Describing the Prevalence of Neural Tube Defects Worldwide: A Systematic Literature Review

Canonical Wnt pathway modulation is required to correctly execute multiple independent cellular dynamic programs during cranial neural tube closure

Defects in cranial neural tube closure are among the most common and deleterious human structural birth defects. Correct cranial closure requires the coordination of multiple cell dynamic programs including cell proliferation and cell shape change. Mutations that impact Wnt signaling, including loss of the pathway co-receptor LRP6, lead to defects in cranial neural tube closure, but the cellular dynamics under control of the Wnt pathway during this critical morphogenetic process remain unclear. Here, we use mice mutant for LRP6 to examine the consequences of conditional and global reduction in Wnt signaling and mutants with conditional inactivation of APC to examine the consequences of pathway hyperactivation. Strikingly, we find that regulated Wnt signaling is required for two independent events during cranial neural tube closure. First, global reduction of Wnt leads to a surprising hyperplasia of the cranial neural folds driven by excessive cell proliferation at early pre-elevation stages, with the increased tissue volume creating a mechanical blockade to efficient closure despite normal apical constriction and cell polarization at later stages. Conversely, conditional hyperactivation of the pathway at later elevation stages prevents correct actin organization, blocking apical constriction and neural fold elevation without impacting tissue scaling. Together these data reveal that Wnt signaling levels must be modulated to restrict proliferation at early stages and promote apical constriction at later elevation stages to drive efficient closure of the cranial neural tube.

Outcomes After Prenatal Exposure to Raltegravir-Containing Antiretroviral Therapy: A Multicohort European Study

BACKGROUND

Raltegravir is an HIV integrase strand transfer inhibitor recommended for use in pregnancy. The aim of this study was to assess risk of birth defects and other suboptimal outcomes after prenatal exposure to raltegravir.

METHODS

We used pooled, prospectively collected individual patient data from studies in the European Pregnancy and Paediatric Infections Cohort Collaboration. Pregnancies with any prenatal exposure to raltegravir with outcomes in 2008-2020 were included. Birth defects were classified according to World Health Organization's International Classification of Diseases and EUROCAT criteria. Earliest prenatal exposure timing was classified as periconception [exposure at ≤6 completed gestational weeks (GWs)], later first trimester (T1) (exposure in T1 at >6 completed GWs), and second/third trimester (exposure at >12 completed GWs).

RESULTS

A total of 1499 pregnancies across 9 cohorts were included. Where timing was available (n = 1449), earliest raltegravir exposure was in the periconception period for 505 (34.8%), later T1 in 65 (4.5%), and T2/T3 in 879 (60.7%). The overall prevalence of birth defects among live-born infants with prenatal raltegravir exposure was 3.9% (95% confidence interval: 2.9, 5.0) (1443/1466) (International Classification of Diseases), with no increased risk observed for those exposed in the periconception period ( P = 0.290). Among singleton live-born infants, 11.9% (160/1346) were born preterm, 11.3% (148/1307) low birthweight, and 8.6% (111/1291) small for gestational age, with no difference in outcomes observed by timing of raltegravir exposure.

CONCLUSIONS

These findings add to the evidence base around safety of raltegravir use in pregnancy, although ongoing safety monitoring is needed to rule out risk of rare outcomes.

Fold-and-fuse neurulation in zebrafish requires vangl2

Shaping of the future brain and spinal cord during neurulation is an essential component of early vertebrate development. In amniote embryos, primary neurulation occurs through a "fold-and-fuse" mechanism by which the edges of the neural plate fuse into the hollow neural tube. Failure of neural fold fusion results in neural tube defects (NTDs), which are among the most devastating and common congenital anomalies worldwide. Unlike amniotes, the zebrafish neural tube develops largely via formation of a solid neural keel that later cavitates to form a midline lumen. Although many aspects of primary neurulation are conserved in zebrafish, including neural fold zippering, it was not clear how well these events resemble analogous processes in amniote embryos. Here, we demonstrate that despite outward differences, zebrafish anterior neurulation closely resembles that of mammals. For the first time in zebrafish embryos, we directly observe enclosure of a lumen by the bilateral neural folds, which fuse by zippering between at least two distinct closure sites. Both the apical constriction that elevates the neural folds and the zippering that fuses them coincide with apical Myosin enrichment. We further show that embryos lacking vangl2, a core planar cell polarity and NTD risk gene, exhibit delayed and abnormal neural fold fusion that fails to enclose a lumen. These defects can also be observed in fixed embryos, enabling their detection without live imaging. Together, our data provide direct evidence for fold-and-fuse neurulation in zebrafish and its disruption upon loss of an NTD risk gene, highlighting the deep conservation of primary neurulation across vertebrates.

Folate and Vitamin B12 Status among Non-Pregnant, Non-Lactating Women of Reproductive Age and Predicted Risk for Neural Tube Defects, Morogoro Region, Tanzania

INTRODUCTION

Population risk for neural tube defects (NTDs) can be determined using red blood cell (RBC) folate. However, a paucity of biomarker and surveillance data among non-lactating, non-pregnant women of reproductive age (NPWRA) from Africa limits accurate assessment. Our study assessed folate and vitamin B12 status among non-lactating NPWRA and predicted population risk of NTDs in Tanzania.

METHODS

A cross-sectional biomarker survey of non-lactating NPWRA (15-49 years) in the Morogoro region, Tanzania was conducted during June-October 2019. Questionnaire interview responses and non-fasting blood samples were collected. Folate was assessed using the CDC microbiologic assay kit and vitamin B12 was measured using an electrochemiluminescence immunoassay. Complex survey design analyses were conducted using SAS-callable SUDAAN (v11.0.1).

RESULTS

Of the 761 participating non-lactating NPWRA, 294 (39.8%) had RBC folate insufficiency (<748 mol/L). The prevalence of RBC folate insufficiency was lower among non-lactating NPWRA living in urban than rural areas (PR: 0.72, 95% CI: 0.52-0.99) but did not differ by age or household wealth index. Vitamin B12 insufficiency was uncommon (< 221 pmol/L, 2.7%). The estimated NTD risk was 10.5 (95% uncertainty interval: 8.1-13.3) per 10,000 births.

DISCUSSION

Elevated NTD risk was predicted in the Morogoro region of Tanzania, where ∼ 40% of non-lactating NPWRA had RBC folate insufficiency and < 3% had vitamin B12 insufficiency. The NTD risk is consistent with surveillance data for the area, limited folic acid fortification of staple foods, and low vitamin B12 insufficiency. Further studies are needed to better understand the context of these findings, especially the impact of micronutrient fortification in Tanzania.

Identification of endocrine disrupting chemicals targeting NTD-related hub genes during pregnancy via in silico analysis

Neural tube defects (NTDs) represent severe congenital malformations of the central nervous system with multifactorial etiology, involving intricate gene-environment interactions that remain incompletely characterized. Endocrine disrupting chemicals (EDCs) are exogenous substances with hormone-disrupting properties that are ubiquitous in our surroundings. These chemicals pose a significant threat to human health, contributing to a range of diseases. Pregnant women are particularly vulnerable to the effects of EDCs, as these substances can traverse the placental barrier and impact the development of both the placenta and fetus. This study utilized placental and fetal transcriptome data to identify hub genes associated with NTDs during pregnancy. By leveraging the Comparative Toxicogenomics Database (CTD), we predicted the EDCs targeting these hub genes and performed molecular docking to assess their interactions. Our findings revealed four hub genes (CTSC, FCER1G, ITGB2, and LYVE1) in NTDs, with 72 EDCs identified as their targets. Molecular docking demonstrated that atrazine, bisphenol A (BPA) and diuron exhibited stable affinity with the proteins encoded by hub genes. These findings provide new insights into the environmental endocrine disruptors that affect the development of NTDs during pregnancy.

Serum Prolidase and Ischemia-Modified Albumin Levels in Neural Tube Defects: A Comparative Study of Myelomeningocele, Meningocele, and Myeloschisis

BACKGROUND Neural tube defects (NTDs) are congenital malformations resulting from incomplete neural tube closure, leading to severe neurological impairments. Despite advances in prenatal screening and surgical interventions, the biochemical mechanisms underlying NTDs remain unclear. Prolidase, an enzyme involved in collagen metabolism, and ischemia-modified albumin (IMA), a marker of oxidative stress, may play roles in NTD pathogenesis. This study aimed to compare serum prolidase and IMA levels in infants with NTDs and healthy controls to assess their potential contribution to NTD development. MATERIAL AND METHODS A case-control study was conducted, including 45 infants diagnosed with NTDs (myelomeningocele, meningocele, and myeloschisis) and 45 age- and sex-matched healthy controls. Serum prolidase and IMA levels were measured using validated spectrophotometric methods. Statistical analyses were performed to compare biomarker levels between groups and among NTD subtypes. RESULTS Serum prolidase levels were significantly elevated in NTD patients (2.21±0.06 IU/L) compared to controls (1.07±0.04 IU/L, p<0.001). Similarly, serum IMA levels were higher in NTD patients (0.40±0.01 ABSU) than in controls (0.22±0.01 ABSU, p<0.001). No significant differences were observed in biomarker levels among the different NTD subtypes (p>0.05). CONCLUSIONS Elevated prolidase and IMA levels in NTD patients suggest a potential role in NTD pathogenesis, possibly through impaired collagen metabolism and oxidative stress. Further research is needed to explore their diagnostic and therapeutic implications in neural tube defect management.

Research advancements in the Use of artificial intelligence for prenatal diagnosis of neural tube defects

Artificial Intelligence is revolutionizing prenatal diagnostics by enhancing the accuracy and efficiency of procedures. This review explores AI and machine learning (ML) in the early detection, prediction, and assessment of neural tube defects (NTDs) through prenatal ultrasound imaging. Recent studies highlight the effectiveness of AI techniques, such as convolutional neural networks (CNNs) and support vector machines (SVMs), achieving detection accuracy rates of up to 95% across various datasets, including fetal ultrasound images, genetic data, and maternal health records. SVM models have demonstrated 71.50% accuracy on training datasets and 68.57% on testing datasets for NTD classification, while advanced deep learning (DL) methods report patient-level prediction accuracy of 94.5% and an area under the receiver operating characteristic curve (AUROC) of 99.3%. AI integration with genomic analysis has identified key biomarkers associated with NTDs, such as Growth Associated Protein 43 (GAP43) and Glial Fibrillary Acidic Protein (GFAP), with logistic regression models achieving 86.67% accuracy. Current AI-assisted ultrasound technologies have improved diagnostic accuracy, yielding sensitivity and specificity rates of 88.9% and 98.0%, respectively, compared to traditional methods with 81.5% sensitivity and 92.2% specificity. AI systems have also streamlined workflows, reducing median scan times from 19.7 min to 11.4 min, allowing sonographers to prioritize critical patient care. Advancements in DL algorithms, including Oct-U-Net and PAICS, have achieved recall and precision rates of 0.93 and 0.96, respectively, in identifying fetal abnormalities. Moreover, AI's evolving role in genetic research supports personalized NTD prevention strategies and enhances public awareness through AI-generated health messages. In conclusion, the integration of AI in prenatal diagnostics significantly improves the detection and assessment of NTDs, leading to greater accuracy and efficiency in ultrasound imaging. As AI continues to advance, it has the potential to further enhance personalized healthcare strategies and raise public awareness about NTDs, ultimately contributing to better maternal and fetal outcomes.

Optical genome mapping identifies rare structural variants in neural tube defects

Neural tube defects (NTDs) are the most common birth defects of the central nervous system and occur as either isolated malformations or accompanied by anomalies of other systems. The genetic basis of NTDs remains poorly understood using karyotyping, chromosomal microarray, and short-read sequencing, with only a limited number of pathogenic variants identified. Collectively, these technologies may fail to detect rare structural variants (SVs) in the genome, which may cause these birth defects. Therefore, optical genome mapping (OGM) was applied to investigate 104 NTD cases, of which 74 were isolated NTDs and 30 were NTDs with other malformations. A stepwise approach was undertaken to ascertain candidate variants using population and internal databases and performing parental studies when possible. This analysis identifies diagnostic findings in 8% of cases (8/104) and candidate findings in an additional 22% of cases (23/104). Of the candidate findings, 9% of cases (9/104) have SVs impacting genes associated with NTDs in mouse, and 13% of cases (14/104) have SVs impacting genes implicated in the neural tube development pathways. This study identifies RMND5A, HNRNPC, FOXD4, and RBBP4 as strong candidate genes associated with NTDs, and expands the phenotypic spectrum of AMER1 and TGIF1 to include NTDs. This study constitutes the first systematic investigation of SVs using OGM to elucidate the genetic determinants of NTDs. The data provide key insights into the pathogenesis of NTDs and demonstrate the contribution of SVs in the genome to these birth defects.

Prevalence of Babies Born With Neural Tube Defects and Geospatial Mapping of Therapeutic Services: A Systematic Review

Background and Aims

Neural tube defects (NTDs) are an important global health concern with high morbidity and mortality. Enhancing access to healthcare for children born with NTDs is crucial for improving health systems and service delivery.

Methods

We conducted a systematic review to assess the global prevalence of NTDs and the accessibility of healthcare services. Our search spanned databases like PubMed, EMBASE, and Scopus, focusing on NTD prevalence, healthcare service mapping, and access barriers. We followed a standardized data extraction process, and the study is registered with PROSPERO (CRD42023425843).

Results

From 3067 records, 65 studies met our inclusion criteria, mainly focusing on newborns. The study durations range from 6 months to 40 years. The NTD prevalence was between 0.4 and 215.13 per 10,000 births, with Spina Bifida, Anencephaly, and Encephalocele being the most common. The African region was the WHO region with the highest prevalence, while the Western Pacific Region had the lowest prevalence. One study used geospatial mapping to identify healthcare access barriers.

Conclusion

Our study revealed wide disparities in the prevalence rates of NTDs with the African region having the highest prevalence. Geospatial mapping was not used to assess access to healthcare services for children born with NTDs in almost all the studies. This underscores the global challenge of access to surgical care for children born with NTDs and the need for strengthening healthcare services in settings with high prevalences.

Sources of bias in studies reporting birth prevalence of congenital anomalies: a scoping review and reporting checklist

BACKGROUND

Data on the birth prevalence of congenital anomalies in low- and middle-income countries report wide variations in prevalence estimates. We conducted a scoping review to identify the sources of bias in studies reporting birth prevalence of congenital anomalies in World Health Organization South-East Asia region (SEAR) countries.

METHODS

PubMed and Google Scholar databases were screened for relevant literature. Data on study characteristics and sources of bias was extracted. A narrative synthesis of the data is reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. A checklist for reporting studies on birth prevalence of congenital anomalies (CD-Checklist) was developed.

RESULTS

The literature search retrieved 47 articles. Birth prevalence varied from 0.21% to 9.68%. Sampling bias was evident as studies were single hospital studies, lacked relevant description of sample, did not justify sample size or describe the process of sampling. Information bias was identified as studies did not mention classification system used, and failed to clearly distinguish between number of malformations and babies with malformations. Observer and reporting bias were noted.

CONCLUSIONS

Several sources of bias introduce variations in birth prevalence reports of congenital anomalies in SEAR countries. A checklist (CD-Checklist) has been suggested which can guide investigators to minimize the risk of bias in studies.

Evolving Insights into Prickle2 in Neurodevelopment and Neurological Disorders

The development of neural circuits is a complex, highly coordinated process crucial for the proper functioning of the nervous system. This process involves the intricate interplay of numerous genes and signaling pathways. Prickle2, a protein encoded by the planar cell polarity (PCP) genes, is a key component of the noncanonical Wnt/PCP signaling pathway and plays a critical role in neural circuit development. Recent studies have highlighted the essential functions of Prickle2 in various stages of neural circuit formation, including the development of the initial segment of neuronal axons, axon elongation and regeneration, dendrite formation, synapse formation, and vesicle transport. The normal expression and spatial distribution of Prickle2 are vital for these processes, and its dysregulation has been associated with several neurological disorders, including congenital neural tube defects, Alzheimer's disease, epilepsy, and autism spectrum disorders. This review aims to systematically summarize the upstream and downstream signaling pathways and regulatory interactions involving Prickle2 in neurodevelopment and neural circuit formation. By discussing the expression patterns of Prickle2 in neurodevelopment and its associations with neurological diseases, we provide insights into the mechanisms through which Prickle2 influences neurodevelopment and its potential implications in neurological disorders.

Chitosan oligosaccharides ameliorates maternal diabetes-induced embryonic neural tube defects via inhibitting excessive pyroptosis of neuroepithelial cells

Maternal diabetes significantly induces embryonic neural tube defects (NTDs). Thus, it is urgent need to further investigate the regulatory mechanism and therapeutic strategy for maternal diabetes-induced embryonic NTDs. Pyroptosis is a novel mode of programmed cell death. The role of pyroptosis on the maternal diabetes-induced embryonic NTDs is still unclear. Chitosan oligosaccharides (COSs) is a kind of natural polysaccharide with anti-inflammatory and anti-oxidant bioactivities, and its role on NTDs formation is poorly understood. Here, we hypothesized that excessive pyroptosis is another important mechanism for diabetes-induced NTDs formation, and COSs can exert its anti-inflammatory and antioxidant activities to alleviate maternal diabetes-mediated embryonic neuroepithelial cells pyroptosis and NTDs formation. Firstly, we confirmed that maternal diabetes significantly induces the embryonic NTDs formation (13.2% of NTDs rate). More interestingly, the mechansim study found that maternal diabetes significantly triggers the elevated pyroptosis level in embryos. And VX765, a pyroptosis inhibitor, significantly ameliorated the diabetes-induced embryonic NTDs (1.9% NTDs). Additionally, COSs treatment significantly reduced the maternal diabetes-associated the embryonic NTDs formation with 2.6% NTDs rate. Mechanistic studies further demonstrated that COSs significantly inhibits maternal diabetes-induced elevated inflammatory response and oxidative stress in embryos, and subsequently ameliorates the pyroptotic level of embryonic neuroepithelial cells through inhibiting TXNIP-NLRP3 complex formation. In a conclusion, pyroptosis is a another key caused event for maternal diabetes-induced embryonic NTDs. COSs exerts its antioxidant effect to inhibit the pyroptosis of neuroepithelial cells and consequently alleviates maternal diabetes-induced embryonic NTDs.

Neural tube defects in a war-torn Tigray regional state of Ethiopia: a retrospective study of 54,626 deliveries

BACKGROUND

The Tigray region of Ethiopia has a significantly high prevalence of neural tube defects (NTDs), ranging from 1.31 to 2.15% of total births. The prevalence has worsened due to ongoing regional war and conflict since October 2020. This study aims to assess NTD prevalence in these challenging conditions.

METHODS

This institution-based, retrospective cross-sectional study was conducted across 11 public hospitals in the Tigray region. The study reviewed all delivery records from October 2020 to December 2023. Data were collected from hospital records, focusing on cases of neural tube defects (NTDs) and relevant maternal and neonatal characteristics. This retrospective analysis aimed to identify the prevalence of NTDs, as well as factors contributing to their occurrence. The data analysis involved using SPSS version 27 for comprehensive data management and statistical evaluation. Descriptive statistics provided an overview of the data, while binary logistic regression offered insights into the factors associated with neural tube defects. The results were systematically presented in both textual, tabular, graph formats to facilitate understanding and interpretation.

RESULTS

Out of 54,626 delivery records, 1,612 cases of NTDs were identified (1,434 NTD cases and 178 isolated hydrocephalus cases). The specific birth prevalence of NTDs was 262.5 per 10,000 (95% CI, 249.1-276.5 per 10,000), with NTDs being the predominant cause of stillbirths. Anencephaly (136.6 per 10,000), spina bifida (110.6 per 10,000) and encephalocele (15.4 per 10,000) were the most common defects. Risk factors for NTDs include maternal age (20-29 years), rural residency, first pregnancies, a history of early neonatal death, lack of folic acid and multivitamin use, as well as neonatal factors like stillbirth, male sex, and preterm birth.

CONCLUSION

This study reveals the alarmingly high prevalence of neural tube defects (NTDs) in the Tigray region, with a birth prevalence of 262.5 per 10,000 births. Anencephaly, spina bifida, and encephalocele were common, contributing to stillbirths. Risk factors include maternal age (20-29), rural residency, first pregnancies, lack of folic acid and multivitamins, and neonatal factors like male sex and preterm birth. The findings stress the need for public health interventions, including folic acid awareness, better prenatal care, maternal nutrition research, stronger health systems, and a national surveillance system to prevent birth defects.

Bibliometric Analysis of Myelomeningocele Management: National Disease Burden versus Publication Volume

BACKGROUND

Myelomeningocele (MMC) disproportionately affects low-resource areas and regions without mandatory folic acid fortification. No specific literature exists on the distribution of research output regarding neurosurgical management of myelomeningocele worldwide in relation to regional disease burden. We aimed to examine the country of origin and patient population of published papers on MMC and topics related to neurosurgical management of MMC, to determine whether these were proportionate to disease burden.

METHODS

A systematic literature search was conducted on neurosurgical aspects of MMC care. The geographic distribution of neurosurgical MMC research output was examined against the national burden of disease. Bibliometric analysis quantified author and patient country affiliations stratified by World Bank income group classification and folic acid fortification status, juxtaposed with disease burden.

RESULTS

From 9692 titles, 1843 were included, representing 107,446 patients and 2650 authorship instances. High-income countries (HICs) constituted 3% of 2019's global neural tube defect (NTD) births, 74% of authorships, and 83% of patients represented. Upper-middle-income countries (UMICs) represented 9% of NTD births, 16% of authorships, and 9% of published patients. Lower-middle-income countries (LMICs) represented 55% of NTD births but only 8.6% of authorships and 7% of patients. Low-income countries (LICs) shouldered 32% of NTD births and contributed 1.3% of authorships and 1.6% of patients. Countries with mandatory folic acid fortification represented 75% of patients and 54% of authorships. Postnatal repair, hydrocephalus, and postoperative complications were the most frequently studied topics.

CONCLUSIONS

The global literature concerning neurosurgical management of myelomeningocele originates predominantly from HICs. Published experiences of myelomeningocele patients from LICs/LMICs are scarce, even though they constitute the majority of the affected population. Neurosurgeons and other health professionals must address this mismatch between disease burden and publication volume in order to inform practice, policy, and advocacy for MMC care worldwide.

Using technology to enhance prevention of pressure injuries in the spina bifida population

Patients with spina bifida (SB) are highly susceptible to pressure injuries (PIs) due to limited mobility and sensory deficits, and they may occur during multiple surgical procedures. The article highlights that PIs, which significantly increase hospital costs and extend patient stays, can be prevented mainly through evidence-based interventions. One of the critical technologies used at this stage is pressure mapping to monitor and optimize pressure distribution on surfaces, whether lying or seated, particularly during prolonged medical procedures. Additionally, the article emphasizes the importance of educating families and caregivers about early signs of PIs, photography, using electronic health records for tracking, and effective home care strategies to prevent these injuries post-discharge. Future research should investigate how to enhance prevention methods in hospital settings, especially for patients undergoing surgeries or other lengthy procedures. Overall, the article underscores the critical role of early identification of risk, intervention, and technological support in reducing the incidence and impact of PIs in patients with SB.

Implementation of in utero laparotomy-assisted fetoscopic spina bifida repair in two centers in Latin America: rationale for this approach in this region

Background

Spina bifida (SB) is a severe congenital malformation that affects approximately 150,000 infants annually, predominantly in low- and middle-income countries, leading to significant morbidity and lifelong disabilities. In Latin America, the birth prevalence of SB is notably high, often exacerbated by limited healthcare resources and poor access to advanced medical care. The implementation of laparotomy-assisted fetoscopic in-utero SB repair programs in Latin America targets reducing prematurity rates and enabling vaginal births while preserving the benefits of decreased need for hydrocephalus treatment and improved mobility in children.

Objective

This study evaluated the safety, efficacy, and outcomes of laparotomy-assisted fetoscopic in-utero SB repair in Latin America compared to traditional open-hysterotomy methods.

Study design

This retrospective cohort study included 39 cases of laparotomy-assisted fetoscopic in-utero SB repair, with 14 cases from Mexico (2017-2021) and 25 cases from Colombia (2019-2024). These cases were compared to 78 cases from the MOMs trial and 314 from other Latin American centers using traditional open-hysterotomy methods. Statistical analyses included the Student's t-test, Kruskal-Wallis test, and Pearson's chi-square test.

Results

The gestational age (GA) at the time of surgery was significantly higher in fetoscopic centers (26±1.27 weeks) compared to the MOMs trial (23.6±1.42 weeks) and traditional hysterotomy methods (25.4±1 weeks) (P<.001). Mean GA at delivery was significantly earlier in the hysterotomy-based groups than in our fetoscopic group (MOMs: 34.1 [± 3.1] vs open-repair centers in LATAM: 34 [±3002] vs Fetoscopic: 35.3 [± 3.79] weeks; P values=.14 and 0004, respectively). Moreover, and the fetoscopic repair group exhibited a significantly lower rate of spontaneous preterm births (<34 weeks) at 15.8%, compared to 46.2% in the MOMs trial group and 49% in the other Latin American centers using traditional open-hysterotomy methods (P=.004 and .001, respectively). Additionally, the fetoscopic group had higher birthweights (2618±738g) and a lower cesarean delivery rate (65.8%) compared to the other groups (P<.001). Hydrocephalus treatment requirements at 12 months were similar across all groups. No maternal deaths or other outcomes such as pulmonary edema or need for maternal transfusion were noted in the fetoscopic SB repair group.

Conclusion

The laparotomy-assisted fetoscopic SB repair offers a feasible and safer alternative to traditional hysterotomy-based techniques in Latin America. This approach significantly reduces the rates of prematurity and cesarean deliveries, facilitating vaginal births and minimizing maternal morbidity. These findings support the broader adoption of fetoscopic SB repair in regions with a high prevalence of SB and suboptimal perinatal outcomes, underscoring its advantages over hysterotomy-based approaches.

Ambulatory status and sexual function and activity in young adults with spina bifida

INTRODUCTION

Young adults with spina bifida may experience altered genital sensation and sexual function. There are no validated questionnaires and few studies examining sexual function and activity in this population. Ambulatory status has previously been associated with better erectile function, but few studies report on other domains of sexual function in men and women.

OBJECTIVE

To understand the sexual function and activity of young adults with spina bifida. We hypothesize that ambulatory status is associated with better sexual function and increased sexual activity in young adults with spina bifida.

METHODS

From 2013 to 2024, young adults with spina bifida were surveyed using a non-validated sexual questionnaire assessing genital sensation, sexual function, and sexual activity. Ambulatory status was defined using the 5-point Hoffer classification; patients were dichotomized for analysis. Fisher's exact and chi square tests were used to compare responses between the groups.

RESULTS

Responses from 103 patients were analyzed. There were 31 ambulatory (19 lumbar, 3 lumbosacral, 9 sacral) and 30 nonambulatory (9 thoracic, 20 lumbar, 1 lumbosacral) men (median age of 20.0 years, range 18.0-26.0 years). 97 % of ambulatory men reported having some penile sensation compared to 74 % of nonambulatory men (p = 0.02). Sexually active nonambulatory men were more likely to report ejaculatory dysfunction (43 %, 6/14) than sexually active ambulatory men (5 %, 1/21; p = 0.01). There were 24 ambulatory (12 lumbar, 2 lumbosacral, 10 sacral) and 18 nonambulatory (3 thoracic, 15 lumbar) women, with a median age of 20.5 years (range 17.8-26.2 years). We found no significant association between ambulatory status and sexual function in women or in sexual activity rates for either sex.

DISCUSSION

In men, ambulatory status was associated with higher rates of reported penile sensation and ability to ejaculate. No differences in sexual function according to ambulatory status were identified in women. Strengths of the study include the relatively large sample size and inclusion of a variety of sexual domains. A limitation of the study was the use of the non-validated questionnaire, though none exists for this target population.

CONCLUSION

In young men with spina bifida, ambulatory status was associated with positive responses regarding penile sensation and ejaculation. However, ambulatory status was not associated with reporting better sexual function in young women with spina bifida. These results can be used to facilitate discussion about sexual health with young adults with spina bifida.

A Systematic Review of Parental Occupational Pesticide Exposure and Geographical Proximity to Agricultural Fields in Association with Neural Tube Defects

Neural tube defects (NTDs) are the second most common congenital anomaly and have been widely associated with exposure to pesticides. This systematic review which analyzes the association between parental exposure to pesticides and NTDs was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The search strategy was designed considering the population, exposure, controls, outcomes, and study design (PECOS). The inclusion criteria were epidemiological studies involving pesticides exposure during embryonic development, written in English, Portuguese, or Spanish, and performed in 12 databases. Based on the eligibility criteria, 16 articles were selected for analysis. The most frequently assessed NTDs were anencephaly and spina bifida, with 14 studies investigating each of these conditions. The assessment of pesticide exposure was based on parental occupation and residential proximity to agricultural fields. Studies differed regarding the pesticides assessed, exposure windows, and parents exposed. Regarding the outcomes, it was observed that geographic proximity to agricultural fields and a greater association with family members exposed to pesticides were found in mothers and neonates with NTDs. In relation to occupational exposure, some articles found an association with NTDs, while others did not. Therefore, an analysis of the available evidence suggests that pesticides are a risk factor in the development of NTDs.

Birth prevalence and determinants of neural tube defects among newborns in Ethiopia: A systematic review and meta-analysis

BACKGROUND

Neural tube defects (NTDs) are complex multifactorial disorders in the neurulation of the brain and spinal cord that develop in humans between 21 and 28 days of conception. Neonates with NTDs may experience morbidity and mortality, with severe social and economic consequences. Therefore, the aim of this systematic review and meta-analysis is to assess the pooled prevalence and determinants for neural tube defects among newborns in Ethiopia.

METHODS

The protocol of this study was registered in the International Prospective Register of Systematic Reviews (PROSPERO Number: CRD42023407095). We systematically searched the databases PubMed, Science Direct, Cochrane Library, Google Scholar and Research Gate. Grey literature was searched on Google. Heterogeneity among studies was assessed using the I2 test statistic and the Cochran Q test statistic. A random effects model was used to estimate the birth prevalence of neural tube defects.

RESULT

Twenty-five articles were included in the meta-analysis to estimate the prevalence and determinants of neural tube defects in Ethiopia. A total of 611,354 newborns were included in the analysis. The pooled birth prevalence of neural tube defects was 83.40 (95% CI: 60.78, 106.02) per 10,000 births. The highest and lowest prevalence rates were 130.9 (95% CI: 113.52, 148.29) in Tigray and 28.60 (95% CI: 18.70, 38.50) per 10,000 births in Amhara regional states. Women's intake of folic acid supplements and planned pregnancy were identified as protective factors for NTDs, while stillbirth history, use of any drugs during pregnancy, exposure to radiation, and pesticides during pregnancy were risk factors for neural tube defects.

CONCLUSION

The pooled birth prevalence of neural tube defects in Ethiopia was found to be high. Effective prevention interventions, especially focusing on periconceptional folic acid supplementation as well as folate fortification, should be prioritized alongside nutrition education, maternal health care, and environmental safety measures.

A Randomized Crossover Trial of Acceptability of Quadruple-Fortified Salt in Women and their Households in Southern India

BACKGROUND

Double-fortified salt (DFS; iron, iodine) improved iron status in randomized trials and was incorporated into India's social safety net programs, suggesting opportunities to address other micronutrient deficiencies.

OBJECTIVES

To evaluate the acceptability of quadruple-fortified salt (QFS; iron, iodine, folic acid, and vitamin B12) in women and their households, using a randomized crossover trial design and triangle tests.

METHODS

Women 18-49 y (n = 77) and their households were randomly assigned to receive QFS or DFS in a randomized crossover design over a 3-wk period (week 1: QFS/DFS, week 2: iodized salt, week 3: DFS/QFS). Each week, participants completed a 9-point hedonic questionnaire (1 = dislike extremely to 9 = like extremely) to evaluate 5 sensory domains (color, odor, taste, texture, and overall acceptability) of the intervention, and the remaining salt was weighed using a digital scale. Triangle tests were conducted among women to evaluate sensory discrimination of salt consumed in rice dishes prepared using standardized recipes. Mixed models were used to examine hedonic ratings and salt use; salt type, sequence, and period were included as fixed effects, and household was included as a random effect. Binomial tests were used to evaluate sensory discrimination of salt type in triangle tests.

RESULTS

Mean hedonic ratings for most of the 5 sensory domains were ≥7 (like moderately) and did not differ by salt type [overall acceptability mean (SD): QFS: 7.8 (0.7) compared with DFS: 7.7 (1.2); P = 0.68]. Household salt use (weighed) did not differ by salt type. During the 3-wk intervention period, weighed salt use and hedonic ratings significantly increased, indicating a period effect independent of salt type or sequence. In triangle tests, rice samples prepared with QFS, DFS, or iodized salt were not distinguishable.

CONCLUSIONS

Acceptability of QFS was high, based on individual hedonic ratings and weighed household salt use. Rice dishes prepared with DFS, QFS, and iodized salt were not distinguishable. Findings informed the design of a randomized trial of QFS in this population. This trial was registered at clinicaltrials.gov as NCT03853304 and CTRI/2024/04/066208.

The DNA demethylase TET1 modifies the impact of maternal folic acid status on embryonic brain development

Folic acid (FA) is well known to prevent neural tube defects (NTDs), but we do not know why many human NTD cases still remain refractory to FA supplementation. Here, we investigate how the DNA demethylase TET1 interacts with maternal FA status to regulate mouse embryonic brain development. We determined that cranial NTDs display higher penetrance in non-inbred than in inbred Tet1-/- embryos and are resistant to FA supplementation across strains. Maternal diets that are either too rich or deficient in FA are linked to an increased incidence of cranial deformities in wild type and Tet1+/- offspring and to altered DNA hypermethylation in Tet1-/- embryos, primarily at neurodevelopmental loci. Excess FA in Tet1-/- embryos results in phospholipid metabolite loss and reduced expression of multiple membrane solute carriers, including a FA transporter gene that exhibits increased promoter DNA methylation and thereby mimics FA deficiency. Moreover, FA deficiency reveals that Tet1 haploinsufficiency can contribute to DNA hypermethylation and susceptibility to NTDs. Overall, our study suggests that epigenetic dysregulation may underlie NTD development despite FA supplementation.

Fold-and-fuse neurulation in zebrafish requires Vangl2

Shaping of the future brain and spinal cord during neurulation is an essential component of early vertebrate development. In amniote embryos, primary neurulation occurs through a "fold-and-fuse" mechanism by which the edges of the neural plate fuse into the hollow neural tube. Failure of neural fold fusion results in neural tube defects (NTDs), which are among the most devastating and common congenital anomalies worldwide. Unlike amniotes, the zebrafish neural tube develops largely via formation of a solid neural keel that later cavitates to form a midline lumen. Although many aspects of primary neurulation are conserved in zebrafish, including neural fold zippering, it was not clear how well these events resemble analogous processes in amniote embryos. Here, we demonstrate that despite outward differences, zebrafish anterior neurulation closely resembles that of mammals. For the first time in zebrafish embryos, we directly observe enclosure of a lumen by the bilateral neural folds, which fuse by zippering between at least two distinct closure sites. Both the apical constriction that elevates the neural folds and the zippering that fuses them coincide with apical Myosin enrichment. We further show that embryos lacking vangl2, a core planar cell polarity and NTD risk gene, exhibit delayed and abnormal neural fold fusion that fails to enclose a lumen. These defects can also be observed in fixed embryos, enabling their detection without live imaging. Together, our data provide direct evidence for fold-and-fuse neurulation in zebrafish and its disruption upon loss of an NTD risk gene, highlighting the deep conservation of primary neurulation across vertebrates.

Understanding perspectives on neural tube defect management: insights from Jordanian parents

INTRODUCTION

Neural tube defects (NTDs) represent a spectrum of heterogeneous birth anomalies characterized by the incomplete closure of the neural tube. In Jordan, NTDs are estimated to occur in approximately one out of every 1000 live births. Timely identification of NTDs during the 18-22 weeks of gestation period offers parents various management options, including intrauterine NTD repair and termination of pregnancy (TOP). This study aims to assess and compare parental knowledge and perceptions of these management modalities between parents of affected children and those with healthy offspring.

MATERIALS AND METHODS

This retrospective case-control study was conducted at Jordan University Hospital (JUH) using telephone-administered questionnaires. Categorical variables were summarized using counts and percentages, while continuous variables were analyzed using mean and standard deviation. The association between exposure variables and outcomes was explored using binary logistic regression. Data analysis was performed using SPSS for Windows version 26 (SPSS Inc., Chicago, IL).

RESULTS

The study sample comprised 143 participants, with 49.7% being parents of children with NTDs. The majority of NTD cases were associated with unplanned pregnancies, lack of folic acid supplementation, and postnatal diagnosis. Concerning parental knowledge of TOP in Jordan, 86% believed it to be legally permissible in certain situations. However, there was no statistically significant difference between cases and controls regarding attitudes toward TOP. While the majority of parents with NTD-affected children (88.7%) expressed a willingness to consider intrauterine surgery, this percentage decreased significantly (to 77.6%) after receiving detailed information about the procedure's risks and benefits (p = .013).

CONCLUSIONS

This study represents the first case-control investigational study in Jordan focusing on parental perspectives regarding TOP versus intrauterine repair of myelomeningocele following a diagnosis of an NTD-affected fetus. Based on our findings, we urge the implementation of a national and international surveillance program for NTDs, assessing the disease burden, facilitating resource allocation toward prevention strategies, and promoting early diagnosis initiatives either by using newly suggested diagnostic biomarkers or early Antenatal ultrasonography.

Analysis of a newly developed multidisciplinary program in the Middle East informed by the recently revised spina bifida guidelines

PURPOSE

This paper describes the development and characteristics of a multi-disciplinary spina bifida clinic in Qatar considering the recently revised and globally available Guidelines for the Care of People with Spina Bifida (GCPSB).

METHODS

A retrospective chart review was performed on individuals in Sidra's multidisciplinary spina bifida clinic database from January 2019 to June 2020. Their electronic health records were reviewed for demographics, as well as neurosurgical, urologic, rehabilitation, and orthopedic interventions.

RESULTS

There were 127 patients in the database; 117 met inclusion criteria for diagnoses of myelomeningocele, meningocele, sacral agenesis/caudal regression, and/or spinal lipoma. Generally, Qatar is following GCPSB recommendations for multidisciplinary care. Consanguineous relationships, difficulties with access to urological and rehabilitation supplies and equipment, school access, and variable timing of neurosurgical closure were areas that demonstrated differences from GCPSB recommendations due to barriers in implementation.

CONCLUSION

The GCPSB recommendations are applicable in an international setting such as Qatar. Despite a few barriers in implementing some of the recommendations, this new multi-disciplinary spina bifida clinic demonstrates alignment with many of the GCPSB guidelines.

Iniencephaly: A Challenging Prenatal Diagnosis of a Neural Tube Defect

Iniencephaly is a rare malformation of the base of the cranium, with an almost always fatal prognosis. This condition is part of the category of defects related to neural tube closure. Prenatal diagnosis can now be performed through ultrasound evaluation, allowing timely counseling. We present the case of a woman for whom an ultrasound diagnosis of iniencephaly at 13 weeks of gestation enabled early termination of the pregnancy.

Quantifying mechanical forces during vertebrate morphogenesis

Morphogenesis requires embryonic cells to generate forces and perform mechanical work to shape their tissues. Incorrect functioning of these force fields can lead to congenital malformations. Understanding these dynamic processes requires the quantification and profiling of three-dimensional mechanics during evolving vertebrate morphogenesis. Here we describe elastic spring-like force sensors with micrometre-level resolution, fabricated by intravital three-dimensional bioprinting directly in the closing neural tubes of growing chicken embryos. Integration of calibrated sensor read-outs with computational mechanical modelling allows direct quantification of the forces and work performed by the embryonic tissues. As they displace towards the embryonic midline, the two halves of the closing neural tube reach a compression of over a hundred nano-newtons during neural fold apposition. Pharmacological inhibition of Rho-associated kinase to decrease the pro-closure force shows the existence of active anti-closure forces, which progressively widen the neural tube and must be overcome to achieve neural tube closure. Overall, our approach and findings highlight the intricate interplay between mechanical forces and tissue morphogenesis.

Tracking the Global Burden of Neural Tube Defects and Assessing Disparities Across World Health Organization Regions: A Scoping Literature Review

BACKGROUND AND OBJECTIVES

Neural tube defects (NTDs) are an important cause of global morbidity worldwide. Well-planned global neurosurgery and public health efforts can aid vulnerable communities, but there is a need to elucidate the global burden of NTDs and identify regions without available data to better target interventions.

METHODS

A scoping review to quantify worldwide NTD prevalence using the PubMed/Medline and birth defects surveillance registries was conducted. Data published after January 1, 1990, encompassing prevalence values of at least the 2 most prevalent NTDs-spina bifida and encephalocele-were abstracted. Average NTD prevalence rates were aggregated by World Health Organization (WHO) region and World Bank classification, and differences were determined using the analysis of variance test. Differences in availability of nationally representative data by WHO region and World Bank classification were determined using χ 2 tests.

RESULTS

This review captured 140 studies from a total of 93 of 194 WHO member countries. The percentage of countries within a geographic region with available NTD prevalence data was highest in the Eastern Mediterranean (EMR) (85.7%) and lowest in Africa (AFR) (31.3%). The NTD prevalence range was 0.9-269.6 per 10 000 births. Statistically significant differences in reported NTD prevalence rates existed by WHO Region ( P = .00027) and World Bank income level of study country ( P = .00193). Forty countries (43%) had conducted national-level studies assessing NTD prevalence. There was a statistically significant difference in the availability of nationally representative prevalence data depending on the WHO region ( P = .0081) and World Bank classification of study country ( P = .0017).

CONCLUSION

There is a gap in availability of NTD prevalence data worldwide, with many WHO member states lacking national-level NTD prevalence estimates. These findings highlight the need for greater NTD surveillance efforts to identify the countries with the greatest need for targeted global intervention.

Society for Birth Defects Research and Prevention Symposium: Health Disparities Within Communities of Color

BACKGROUND

High-risk pregnancies and birth defects are often greater within communities of color where resources for a healthy pregnancy are generally lacking. Infant and maternal mortality, preterm birth, and instances of increased developmental and physical defects are related to environmental exposures (e.g., pesticides, lead in water, wildfire smoke), dietary additives, and lack of access to adequate healthcare. More frequently people of color and other under-served groups, are affected by historical inequality and unconscious bias. Compounding these disparities, research into these issues and efforts to address them are poorly supported.

METHODS

The speakers in this symposium presented evidence for health disparities within communities of color to foster research aimed at identifying toxic levels of potentially hazardous dietary chemicals, or exposures in the pediatric population can focus on addressing the current inadequacy of translating scientific findings into enforceable policies.

RESULTS

The disparities discussed within this symposium highlighted key areas in desperate need of policy reform. In the United States, regulatory exposure levels have been established for lead exposures but frequently exceed these limits without mitigation. Neural tube defects can be prevented by a simple dietary solution such as fortification of staple foods with folic acid. Recent literature on gender as a social determinant of health has determined women suffer more negative health consequences due to social attitudes.

CONCLUSIONS

Ultimately, this symposium provided an understanding of the experience of disadvantaged and marginalized persons during pregnancy, illustrated the disparities that exist in reproductive health, and described the need to address and prevent them.

From Awareness to Action: Addressing Folic Acid Supplementation in Western India Among Women of Reproductive Age

Background Folate, a vitamin B9, can be sourced naturally in the diet or the form of supplements. Studies highlight the prevention of neural tube abnormalities in women of reproductive age. To prevent these, low daily doses of FA (400-800 μg) are recommended for all women planning pregnancy, with higher doses for those with previous NTD-affected pregnancies. Folic acid supplementation lowers the risk of NTDs, other birth defects, and obstetrical complications. Methods The study explored awareness of and knowledge of folic acid supplements among women of childbearing age in Pune City, western Maharashtra, India. The cross-sectional survey was carried out at Symbiosis University Hospital and Research Centre (SUHRC), involving 300 female participants aged 16-44 years. The study utilized a structured questionnaire to evaluate participants' knowledge of folic acid supplements, their benefits, and usage patterns. Results Use as well as awareness of folic acid supplements was strongly associated with educational attainment. The awareness was low or none in participants who never attended school, and highest among the university graduates. The study included 300 women aged 16-45. About 43% of the study participants were between the ages of 23 and 29 years old; 57.7% were single, and 59.3% among them were university graduates. 59.7% of the study participants knew about folic acid supplements, but only 20% took them regularly. Knowledge about ideal timing and benefits was limited among them. 38% correctly identified prepregnancy as the ideal time to start. Only 18% knew it prevents neural tube defects, and 27% knew it could be obtained naturally. Conclusion The study highlights a lack of detailed knowledge about folic acid supplements among the study participants. Recommendations to enhance the supplement's intake include public health campaigns, enhanced healthcare provider education, easy-to-read informational materials, and strengthening government supplement programs to improve awareness and food fortification. Further research on consumption barriers for the supplement needs to be carried out.

Bibliometric Analysis and a Call for Increased Rigor in Citing Scientific Literature: Folic Acid Fortification and Neural Tube Defect Risk as an Example

The health benefits of vitamin B9 (folate) are well documented, particularly in regard to neural tube defects during pregnancy; however, much remains to be learned regarding the health effects and risks of consuming folic acid supplements and foods fortified with folic acid. In 2020, our laboratory conducted a population-based analysis of the Food Fortification Initiative (FFI) dataset to determine the strength of the evidence regarding the prevalence of neural tube defects (NTD) at the national level in response to mandatory fortification of cereal grains with folic acid. We found a very weak correlation between the prevalence of NTDs and the level of folic acid fortification irrespective of the cereal grain fortified (wheat, maize, or rice). We found a strong linear relationship between reduced NTDs and higher socioeconomic status (SES). Our paper incited a debate on the proper statistics to employ for population-level data. Subsequently, there has been a large number of erroneous citations to our original work. The objective here was to conduct a bibliometric analysis to quantitate the accuracy of citations to Murphy and Westmark's publication entitled, "Folic Acid Fortification and Neural Tube Defect Risk: Analysis of the Food Fortification Initiative Dataset". We found a 70% inaccuracy rate. These findings highlight the dire need for increased rigor in citing scientific literature, particularly in regard to biomedical research that directly impacts public health policy.

Folate and Vitamin B12 Status in Women of Reproductive Age in Rural Haryana, India: Estimating Population-Based Prevalence for Neural Tube Defects

BACKGROUND

Folate and vitamin B12 deficiencies in pregnant women are associated with increased risk for adverse maternal and infant health outcomes, including neural tube defects (NTDs).

METHODS

A population-based cross-sectional survey was conducted in two rural areas in Ambala District, Haryana, India in 2017 to assess baseline folate and vitamin B12 status among women of reproductive age (WRA) and predict the prevalence of NTDs. We calculated the prevalence of folate and vitamin B12 deficiency and insufficiency by demographic characteristics among 775 non-pregnant, non-lactating WRA (18-49 years). Using red blood cell (RBC) folate distributions and an established Bayesian model, we predicted NTD prevalence. All analyses were conducted using SAS-callable SUDAAN Version 11.0.4 to account for complex survey design.

RESULTS

Among WRA, 10.1% (95% CI: 7.9, 12.7) and 9.3% (95% CI: 7.4, 11.6) had serum (<7 nmol/L) and RBC folate (<305 nmol/L) deficiency, respectively. The prevalence of RBC folate insufficiency (<748 nmol/L) was 78.3% (95% CI: 75.0, 81.3) and the predicted NTD prevalence was 21.0 (95% uncertainly interval: 16.9, 25.9) per 10,000 live births. Prevalences of vitamin B12 deficiency (<200 pg/mL) and marginal deficiency (≥200 pg/mL and ≤300 pg/mL) were 57.7% (95% CI: 53.9, 61.4) and 23.5% (95% CI: 20.4, 26.9), respectively.

CONCLUSIONS

The magnitude of folate insufficiency and vitamin B12 deficiency in this Northern Indian population is a substantial public health concern. The findings from the survey help establish the baseline against which results from future post-fortification surveys can be compared.

Epigenetic regulation by TET1 in gene-environmental interactions influencing susceptibility to congenital malformations

The etiology of neural tube defects (NTDs) involves complex gene-environmental interactions. Folic acid (FA) prevents NTDs, but the mechanisms remain poorly understood and at least 30% of human NTDs resist the beneficial effects of FA supplementation. Here, we identify the DNA demethylase TET1 as a nexus of folate-dependent one-carbon metabolism and genetic risk factors post-neural tube closure. We determine that cranial NTDs in Tet1 -/- embryos occur at two to three times higher penetrance in genetically heterogeneous than in homogeneous genetic backgrounds, suggesting a strong impact of genetic modifiers on phenotypic expression. Quantitative trait locus mapping identified a strong NTD risk locus in the 129S6 strain, which harbors missense and modifier variants at genes implicated in intracellular endocytic trafficking and developmental signaling. NTDs across Tet1 -/- strains are resistant to FA supplementation. However, both excess and depleted maternal FA diets modify the impact of Tet1 loss on offspring DNA methylation primarily at neurodevelopmental loci. FA deficiency reveals susceptibility to NTD and other structural brain defects due to haploinsufficiency of Tet1. In contrast, excess FA in Tet1 -/- embryos drives promoter DNA hypermethylation and reduced expression of multiple membrane solute transporters, including a FA transporter, accompanied by loss of phospholipid metabolites. Overall, our study unravels interactions between modified maternal FA status, Tet1 gene dosage and genetic backgrounds that impact neurotransmitter functions, cellular methylation and individual susceptibilities to congenital malformations, further implicating that epigenetic dysregulation may underlie NTDs resistant to FA supplementation.

The Importance of Neurosurgical Intervention and Surgical Timing for Management of Pediatric Patients with Myelomeningoceles in Bangladesh

OBJECTIVE

Reports on the management and survival of children with myelomeningocele defects in Bangladesh are limited. This study describes the characteristics and outcomes of these children, focusing on the timing of surgical repair and factors affecting survival.

METHODS

We enrolled patients with myelomeningoceles in a case-control study on arsenic exposure and spina bifida in Bangladesh. Cases were subsequently followed at regular intervals to assess survival. Demographic, clinical, and surgical characteristics were reviewed. Univariate tests identified factors affecting survival.

RESULTS

Between 2016 and 2022, we enrolled 272 patients with myelomeningocele. Postnatal surgical repair was performed in 63% of cases. However, surgery within 5 days after birth was infrequent (<10%) due to delayed presentation, and there was a high rate (29%) of preoperative deaths. Surgical repair significantly improved patient survival (P < 0.0001). Older age at time of surgery was also associated with improved survival rates, which most likely represents that those who survived to older ages prior to surgery accommodated better with their lesions. Patients who presented with ruptured lesions had lower survival rates.

CONCLUSIONS

Timely neurosurgical repair of myelomeningoceles in Bangladesh is hindered by late patient presentation, resulting in a high preoperative patient death rate. Neurosurgical intervention remains a significant predictor of survival. Increased access to neurosurgical care and education of families and non-neurosurgical providers on the need for timely surgical intervention are important for improving the survival of infants with myelomeningoceles.

Prevalence of neural tube defect and its identification during antenatal period: a cross-sectional study in eastern Indian state

OBJECTIVE

To estimate the prevalence of neural tube defects among all birth outcomes in Odisha during 2016-2022. Additionally, to estimate the identification rate of neural tube defects during Pradhan Mantri Surakshit Matritva Abhiyan sessions.

DESIGN

A population-based cross-sectional study with a household survey for neural tube defects using pictorial card as well as a hospital-based study for antenatal ultrasonography data.

SETTING

The sample population was selected through multistage random sampling. In the first stage, one district from each zone was selected randomly. In the second stage, using simple random sampling, one community health centre and one urban primary health centre were selected from each district. In the third stage, the population from a block and ward were picked from the selected rural and urban settings, respectively.

PARTICIPANTS

All married women in the reproductive age group (18-49 years) residing in these cluster villages in the selected districts were enrolled.

RESULTS

The study surveyed 49 215 women and recorded 50 196 birth outcomes, including 49 174 live births, 890 stillbirths and 132 medical terminations of pregnancy. A total of 30 neural tube defect cases were detected. The overall prevalence rate of neural tube defect was 0.59 per 1000 birth outcomes. Spina bifida was the most prevalent neural tube defect with the prevalence of, followed by anencephaly and encephalocele. Despite 26 860 mothers receiving antenatal ultrasonography Pradhan Mantri Surakshit Matritva Abhiyan session, data on neural tube defects and other birth defects detected through these scans is unavailable.

CONCLUSION

This study found a low prevalence of neural tube defect in Odisha, which is far lower compared with the older studies from India. There is an urgent need to strengthen the quality of antenatal care services provided under Pradhan Mantri Surakshit Matritva Abhiyan through better training regarding anomaly scans and better data keeping at public healthcare facilities.

TRIAL REGISTRATION NUMBER

CTRI/2021/06/034487.

Risk Factors for Neural-Tube Defects Detected in Utero: A Prospective Community-Based Study from Addis Ababa

BACKGROUND

A recent community-based study from Addis Ababa identifying Neural Tube Defect (NTD) cases by ultrasound examination of pregnant women showed a higher prevalence of 17 per 1000 fetuses. The risk factors behind the high prevalence remain unclear.

METHODS

Altogether 891 of the 958 women participated in the ultrasound examination. Thirteen with unaffected twin pregnancies were excluded. Among 878 singleton pregnancies, 15 NTD cases were identified. Serum Folate, vitamin B12, and homocysteine levels were measured in case-mothers and a sub-set of 28 noncase mothers. Because of the modest sample size, exact logistic regression analysis was used to estimate associations between risk factors and NTDs.

RESULTS

Serum vitamin status was generally poor for participants in the study. Still, relatively higher values of folate or vitamin B12 in serum, appeared to be protective for NTD (odds ratio [OR] = 0.61 per ng/ml, 95% Confidence interval [CI]: 0.42-0.85 and OR = 0.67 per 100 pg/ml, 95% CI: 0.41-1.02, respectively). High serum homocysteine was associated with higher risk of NTD (OR = 1.3 per μmol/l, 95% CI: 1.02-1.8). Women aged 30 years or more had an OR of 3.5 (95% CI: 1.1-12) for having a NTD child, and families with NTD children had lower household income. Women in the NTD group also had more spontaneous abortions or stillbirths in previous pregnancies. Self-reported intake of folate did not appear to protect against NTDs.

CONCLUSIONS

Within this high-prevalence community, poor vitamin status was identified as a risk factor for NTDs detected at ultrasound examination. Improving food security and fortification of foods or food ingredients could be alternative measures.

Surgical limits, pitfalls, and potential solutions in kyphectomy in myelomeningocele: three cases and systematic review of the literature

OBJECTIVES

To describe surgical treatment of 3 cases of severe and progressive thoracolumbar kyphosis in myelomeningocele and provide a systematic review of the available literature on the topic.

METHODS

Medical records and pre- and post-operative imaging of 3 patients with thoracolumbar kyphosis and myelomeningocele were reviewed. A database search was performed for all manuscripts published on kyphectomy and/or surgical treatment of kyphosis in myelomeningocele. Patients' information, preoperative kyphosis angle, type of surgery, levels of surgery degrees of correction after surgery and at follow-up, and complications were reviewed for the included studies.

RESULTS

Three cases underwent posterior vertebral column resection (pVCR) of 2-4 segments at the apex of the kyphosis (kyphectomy). Long instrumentation was performed with all pedicle screws constructed from the thoracic spine to the pelvis using iliac screws. According to literature review, a total of 586 children were treated for vertebral kyphosis related to myelomeningocele. At least one vertebra was excised to gain some degree of correction of the deformity. Different types of instrumentation were used over time and none of them demonstrated to be superior over the other.

CONCLUSION

Surgical treatment of progressive kyphosis in myelomeningocele has evolved over the years incorporating all major advances in spinal instrumentation techniques. Certainly, the best results in terms of preservation of correction after surgery and less revision rates were obtained with long construct and screws. However, complication rate remains high with skin problems being the most common complication. The use of low-profile instrumentation remains critical for treatment of these patients.

Exploring research hotspots and future directions in neural tube defects field by bibliometric and bioinformatics analysis

Background

Neural tube defects (NTDs) is the most common birth defect of the central nervous system (CNS) which causes the death of almost 88,000 people every year around the world. Much efforts have been made to investigate the reasons that contribute to NTD and explore new ways to for prevention. We trawl the past decade (2013-2022) published records in order to get a worldwide view about NTDs research field.

Methods

7,437 records about NTDs were retrieved from the Web of Science (WOS) database. Tools such as shell scripts, VOSviewer, SCImago Graphica, CiteSpace and PubTator were used for data analysis and visualization.

Results

Over the past decade, the number of publications has maintained an upward trend, except for 2022. The United States is the country with the highest number of publications and also with the closest collaboration with other countries. Baylor College of Medicine has the closest collaboration with other institutions worldwide and also was the most prolific institution. In the field of NTDs, research focuses on molecular mechanisms such as genes and signaling pathways related to folate metabolism, neurogenic diseases caused by neural tube closure disorders such as myelomeningocele and spina bifida, and prevention and treatment such as folate supplementation and surgical procedures. Most NTDs related genes are related to development, cell projection parts, and molecular binding. These genes are mainly concentrated in cancer, Wnt, MAPK, PI3K-Akt and other signaling pathways. The distribution of NTDs related SNPs on chromosomes 1, 3, 5, 11, 14, and 17 are relatively concentrated, which may be associated with high-risk of NTDs.

Conclusion

Bibliometric analysis of the literature on NTDs field provided the current status, hotspots and future directions to some extant. Further bioinformatics analysis expanded our understanding of NTDs-related genes function and revealed some important SNP clusters and loci. This study provided some guidance for further studies. More extensive cooperation and further research are needed to overcome the ongoing challenge in pathogenesis, prevention and treatment of NTDs.

Knowledge, awareness, and use of folic acid among women of childbearing age living in a peri-urban community in Ghana: a cross-sectional survey

BACKGROUND

Folic acid, a water-soluble B-complex vitamin, plays a crucial role in DNA synthesis and maintenance, making it particularly significant during reproduction. Its well-known ability to reduce the risk of congenital anomalies during the periconceptional period underscores its importance. The increased requirement for folate during pregnancy and lactation is essential to support the physiological changes of the mother and ensure optimal growth and development of the foetus and offspring. This study assessed the knowledge, awareness, and use of folic acid among pregnant and lactating women of reproductive age residing in Dodowa in the Shai Osu-Doku District, Accra, Ghana.

METHODS

The study was a cross-sectional design that involved 388 randomly selected participants (97 pregnant and 291 lactating women). Structured questionnaires were administered to gather information on the socioeconomic demographic characteristics, knowledge, awareness, and use of folic acid of the participants. Dietary intake was assessed using a food frequency questionnaire. The data were analysed using descriptive statistics and Pearson's chi-square analysis tests and are presented as frequencies and percentages, means, standard deviations, bar graphs, and pie charts. The significance of the results was determined at a 95% confidence interval.

RESULTS

The mean age of the participants was 31 ± 5.0 years. Among the study participants, 46.1% demonstrated knowledge of folic acid deficiency, while approximately 68.3% had a high awareness of folic acid supplementation. Approximately 75% of the participants indicated that they had not used folic acid supplements within the week, and 15.5% reported consuming folic acid-fortified food per week.

CONCLUSIONS

The women exhibited high awareness but poor knowledge regarding the usage of folic acid supplementation during pregnancy and lactation. Consequently, this lack of knowledge influenced the low use of folic acid supplements and low intake of folate-rich foods among pregnant and lactating mothers.

Prenatal cadmium exposure impairs neural tube closure via inducing excessive apoptosis in neuroepithelium

Birth defects have become a public health concern. The hazardous environmental factors exposure to embryos could increase the risk of birth defects. Cadmium, a toxic environmental factor, can cross the placental barrier during pregnancy. Pregnant woman may be subjected to cadmium before taking precautionary protective actions. However, the link between birth defects and cadmium remains obscure. Cadmium exposure can induce excessive apoptosis in neuroepithelium during embryonic development progresses. Cadmium exposure activated the p53 via enhancing the adenosine 5'-monophosphate (AMP)-activated protein kinase (AMPK) and reactive oxygen species' (ROS) level. And cadmium decreases the level of Paired box 3 (Pax3) and murine double minute 2 (Mdm2), disrupting the process of p53 ubiquitylation. And p53 accumulation induced excessive apoptosis in neuroepithelium during embryonic development progresses. Excessive apoptosis led to the failure of neural tube closure. The study emphasizes that environmental materials may increase the health risk for embryos. Cadmium caused the failure of neural tube closure during early embryotic day. Pregnant women may be exposed by cadmium before taking precautionary protective actions, because of cadmium concentration-containing foods and environmental tobacco smoking. This suggests that prenatal cadmium exposure is a threatening risk factor for birth defects.

Genome-wide analysis of spina bifida risk variants in a case-control study from Bangladesh

BACKGROUND

Human studies of genetic risk factors for neural tube defects, severe birth defects associated with long-term health consequences in surviving children, have predominantly been restricted to a subset of candidate genes in specific biological pathways including folate metabolism.

METHODS

In this study, we investigated the association of genetic variants spanning the genome with risk of spina bifida (i.e., myelomeningocele and meningocele) in a subset of families enrolled from December 2016 through December 2022 in a case-control study in Bangladesh, a population often underrepresented in genetic studies. Saliva DNA samples were analyzed using the Illumina Global Screening Array. We performed genetic association analyses to compare allele frequencies between 112 case and 121 control children, 272 mothers, and 128 trios.

RESULTS

In the transmission disequilibrium test analyses with trios only, we identified three novel exonic spina bifida risk loci, including rs140199800 (SULT1C2, p = 1.9 × 10-7), rs45580033 (ASB2, p = 4.2 × 10-10), and rs75426652 (LHPP, p = 7.2 × 10-14), after adjusting for multiple hypothesis testing. Association analyses comparing cases and controls, as well as models that included their mothers, did not identify genome-wide significant variants.

CONCLUSIONS

This study identified three novel single nucleotide polymorphisms involved in biological pathways not previously associated with neural tube defects. The study warrants replication in larger groups to validate findings and to inform targeted prevention strategies.

Plasma GDNF levels in spinal dysraphism and its relation with neurological impairment in children: A point of care study

AIMS

GDNF plays a crucial role in the stimulation of recovery, neuroplasticity and synaptic reorganization after spinal cord injury providing neuroprotection and neuroregeneration. Plasma GDNF levels are upregulated in cases of spina bifida owing to the intrauterine damage of the exposed spinal cord. Our aim was to compare the plasma GDNF levels in patients of spina bifida with non-spina bifida cases and assess the correlation with neurological impairment at one year of follow up.

METHODS

Single centre prospective analysis of cases of spina bifida from 2020 to 2022 at presentation and after one year of follow up post-surgery. Cases with hernia and hydrocele without any other disorders were recruited into the control group. Plasma GDNF levels were assessed with immunoassay kits and compared with neurological involvement.

RESULTS

85 cases were included in the study. GDNF levels were elevated in cases compared to controls (mean 6.62 vs 1.76) with significant p value (<0.01). Same was observed for open and closed defects (mean 7.63 vs 4.86: p < 0.01). At follow up of 52 cases post-surgery cases with neurogenic bladder with abnormal urodynamic studies, sphincter involvement and motor impairment had significantly elevated baseline levels of GDNF compared with those who did not have this neurological impairment (p < 0.01).

DISCUSSION

The neurotrophic factor up-regulation can reflect an endogenous attempt at neuroprotection against the biochemical and molecular cascades triggered by the spinal cord damage. This upregulation can be represented as important biochemical markers of severe spinal cord damage and can be associated with severity of spine injury in MMC patients. Our results are in keeping with these findings, that, there were increased levels of plasma GDNF levels in cases of spinal dysraphism compared to control population. Also, the type of lesion reflecting the severity whether a closed or an open dysraphism, showed significant difference in levels between them suggesting, yet again, more damage in open defect as expected. The levels were higher with involvement of bladder, sphincter and lower limb power.

CONCLUSION

There is significant elevation of plasma GDNF levels in cases of spina bifida and this elevation is proportional to the degree of spinal damage and hence the neurological impairment. GDNF levels are a good predictor for assessing the severity of the lesion and thus the outcome in these cases. Additional prospective and long-term studies with a larger cohort are needed for a better understanding of neurotrophin pattern modulation in MMC.

ARMC5 controls the degradation of most Pol II subunits, and ARMC5 mutation increases neural tube defect risks in mice and humans

BACKGROUND

Neural tube defects (NTDs) are caused by genetic and environmental factors. ARMC5 is part of a novel ubiquitin ligase specific for POLR2A, the largest subunit of RNA polymerase II (Pol II).

RESULTS

We find that ARMC5 knockout mice have increased incidence of NTDs, such as spina bifida and exencephaly. Surprisingly, the absence of ARMC5 causes the accumulation of not only POLR2A but also most of the other 11 Pol II subunits, indicating that the degradation of the whole Pol II complex is compromised. The enlarged Pol II pool does not lead to generalized Pol II stalling or a generalized decrease in mRNA transcription. In neural progenitor cells, ARMC5 knockout only dysregulates 106 genes, some of which are known to be involved in neural tube development. FOLH1, critical in folate uptake and hence neural tube development, is downregulated in the knockout intestine. We also identify nine deleterious mutations in the ARMC5 gene in 511 patients with myelomeningocele, a severe form of spina bifida. These mutations impair the interaction between ARMC5 and Pol II and reduce Pol II ubiquitination.

CONCLUSIONS

Mutations in ARMC5 increase the risk of NTDs in mice and humans. ARMC5 is part of an E3 controlling the degradation of all 12 subunits of Pol II under physiological conditions. The Pol II pool size might have effects on NTD pathogenesis, and some of the effects might be via the downregulation of FOLH1. Additional mechanistic work is needed to establish the causal effect of the findings on NTD pathogenesis.

Global heterogeneity in folic acid fortification policies and implications for prevention of neural tube defects and stroke: a systematic review

Background

Folic acid (pteroylmonoglutamic acid) supplements are highly effective for prevention of neural tube defects (NTD) prompting implementation of mandatory or voluntary folic acid fortification for prevention of NTDs. We used plasma folate levels in population studies by country and year to compare effects of folic acid fortification types (mandatory or voluntary folic acid fortification policies) on plasma folate levels, NTD prevalence and stroke mortality rates.

Methods

We conducted systematic reviews of (i) implementation of folic acid fortification in 193 countries that were member states of the World Health Organization by country and year, and (ii) estimated population mean plasma folate levels by year and type of folic acid fortification. We identified relevant English language reports published between Jan 1, 1990 and July 31, 2023 using Google Scholar, Medline, Embase and Global Health. Eligibility criteria were observational or interventional studies with >1000 participants. Studies of pregnant women or children <15 years were excluded. Using an ecological study design, we examined the associations of folic acid fortification types with NTD prevalence (n = 108 studies) and stroke mortality rates (n = 3 countries).

Findings

Among 193 countries examined up to 31 July 2023, 69 implemented mandatory folic acid fortification, 47 had voluntary fortification, but 77 had no fortification (accounting for 32%, 53% and 15% of worldwide population, respectively). Mean plasma folate levels were 36, 21 and 17 nmol/L in populations with mandatory, voluntary and no fortification, respectively (and proportions with mean folate levels >25 nmol/L were 100%, 15% and 7%, respectively). Among 75 countries with NTD prevalence, mean (95% CI) prevalence per 10,000 population were 4.19 (4.11-4.28), 7.61 (7.47-7.75) and 9.66 (9.52-9.81) with mandatory, voluntary and no folic acid fortification, respectively. However, age-standardised trends in stroke mortality rates were unaltered by the introduction of folic acid fortification.

Interpretation

There is substantial heterogeneity in folic acid fortification policies worldwide where folic acid fortification are associated with 50-100% higher population mean plasma folate levels and 25-50% lower NTD prevalence compared with no fortification. Many thousand NTD pregnancies could be prevented yearly if all countries implemented mandatory folic acid fortification. Further trials of folic acid for stroke prevention are required in countries without effective folic acid fortification policies.

Funding

Medical Research Council (UK) and British Heart Foundation.

Spina Bifida Prevention: A Narrative Review of Folic Acid Supplements for Childbearing Age Women

Neural tube defects (NTDs) are malformations that occur during embryonic development, and they account for most central nervous system birth anomalies. Genetic and environmental factors have been shown to play a role in the etiology of NTDs. The different types of NTDs are classified according to anatomic location and severity of the defect, with most of the neural axis anomalies occurring in the caudal spinal or cranial areas. Spina bifida is a type of NTD that is characterized by an opening in the vertebral arch, and the level of severity is determined by the extent to which the neural tissue protrudes through the opened arch(es). Prevention of NTDs by administration of folic acid has been studied and described in the literature, yet there are approximately 300,000 cases of NTDs that occur annually, with 88,000 deaths occurring per year worldwide. A daily intake of at least 400 μg of folic acid is recommended especially for women of childbearing age. To provide the benefits of folic acid, prenatal vitamins are recommended in pregnancy, and many countries have been fortifying foods such as cereal grain products with folic acid; however, not all countries have instituted folic acid fortification programs. The present investigation includes a description of the pharmacology of folic acid, neural tube formation, defects such as spina bifida, and the relevance of folic acid to developing spina bifida. Women's knowledge and awareness of folic acid regarding its importance in the prevention of spina bifida is a major factor in reducing incidence worldwide.

Lethal Neural Tube Defects: Reports of Anencephaly and Craniorachischisis Cases and Literature Review

Neural tube defects are serious birth defects of the central nervous system that result from a multifaceted disruption of normal embryogenesis of the nervous system. Although largely preventable, they nonetheless pose a serious threat to global morbidity, disability, mortality, and financial expenses. Despite this, it has been neglected and has only been the subject of limited research until recently. Furthermore, surveillance efforts for neural tube defects remain limited, and no decline in defects has been documented in less developed countries. Here, we report two cases of craniorachischisis and one case of discordant twins for anencephaly. Moreover, the relevant works of literature that are necessary to understand and address this unrelenting phenomenon are provided.

Exencephaly-Anencephaly Sequence Associated with Maxillary Brachygnathia, Spinal Defects, and Palatoschisis in a Male Domestic Cat

Anencephaly, a severe neural tube defect characterized by the absence of major parts of the brain and skull, is a rare congenital disorder that has been observed in various species, including cats. Considering the uncommon appearance of anencephaly, this paper aims to present anencephaly in a stillborn male kitten from an accidental inbreeding using various paraclinical methods. Histological examination of tissue samples from the cranial region, where parts of the skull were absent, revealed the presence of atypical nerve tissue with neurons and glial cells organized in clusters, surrounded by an extracellular matrix and with an abundance of blood vessels, which are large, dilated, and filled with blood, not characteristic of nerve tissue structure. In CT scans, the caudal part of the frontal bone, the fronto-temporal limits, and the parietal bone were observed to be missing. CT also revealed that the dorsal tubercle of the atlas, the dorsal neural arch, and the spinal process of the C2-C7 bones were missing. In conclusion, the kitten was affected by multiple congenital malformations, a combination of exencephaly-anencephaly, maxillary brachygnathism, closed cranial spina bifida at the level of cervical vertebrae, kyphoscoliosis, palatoschisis, and partial intestinal atresia. The importance of employing imaging techniques cannot be overstated when it comes to the accurate diagnosis of neural tube defects.

Influence of folic acid knowledge on effective folic acid intake in Chinese pregnant women: a cross-sectional study

PURPOSE

This study aimed to investigate the current status of effective folic acid intake and the level of folic acid knowledge of Chinese pregnant women and to analyze the relationship between effective folic acid intake and folic acid knowledge.

METHODS

From November 2021 to May 2022, 140 pregnant women at Yantai Yuhuangding Hospital in the Chinese province of Shandong, answered questions about their general characteristics, folic acid intake, and folic acid knowledge. The data were analyzed using the t-test, chi-square test, and logistic regression analysis, and were presented with frequency with percentage or mean±standard deviation.

RESULTS

Only 16.4% of the pregnant women (n=23) took folic acid effectively, using the following four criteria. Of all pregnant women who took folic acid, 72.2% took folic acid starting 1 month before pregnancy, 70.8% took folic acid up to 3 months after pregnancy, 36.8% took 400 μg every time, and 78.6% took folic acid more than 24 days every month. The score for folic acid knowledge was relatively high (5.61±2.18 on a scale of 0-9). A higher folic acid knowledge score correlated with more effective folic acid intake (t=4.10, p<.001).

CONCLUSION

Our study shows that the current recommendations to prevent neural tube defects through effective folic acid intake supplementation are not being fully implemented in China. Furthermore, folic acid knowledge was positively correlated with the effectiveness of its intake. Future education related to effective folic acid intake should emphasize the four methods of effective folic acid intake, especially regarding the recommended dose of 400 μg every time.

Systematic review and meta-analysis to study the outcomes of proactive versus delayed management in children with a congenital neurogenic bladder

PURPOSE

To review the urological outcomes of proactive versus delayed management of children with a neurogenic bladder (NB).

METHODS

We performed a literature search on EMBASE, MEDLINE, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials between January 1, 2000 to August 21, 2023 for studies investigating the management of spina bifida-associated NB in pediatric patients (0-18 years of age). Proactive management was defined as use of clean intermittent catheterization, and/or anticholinergics at presentation, or based on initial high-risk urodynamic findings by 1 year of age. Delayed management was defined as beginning management after 1 year of age or no intervention. Outcomes included incidence or diagnosis of secondary vesicoureteral reflux (VUR), urinary tract infection (UTI), and renal deterioration, which included renal scarring, loss of differential renal function on a nuclear scan, or a decrease in renal function defined by glomerular filtration rate or serum creatinine estimation. Forest plots were synthesized using the Inverse Variance method with random-effect model. The Risk of Bias was assessed using the ROBINS-I tool.

RESULTS

We included 8 observational studies on 652 pediatric patients with spina bifida-associated NB (mean follow-up - 7 years). Proactive management following initial assessment was associated with significantly lower risks of secondary VUR (OR 0.37 [0.19, 0.74], p = 0.004), non-febrile UTI (OR 0.35 [0.19, 0.62], p = 0.0004), and renal deterioration (OR 0.31 [0.20, 0.47], p < 0.00001).

DISCUSSION

Delayed management of NB potentially has 3 times higher risks of secondary VUR, non-febrile UTI, and renal deterioration. However, the evidence is limited by the high risk of bias due to lack of randomization and standardized reporting in observational studies.

CONCLUSION

While further well-defined prospective studies with long-term follow-up should be conducted to confirm this finding, this study supports the EAU/ESPU recommendations for early intervention in children with NB.