sampling design.

METHODS

Among military infants born from 2006 through 2014, a random sample of ICD-9-CM screen-positive cases (for six genitourinary birth defects) and screen-negative cases were selected for chart review. PPV, NPV, sensitivity, and specificity were calculated for individual defects and any included defect (i.e., overall); measures were weighted by the inverse probability of being sampled.

RESULTS

Of 461,557 infants, 686 were sampled for chart review. Bladder exstrophy was accurately reported (PPV: >90%), while the accuracy of renal dysplasia, renal agenesis/hypoplasia, and hypospadias was moderate (PPVs: 66%-68%) and congenital hydronephrosis was low (PPV: 20%). Specificity and NPVs always exceeded 98%. The overall PPV was 50%; however, excluding congenital hydronephrosis screen-positive cases and requiring at least two inpatient or outpatient diagnostic codes resulted in a PPV of 85%.

CONCLUSIONS

The validity of major genitourinary birth defect codes varied in MHS administrative data. The accuracy of an overall defect measure improved by omitting congenital hydronephrosis and requiring at least two diagnostic codes. Although PPV is generally useful for research, additional calculation of NPV, sensitivity, and specificity better informs the identification of appropriate selection criteria across surveillance and research settings.

Exceptional longevity of mammalian ovarian and oocyte macromolecules throughout the reproductive lifespan

The mechanisms contributing to age-related deterioration of the female reproductive system are complex, however aberrant protein homeostasis is a major contributor. We elucidated exceptionally stable proteins, structures, and macromolecules that persist in mammalian ovaries and gametes across the reproductive lifespan. Ovaries exhibit localized structural and cell-type specific enrichment of stable macromolecules in both the follicular and extrafollicular environments. Moreover, ovaries and oocytes both harbor a panel of exceptionally long-lived proteins, including cytoskeletal, mitochondrial, and oocyte-derived proteins. The exceptional persistence of these long-lived molecules suggest a critical role in lifelong maintenance and age-dependent deterioration of reproductive tissues.

Caregiver experiences helping children with Down syndrome use positive airway pressure to treat obstructive sleep apnea

BACKGROUND/OBJECTIVE

While positive airway pressure (PAP) is an efficacious intervention for the treatment of obstructive sleep apnea syndrome (OSAS) in children with Down syndrome (DS), implementation and consistent use can be difficult. Caregiver perspectives and experiences using PAP are described with the aim of informing clinical practice.

METHODS

Qualitative semi-structured phone interviews were conducted with 40 caregivers (i.e., mothers) of children with DS and OSAS treated with PAP for at least 6 months. Content analysis was used to identify themes associated with adherence and non-adherence.

RESULTS

Respondents indicated variability in caregiver experience with the adoption of PAP and observed benefits of PAP. Varied experiences were attributed to several themes including accessing supplies, interactions with the medical team and equipment company, and patients' unique needs and behaviors, including the child's willingness and ability to adapt to PAP, sensory sensitivities, keeping the mask on all night, and differences in daytime behavior. Many families reported that desensitization with a reward system and trust within the caregiver-patient relationship were helpful. Caregiver suggestions for improving PAP adherence for families of children with DS included improving communication with the medical team and medical equipment company, emphasizing patience, using visual supports, and social support and education for extended family.

CONCLUSIONS

Although family experiences varied, several actionable strategies by both the medical team and families emerged for improving the experience of and adherence to PAP in children with DS.

Decannulation in Trisomy 21 patients undergoing laryngotracheal reconstruction

BACKGROUND

Down Syndrome (DS) patients are more susceptible to either congenital or acquired subglottic stenosis (SGS). This often creates a multilevel airway obstruction and can lead to tracheostomy dependence early in life. As a result, they may require Laryngotracheal Reconstruction (LTR) to achieve decannulation. The primary objective of this study was to assess decannulation rates, time to decannulation and potential barriers to decannulation in DS patients undergoing LTR.

METHODS

We performed a retrospective chart review from 2008 to 2021 of 193 children who underwent LTR for treatment for laryngotracheal stenosis at a stand-alone tertiary children's hospital. The relationship between clinical data and decannulation status was evaluated using multivariable logistic regression and Fisher exact tests. Time to decannulation analysis was performed using Kaplan Meier analysis and evaluated with log-rank and Cox proportional hazards regression.

RESULTS

We determined that DS patients carry an inherit risk for decannulation failure compared to the general population (OR: 6.112, P = . 044, CI 1.046-35.730). Of the 8 patients with DS only three were decannulated. Overall, patients with Trisomy 21 had a significantly increased time to decannulation when compared to all LTR patients (P = .008, Log-rank). We found that these patients are more likely to have both suprastomal collapse (P = .0004, Fischer's Exact) and Tracheomalacia (P = .034, Fischer's Exact) compared to all other LTR patients. While post-operative tracheomalacia did not significantly affect decannulation failure (P = .056, Fischer's Exact) it did significantly prolong decannulation in all LTR patients (P = .018, Log-rank).

CONCLUSION

Trisomy 21 patients are at an increased risk for decannulation failure. Our study illustrates that these poor outcomes are likely a result of conditions more commonly found in this cohort including: narrow tracheal caliber, tracheomalacia and hypotonia.

Comparing Non-invasive Prenatal Testing With Invasive Testing for the Detection of Trisomy 21

Background Non-invasive prenatal test (NIPT) is an intermediate step between serum screening and invasive diagnostic testing. It involves analysis of the cell-free fetal DNA (cffDNA) present in the maternal blood sample for determining the likelihood of fetal aneuploidy. Owing to its high sensitivity and specificity, NIPT has quickly gained popularity across the globe since its introduction to clinical practice, making it an attractive alternative to the available screening and diagnostic tests in use. Amniocentesis is currently the gold standard test for obtaining fetal DNA and diagnosing fetal trisomy prenatally, but it is invasive and has procedure-related adverse effects. This study aims to compare NIPT and amniocentesis in pregnancies screened positive for fetal trisomy. Material and methods This is an analytic cross-sectional prospective study conducted in the Department of Obstetrics & Gynecology, Patna Medical College and Hospital, for two and half years from December 2018 to June 2021. A total of 34 pregnant women screened positive for trisomy 21, attending the antenatal care outpatient department, in their second trimester, with their written consent, were enrolled in the study. Results Out of 34 pregnant patients, three refused NIPT and directly opted for amniocentesis. A total of 31 pregnant women have undergone NIPT. A total of 28 cases were positive for trisomy 21 on both NIPT and amniocentesis. The sensitivity of NIPT was 100% with the confidence interval being 87.66% to 100.00%. The specificity of NIPT was 100% with the confidence interval being 29.24% to 100.00%. Conclusion The high performance and effectiveness of NIPT are undeniable. Though the process by which this test has to be integrated into the clinical practice needs more study and should be determined with meticulous assessment.

Assessment of the Correlation between the Levels of Physical Activity and Technology Usage among Children with Down Syndrome in the Riyadh Region

Background: Children with Down Syndrome (C-DS) have language, cognitive and communication difficulties, in addition to consistent physical inactivity that contributes to poor health and higher-disability-adjusted life years. The purpose of this study was to determine the correlation between the use of electronic technology and levels of physical activity in C-DS in the Riyadh region of Saudi Arabia. Methods: A cross-sectional study was conducted with 49 mothers, where each had a child (6-12 years of age) with Down Syndrome (DS), and who were recruited using purposive sampling from three DS centers in Riyadh, Saudi Arabia. The Children's Physical Activity Questionnaire and Research Questionnaire on the Impact of Technology on Children were used. Descriptive statistics were used to describe the demographics. Pearson's correlation, Student's t-test and the Chi-square test were used to assess the association between technology use, physical activity levels and socio-demographic variables. Results: There was no significant correlation between physical activity and the use of technology by C-DS. However, there was a negative correlation between a high level of physical activity and technology use (R = -0.037). Although, no significant correlation between the mother's characteristics and technology use was found; there was a significantly positive correlation (p = 0.05) between the education level of mothers and the technology use by C-DS. Nonetheless, there was no association between the physical activity level and the gender of the child with DS. Conclusions: This study found that no significant relationship exists between the use of electronic gadgets and the level of physical activity in C-DS.

Congenital anomalies and maternal age: A systematic review and meta-analysis of observational studies

INTRODUCTION

Several studies have reported on the maternal age-associated risks of congenital anomalies. However, there is a paucity of studies with comprehensive review of anomalies. We aimed to quantify the risk of birth defects in children born to middle-aged mothers compared with that in children born to young or older mothers.

MATERIAL AND METHODS

We classified maternal ages into three groups: young (<20 years old), middle (20-34 years old) and older age (≥35 years old). Observational studies that met our age criteria were eligible for inclusion. The articles searched using the Embase and MEDLINE databases were those published from 1989 to January 21, 2021. The Newcastle-Ottawa scale was used to assess the risk of bias. If heterogeneity exceeded 50%, the random effect method was used; otherwise, the fixed-effect method was used. Prospero registration number: CRD42021235229.

RESULTS

We included 15 cohort, 14 case-control and 36 cross-sectional studies. The pooled unadjusted odds ratio (95% CI) of any congenital anomaly was 1.64 (1.40-1.92) and 1.05 (0.95-1.15) in the older and young age groups, respectively (very low quality of evidence). The pooled unadjusted odds ratio of chromosomal anomaly was 5.64 (5.13-6.20) and 0.69 (0.54-0.88) in the older and young age groups, respectively. The pooled unadjusted odds ratio of non-chromosomal anomaly was 1.09 (1.01-1.17) and 1.10 (1.01-1.21) in the older and young age groups, respectively (very low quality of evidence). The incidence of abdominal wall defects was increased in children of women in the young maternal age group.

CONCLUSIONS

We identified that very low quality evidence suggests that women in the older maternal age group had increased odds of having children with congenital anomalies compared with those in the 20-34 year age group. There was no increase in odds of children with congenital anomalies in women of <20 year age group except for abdominal defects compared with those in the 20-34 year age group. The results stem from very low quality evidence with no adjustment of confounders.

The impact of prenatal screening tests on prenatal diagnosis in Taiwan from 2006 to 2019: a regional cohort study

BACKGROUND

The purpose of this study is to evaluate the impact of prenatal screening tests on prenatal diagnosis in Taiwan's 14 years from 2006 to 2019.

METHODS

The prenatal screening methods evolved from the second-trimester serum screening to combined first-trimester screening (cFTS) and then followed by the non-invasive cell-free DNA prenatal test (NIPT). The data used by the Department of Statistics, the Ministry of Health and Welfare and Department of Household Registration, Ministry of the Interior public website.

RESULTS

This regional registry-based cohort retrospective study examined a total of 2,775,792 births from January 2006 to December 2019. The proportion of advanced maternal age (AMA) pregnancies increased from 11.63% in 2006 to 30.94% in 2019. Overall, invasive diagnostic testing was used in 87.22% of AMA pregnancies. The prenatal detection rate of trisomy 21 and 18 increased from 74.1% and 83.3% in 2006 to 96.9% and 98.8% in 2019, respectively.

CONCLUSION

During the second-trimester and cFTS periods, the percentage of AMA pregnancies increased every year and the number of invasive procedures also accompany with increased percentage of AMA. However, during the period that NIPT were implemented, the percentage of invasive procedures decreased.

Changes in the birth prevalence of orofacial clefts in Japan: Has the birth prevalence of orofacial clefts been affected by improved accuracy of prenatal diagnosis?

We have been conducting a survey on the birth prevalence of orofacial clefts, including cleft lip with or without cleft palate and cleft palate, in the Tokai area in central Japan every year for 37 years. Along with the yearly trends in the birth prevalence of orofacial clefts in that area for the past 37 years, we discuss whether the artificial abortion rate of fetuses with orofacial clefts has increased through the improved performance of ultrasonic imaging equipment. We also compare the yearly trends in the birth prevalence of congenital anomalies, including orofacial clefts, in Japan with those in other countries or areas where artificial abortion due to birth defects is legally permitted, and discuss the impact of improved accuracy of ultrasound imaging on the rate of artificial termination of pregnancy. The fact that the birth prevalence of orofacial clefts has basically remained unchanged for more than 30 years, even with recent more detailed prenatal diagnosis based on the improvement of ultrasonic diagnostic equipment, has allowed us tentatively to conclude that prenatal diagnosis is not currently threatening the right to life of the fetuses with orofacial clefts.

One-carbon metabolism and global DNA methylation in mothers of individuals with Down syndrome

Down syndrome (DS) is the most common chromosomal disorder, resulting from the failure of normal chromosome 21 segregation. Studies have suggested that impairments within the one-carbon metabolic pathway can be of relevance for the global genome instability observed in mothers of individuals with DS. Based on the association between global DNA hypomethylation, genome instability, and impairments within the one-carbon metabolic pathway, the present study aimed to identify possible predictors, within the one-carbon metabolism, of global DNA methylation, measured by methylation patterns of LINE-1 and Alu repetitive sequences, in mothers of individuals with DS and mothers of individuals without the syndrome. In addition, we investigated one-carbon genetic polymorphisms and metabolites as maternal predisposing factors for the occurrence of trisomy 21 in children. Eighty-three samples of mothers of children with DS with karyotypically confirmed free trisomy 21 (case group) and 84 of mothers who had at least one child without DS or any other aneuploidy were included in the study. Pyrosequencing assays were performed to access global methylation. The results showed that group affiliation (case or control), betaine-homocysteine methyltransferase (BHMT) G742A and transcobalamin 2 (TCN2) C776G polymorphisms, and folate concentration were identified as predictors of global Alu DNA methylation values. In addition, thymidylate synthase (TYMS) 28-bp repeats 2R/3R or 3R/3R genotypes are independent maternal predisposing factors for having a child with DS. This study adds evidence that supports the association of impairments in the one-carbon metabolism, global DNA methylation, and the possibility of having a child with DS.

Ten-year trends in the incidence of microtia: a nationwide population-based study from Taiwan

PURPOSE

Few studies have explored population-based incidence rates of microtia using nationwide data. The aim of this study was to analyze the 10-year secular trends in the incidence of microtia and/or anotia in Taiwan from 2008 to 2017 using nationwide population-based data.

METHODS

Patient data were retrieved from Taiwan's National Health Insurance Dataset, after identifying 1152 children aged ≤ 1 year with a first-time diagnosis of microtia or anotia between January 2008 and December 2017. The annual microtia-anotia incidence rate was the sum of new microtia-anotia cases in a year divided by total infant population in the year. Furthermore, we used the annual percent change (APC) to study the secular trend in microtia-anotia incidence rate.

RESULTS

The annual incidence rate of microtia-anotia averaged across the 10-year period was 57.7 per 100,000 infants (standard deviation = 8.6). The annual incidence rates of microtia and anotia were 53.3 and 4.4 per 100,000 infants, respectively, during this period. Furthermore, female infants had a higher incidence than males (63.3 vs. 52.4 per 100,000). The incidence of microtia-anotia gradually decreased between 2008 and 2017 with an APC of - 5.64% (95% CI - 9.31 ~ - 1.18%, p = 0.004). Since 2011, females had a significantly higher annual incidence rate of microtia-anotia than males.

CONCLUSIONS

The incidence of microtia-anotia was 57.7 per 100,000 infants in Taiwan, which declined during the study period 2008-2017. The female-to-male incidence ratio was 1.21:1.

Causes of Phenotypic Variability and Disabilities after Prenatal Viral Infections

Prenatal viral infection can lead to a spectrum of neurodevelopmental disabilities or fetal demise. These can include microencephaly, global developmental delay, intellectual disability, refractory epilepsy, deafness, retinal defects, and cortical-visual impairment. Each of these clinical conditions can occur on a semi-quantitative to continuous spectrum, from mild to severe disease, and often as a collective of phenotypes. Such serious outcomes result from viruses’ overlapping neuropathology and hosts’ common neuronal and gene regulatory response to infections. The etiology of variability in clinical outcomes is not yet clear, but it may be related to viral, host, vector, and/or environmental risk and protective factors that likely interact in multiple ways. In this perspective of the literature, we work toward understanding the causes of phenotypic variability after prenatal viral infections by highlighting key aspects of the viral lifecycle that can affect human disease, with special attention to the 2015 Zika pandemic. Therefore, this work offers important insights into how viral infections and environmental teratogens affect the prenatal brain, toward our ultimate goal of preventing neurodevelopmental disabilities.

Association of Gestational Opioid Exposure and Risk of Major and Minor Congenital Malformations

IMPORTANCE

The rapid increase of opioid-related overdoses and deaths has become a public health concern in the US. Use of prescription opioids in pregnant women has increased; results from teratogenicity studies remain controversial.

OBJECTIVE

To evaluate the association between maternal prescription opioid use (excluding opioid use disorders) during pregnancy and the incidence of congenital malformations.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective population-based cohort study evaluated linked Rhode Island Medicaid claims and vital statistics data of live births from January 1, 2008, to December 31, 2016. Data analysis was conducted from May 1, 2019, to May 31, 2020. Women who had a live birth during the study period, but no cancer or opioid use disorder, were followed up from 3 months before pregnancy to the end of pregnancy.

EXPOSURES

Data on the mother's prescription opioid exposure were obtained through pharmacy claims and exposure was defined as dispensing of at least 1 prescription opioid during the first, second, or third trimester.

MAIN OUTCOMES AND MEASURES

The primary outcome was overall major or minor congenital malformations, defined as 1 or more major or minor congenital malformation. Secondary outcomes were defined as 10 specific categories of congenital malformations classified by organ systems using International Classification of Diseases diagnosis codes.

RESULTS

Of 12 424 included pregnancies, 891 mothers (7.2%) received prescription opioids during pregnancy and 3153 infants (25.4%) were diagnosed with major or minor congenital malformations. Comparing prescription opioid exposure vs nonexposure, no excess risk was observed for major birth defects in infants with opioid exposure in trimester 1 (adjusted relative risk [aRR], 1.40; 95% CI, 0.84-2.34), and higher risks were found for overall minor birth defects in trimester 3 (aRR, 1.26; 95% CI, 1.04-1.53) and minor birth defects in the musculoskeletal system in trimester 2 (aRR, 1.50; 95% CI, 1.10-2.03) and trimester 3 (aRR, 1.65; 95% CI, 1.23-2.22). Significant dose responses in selected minor malformations and effects of specific opioids were also identified. Hydrocodone in trimester 2 (aRR, 3.01; 95% CI, 1.80-5.03) and oxycodone in trimester 3 (aRR, 2.43; 95% CI, 1.37-4.02) were associated with plagiocephaly, polydactyly, and other specified congenital deformities of the hip.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest a higher risk of minor congenital malformations associated with use of prenatal prescription opioids in trimester 3, which seems to be dose-dependent. Further investigation is needed to establish causality and explore the physiologic plausibility of the association.

Automated Lateral Ventricular and Cranial Vault Volume Measurements in 13,851 Patients Using Deep Learning Algorithms

BACKGROUND

No large dataset-derived standard has been established for normal or pathologic human cerebral ventricular and cranial vault volumes. Automated volumetric measurements could be used to assist in diagnosis and follow-up of hydrocephalus or craniofacial syndromes. In this work, we use deep learning algorithms to measure ventricular and cranial vault volumes in a large dataset of head computed tomography (CT) scans.

METHODS

A cross-sectional dataset comprising 13,851 CT scans was used to deploy U-Net deep learning networks to segment and quantify lateral cerebral ventricular and cranial vault volumes in relation to age and sex. The models were validated against manual segmentations. Corresponding radiologic reports were annotated using a rule-based natural language processing framework to identify normal scans, cerebral atrophy, or hydrocephalus.

RESULTS

U-Net models had high fidelity to manual segmentations for lateral ventricular and cranial vault volume measurements (Dice index, 0.878 and 0.983, respectively). The natural language processing identified 6239 (44.7%) normal radiologic reports, 1827 (13.1%) with cerebral atrophy, and 1185 (8.5%) with hydrocephalus. Age-based and sex-based reference tables with medians, 25th and 75th percentiles for scans classified as normal, atrophy, and hydrocephalus were constructed. The median lateral ventricular volume in normal scans was significantly smaller compared with hydrocephalus (15.7 vs. 82.0 mL; P < 0.001).

CONCLUSIONS

This is the first study to measure lateral ventricular and cranial vault volumes in a large dataset, made possible with artificial intelligence. We provide a robust method to establish normal values for these volumes and a tool to report these on CT scans when evaluating for hydrocephalus.

Quality of life in individuals with Down syndrome aged 4 to 21 years

BACKGROUND

To date, investigations of quality of life (QoL) in children with Down syndrome (DS) are rather limited. The purpose of this study was twofold: to examine QoL in children with DS and to explore possible differences in the QoL by age and gender.

METHODS

A cross-sectional study of 211 parents of children with DS was conducted using an online survey that included a consent form, a demographic questionnaire and the English version of KidsLife, which is a measure of children's QoL.

RESULTS

Our results demonstrated moderate or favourable levels of QoL except for the emotional well-being domain among children with DS. The children's QoL showed no variance by gender. However, emotional and material well-being, interpersonal relations and social inclusion varied by age.

CONCLUSIONS

The current findings provide important evidence that will help healthcare, educational and social services professionals to understand the multiple aspects of QoL in children with DS and support parents in their efforts to ensure the child's QoL. The results also point to the need to develop interventions aimed at improving QoL in those areas where children with DS are at increased risk for poorer QoL.

Secular trends in longevity among people with Down syndrome in Japan, 1995-2016

BACKGROUND

Life expectancy in Japan has increased dramatically and is one of the longest in the world. However, the changes in lifespan in Japanese individuals with congenital diseases remain unknown. We investigated secular changes in the lifespan of people with Down syndrome over the last 20 years.

METHODS

We observed secular trends in the number of stillbirths, deaths and the mortality rates at ages 20, 40, and 60 among all deaths registered with Down syndrome as the cause of death (ICD10 code: Q90) in the Japan national death registry database between 1995 and 2016. Changes in the median age at death between 1995-2005 and 2006-2016 were investigated based on sex and history of surgery.

RESULTS

We identified 240 stillbirths and 1,099 deaths in this period. The annual number of stillbirths and deaths above the age of 1 year increased, whereas the number of deaths below 1 year did not change. The proportional mortality indicator at ages 20, 40, and 60 increased from 21.7%, 11.7%, and 1.7% in 1995 to 69.9%, 66.7%, and 36.6% in 2016, respectively. The median age at death was higher in females, individuals without a surgical history, and deaths occurring in 2006-2016. The median age at death increased over the period in those without a surgical history.

CONCLUSIONS

The age at death among people with Down syndrome has increased over the last 20 years, with currently 1 in 3 persons living over 60 years, necessitating adequate social welfare services in this aging population.

Cardiac Surgery in Trisomy 13 and 18: A Guide to Clinical Decision-Making

There has been substantial controversy regarding treatment of congenital heart defects in infants with trisomies 13 and 18. Most reports have focused on surgical outcomes versus expectant treatment, and rarely there has been an effort to consolidate existing evidence into a more coherent way to help clinicians with decision-making and counseling families. An extensive review of the existing literature on cardiac surgery in patients with these trisomies was conducted from 2004 to 2020. The effects of preoperative and perioperative factors on in-hospital and long-term mortality were analyzed, as well as possible predictors for postoperative chronic care needs such as tracheostomy and gastrostomy. Patients with minimal or no preoperative pulmonary hypertension and mechanical ventilation undergoing corrective surgery at a weight greater than 2.5 kg suffer from lower postoperative mortality. Infants with lower-complexity cardiac defects are likely to benefit the most from surgery, although their expected mortality is higher than that of infants without trisomy. Omphalocele confers an increased mortality risk regardless of cardiac surgery. Gastrointestinal comorbidities increased the risk of gastrostomy tube placement, while those with prolonged mechanical ventilation and respiratory comorbidities are more likely to require tracheostomy. Cardiac surgery is feasible in children with trisomies 13 and 18 and can provide improved long-term results. However, this is a clinically complex population, and both physicians and caretakers should be aware of the long-term challenges these patients face following surgery when discussing treatment options.

No 380 - Évaluation et prise en charge de la microcéphalie détectée avant la naissance

OBJECTIF

Informer les fournisseurs canadiens de soins de santé périnatale des critères diagnostiques de la microcéphalie fœtale et fournir l'information sur les analyses pertinentes, le pronostic, et la prise en charge prénatale et périnatale en lien avec a cette observation prénatale.

DESTINATAIRES

Tous les fournisseurs de soins de maternité (fournisseurs principaux de soins de santé) et de soins de pédiatrie; les conseiller(e)s en génétique; les infirmièr(e)s en soins de maternité; les infirmièr(e)s practicien(ne)s, les administrateur(trice)s provinciaux de soins de maternité; les étudiant(e)s, en médecine; les résident(e)s postdoctoraux et les stagiaires (fellows). RéSULTATS: Fournir de meilleurs conseils et une prise en charge clinique adéquate aux femmes et aux familles qui ont reçu un diagnostic prénatal de microcéphalie fœtale. DONNéES PROBANTES: La documentation publiée est tirée de recherches effectuées en 2018 dans le moteur PubMed et les bases de données Medline, CINAHL et Cochrane Library au moyen de mots-clés anglais pertinents (prenatal ultrasound, prenatal imaging, fetal, antenatal ou prenatal microcephaly). Des publications supplémentaires ont été sélectionnées à partir des notices bibliographiques de ces articles. PéRIODE DE RECHERCHE: Sept ans (2010-2018); la dernière recherche a été effectuée le 19 avril 2018. L'auteur principal a terminé la validation des articles. AVANTAGES, PRéJUDICES ET COûTS: Le présent document renseigne les lecteurs au sujet (1) des critères diagnostiques de la microcéphalie fœtale, (2) de ses étiologies potentielles et (3) des analyses et options de prise en charge avant et après la naissance. Il propose une méthode fondée sur des données probantes pour établir le diagnostic et déterminer la prise en charge de la microcéphalie détectée avant la naissance. Ces recommandations sont fondées sur l'opinion d'experts, mais n'ont pas fait l'objet d'une évaluation économique de la santé. Une mise en œuvre aux échelles locale ou provinciale sera requise. Les auteurs reconnaissent que l'accès aux services et ressources mentionnés varie au Canada. Par conséquent, ces recommandations ont été formulées dans la perspective de promouvoir l'accès et de fournir une orientation pour toutes les provinces et tous les territoires du pays. CRITèRES: La solidité des données probantes indiquées s'appuie sur les critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs. RECOMMANDATIONS.

No. 380-Investigation and Management of Prenatally Identified Microcephaly

OBJECTIVE

To update Canadian maternity care and reproductive health care providers on the diagnostic criteria of fetal microcephaly and provide information on the relevant investigations, prognosis, and pre- and perinatal management of this prenatal finding.

INTENDED USERS

All maternity care (most responsible health provider [MRHP]) and pediatric providers; genetic counsellors; maternity nurses; nurse practitioners; provincial maternity care administrators; medical students; postgraduate residents, and fellows.

OUTCOMES

To provide better counselling and appropriate clinical management to women and families who have received a prenatal diagnosis of fetal microcephaly.

EVIDENCE

Published literature was retrieved through searches of PubMed or Medline, CINAHL, and The Cochrane Library in 2018, using appropriate key words (prenatal ultrasound, prenatal imaging, fetal, antenatal, or prenatal microcephaly). Additional publications were identified from the bibliographies of these articles.

SEARCH PERIOD

Seven years (2010-2018); completed final search April 19, 2018. The primary author completed validation of the articles.

BENEFITS, HARMS, AND COSTS

This document educates readers about (1) the diagnostic criteria for fetal microcephaly, (2) its potential etiologies, (3) investigation and management options both pre- and postnatally. It proposes an evidence-based approach to the diagnosis and management of prenatally detected microcephaly. These recommendations are based on expert opinion and have not been subjected to a health economics assessment. Local or provincial implementation will be required. The authors recognize that there is variability across Canada in access to the cited services and resources. As such, these recommendations were developed in an attempt to promote access and to provide guidance for all provinces and territories across the country.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care.

RECOMMENDATIONS

Attitudes Toward Hypothetical Uses of Gene-Editing Technologies in Parents of People with Autosomal Aneuploidies

Researchers are exploring the use of gene-editing technologies to prevent and/or treat genetic conditions in humans. Stakeholder views, including those of patient and family populations, are important in the ongoing bioethical discussion. We conducted 27 semi-structured interviews with parents of people with trisomy 21 (T21; N = 10), trisomy 18 (T18; N = 8), and trisomy 13 (T13; N = 9)-conditions not previously studied in regard to attitudes toward hypothetical gene editing. While many discussions focus on the morality of gene editing, parents in our study focused on quality of life and concerns about changing their children's identity. All participants prioritized ameliorating life-threatening health issues when those were present; many also emphasized increasing their children's communication and cognitive ability. These results suggest that patient populations with the lived experience of genetic conditions have unique concerns that may differ from broader discourse.

Management of apnea in infants with trisomy 18

This case series aimed to characterize the clinical features, management, and outcomes of apnea in infants with trisomy 18. Participants in this study were infants with trisomy 18 who were born alive and admitted to the neonatal intensive care unit in Kyushu University Hospital from 2000 to 2018. Retrospective analysis was performed on clinical data recorded in our department. Twenty-seven infants with trisomy 18 were admitted to our hospital during the study period, of which 25 (nine males, 16 females) were enrolled as eligible participants in this study. Among them, 14 started presenting with apnea from median 3.5 days of age (range 0-47d). In these infants with apnea, eight received respiratory support of positive pressure ventilation (PPV). The 1-year survival rate of infants in the PPV group was higher than that of non-PPV-supported infants (5 out of 8 vs 0 out of 6 infants). Five PPV-supported infants received a diagnosis of epilepsy, which was controlled by antiepileptic drugs. Postnatal respiratory intervention provides better prognosis in infants with trisomy 18. Improved survival leads to accurate diagnosis and treatment of apneic events in association with epilepsy. WHAT THIS PAPER ADDS: Respiratory support is effective against apnea in infants with trisomy 18. Intervention with ventilation provides a higher chance of prolonged survival. Improved survival leads to the accurate diagnosis and treatment of epilepsy-associated apnea.

Vowel Acoustics and Speech Intelligibility in Young Adults With Down Syndrome

Purpose Speech production deficits and reduced intelligibility are frequently noted in individuals with Down syndrome (DS) and are attributed to a combination of several factors. This study reports acoustic data on vowel production in young adults with DS and relates these findings to perceptual analysis of speech intelligibility. Method Participants were eight young adults with DS as well as eight age- and gender-matched typically developing (TD) controls. Several different acoustic measures of vowel centralization and variability were applied to tokens of corner vowels (/ɑ/, /æ/, /i/, /u/) produced in common English words. Intelligibility was assessed for single-word productions of speakers with DS, by means of transcriptions from 14 adult listeners. Results Group differentiation was found for some, but not all, of the acoustic measures. Low vowels were more acoustically centralized and variable in speakers with DS than TD controls. Acoustic findings were associated with overall intelligibility scores. Vowel formant dispersion was the most sensitive measure in distinguishing DS and TD formant data. Conclusion Corner vowels are differentially affected in speakers with DS. The acoustic characterization of vowel production and its association with speech intelligibility scores within the DS group support the conclusion of motor control deficits in the overall speech impairment. Implications are discussed for effective treatment planning.

Trends in Infant Mortality After TAPVR Repair over 18 Years in Texas and Impact of Hospital Surgical Volume

For some congenital heart lesions, higher institutional surgical volume has been associated with better survival than in lower volume centers. The relationship between institutional surgical volume and mortality in infants after total anomalous pulmonary vein return (TAPVR) repair has not been well explored. The Texas Inpatient Public Use Data File was queried for hospitalizations including TAPVR repair in infants between January 1, 1999 and December 31, 2016. We first evaluated the change in mortality over the study period. We then evaluated associations between institutional TAPVR surgical volume and mortality using univariable analysis and multivariable analysis accounting for center effects. For secondary analyses, we evaluated the association between volume and mortality among non-mutually exclusive TAPVR subsets, including isolated TAPVR, TAPVR with other congenital heart disease (CHD), TAPVR with heterotaxy, and TAPVR with single ventricle anatomy. Of 971 surgical hospitalizations that met inclusion criteria, 62% were male. Mortality after TAPVR repair decreased over the study period from 15.1% (1999-2004) to 7.6% (2012-2016) with an odds ratio per increasing year of 0.96 (95% CI 0.92-0.99, p = 0.030). By univariable analysis, earlier era, preterm birth, lower institutional surgical volume, heterotaxy, and additional CHD were associated with increased mortality. Institutional surgical volume remained significant in multivariate analysis with an odds ratio per increase in surgical volume of every 10 patients of 0.93 (95% CI 0.90-0.96, p < 0.001). When examining by subgroup, isolated TAPVR had the lowest mortality (n = 606, mortality = 6%), compared to TAPVR with other CHD (n = 359, mortality = 20%), TAPVR with heterotaxy (n = 135, mortality = 21%), and TAPVR with single ventricle (n = 128, mortality = 23%). In all groups except those with single ventricle, higher surgical volume was associated with lower mortality in multivariate analyses (isolated TAPVR p = 0.001, TAPVR with other CHD p = 0.009, TAPVR with heterotaxy p < 0.001, TAPVR with single ventricle p = 0.161). This is the first study to demonstrate an association between institutional surgical volume and mortality after TAPVR repair. Higher volume centers are associated with lower hospital mortality after TAPVR repair, including TAPVR with other CHD.

Whole genome bisulfite sequencing of Down syndrome brain reveals regional DNA hypermethylation and novel disorder insights

Down Syndrome (DS) is the most common genetic cause of intellectual disability, in which an extra copy of human chromosome 21 (HSA21) affects regional DNA methylation profiles across the genome. Although DNA methylation has been previously examined at select regulatory regions across the genome in a variety of DS tissues and cells, differentially methylated regions (DMRs) have yet to be examined in an unbiased sequencing-based approach. Here, we present the first analysis of DMRs from whole genome bisulfite sequencing (WGBS) data of human DS and matched control brain, specifically frontal cortex. While no global differences in DNA methylation were observed, we identified 3,152 DS-DMRs across the entire genome, the majority of which were hypermethylated in DS. DS-DMRs were significantly enriched at CpG islands and de-enriched at specific gene body and regulatory regions. Functionally, the hypermethylated DS-DMRs were enriched for one-carbon metabolism, membrane transport, and glutamatergic synaptic signalling, while the hypomethylated DMRs were enriched for proline isomerization, glial immune response, and apoptosis. Furthermore, in a cross-tissue comparison to previous studies of DNA methylation from diverse DS tissues and reference epigenomes, hypermethylated DS-DMRs showed a strong cross-tissue concordance, while a more tissue-specific pattern was observed for the hypomethylated DS-DMRs. Overall, this approach highlights that low-coverage WGBS of clinical samples can identify epigenetic alterations to known biological pathways, which are potentially relevant to therapeutic treatments and include metabolic pathways. These results also provide new insights into the genome-wide effects of genetic alterations on DNA methylation profiles indicative of altered neurodevelopment and brain function.

Explanatory models in neonatal intensive care: a tutorial

Background

Acute care providers intervening on fragile patients face many knowledge and information related challenges. Explanation based on causal chains of events has limitations when applied to complex physiological systems, and model-driven educational software may overwhelm the learner with information. We introduce a new concept and educational technology to facilitate understanding, reasoning, and communication in the clinical environment. The aim is to grasp complex physiology in a more intuitive way.

Explanatory models (EM)

An EM is a representation of relevant physiologic processes that provides insight into the relationships between therapeutic interventions and monitored variables, and their dependency on incidents and pathologies. We systematically analyze types of information incorporated into models and displayed in simulations and consider their explanatory relevance.

Transposition of the great arteries (TGA)

A conceptual model (diagram) of the normal neonatal cardiorespiratory system is adapted to reflect TGA and implemented in animated, interactive software.

Illustration of educational use

The use of this model is illustrated via the explanation to pediatric residents of the relationships between blood pressures, blood flow rates, ventilation, oxygen saturation, and oxygen distribution in a neonate with TGA. Learners explore clinical scenarios and effects of therapeutic interventions.

Discussion

Explanatory models hold promise as mental models for clinical practice and could possibly play a role in clinical decision making in neonatal intensive care and beyond.

Companion software

The software is freely available via the web addendum: https://www.dropbox.com/sh/ciufq5rqxgs9bkt/AAC7oKsvkEr73eYUJkx0pZ1Ya?dl=0

Maternal residential exposure to specific agricultural pesticide active ingredients and birth defects in a 2003-2005 North Carolina birth cohort

BACKGROUND

Previously we observed elevated odds ratios (ORs) for total pesticide exposure and 10 birth defects: three congenital heart defects and structural defects affecting the gastrointestinal, genitourinary and musculoskeletal systems. This analysis examines association of those defects with exposure to seven commonly applied pesticide active ingredients.

METHODS

Cases were live-born singleton infants from the North Carolina Birth Defects Monitoring Program linked to birth records for 2003-2005; noncases served as controls (total n = 304,906). Pesticide active ingredient exposure was assigned using a previously constructed metric based on crops within 500 m of residence, dates of pregnancy, and likely chemical application dates for each pesticide-crop combination. ORs (95% CI) were estimated with logistic regression for categories of exposure compared to unexposed. Models were adjusted for maternal race/ethnicity, age at delivery, education, marital status, and smoking status.

RESULTS

Associations varied by birth defect and pesticide combinations. For example, hypospadias was positively associated with exposures to 2,4-D (OR_{50th to <90th percentile} : 1.39 [1.18, 1.64]), mepiquat (OR_{50th to <90th percentile} : 1.10 [0.90, 1.34]), paraquat (OR_{50th to <90th} : 1.14 [0.93, 1.39]), and pendimethalin (OR_{50th to <90th} : 1.21 [1.01, 1.44]), but not S-metolachlor (OR_{50th to <90th} : 1.00 [0.81, 1.22]). Whereas atrial septal defects were positively associated with higher levels of exposure to glyphosate, cyhalothrin, S-metolachlor, mepiquat, and pendimethalin (ORs ranged from 1.22 to 1.35 for 50th to <90th exposures, and 1.72 to 2.09 for >90th exposures); associations with paraquat were null or inconsistent (OR 50th to <90th: 1.05 (0.87, 1.27).

CONCLUSION

Our results suggest differing patterns of association for birth defects with residential exposure to seven pesticide active ingredients in North Carolina.

Family-Centered Perinatal Services for Children With Down Syndrome and Their Families in Florida

OBJECTIVE

To examine the experiences of parents or caregivers of children with Down syndrome related to prenatal care, the birth setting, primary and specialty care, and care coordination.

DESIGN

Cross-sectional, mixed-methods study.

SETTING

Florida.

PARTICIPANTS

English- or Spanish-speaking parents/primary caregivers (N = 101) of children who were 0 to 18 years old, had a diagnosis of Down syndrome, and were born in Florida.

METHODS

Participants were identified through snowball sampling and completed an online version of the Family Experiences Survey. Analyses included descriptive statistics, Fisher exact tests, and content analysis of the open-ended questions.

RESULTS

Fewer than half of the 101 respondents reported receipt of adequate information after diagnosis of Down syndrome during the prenatal period (n = 18, 19.3%) or in the birth setting (n = 35, 41.2%). Most participants (52.9%-95.4%) reported that they received adequate time and specific information needed and that providers were sensitive to their feelings, values, and family customs during the prenatal period, in the birth setting, and during primary and specialty care. However, fewer than 60% of participants (19.3%-59.1%) recalled that they received information about Down syndrome or helpful programs such as Children's Medical Services, Early Steps, or Healthy Start either from prenatal care providers or in the birth settings.

CONCLUSION

Our findings highlight the critical role that perinatal care providers play in the establishment of access to and use of specialty care services for neonates with Down syndrome and emphasize the need for family-centered care in prenatal and birth settings.

Cost-effectiveness of cell-free DNA in maternal blood testing for prenatal detection of trisomy 21, 18 and 13: a systematic review

The aim of this paper was to conduct a systematic review of the cost-effectiveness of the analysis of cell-free DNA in maternal blood, often called the non-invasive prenatal test (NIPT), in the prenatal screening of trisomy in chromosomes 21, 18 and 13. MEDLINE, MEDLINE in process, EMBASE, and Cochrane Library were searched in April 2017. We selected: (1) economic evaluations that estimated the costs and detected cases of trisomy 21, 18 or 13; (2) comparisons of prenatal screening with NIPT (universal or contingent strategies) and the usual screening without NIPT, (3) in pregnant women with any risk of foetal anomalies. Studies were reviewed by two researchers. Data were extracted, the methodological quality was assessed and a narrative synthesis was prepared. In total, 12 studies were included, four of them performed in Europe. Three studies evaluated NIPT as a contingent test, three studies evaluated a universal NIPT, and six studies evaluated both. The results are heterogeneous, especially for the contingent NIPT where the results range from NIPT being dominant to a dominated strategy. Universal NIPT was found to be more effective but also costlier than the usual screening, with very high incremental cost-effectiveness ratios. One advantage of screening with NIPT is lower invasive procedure-related foetal losses than with usual screening. In conclusion, the cost-effectiveness of contingent NIPT is uncertain according to several studies, while the universal NIPT is not cost-effective currently.

Musculoskeletal development in patients with Down syndrome

Down syndrome is a chromosomal aneuploidy that results in disruptions in multiple body systems, including musculoskeletal function. Early intervention to focus on bone mineral density, gait correction, agility, balance, and muscle strength is imperative in order for patients to achieve maximum potential.

Differing molecular response of young and advanced maternal age human oocytes to IVM

STUDY QUESTION

What effect does maternal age have on the human oocyte's molecular response to in vitro oocyte maturation?

SUMMARY ANSWER

Although polyadenylated transcript abundance is similar between young and advanced maternal age (AMA) germinal vesicle (GV) oocytes, metaphase II (MII) oocytes exhibit a divergent transcriptome resulting from a differential response to in vitro oocyte maturation.

WHAT IS KNOWN ALREADY

Microarray studies considering maternal age or maturation stage have shown that either of these factors will affect oocyte polyadenylated transcript abundance in human oocytes. However, studies considering both human oocyte age and multiple stages simultaneously are limited to a single study that examined transcript levels for two genes by qPCR. Thus, polyadenylated RNA sequencing (RNA-Seq) could provide novel insight into age-associated aberrations in gene expression in GV and MII oocytes.

STUDY DESIGN, SIZE, DURATION

The effect of maternal age (longitudinal analysis) on polyadenylated transcript abundance at different stages was analyzed by examining single GV and single in vitro matured MII oocytes derived from five young (YNG; < 30 years; average age 26.8; range 20-29) and five advanced maternal age (AMA; ≥40 years; average age 41.6 years; range 40-43 years) patients. Thus, a total of 10 YNG (5 GV and 5 MII) and 10 AMA (5 GV and 5 MII) oocytes were individually processed for RNA-Seq analysis.

PARTICIPANTS/MATERIALS, SETTINGS, METHODS

Patients undergoing infertility treatment at the Colorado Center for Reproductive Medicine (Lone Tree, CO, USA) underwent ovarian stimulation with FSH and received hCG for final follicular maturation prior to ultrasound guided oocyte retrieval. Unused GV oocytes obtained at retrieval were donated for transcriptome analysis. Single oocytes were stored (at -80°C in PicoPure RNA Extraction Buffer; Thermo Fisher Scientific, USA) immediately upon verification of immaturity or after undergoing in vitro oocyte maturation (24 h incubation), representing GV and MII samples, respectively. After isolating RNA and generating single oocyte RNA-Seq libraries (SMARTer Ultra Low Input RNA HV kit; Clontech, USA), Illumina sequencing (100 bp paired-end reads on HiSeq 2500) and bioinformatics analysis (CLC Genomics Workbench, DESeq2, weighted gene correlation network analysis (WGCNA), Ingenuity Pathway Analysis) were performed.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 12 770 genes were determined to be expressed in human oocytes (reads per kilobase per million mapped reads (RPKM) > 0.4 in at least three of five replicates for a minimum of one sample type). Differential gene expression analysis between YNG and AMA oocytes (within stage) identified 1 and 255 genes that significantly differed (adjusted P < 0.1 and log2 fold change >1) in polyadenylated transcript abundance for GV and MII oocytes, respectively. These genes included CDK1, NLRP5 and PRDX1, which have been reported to affect oocyte developmental potential. Despite the similarity in transcript abundance between GV oocytes irrespective of age, divergent expression patterns emerged during oocyte maturation. These age-specific differentially expressed genes were enriched (FDR < 0.05) for functions and pathways associated with mitochondria, cell cycle and cytoskeleton. Gene modules generated by WGCNA (based on gene expression) and patient traits related to oocyte quality (e.g. age and blastocyst development) were correlated (P < 0.05) and enriched (FDR < 0.05) for functions and pathways associated with oocyte maturation.

LARGE SCALE DATA

Raw data from this study can be accessed through GSE95477.

LIMITATIONS, REASONS FOR CAUTION

The human oocytes used in the current study were obtained from patients with varying causes of infertility (e.g. decreased oocyte quality and oocyte quality-independent factors), possibly affecting oocyte gene expression. Oocytes in this study were retrieved at the GV stage following hCG administration and the MII oocytes were derived by IVM of patient oocytes. Although the approach has the benefit of identifying intrinsic differences between samples, it may not be completely representative of in vivo matured oocytes.

WIDER IMPLICATIONS OF THE FINDINGS

Transcriptome profiles of YNG and AMA oocytes, particularly at the MII stage, suggest that aberrant transcript abundance may contribute to the age-associated decline in fertility.

STUDY FUNDING/COMPETING INTEREST(S)

J.M.R. was supported by an Austin Eugene Lyons Fellowship awarded by the University of California, Davis. The Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health (awarded to P.J.R.; R01HD070044) and the Fertility Laboratories of Colorado partly supported the research presented in this manuscript.

Imaging single DNA molecules for high precision NIPT

Cell-free DNA analysis is becoming adopted for first line aneuploidy screening, however for most healthcare programs, cost and workflow complexity is limiting adoption of the test. We report a novel cost effective method, the Vanadis NIPT assay, designed for high precision digitally-enabled measurement of chromosomal aneuploidies in maternal plasma. Reducing NIPT assay complexity is achieved by using novel molecular probe technology that specifically label target chromosomes combined with a new readout format using a nanofilter to enrich single molecules for imaging and counting without DNA amplification, microarrays or sequencing. The primary objective of this study was to assess the Vanadis NIPT assay with respect to analytical precision and clinical feasibility. Analysis of reference DNA samples indicate that samples which are challenging to analyze with low fetal-fraction can be readily detected with a limit of detection determined at <2% fetal-fraction. In total of 286 clinical samples were analysed and 30 out of 30 pregnancies affected by trisomy 21 were classified correctly. This method has the potential to make cost effective NIPT more widely available with more women benefiting from superior detection and false positive rates.

The evaluation and management of respiratory disease in children with Down syndrome (DS)

Children with Down syndrome (DS) have wide range of respiratory problems. Although underlying abnormalities in the respiratory system are important causes of morbidity and mortality in children with DS, particularly in the young, abnormalities in other organ systems may also impact respiratory function. A comprehensive evaluation of the child with DS and respiratory disease may prevent short-term morbidity and mortality, and reduce the incidence of complications in the long term. This review provides an overview of the various causes of respiratory disease, and insight into some of the newer therapies available to treat obstructive sleep apnea, in this population.

Zika virus infection estimates, Mexico

Objective

To assess the magnitude of the Mexican epidemic of Zika virus infection and the associated risk of microcephaly.

Methods

From the reported number of laboratory-confirmed symptomatic infections among pregnant women and the relevant birth rate, we estimated the number of symptomatic cases of infection that occurred in Mexico between 25 November 2015, when the first confirmed Mexican case was reported, and 20 August 2016. We used data from the birth certificates to compare mean monthly incidences of congenital microcephaly before (1 January 2010–30 November 2015) and after (1 December 2015–30 September 2017) the introduction of Zika virus, stratifying the data according to whether the mother’s place of residence was at an altitude of at least 2200 m above sea level. We used Poisson interrupted time series, statistical modelling and graphical analyses.

Findings

Our estimated number of symptomatic cases of infection that may have occurred in the general population of Mexico between 25 November 2015 and 20 August 2016, 60 172, was 7.3-fold higher than the corresponding number of reported cases. The monthly numbers of microcephaly cases per 100 000 live births were significantly higher after the introduction of the virus than before (incidence rate ratio, IRR: 2.9; 95% confidence interval, CI: 2.3 to 3.6), especially among the babies of women living at altitudes below 2200 m (IRR: 3.4; 95% CI: 2.9 to 3.9).

Conclusion

The Mexican epidemic appears to be much larger than indicated by estimates based solely on counts of laboratory-confirmed cases, and to be associated with significantly increased risk of microcephaly.

Zika Virus Infection in Pregnancy: Maternal, Fetal, and Neonatal Considerations

An infection with the Zika virus (ZIKV) is usually mild, with nonspecific symptoms and most often asymptomatic. However, because of its causal relationship with severe congenital malformations, the ZIKV epidemic became an imperative for mobilization, renewed strategies for vector control, and biomedical research. A congenital Zika syndrome (CZS) has been characterized with 5 distinctive features that focus on brain development abnormalities (including microcephaly and brain calcifications), retinal manifestations, and defects on extremities including congenital contractures and hypertonia. The CZS could be just "the tip of the iceberg", pending the documentation of a spectrum of disease that could manifest later in life, from mild dysfunction to severe disease. It will be a matter of time for neurodevelopmental abnormalities, learning disabilities, and other unknown but yet-to-be-described outcomes to be associated with intrauterine ZIKV infection. In addition, ZIKV infection during pregnancy has been associated with other adverse outcomes. Reports mostly include ZIKV-affected pregnancies, and it will be difficult to clearly establish causality without appropriate control groups. We are summarizing some of the known or reported consequences of such infection during pregnancy. Women of reproductive age and particularly pregnant women are the most vulnerable to the adverse consequences of the ZIKV epidemic. Vector control programs need to be expanded to curtail new infections. Research is needed to develop safe and effective treatments, a preventive or therapeutic vaccine, and specific and sensitive tests and to diagnose and identify correlates of long-term immunity. Vaccines and treatments should be safe to be used in pregnancy. To do nothing would allow thousands of pregnant women to expose their fetuses to an infection that causes birth defects and other problems. Prenatal diagnosis technology development is necessary to be able to predict or diagnose adverse fetal outcomes related to ZIKV. Moreover, these tests should be used in a manner similar to the testing/screening method for neural tube defects and common chromosomal anomalies during prenatal care.

Population-based microcephaly surveillance in the United States, 2009 to 2013: An analysis of potential sources of variation

BACKGROUND

Congenital microcephaly has been linked to maternal Zika virus infection. However, ascertaining infants diagnosed with microcephaly can be challenging.

METHODS

Thirty birth defects surveillance programs provided data on infants diagnosed with microcephaly born 2009 to 2013. The pooled prevalence of microcephaly per 10,000 live births was estimated overall and by maternal/infant characteristics. Variation in prevalence was examined across case finding methods. Nine programs provided data on head circumference and conditions potentially contributing to microcephaly.

RESULTS

The pooled prevalence of microcephaly was 8.7 per 10,000 live births. Median prevalence (per 10,000 live births) was similar among programs using active (6.7) and passive (6.6) methods; the interdecile range of prevalence estimates was wider among programs using passive methods for all race/ethnicity categories except Hispanic. Prevalence (per 10,000 live births) was lowest among non-Hispanic Whites (6.5) and highest among non-Hispanic Blacks and Hispanics (11.2 and 11.9, respectively); estimates followed a U-shaped distribution by maternal age with the highest prevalence among mothers <20 years (11.5) and ≥40 years (13.2). For gestational age and birth weight, the highest prevalence was among infants <32 weeks gestation and infants <1500 gm. Case definitions varied; 41.8% of cases had an HC ≥ the 10^th percentile for sex and gestational age.

CONCLUSION

Differences in methods, population distribution of maternal/infant characteristics, and case definitions for microcephaly can contribute to the wide range of observed prevalence estimates across individual birth defects surveillance programs. Addressing these factors in the setting of Zika virus infection can improve the quality of prevalence estimates. Birth Defects Research (Part A) 106:972-982, 2016. © 2016 Wiley Periodicals, Inc.

The prevalence of selected major birth defects in the United States

Although collectively they are fairly common, birth defects receive limited attention as a group of outcomes either clinically or from a public health perspective. This article provides an overview of the prevalence, trends and selected socio-demographic risk factors for several major birth defects, including neural tube defects, cranio-facial anomalies, congenital heart defects, trisomies 13, 18, and 21, and gastroschisis and omphalocele. Attention should focus on strengthening existing registries, creating birth defects surveillance programs in states that do not have them, and standardizing registry methods so that broadly national data to monitor these trends are available.

The Accuracy of Hospital Discharge Diagnosis Codes for Major Birth Defects: Evaluation of a Statewide Registry With Passive Case Ascertainment

CONTEXT

Birth defects prevention, research, education, and support activities can be improved through surveillance systems that collect high-quality data.

OBJECTIVE

To estimate the overall and defect-specific accuracy of Florida Birth Defects Registry (FBDR) data, describe reasons for false-positive diagnoses, and evaluate the impact of statewide case confirmation on frequencies and prevalence estimates.

DESIGN

Retrospective cohort evaluation study.

PARTICIPANTS

A total of 8479 infants born to Florida resident mothers between January 1, 2007, and December 31, 2011, and diagnosed with 1 of 13 major birth defects in the first year of life.

MAIN OUTCOME MEASURES

Positive predictive value: calculated overall (proportion of FBDR-identified cases confirmed by medical record review, regardless of which of the 13 defects were confirmed) and defect-specific (proportion of FBDR-identified cases confirmed by medical record review with the same defect) indices.

RESULTS

The FBDR's overall positive predictive value was 93.3% (95% confidence interval, 92.7-93.8); however, there was variation in accuracy across defects, with positive predictive values ranging from 96.0% for gastroschisis to 54.4% for reduction deformities of the lower limb. Analyses suggested that International Classification of Diseases, Ninth Edition, Clinical Modification, codes, upon which FBDR diagnoses are based, capture the general occurrence of a defect well but often fail to identify the specific defect with high accuracy. Most infants with false-positive diagnoses had some type of birth defect that was incorrectly documented or coded. If prevalence rates reported by the FBDR for these 13 defects were adjusted to incorporate statewide case confirmation, there would be an overall 6.2% rate reduction from 82.6 to 77.5 per 10 000 live births.

CONCLUSIONS

A statewide birth defects surveillance system, relying on linkage of administrative databases, is capable of achieving high accuracy (>93%) for identifying infants with any one of the 13 major defects included in this study. However, the level of accuracy and the ability to minimize false-positive diagnoses vary depending on the defect.

Population surveillance for microcephaly

Surveillance is an essential part of the response to Zika and must be improved

Hypoglossal Nerve Stimulator Implantation in an Adolescent With Down Syndrome and Sleep Apnea

Obstructive sleep apnea (OSA) is more common in children with Down syndrome, affecting up to 60% of patients, and may persist in up to 50% of patients after adenotonsillectomy. These children with persistent moderate to severe OSA require continuous positive airway pressure, which is often poorly tolerated, or even tracheotomy for severe cases. The hypoglossal nerve stimulator is an implantable device that produces an electrical impulse to the anterior branches of the hypoglossal nerve, resulting in tongue protrusion in response to respiratory variation. It is an effective treatment of sleep apnea in select adult patients because it allows for alleviation of tongue base collapse, improving airway obstruction. Herein we describe the first pediatric hypoglossal nerve stimulator implantation, which was performed in an adolescent with Down syndrome and refractory severe OSA (apnea hypopnea index [AHI]: 48.5 events/hour). The patient would not tolerate continuous positive airway pressure and required a long-standing tracheotomy. Hypoglossal nerve stimulator therapy was well tolerated and effective, resulting in significant improvement in the patient's OSA (overall AHI: 3.4 events/hour; AHI: 2.5-9.7 events/hour at optimal voltage settings depending on sleep stage and body position). Five months after implantation, the patient's tracheotomy was successfully removed and he continues to do well with nightly therapy.