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Luo HY, Xie K, Ma PP, Lu W, Ren J, Liu YQ, Zhang J, Hu B, Lu Q, Yang BC. Portable collection of breath phenylpyruvic acid for noninvasive assessment of pediatric hyperphenylalaninemia by mass spectrometry. Talanta 2025; 293:128087. [PMID: 40209531 DOI: 10.1016/j.talanta.2025.128087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2024] [Revised: 03/31/2025] [Accepted: 04/02/2025] [Indexed: 04/12/2025]
Abstract
Despite the efforts of Hyperphenylalaninemia (HPA) prevention in prenatal testing, many infants with HPA are still found in new-born screening. Because there is no definitively effective cure for HPA, routine examination and monitoring is of paramount importance to effective management of HPA conditions through dietary restriction. Blood phenylalanine (Phe) has been one of the metabolic biomarkers of the HPA and thus is considered as indicators for HPA management but poses a challenge in invasive sampling. Phenylpyruvic acid (PPA) is also a biomarker of HPA with greatly increased levels in blood and urine of the patients. In the present study, a portable breath sampler was developed for in situ extraction and storage of PPA from exhaled breath metabolites of HPA patients and healthy volunteers, and breath PPA was then identified and quantified by mass spectrometry. The analytical parameters of PPA detection were optimized, showing the good sensitivity (LLOQ: 0.04 ng/mL, S/N = 10), reproducibility (intraday RSDs: 6.18 % for 0.2 ng/mL, 7.32 % for 1.0 ng/mL, n = 6; inter-day RSDs: 6.08 % for 0.2 ng/mL, 11.29 % for 1.0 ng/mL, n = 6), and recoveries (intraday: 83.34 % for 0.2 ng/mL, 81.73 % for 1.0 ng/mL, n = 6; inter-day: 88.44 % for 0.2 ng/mL, 85.11 % for 1.0 ng/mL, n = 6), good quantitation capacity (linear range: 0.05-1.0 ng/mL, R2 = 0.9968), and low matrix effect (1.0 ng/mL, 98.25 %). It was observed that there is a significant difference (p < 0.01) of breath PPA between HPA patients and healthy volunteers. Furthermore, the detection results of breath PPA and blood Phe were compared, showing a linear correlation (R2 = 0.6262) of breath PPA and blood Phe. Overall, this work provided valuable insights into breath PPA in HPA patients and showed a potential tool for noninvasive investigating of HPA.
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Affiliation(s)
- Hai-Yan Luo
- Jiangxi Key Laboratory of Birth Defect Prevention and Control, Jiangxi Maternal and Child Health Hospital, Nanchang, 310003, China
| | - Kang Xie
- Jiangxi Key Laboratory of Birth Defect Prevention and Control, Jiangxi Maternal and Child Health Hospital, Nanchang, 310003, China
| | - Peng-Peng Ma
- Jiangxi Key Laboratory of Birth Defect Prevention and Control, Jiangxi Maternal and Child Health Hospital, Nanchang, 310003, China
| | - Wan Lu
- Jiangxi Key Laboratory of Birth Defect Prevention and Control, Jiangxi Maternal and Child Health Hospital, Nanchang, 310003, China
| | - Jia Ren
- Jiangxi Key Laboratory of Birth Defect Prevention and Control, Jiangxi Maternal and Child Health Hospital, Nanchang, 310003, China
| | - Yan-Qiu Liu
- Jiangxi Key Laboratory of Birth Defect Prevention and Control, Jiangxi Maternal and Child Health Hospital, Nanchang, 310003, China
| | - Jianfeng Zhang
- College of Environment and Climate, Institute of Mass Spectrometry and Atmospheric Environment, Guangdong Provincial Engineering Research Center for On-line Source Apportionment System of Air Pollution, and Guangdong Provincial Key Laboratory of Speed Capability, Jinan University, Guangzhou 510632, China
| | - Bin Hu
- College of Environment and Climate, Institute of Mass Spectrometry and Atmospheric Environment, Guangdong Provincial Engineering Research Center for On-line Source Apportionment System of Air Pollution, and Guangdong Provincial Key Laboratory of Speed Capability, Jinan University, Guangzhou 510632, China.
| | - Qing Lu
- Jiangxi Key Laboratory of Birth Defect Prevention and Control, Jiangxi Maternal and Child Health Hospital, Nanchang, 310003, China.
| | - Bi-Cheng Yang
- Jiangxi Key Laboratory of Birth Defect Prevention and Control, Jiangxi Maternal and Child Health Hospital, Nanchang, 310003, China.
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Shang Z, Xie P, Pan K, Liu J, Xu W, Hu Y, Tang L, Leng Q, Liu S, He C. Predictive value of fluorometric method and tandem mass spectrometry for hyperphenylalaninemia and its subtypes in China: A systematic review and meta‑analysis. Exp Ther Med 2024; 28:278. [PMID: 38800050 PMCID: PMC11117103 DOI: 10.3892/etm.2024.12566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 04/04/2024] [Indexed: 05/29/2024] Open
Abstract
The present study aimed to conduct a comprehensive meta-analysis to assess the diagnostic value of fluorometric assays and tandem mass spectrometry (MS/MS) for hyperphenylalaninemia (HPA) and its subtypes. The PubMed, Embase and Cochrane Library databases were searched from inception to October 2023. The present study included studies that reported the newborn screening and genetic features of patients with HPA and excluded duplicate publications, studies without full text, studies with incomplete information, studies from which it was not possible to extract data, animal experiments, reviews and systematic reviews. STATA 15.1 was used to analyze the data. The pooled results revealed that 0.04% [95% confidence interval (CI): 0.019-0.069] of neonatal HPA fluorometric assays and MS/MS. The positive predictive value (PPV) of neonatal HPA screening using fluorometric assays and tandem mass spectrometry was 31.7% (95% CI: 19.6-45.2). Notably, the PPV of neonatal HPA screening using fluorometric assays was 8.3% (95% CI: 7.1-9.6), while the PPV of neonatal HPA screening using tandem mass spectrometry was 31.8% (95% CI: 16.4-49.4). Additionally, the pooled results showed that the incidence of tetrahydrobiopterin deficiency (BH4D) in HPA patients was 12.43% (95% CI: 3.28-25.75) and the incidence of phenylalanine hydroxylase deficiency (PAHD) in HPA patients was 88.65% (95% CI: 78.84-95.86). Newborn screening is an effective method for the early detection of HPA and MS/MS has a greater PPA than fluorometric assays for diagnosing HPA. In addition, in the screening of HPA, the proportion of HPA patients with PAHD was significantly higher than that of patients with BH4D.
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Affiliation(s)
- Zhirong Shang
- Department of Clinical Laboratory, Mianyang Maternity and Child Healthcare Hospital, Mianyang, Sichuan 621000, P.R. China
| | - Pan Xie
- Department of Clinical Laboratory, Mianyang Maternity and Child Healthcare Hospital, Mianyang, Sichuan 621000, P.R. China
| | - Ke Pan
- Department of Clinical Laboratory, Mianyang Maternity and Child Healthcare Hospital, Mianyang, Sichuan 621000, P.R. China
| | - Jialin Liu
- Department of Clinical Laboratory, Mianyang Maternity and Child Healthcare Hospital, Mianyang, Sichuan 621000, P.R. China
| | - Wei Xu
- Department of Clinical Laboratory, Mianyang Maternity and Child Healthcare Hospital, Mianyang, Sichuan 621000, P.R. China
| | - Yue Hu
- Department of Clinical Laboratory, Mianyang Maternity and Child Healthcare Hospital, Mianyang, Sichuan 621000, P.R. China
| | - Li Tang
- Department of Clinical Laboratory, Mianyang Maternity and Child Healthcare Hospital, Mianyang, Sichuan 621000, P.R. China
| | - Qinghua Leng
- Department of Clinical Laboratory, Mianyang Maternity and Child Healthcare Hospital, Mianyang, Sichuan 621000, P.R. China
| | - Shuyu Liu
- Department of Clinical Laboratory, Mianyang Maternity and Child Healthcare Hospital, Mianyang, Sichuan 621000, P.R. China
| | - Chengchuan He
- Department of Clinical Laboratory, Mianyang Maternity and Child Healthcare Hospital, Mianyang, Sichuan 621000, P.R. China
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Wang Y, Liu Y, Du G, Liu Y, Zeng Y. Epidemiology and distribution of 207 rare diseases in China: A systematic literature review. Intractable Rare Dis Res 2024; 13:73-88. [PMID: 38836174 PMCID: PMC11145401 DOI: 10.5582/irdr.2024.01001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 02/16/2024] [Accepted: 04/03/2024] [Indexed: 06/06/2024] Open
Abstract
Epidemiological data on rare diseases in China are currently limited. The objective of this study was to provide a comprehensive understanding of the prevalence and incidence of rare diseases by systematically analyzing the available epidemiological data. We conducted a comprehensive search of English and Chinese databases, the Incidence and Prevalence Database, the Chinese Rare Disease Guideline, and the Taiwan Health Promotion Administration from 2010 to 2023. We identified the top diseases and regions based on epidemiological data and present the maximum, minimum, and median prevalence and incidence values in tables and forest plots. 1,264 prevalence and incidence data were retrieved from 277 studies, guidelines and official websites, covering 110 rare diseases (53.1%) and 32 regions (94.1%). In terms of geographical regions, incidence or prevalence data were available for 32 regions (94.1%), excluding Tibet Hui Autonomous Region and Macao Special Administrative Region. In terms of rate, 60 and 77 out of 207 diseases (29.0% and 37.2%) had available incidence and prevalence data, respectively. Eight diseases had an incidence rate equal to or greater than that of 1,000 patients per million. The present study provides a comprehensive epidemiological analysis and valuable insights into the prevalence and incidence of rare diseases in China. Our findings underscore the pressing need for sustained drug research and medical support for individuals and families impacted by rare diseases.
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Affiliation(s)
| | | | | | - Yonghui Liu
- School of Medicine, Tongji University, Shanghai, China
| | - Ying Zeng
- School of Medicine, Tongji University, Shanghai, China
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Zhu S, Hu Q, Yang Y, Zhu H, Wang J, Luo Z, Ou M, Chen A, Huang Y, Xiong F, Zhou J, Liu J, Lei X, Zeng L. Genotype characterization of tetrahydrobiopterin deficiency in two Tibetan children. Heliyon 2024; 10:e27050. [PMID: 38434370 PMCID: PMC10907759 DOI: 10.1016/j.heliyon.2024.e27050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 12/11/2023] [Accepted: 02/22/2024] [Indexed: 03/05/2024] Open
Abstract
Background Tetrahydrobiopterin (BH4) deficiency is a rare cause of hyperphenylalaninemia (HPA). The incidence of this condition varies based on region and ethnicity. In the early stages, patients typically do not exhibit any symptoms, and HPA is identified only through newborn screening for diseases. It is important to distinguish BH4 deficiency from phenylketonuria (PKU, MIM # 261600). Timely diagnosis and treatment of BH4 deficiency are crucial for the prognosis of patients. Case presentation We present two rare cases of Chinese Tibetan children with BH4D, diagnosed through biochemical tests and genetic sequencing. Case 1 is a male infant, 2 months old, with a newborn screening (NBS) Phe level of 1212 μmol/L (reference range <120 μmol). The biopterin(B) level was 0.19 mmol/molCr (reference range: 0.42-1.92 mmol/molCr), with a B% of 5.67% (reference range: 19.8%-50.3%). Gene sequencing revealed a homozygous missense variant [NM_000317.3 (PTS): c.259C > T (p.Pro87Ser), rs104894276, ClinVar variation ID: 480]. The patient was treated with a Phe-reduced diet and oral sapropterin, madopar and is currently 3 years and 4 months old, showing mild global developmental delay. Case 2 is a 40-day-old female infant with a Phe level of 2442.11 μmol/L and dihydropteridine reductase (DHPR) activity of 0.84 nmol/(min. 5 mm disc) (reference range: 1.02-3.35 nmol/min.5 mm disc. Gene sequencing revealed a compound heterozygous genotype [NM_000320.3(QDPR): c.68G > A (p.Gly23Asp), rs104893863, ClinVar Variation ID: 490] and [NM_000320.3(QDPR) c.419C > A (p. Ala140Asp), ClinVar ID: 2444501]. The patient was treated with a Phe-reduced diet and oral madopar, 5-hydroxytryptophan. At the age of 1 year, she exhibited severe global developmental delay with seizures. Conclusion We identified and treated two cases of BH4D in Tibetan populations in China, marking the first confirmed instances. Our report emphasizes the significance of conducting differential diagnosis tests for BH4D.
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Affiliation(s)
- Shuyao Zhu
- Department of Pediatrics, Sichuan Provincial Maternity and Child Health Care Hospital, Chengdu, Sichuan, China
| | - Qi Hu
- Department of Neonatal Screening Centre in Sichuan Province Maternity and Child Health Care Hospital, Chengdu, Sichuan, China
| | - Yunxia Yang
- Department of Neonatal Screening Centre in Sichuan Province Maternity and Child Health Care Hospital, Chengdu, Sichuan, China
| | - Hui Zhu
- Department of Pediatrics, Sichuan Provincial Maternity and Child Health Care Hospital, Chengdu, Sichuan, China
| | - Jin Wang
- Department of Medical Genetics and Prenatal Diagnosis, Sichuan Provincial Maternity and Child Health Care Hospital, Chengdu, Sichuan, 610031, China
| | - Zemin Luo
- Department of Pediatrics, Sichuan Provincial Maternity and Child Health Care Hospital, Chengdu, Sichuan, China
| | - Mincai Ou
- Department of Neonatal Screening Centre in Sichuan Province Maternity and Child Health Care Hospital, Chengdu, Sichuan, China
| | - Ai Chen
- Department of Pediatrics, Sichuan Provincial Maternity and Child Health Care Hospital, Chengdu, Sichuan, China
| | - Yu Huang
- Department of Pediatrics, Sichuan Provincial Maternity and Child Health Care Hospital, Chengdu, Sichuan, China
| | - Fu Xiong
- Department of Pediatrics, Sichuan Provincial Maternity and Child Health Care Hospital, Chengdu, Sichuan, China
| | - Jiaji Zhou
- Department of Pediatrics, Sichuan Provincial Maternity and Child Health Care Hospital, Chengdu, Sichuan, China
| | - Jinglin Liu
- Department of Neonatal Screening Centre in Sichuan Province Maternity and Child Health Care Hospital, Chengdu, Sichuan, China
| | - Xunming Lei
- Department of Pediatrics, Sichuan Provincial Maternity and Child Health Care Hospital, Chengdu, Sichuan, China
| | - Lan Zeng
- Department of Medical Genetics and Prenatal Diagnosis, Sichuan Provincial Maternity and Child Health Care Hospital, Chengdu, Sichuan, 610031, China
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Qiu X, Zhao P, Luo J, Li G, Deng L, Zeng Y, Xu L, Zhou J. Biochemical and molecular features of tetrahydrobiopterin deficiency in Fujian Province, southeastern China. Front Genet 2023; 14:1250568. [PMID: 37636258 PMCID: PMC10451069 DOI: 10.3389/fgene.2023.1250568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 08/04/2023] [Indexed: 08/29/2023] Open
Abstract
The estimated prevalence of tetrahydrobiopterin deficiency (BH4D) and the mutational spectrum of the causal 6-pyruvoyl-tetrahydropterin synthase (PTS) gene vary widely according to race and region. This study assessed the prevalence and genetic characteristics of BH4D in Fujian Province, southeastern China. A total of 3,204,067 newborns were screened between 2012 and 2022 based on the phenylalanine level and the phenylalanine/tyrosine ratio in dried blood spots. Differential diagnosis was determined by the urine purine spectrum, dihydropteridine reductase activity in red blood cells, and genetic testing. The PTS mutation spectrum and genotypes were determined by next-generation sequencing. A total of 189 newborns were diagnosed with hyperphenylalaninemia (HPA) over the study period, including 159 with phenylalanine hydroxylase deficiency and 30 with BH4D. Therefore, the prevalence of BH4D in Fujian was 9.36 per 1,000,000 live births (30/3,204,067) and the proportion of BH4D among patients with HPA was 15.87% (30/189). A total of 58 PTS alleles were identified in the 29 patients with PTS deficiency (PTPSD), and those alleles were composed of 10 different variants, including eight missense variants and two splice-site variants. The most prevalent variants were c.155A>G, p.Asn52Ser (44.83%); c.259C>T, p.Pro87Ser (39.66%); and c.84-291A>G, p.Tyr27Argfs*8 (3.45%). The predominant genotype was c [155A>G]; [259C>T] (11/29, 37.93%). The prevalence of BH4D and the spectrum of associated PTS mutations were successfully determined for the first time in Fujian Province, southeastern China. Since the mutation spectrum of PTS is region-specific, such data will facilitate molecular diagnosis and genetic counseling in PTPSD cases.
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Affiliation(s)
- Xiaolong Qiu
- Genetic Diagnosis and Therapy Center, Fujian Key Laboratory for Prenatal Diagnosis and Birth Defect, Fujian Maternity and Child Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Peiran Zhao
- Genetic Diagnosis and Therapy Center, Fujian Key Laboratory for Prenatal Diagnosis and Birth Defect, Fujian Maternity and Child Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Jinying Luo
- Obstetrics and Gynecology Department, Fujian Maternity and Child Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Guilin Li
- Department of Preventive Medicine, School of Public Health, Fujian Medical University, Fuzhou, China
| | - Lin Deng
- Obstetrics and Gynecology Department, Fujian Maternity and Child Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Yinglin Zeng
- Genetic Diagnosis and Therapy Center, Fujian Key Laboratory for Prenatal Diagnosis and Birth Defect, Fujian Maternity and Child Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Liangpu Xu
- Genetic Diagnosis and Therapy Center, Fujian Key Laboratory for Prenatal Diagnosis and Birth Defect, Fujian Maternity and Child Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Jinfu Zhou
- Genetic Diagnosis and Therapy Center, Fujian Key Laboratory for Prenatal Diagnosis and Birth Defect, Fujian Maternity and Child Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
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Zeng B, Lu Q, Chen S, Guan H, Xu X, Zou Y, Wang F, Huang S, Liu Y, Yang B. Screening and mutation analysis of phenylalanine hydroxylase deficiency in newborns from Jiangxi province. Front Genet 2023; 14:1049816. [PMID: 36845377 PMCID: PMC9946975 DOI: 10.3389/fgene.2023.1049816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 01/31/2023] [Indexed: 02/11/2023] Open
Abstract
Background: Phenylalanine hydroxylase deficiency (PAHD) is an autosomal recessive disorder of amino acid metabolism and caused by mutations in the phenylalanine hydroxylase (PAH) gene. Without timely and appropriate dietary management, the disturbance of amino acid metabolism may impair cognitive development and neurophysiological function. Newborn screening (NBS) can aid the early diagnosis of PAHD, which can give accurate therapy to PAHD patients in time. In China, the PAHD incidence and PAH mutation spectrum vary enormously across the provinces. A total of 5,541,627 newborns from Jiangxi province were screened by NBS between 1997 and 2021. Method: One seventy one newborns from Jiangxi province were diagnosed with PAHD. By Sanger sequencing and the multiplex ligation-dependent probe amplification (MLPA) analysis, mutation analysis was performed in 123 PAHD patients. Using an arbitrary values (AV)-based model, we compared the observed phenotype with the predicted phenotype based on the genotype. Results: In this study, we speculated the PAHD incidence of Jiangxi province was about 30.9 per 1,000,000 live births (171/5,541,627). We summarized the PAH mutation spectrum in Jiangxi province for the first time. Two novel variants (c.433G > C, c.706 + 2T > A) were found. The most prevalent variant was c.728G > A (14.1%). The overall prediction rate of the genotype-phenotype was 77.4%. Conclusion: This mutation spectrum is very meaningful to improve the diagnostic rate of PAHD and to increase the accuracy genetic counseling. This study offers data for the genotype-phenotype prediction suitable for Chinese population.
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Affiliation(s)
- Baitao Zeng
- Department of Medical Genetics, Jiangxi Maternal and Child Health Hospital, Nanchang, China,Jiangxi Provincial Key Laboratory of Birth Defect for Prevention and Control, Jiangxi Maternal and Child Health Hospital, Nanchang, China
| | - Qing Lu
- Department of Medical Genetics, Jiangxi Maternal and Child Health Hospital, Nanchang, China,Jiangxi Provincial Key Laboratory of Birth Defect for Prevention and Control, Jiangxi Maternal and Child Health Hospital, Nanchang, China
| | - Shaohong Chen
- Jiangxi Provincial Key Laboratory of Birth Defect for Prevention and Control, Jiangxi Maternal and Child Health Hospital, Nanchang, China
| | - Huizhen Guan
- Department of Medical Genetics, Jiangxi Maternal and Child Health Hospital, Nanchang, China,Jiangxi Provincial Key Laboratory of Birth Defect for Prevention and Control, Jiangxi Maternal and Child Health Hospital, Nanchang, China
| | - Xiaolan Xu
- Department of Medical Genetics, Jiangxi Maternal and Child Health Hospital, Nanchang, China,Jiangxi Provincial Key Laboratory of Birth Defect for Prevention and Control, Jiangxi Maternal and Child Health Hospital, Nanchang, China
| | - Yongyi Zou
- Department of Medical Genetics, Jiangxi Maternal and Child Health Hospital, Nanchang, China,Jiangxi Provincial Key Laboratory of Birth Defect for Prevention and Control, Jiangxi Maternal and Child Health Hospital, Nanchang, China
| | - Feng Wang
- Department of Medical Genetics, Jiangxi Maternal and Child Health Hospital, Nanchang, China,Jiangxi Provincial Key Laboratory of Birth Defect for Prevention and Control, Jiangxi Maternal and Child Health Hospital, Nanchang, China
| | - Shuhui Huang
- Department of Medical Genetics, Jiangxi Maternal and Child Health Hospital, Nanchang, China,Jiangxi Provincial Key Laboratory of Birth Defect for Prevention and Control, Jiangxi Maternal and Child Health Hospital, Nanchang, China
| | - Yanqiu Liu
- Department of Medical Genetics, Jiangxi Maternal and Child Health Hospital, Nanchang, China,Jiangxi Provincial Key Laboratory of Birth Defect for Prevention and Control, Jiangxi Maternal and Child Health Hospital, Nanchang, China,*Correspondence: Yanqiu Liu, ; Bicheng Yang,
| | - Bicheng Yang
- Department of Medical Genetics, Jiangxi Maternal and Child Health Hospital, Nanchang, China,Jiangxi Provincial Key Laboratory of Birth Defect for Prevention and Control, Jiangxi Maternal and Child Health Hospital, Nanchang, China,*Correspondence: Yanqiu Liu, ; Bicheng Yang,
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