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Guilbaud L, Carreras E, Garel C, Maiz N, Dhombres F, Deprest J, Jouannic JM. Proposal for standardized prenatal assessment of fetal open dysraphisms by the European reference network for Intellectual disability, TeleHealth, Autism and Congenital Anomalies (ITHACA) and eUROGEN. Prenat Diagn 2024. [PMID: 38898590 DOI: 10.1002/pd.6618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 05/14/2024] [Accepted: 05/29/2024] [Indexed: 06/21/2024]
Abstract
Open dysraphisms, that is, myelomeningocele and myeloschisis, are rare diseases associated with a risk of severe disability, including lower limb motor and sensory deficiency, sphincter deficiency, and potential intellectual deficiency. Open dysraphism is diagnosed in Europe in 93.5% of cases. In case of suspicion of fetal open dysraphism, a detailed fetal morphologic assessment is required to confirm the diagnosis and exclude associated structural anomalies, as well as genetic assessment. In case of isolated fetal open dysraphism, assessment of prognosis is based on fetal imaging including the level of the lesion, the presence or not of a sac, the presence and nature of intra cranial anomalies, and the anatomical and functional evaluation of the lower extremities. Based on these biomarkers, a personalized prognosis as well as comprehensive information about prenatal management alternatives will allow parents to decide on further management options. Standardization of prenatal assessment is essential to compare outcomes with benchmark data and make assessment of surgical innovation possible. Herein, we propose a protocol for the standardized ultrasound assessment of fetuses with isolated open dysraphism.
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Affiliation(s)
- Lucie Guilbaud
- Fetal Medicine Department, Armand Trousseau University Hospital, Spin@ Reference Center, Sorbonne University, Paris, France
| | - Elena Carreras
- Maternal-Fetal Medicine Unit, Department of Obstetrics, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Catherine Garel
- Pediatric Radiology Department, Armand Trousseau University Hospital, Sorbonne University, Paris, France
| | - Nerea Maiz
- Maternal-Fetal Medicine Unit, Department of Obstetrics, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ferdinand Dhombres
- Fetal Medicine Department, Armand Trousseau University Hospital, Spin@ Reference Center, Sorbonne University, Paris, France
| | - Jan Deprest
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Institute of Women's Health, University College London, London, UK
| | - Jean-Marie Jouannic
- Fetal Medicine Department, Armand Trousseau University Hospital, Spin@ Reference Center, Sorbonne University, Paris, France
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Yue F, Yang X, Liu N, Liu R, Zhang H. Prenatal diagnosis and pregnancy outcomes in fetuses with ventriculomegaly. Front Med (Lausanne) 2024; 11:1349171. [PMID: 38784233 PMCID: PMC11111914 DOI: 10.3389/fmed.2024.1349171] [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: 12/04/2023] [Accepted: 04/26/2024] [Indexed: 05/25/2024] Open
Abstract
Objective Genetic etiology plays a critical role in fetal ventriculomegaly (VM). However, the studies on chromosomal copy number variants (CNVs) in fetal VM are limited. This study aimed to investigate the chromosomal CNVs in fetuses with mild to moderate VM, and explore its genotype-phenotype correlation. Methods A total of 242 fetuses with mild to moderate VM detected by prenatal ultrasound were enrolled in our study from October 2018 to October 2022. All cases underwent chromosomal microarray analysis (CMA) and G-banding simultaneously. All VM cases were classified different subgroups according to the maternal age, severity, VM distribution and presence/absence of other ultrasound abnormalities. The pregnancy outcomes and health conditions after birth were followed up. We also performed a pooled analysis regarding likely pathogenic and pathogenic CNVs (LP/P CNVs) for VM. Results The detection rate of chromosomal abnormalities by karyotyping was 9.1% (22/242), whereas it was 16.5% (40/242) when CMA was conducted (P < 0.05). The total detection rate of chromosomal abnormalities by karyotyping and CMA was 21.1% (51/242). A 12.0% incremental yield of CMA over karyotyping was observed. The detection rate of total genetic variants in fetuses with bilateral VM was significantly higher than in fetuses with unilateral VM (30.0% vs. 16.7%, P = 0.017). No significant differences were discovered between isolated VM and non-isolated VM, or between mild and moderate VM, or between advanced maternal age (AMA) and non-AMA (all P > 0.05). 28 fetuses with VM were terminated and 214 fetuses were delivered: one presented developmental delay and one presented congenital heart disease. The VM cases with both positive CMA and karyotypic results had a higher rate of termination of pregnancy than those with either a positive CMA or karyotypic result, or both negative testing results (P < 0.001). Conclusion The combination of CMA and karyotyping should be adopted to improve the positive detection rate of chromosomal abnormalities for VM. The total genetic abnormalities detected using both techniques would affect the final pregnancy outcomes. LP/P CNVs at 16p11.2, 17p13, and 22q11.21 were identified as the top three chromosomal hotspots associated with VM, which would enable genetic counselors to provide more precise genetic counseling for VM pregnancies.
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Affiliation(s)
- Fagui Yue
- Center for Reproductive Medicine and Center for Prenatal Diagnosis, First Hospital, Jilin University, Changchun, China
- Jilin Engineering Research Center for Reproductive Medicine and Genetics, Jilin University, Changchun, China
| | - Xiao Yang
- Center for Reproductive Medicine and Center for Prenatal Diagnosis, First Hospital, Jilin University, Changchun, China
- Jilin Engineering Research Center for Reproductive Medicine and Genetics, Jilin University, Changchun, China
| | - Ning Liu
- Center for Reproductive Medicine and Center for Prenatal Diagnosis, First Hospital, Jilin University, Changchun, China
- Jilin Engineering Research Center for Reproductive Medicine and Genetics, Jilin University, Changchun, China
| | - Ruizhi Liu
- Center for Reproductive Medicine and Center for Prenatal Diagnosis, First Hospital, Jilin University, Changchun, China
- Jilin Engineering Research Center for Reproductive Medicine and Genetics, Jilin University, Changchun, China
| | - Hongguo Zhang
- Center for Reproductive Medicine and Center for Prenatal Diagnosis, First Hospital, Jilin University, Changchun, China
- Jilin Engineering Research Center for Reproductive Medicine and Genetics, Jilin University, Changchun, China
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Giorgione V, Haratz KK, Constantini S, Birnbaum R, Malinger G. Fetal cerebral ventriculomegaly: What do we tell the prospective parents? Prenat Diagn 2022; 42:1674-1681. [PMID: 36371614 PMCID: PMC10099769 DOI: 10.1002/pd.6266] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 10/16/2022] [Accepted: 11/09/2022] [Indexed: 11/14/2022]
Abstract
Fetal cerebral ventriculomegaly is a relatively common finding, observed during approximately 1% of obstetric ultrasounds. In the second and third trimester, mild (≥10 mm) and severe ventriculomegaly (≥15 mm) are defined according to the measurement of distal lateral ventricles that is included in the routine sonographic examination of central nervous system. A detailed neurosonography and anatomy ultrasound should be performed to detect other associated anomalies in the central nervous system and in other systems, respectively. Fetal MRI might be useful when neurosonography is unavailable or suboptimal. The risk of chromosomal and non-chromosomal genetic disorders associated with ventriculomegaly is high, therefore invasive genetic testing, including microarray, is recommended. Screening for prenatal infections, in particular cytomegalovirus and toxoplasmosis, should also be carried out at diagnosis. The prognosis is determined by the severity of ventriculomegaly and/or by the presence of co-existing abnormalities. Fetal ventriculoamniotic shunting in progressive isolated severe ventriculomegaly is an experimental procedure. After delivery, ventricular-peritoneal shunting or ventriculostomy are the two available options to treat hydrocephalus in specific conditions with similar long-term outcomes. A multidisciplinary fetal neurology team, including perinatologists, geneticists, pediatric neurologists, neuroradiologists and neurosurgeons, can provide parents with the most thorough prenatal counseling. This review outlines the latest evidence on diagnosis and management of pregnancies complicated by fetal cerebral ventriculomegaly.
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Affiliation(s)
- Veronica Giorgione
- Ob-Gyn Ultrasound Unit, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Karina Krajden Haratz
- Ob-Gyn Ultrasound Unit, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shlomi Constantini
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Pediatric Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Roee Birnbaum
- Ob-Gyn Ultrasound Unit, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gustavo Malinger
- Ob-Gyn Ultrasound Unit, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Leibovitz Z, Lerman-Sagie T, Haddad L. Fetal Brain Development: Regulating Processes and Related Malformations. Life (Basel) 2022; 12:life12060809. [PMID: 35743840 PMCID: PMC9224903 DOI: 10.3390/life12060809] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/24/2022] [Accepted: 05/25/2022] [Indexed: 11/16/2022] Open
Abstract
This paper describes the contemporary state of knowledge regarding processes that regulate normal development of the embryonic–fetal central nervous system (CNS). The processes are described according to the developmental timetable: dorsal induction, ventral induction, neurogenesis, neuronal migration, post-migration neuronal development, and cortical organization. We review the current literature on CNS malformations associated with these regulating processes. We specifically address neural tube defects, holoprosencephaly, malformations of cortical development (including microcephaly, megalencephaly, lissencephaly, cobblestone malformations, gray matter heterotopia, and polymicrogyria), disorders of the corpus callosum, and posterior fossa malformations. Fetal ventriculomegaly, which frequently accompanies these disorders, is also reviewed. Each malformation is described with reference to the etiology, genetic causes, prenatal sonographic imaging, associated anomalies, differential diagnosis, complimentary diagnostic studies, clinical interventions, neurodevelopmental outcome, and life quality.
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Affiliation(s)
- Zvi Leibovitz
- Obstetrics-Gynecology Ultrasound Unit, Department of Obstetrics and Gynecology, Fetal Neurology Clinic, Wolfson Medical Center, Holon and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv 5822012, Israel;
- Obstetrics-Gynecology Ultrasound Unit, Bnai-Zion Medical Center, Rappaport Faculty of Medicine, The Technion, Haifa 31048, Israel;
- Correspondence:
| | - Tally Lerman-Sagie
- Obstetrics-Gynecology Ultrasound Unit, Department of Obstetrics and Gynecology, Fetal Neurology Clinic, Wolfson Medical Center, Holon and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv 5822012, Israel;
- Pediatric Neurology Unit, Wolfson Medical Center, Holon and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv 5822012, Israel
| | - Leila Haddad
- Obstetrics-Gynecology Ultrasound Unit, Bnai-Zion Medical Center, Rappaport Faculty of Medicine, The Technion, Haifa 31048, Israel;
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Greenbaum L, Maya I, Sagi-Dain L, Sukenik-Halevy R, Berkenstadt M, Yonath H, Rienstein S, Shalata A, Katorza E, Singer A. Chromosomal Microarray Analysis in Pregnancies With Corpus Callosum or Posterior Fossa Anomalies. Neurol Genet 2021; 7:e585. [PMID: 34079909 PMCID: PMC8163489 DOI: 10.1212/nxg.0000000000000585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 02/17/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVE We investigated the detection rate of clinically significant chromosomal microarray analysis (CMA) results in pregnancies with sonographic diagnosis of fetal corpus callosum anomalies (CCA) or posterior fossa anomalies (PFA). METHODS All CMA tests in pregnancies with CCA or PFA performed between January 2015 and June 2020 were retrospectively evaluated from the Israeli Ministry of Health database. The rate of CMA with clinically significant (pathogenic or likely pathogenic) findings was calculated and compared to a local Israeli cohort of 5,541 pregnancies with normal ultrasound. RESULTS One hundred eighty-two pregnancies were enrolled: 102 cases with CCA and 89 with PFA (9 cases had both). Clinically significant CMA results were found in 7/102 of CCA (6.9%) and in 7/89 of PFA (7.9%) cases. The CMA detection rate in pregnancies with isolated CCA (2/57, 3.5%) or PFA (2/50, 4.0%) was lower than in nonisolated cases, including additional CNS and/or extra-CNS sonographic anomalies (CCA-5/45, 11.1%; PFA-5/39, 12.8%), but this was not statistically significant. However, the rate among pregnancies that had extra-CNS anomalies, with or without additional CNS involvement (CCA-5/24, 20.8%; PFA-5/29, 17.2%), was significantly higher compared to all other cases (p = 0.0075 for CCA; p = 0.035 for PFA). Risk of CMA with clinically significant results for all and nonisolated CCA or PFA pregnancies was higher compared to the background risk reported in the control cohort (p < 0.001), but was not significant for isolated cases. CONCLUSIONS Our findings suggest that CMA testing is beneficial for the genetic workup of pregnancies with CCA or PFA, and is probably most informative when additional extra-CNS anomalies are observed.
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Affiliation(s)
- Lior Greenbaum
- From the The Danek Gertner Institute of Human Genetics (L.G., M.B., H.Y., S.R.), Sheba Medical Center, Tel Hashomer; The Joseph Sagol Neuroscience Center (L.G.), Sheba Medical Center, Tel Hashomer; Sackler Faculty of Medicine (L.G., I.M., R.S.-H., M.B., H.Y., E.K.), Tel Aviv University; Recanati Genetics Institute (I.M., R.S.-H.), Beilinson Hospital, Rabin Medical Center, Petach Tikva; Genetics Institute (L.S.-D.), Carmel Medical Center, Affiliated to the Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa; Internal Medicine A (H.Y.), Sheba Medical Center, Tel Hashomer; The Simon Winter Institute for Human Genetics (A.S.), Bnai Zion Medical Center, Haifa; Department of Obstetrics and Gynecology (E.K.), Sheba Medical Center, Tel Hashomer; and Department of Community Genetics (A.S.), Public Health Services, Ministry of Health, Jerusalem, Israel.
| | - Idit Maya
- From the The Danek Gertner Institute of Human Genetics (L.G., M.B., H.Y., S.R.), Sheba Medical Center, Tel Hashomer; The Joseph Sagol Neuroscience Center (L.G.), Sheba Medical Center, Tel Hashomer; Sackler Faculty of Medicine (L.G., I.M., R.S.-H., M.B., H.Y., E.K.), Tel Aviv University; Recanati Genetics Institute (I.M., R.S.-H.), Beilinson Hospital, Rabin Medical Center, Petach Tikva; Genetics Institute (L.S.-D.), Carmel Medical Center, Affiliated to the Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa; Internal Medicine A (H.Y.), Sheba Medical Center, Tel Hashomer; The Simon Winter Institute for Human Genetics (A.S.), Bnai Zion Medical Center, Haifa; Department of Obstetrics and Gynecology (E.K.), Sheba Medical Center, Tel Hashomer; and Department of Community Genetics (A.S.), Public Health Services, Ministry of Health, Jerusalem, Israel.
| | - Lena Sagi-Dain
- From the The Danek Gertner Institute of Human Genetics (L.G., M.B., H.Y., S.R.), Sheba Medical Center, Tel Hashomer; The Joseph Sagol Neuroscience Center (L.G.), Sheba Medical Center, Tel Hashomer; Sackler Faculty of Medicine (L.G., I.M., R.S.-H., M.B., H.Y., E.K.), Tel Aviv University; Recanati Genetics Institute (I.M., R.S.-H.), Beilinson Hospital, Rabin Medical Center, Petach Tikva; Genetics Institute (L.S.-D.), Carmel Medical Center, Affiliated to the Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa; Internal Medicine A (H.Y.), Sheba Medical Center, Tel Hashomer; The Simon Winter Institute for Human Genetics (A.S.), Bnai Zion Medical Center, Haifa; Department of Obstetrics and Gynecology (E.K.), Sheba Medical Center, Tel Hashomer; and Department of Community Genetics (A.S.), Public Health Services, Ministry of Health, Jerusalem, Israel.
| | - Rivka Sukenik-Halevy
- From the The Danek Gertner Institute of Human Genetics (L.G., M.B., H.Y., S.R.), Sheba Medical Center, Tel Hashomer; The Joseph Sagol Neuroscience Center (L.G.), Sheba Medical Center, Tel Hashomer; Sackler Faculty of Medicine (L.G., I.M., R.S.-H., M.B., H.Y., E.K.), Tel Aviv University; Recanati Genetics Institute (I.M., R.S.-H.), Beilinson Hospital, Rabin Medical Center, Petach Tikva; Genetics Institute (L.S.-D.), Carmel Medical Center, Affiliated to the Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa; Internal Medicine A (H.Y.), Sheba Medical Center, Tel Hashomer; The Simon Winter Institute for Human Genetics (A.S.), Bnai Zion Medical Center, Haifa; Department of Obstetrics and Gynecology (E.K.), Sheba Medical Center, Tel Hashomer; and Department of Community Genetics (A.S.), Public Health Services, Ministry of Health, Jerusalem, Israel.
| | - Michal Berkenstadt
- From the The Danek Gertner Institute of Human Genetics (L.G., M.B., H.Y., S.R.), Sheba Medical Center, Tel Hashomer; The Joseph Sagol Neuroscience Center (L.G.), Sheba Medical Center, Tel Hashomer; Sackler Faculty of Medicine (L.G., I.M., R.S.-H., M.B., H.Y., E.K.), Tel Aviv University; Recanati Genetics Institute (I.M., R.S.-H.), Beilinson Hospital, Rabin Medical Center, Petach Tikva; Genetics Institute (L.S.-D.), Carmel Medical Center, Affiliated to the Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa; Internal Medicine A (H.Y.), Sheba Medical Center, Tel Hashomer; The Simon Winter Institute for Human Genetics (A.S.), Bnai Zion Medical Center, Haifa; Department of Obstetrics and Gynecology (E.K.), Sheba Medical Center, Tel Hashomer; and Department of Community Genetics (A.S.), Public Health Services, Ministry of Health, Jerusalem, Israel.
| | - Hagith Yonath
- From the The Danek Gertner Institute of Human Genetics (L.G., M.B., H.Y., S.R.), Sheba Medical Center, Tel Hashomer; The Joseph Sagol Neuroscience Center (L.G.), Sheba Medical Center, Tel Hashomer; Sackler Faculty of Medicine (L.G., I.M., R.S.-H., M.B., H.Y., E.K.), Tel Aviv University; Recanati Genetics Institute (I.M., R.S.-H.), Beilinson Hospital, Rabin Medical Center, Petach Tikva; Genetics Institute (L.S.-D.), Carmel Medical Center, Affiliated to the Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa; Internal Medicine A (H.Y.), Sheba Medical Center, Tel Hashomer; The Simon Winter Institute for Human Genetics (A.S.), Bnai Zion Medical Center, Haifa; Department of Obstetrics and Gynecology (E.K.), Sheba Medical Center, Tel Hashomer; and Department of Community Genetics (A.S.), Public Health Services, Ministry of Health, Jerusalem, Israel.
| | - Shlomit Rienstein
- From the The Danek Gertner Institute of Human Genetics (L.G., M.B., H.Y., S.R.), Sheba Medical Center, Tel Hashomer; The Joseph Sagol Neuroscience Center (L.G.), Sheba Medical Center, Tel Hashomer; Sackler Faculty of Medicine (L.G., I.M., R.S.-H., M.B., H.Y., E.K.), Tel Aviv University; Recanati Genetics Institute (I.M., R.S.-H.), Beilinson Hospital, Rabin Medical Center, Petach Tikva; Genetics Institute (L.S.-D.), Carmel Medical Center, Affiliated to the Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa; Internal Medicine A (H.Y.), Sheba Medical Center, Tel Hashomer; The Simon Winter Institute for Human Genetics (A.S.), Bnai Zion Medical Center, Haifa; Department of Obstetrics and Gynecology (E.K.), Sheba Medical Center, Tel Hashomer; and Department of Community Genetics (A.S.), Public Health Services, Ministry of Health, Jerusalem, Israel.
| | - Adel Shalata
- From the The Danek Gertner Institute of Human Genetics (L.G., M.B., H.Y., S.R.), Sheba Medical Center, Tel Hashomer; The Joseph Sagol Neuroscience Center (L.G.), Sheba Medical Center, Tel Hashomer; Sackler Faculty of Medicine (L.G., I.M., R.S.-H., M.B., H.Y., E.K.), Tel Aviv University; Recanati Genetics Institute (I.M., R.S.-H.), Beilinson Hospital, Rabin Medical Center, Petach Tikva; Genetics Institute (L.S.-D.), Carmel Medical Center, Affiliated to the Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa; Internal Medicine A (H.Y.), Sheba Medical Center, Tel Hashomer; The Simon Winter Institute for Human Genetics (A.S.), Bnai Zion Medical Center, Haifa; Department of Obstetrics and Gynecology (E.K.), Sheba Medical Center, Tel Hashomer; and Department of Community Genetics (A.S.), Public Health Services, Ministry of Health, Jerusalem, Israel.
| | - Eldad Katorza
- From the The Danek Gertner Institute of Human Genetics (L.G., M.B., H.Y., S.R.), Sheba Medical Center, Tel Hashomer; The Joseph Sagol Neuroscience Center (L.G.), Sheba Medical Center, Tel Hashomer; Sackler Faculty of Medicine (L.G., I.M., R.S.-H., M.B., H.Y., E.K.), Tel Aviv University; Recanati Genetics Institute (I.M., R.S.-H.), Beilinson Hospital, Rabin Medical Center, Petach Tikva; Genetics Institute (L.S.-D.), Carmel Medical Center, Affiliated to the Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa; Internal Medicine A (H.Y.), Sheba Medical Center, Tel Hashomer; The Simon Winter Institute for Human Genetics (A.S.), Bnai Zion Medical Center, Haifa; Department of Obstetrics and Gynecology (E.K.), Sheba Medical Center, Tel Hashomer; and Department of Community Genetics (A.S.), Public Health Services, Ministry of Health, Jerusalem, Israel.
| | - Amihood Singer
- From the The Danek Gertner Institute of Human Genetics (L.G., M.B., H.Y., S.R.), Sheba Medical Center, Tel Hashomer; The Joseph Sagol Neuroscience Center (L.G.), Sheba Medical Center, Tel Hashomer; Sackler Faculty of Medicine (L.G., I.M., R.S.-H., M.B., H.Y., E.K.), Tel Aviv University; Recanati Genetics Institute (I.M., R.S.-H.), Beilinson Hospital, Rabin Medical Center, Petach Tikva; Genetics Institute (L.S.-D.), Carmel Medical Center, Affiliated to the Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa; Internal Medicine A (H.Y.), Sheba Medical Center, Tel Hashomer; The Simon Winter Institute for Human Genetics (A.S.), Bnai Zion Medical Center, Haifa; Department of Obstetrics and Gynecology (E.K.), Sheba Medical Center, Tel Hashomer; and Department of Community Genetics (A.S.), Public Health Services, Ministry of Health, Jerusalem, Israel.
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