[Detection and treatment of familial hypercholesterolaemia; the earlier, the better?]

A recent Dutch study in patients with familial hypercholesterolaemia (FH), suggests that long-term statin treatment initiated at childhood reduces the risk for cardiovascular events in adulthood. None of the patients developed rhabdomyolysis or other serious adverse effects. Early detection of FH is crucial for early treatment initiation. However, the Dutch cascade screening program ended at the end of 2013, at which point approximately 40,000 FH patients had not yet been identified. In order to trace this cohort, in 2014 the 'LEEFH' foundation (National Expertise Centre for Genetic Testing for Familial Cardiovascular Diseases) was set up. Family members of index patients are no longer actively approached to be tested, and as a result the number of detected family members has decreased significantly. These study findings underline the importance of actively screening the family members of index patients, including children and adolescents.

Recent developments in genetics and medically assisted reproduction: from research to clinical applications

Two leading European professional societies, the European Society of Human Genetics and the European Society for Human Reproduction and Embryology, have worked together since 2004 to evaluate the impact of fast research advances at the interface of assisted reproduction and genetics, including their application into clinical practice. In September 2016, the expert panel met for the third time. The topics discussed highlighted important issues covering the impacts of expanded carrier screening, direct-to-consumer genetic testing, voiding of the presumed anonymity of gamete donors by advanced genetic testing, advances in the research of genetic causes underlying male and female infertility, utilisation of massively parallel sequencing in preimplantation genetic testing and non-invasive prenatal screening, mitochondrial replacement in human oocytes, and additionally, issues related to cross-generational epigenetic inheritance following IVF and germline genome editing. The resulting paper represents a consensus of both professional societies involved.

Recent developments in genetics and medically-assisted reproduction: from research to clinical applications†‡

Two leading European professional societies, the European Society of Human Genetics and the European Society for Human Reproduction and Embryology, have worked together since 2004 to evaluate the impact of fast research advances at the interface of assisted reproduction and genetics, including their application into clinical practice. In September 2016, the expert panel met for the third time. The topics discussed highlighted important issues covering the impacts of expanded carrier screening, direct-to-consumer genetic testing, voiding of the presumed anonymity of gamete donors by advanced genetic testing, advances in the research of genetic causes underlying male and female infertility, utilisation of massively-parallel sequencing in preimplantation genetic testing and non-invasive prenatal screening, mitochondrial replacement in human oocytes, and additionally, issues related to cross-generational epigenetic inheritance following IVF and germline genome editing. The resulting paper represents a consensus of both professional societies involved.

A genetic diagnosis of maturity-onset diabetes of the young (MODY): experiences of patients and family members

AIMS

Genetic testing for maturity-onset diabetes of the young (MODY) facilitates a correct diagnosis, enabling treatment optimization and allowing monitoring of asymptomatic family members. To date, the majority of people with MODY remain undiagnosed. To identify patients' needs and areas for improving care, this study explores the experiences of patients and family members who have been genetically tested for MODY.

METHODS

Fourteen semi-structured interviews with patients and the parents of patients, and symptomatic and asymptomatic family members were conducted. Atlas.ti was used for thematic analysis.

RESULTS

Most people with MODY were initially misdiagnosed with Type 1 or Type 2 diabetes; they had been seeking for the correct diagnosis for a long time. Reasons for having a genetic test included reassurance, removing the uncertainty of developing diabetes (in asymptomatic family members) and informing relatives. Reasons against testing were the fear of genetic discrimination and not having symptoms. Often a positive genetic test result did not come as a surprise. Both patients and family members were satisfied with the decision to get tested because it enabled them to adjust their lifestyle and treatment accordingly. All participants experienced a lack of knowledge of MODY among healthcare professionals, in their social environment and in patient organizations. Additionally, problems with the reimbursement of medical expenses were reported.

CONCLUSIONS

Patients and family members are generally positive about genetic testing for MODY. More education of healthcare professionals and attention on the part of diabetes organizations is needed to increase awareness and optimize care and support for people with MODY.

Determining the genome-wide kinship coefficient seems unhelpful in distinguishing consanguineous couples with a high versus low risk for adverse reproductive outcome

Background

Offspring of consanguineous couples are at increased risk of congenital disorders. The risk increases as parents are more closely related. Individuals that have the same degree of relatedness according to their pedigree, show variable genomic kinship coefficients. To investigate whether we can differentiate between couples with high- and low risk for offspring with congenital disorders, we have compared the genomic kinship coefficient of consanguineous parents with a child affected with an autosomal recessive disorder with that of consanguineous parents with only healthy children, corrected for the degree of pedigree relatedness.

Methods

151 consanguineous couples (73 cases and 78 controls) from 10 different ethnic backgrounds were genotyped on the Affymetrix platform and passed quality control checks. After pruning SNPs in linkage disequilibrium, 57,358 SNPs remained. Kinship coefficients were calculated using three different toolsets: PLINK, King and IBDelphi, yielding five different estimates (IBDelphi, PLINK (all), PLINK (by population), King robust (all) and King homo (by population)). We performed a one-sided Mann Whitney test to investigate whether the median relative difference regarding observed and expected kinship coefficients is bigger for cases than for controls. Furthermore, we fitted a mixed effects linear model to correct for a possible population effect.

Results

Although the estimated degrees of genomic relatedness with the different toolsets show substantial variability, correlation measures between the different estimators demonstrated moderate to strong correlations. Controls have higher point estimates for genomic kinship coefficients. The one-sided Mann Whitney test did not show any evidence for a higher median relative difference for cases compared to controls. Neither did the regression analysis exhibit a positive association between case–control status and genomic kinship coefficient.

Conclusions

In this case–control setting, in which we compared consanguineous couples corrected for degree of pedigree relatedness, a higher degree of genomic relatedness was not significantly associated with a higher likelihood of having an affected child. Further translational research should focus on which parts of the genome and which pathogenic mutations couples are sharing. Looking at relatedness coefficients by determining genome-wide SNPs does not seem to be an effective measure for prospective risk assessment in consanguineous parents.

Electronic supplementary material

The online version of this article (doi:10.1186/s12881-015-0191-0) contains supplementary material, which is available to authorized users.

Neonatal diagnosis of Down syndrome in The Netherlands: suspicion and communication with parents

OBJECTIVES

To analyse which dysmorphic features are most recognised in newborns with Down syndrome (DS). Furthermore to evaluate the communication techniques used by clinicians to inform parents about the postnatal diagnosis and compare these to current best practice guidelines.

STUDY DESIGN

Prospective study of a birth cohort of newborns with DS born between 1 January 2003 and 31 December 2006 registered by the Dutch Paediatric Surveillance Unit (DPSU).

RESULTS

A total of 586 children with trisomy 21 were analysed. Most recognised dysmorphic features in DS newborns were 'upslanted palpebral fissures' (74.1%; n = 426), 'hypotonia' (73.7%; n = 424) and 'epicanthic folds' (68.5%; n = 394). The majority of parents were informed about the suspected diagnosis on the day of birth (76.5%; n = 390). Hospital deliveries had a significantly earlier suspected diagnosis (mean age 3-4 days) compared with home deliveries (mean age 7 days) (P < 0.05). In 10% (n = 44), paediatricians described dissatisfaction with the first conversation with parents. In 88.9% (n = 499) parents were both present when the diagnosis was told, however the child was not present during the conversation in 51.3% (n = 288). In 10.8% (n = 61) parents were not informed about local parent support groups or community resources.

CONCLUSION

DS is still often diagnosed after birth, usually on the first day of postnatal life. Most identified clinical features were upslanted palpebral fissures, epicanthic folds and hypotonia. Special attention for recognition of all present clinical features is needed for early diagnosis. Appropriate communication with the parents of the message that their child has DS can be difficult. Guidelines can help to make counselling easier and more effective, which in turn may increase parental satisfaction. Not all recommendations for the first conversation with parents were fully implemented in Dutch clinical practice.

Informed consent for exome sequencing in diagnostics: exploring first experiences and views of professionals and patients

Next-generation sequencing is increasingly being chosen as a diagnostic tool for cases of expected genetic, but unresolved origin. The consequential increased need for decisions on disclosure of unsolicited findings poses a challenge for the informed consent procedure. This study explored the first experiences with, and needs for, the informed consent procedure in diagnostic exome sequencing, with the stakeholders involved. Semi-structured interviews were conducted with 11 professional experts and one professional gave a written response. Furthermore, the counseling process was observed in three cases where exome sequencing was offered, followed by interviews with the patient (representative) and the genetic counselor. The respondents not only preferred an opt-out for unsolicited findings but also identified many challenges and therefore more experiences with exome sequencing was considered needed. Context-dependent decision-making was observed and an Advisory Board for unsolicited findings was considered helpful while doubts were raised about the feasibility and the possibility of undermining patients' autonomy. Finally, respondents brought up the complexity of information provision, and division of responsibilities between clinicians and the lab. These challenges and needs, raised by stakeholders involved, provide more insight in the next steps needed for an optimal informed consent procedure for exome sequencing in diagnostics.

'A morass of considerations': exploring attitudes towards ethnicity-based haemoglobinopathy-carrier screening in primary care

BACKGROUND

The Netherlands does not have a national haemoglobinopathy (HbP)-carrier screening programme aimed at facilitating informed reproductive choice. HbP-carrier testing for those at risk is at best offered on the basis of anaemia. Registration of ethnicity has proved controversial and may complicate the introduction of a screening programme if based on ethnicity. However, other factors may also play a role.

OBJECTIVE

To explore perceived barriers and attitudes among GPs and midwives regarding the registration of ethnicity and ethnicity-based HbP-carrier screening.

METHODS

Six focus groups in Dutch primary care, with a total of 37 GPs (n = 9) and midwives (n = 28) were conducted, transcribed and content analysed using Atlas-ti.

RESULTS

Both GPs and midwives struggled with correctly identifying ethnicities at risk for HbP. Ethical concerns regarding privacy seemed to originate from World War II experiences, when ethnic and religious registration facilitated deportation of Jewish citizens, coupled with the political climate at the time focus groups were held. Some respondents thought the ethnicity question might undermine the relationship with their clients. Software programmes prevented GPs from registering ethnicity of patients at risk. Financial implications for patients were also a concern. Despite this, respondents seemed positive about screening and were familiar with identifying ethnicity and used this for individual patient care.

CONCLUSIONS

Although health professionals are generally positive about screening, ethical, financial and practical issues surrounding ethnicity-based HbP-carrier screening need to be clarified before introducing such a programme. Primary care professionals can be targeted through professional organizations but they need national policy support.

Population-based birth-defect and risk-factor surveillance: data from the Northern Netherlands

In many countries, birth defect monitoring systems have been set up in order to identify new teratogens as soon as possible. The usual approach to monitoring involves analysis of the frequency of specific birth defects over time. This approach has been criticized as having poor statistical power to detect epidemics due to new rare teratogenic exposures. A proposed alternative approach is the on-going analysis of risk-factor data with a case-control approach. In this paper, we present birth-defects and risk-factor surveillance data from the Northern Netherlands (NNL). For years of birth 1981-1994, 4014 cases had been registered. We investigated combinations of 32 diagnostic categories and 77 risk factors. For 10 combinations a P value < 0.01 was found; for another 25, the P value was between 0.01 and 0.05. We then checked these positive associations against data from the Metropolitan Atlanta Congenital Defects Program (MACDP) and the MAternal DRug Exposure surveillance project (MADRE). In all three data sets, an association between maternal use of psychotropic drugs (psycholeptics) and cleft lip with or without cleft palate (CLP) was present. The highest odds ratio was found for CLP and maternal use of oxazepam in the NNL data (OR = 8.17, 95% CI 1.26-42.2). Both in the MACDP data and in the NNL data, an association between maternal smoking and clubfoot was found. Although the odds ratios were low, the attributable fraction derived from the NNL data was 11%. Methodologic issues that should be considered in this approach include exposure ascertainment and classification, outcome specificity, and type I errors. The strengths of this approach include its population-based nature and the ability of users to check results against results from other similar systems.

Monitoring of risk factor/outcome combinations: a valuable supplement to birth defect monitoring

Since the thalidomide disaster in the early sixties many birth defect monitoring systems and registries have been set up to detect changes in the frequencies of specific birth defects. The primary methods of monitoring have been the statistical analysis of data on birth prevalences and teratologic analysis. The yield of this monitoring effect has nevertheless been low when one considers the lack of etiologic factors detected in this way. We therefore propose an additional strategy involving (periodic) classification of all cases in a birth defect registry according to possible risk factors and notified anomalies coupled with a search for specific associations between risk factors and (patterns of) anomalies. We here present data showing the sensitivity of the method. Sensitivity was studied by looking at some already well known associations between risk factors and congenital anomalies in our registry involving 1850 cases. The associations studied were neural tube defects and maternal use of valproic acid, numerical chromosomal anomalies and advanced maternal age, gastroschisis and low maternal age, and autosomal recessive disorders and parental consanguinity. Each of these associations was apparent in the registry, suggesting that risk factor/outcome monitoring as described here is a potentially strong method for finding new etiologic factors in birth defects.

Registration of drug use in a birth defect monitoring system: a priority worthy of emphasis!

This article examines sources of information on drug use during pregnancy in the northeastern part of The Netherlands, comparing data from a congenital anomalies registry and figures obtained from community pharmacy records for a drug utilization study. Physicians and midwives report to the congenital anomalies registry on a voluntary basis. A limited quantity of exposure data is registered. According to the congenital anomalies registry, drug use during pregnancy is significantly less than it is according to the drug utilization study in the same area, suggesting that the former obtains incomplete data.For anomalies occurring spontaneously in a relatively high frequency, any link between a small further increase in the frequency of these anomalies and the maternal use of certain drugs is likely to go undetected if one monitors only the frequency of these anomalies, the increase being rendered inconspicuous by spontaneous variations. Routine monitoring of drug use in association with congenital anomalies will be needed if such links are to be profiled. Preferably, a complete and correct registration of all drug use should be assured, from three months before conception to the time of delivery.Data retrieved from the records of community pharmacies on the use of prescription drugs, complemented by data on hospital drug use and information from the women themselves on their self-medication is likely to produce a relatively complete picture of drug utilization for the purpose of a register of congenital anomalies.

Ovulation-inducing drugs: a drug utilization and risk study in the Dutch population

This study describes the use of the ovulation stimulating drugs clomifene, human chorionic gonadotropin (hCG) and human menopausal gonadotropin (hMG) in a representative sample of a population of Dutch women in the child-bearing age group. Clomifene or hMG/hCG are seldom used alone. A considerable percentage of the women received at least four different ovulation-inducing and related drugs during the observation period of two years. Thirty percent of the women who used clomifene were treated for 6 or more cycles. These findings argue for a relative "overuse" and "misuse" of clomifene. Buserelin, a drug not registered for the indication ovulation induction in The Netherlands but used in in vitro fertilization (IVF) programs as inhibitors of pituitary gonadotropin production, was nevertheless prescribed to 38% of the hMG /hCG users and to 11 % of the clomifene users. Our study indicates that, though the potential risks of congenital malformations due to clomifene are difficult to assess, they may be considerable; this, and the fact that different ovulation-inducing drugs are used together with clomifene, emphasizes the need for post-marketing surveillance.

Patients' intentions to inform relatives about Type 2 diabetes risk: the role of worry in the process of family risk disclosure

AIMS

Patients with Type 2 diabetes may play a role as intermediary between medical professionals and at-risk relatives to promote diabetes prevention in their family. This study aimed to further our understanding of factors that influence the decisional process of familial risk disclosure in patients with diabetes.

METHODS

In a cross-sectional study, patients with Type 2 diabetes (n = 546) filled in a questionnaire assessing family risk perception, worry, personal beliefs regarding diabetes prevention, diabetes-related family communication, intention and perceived ability to inform relatives about familial risk of diabetes. Data were analysed using hierarchical logistic regression and multiple mediation analyses.

RESULTS

Sixty per cent of the patients were willing to inform their relatives about familial diabetes risk; 61% reported high family risk perception and 41% had positive control beliefs with regard to preventive options in relatives. A majority (69%) did not express serious concern about relatives developing diabetes. Worry about relatives, knowing what to tell, whom to notify, and communication about diabetes in general appeared to facilitate family risk disclosure. Unexpectedly, high family risk perception in itself did not significantly increase patients' intentions to inform relatives; rather, risk perception appeared to exert an indirect effect through worry and beliefs about diabetes prevention.

CONCLUSIONS

Worry in patients with diabetes appears to be a key factor in the process of family risk disclosure. When professionals guide their patients in this process, they should not only provide risk information, but also address worries and emphasize opportunities for diabetes prevention.

Counselling women about periconceptional use of folic acid: the role of the community pharmacist can be improved

Objective

To assess community pharmacists' attitudes towards, and practice behaviour, relating to the periconceptional use of folic acid to prevent neural tube defects

Method

A postal questionnaire was sent to a random sample of 150 community pharmacists at the end of 1996. The questionnaire covered knowledge, attitude and behaviour regarding the use of folic acid by women of childbearing age

Setting

Two regions in the Netherlands (Northern and Western Netherlands)

Key findings

The response rate was 72 per cent. Pharmacists' attitudes towards promoting the use of folic acid by women who wish to have a child are positive. Most pharmacists reported distributing folic acid brochures in their pharmacy and many stated that they displayed posters to promote the use of folic acid. Nearly 30 per cent of pharmacists reported using an additional label on the packaging of oral contraceptives with the standard text: “If you stop using the pill because you wish to have a child, please ask your pharmacist for information about the use of folic acid before you become pregnant”. Perceived attitudes of local general practitioners seemed to influence the willingness of pharmacists to promote the use of folic acid. The results indicate a tendency for some pharmacists to be more reactive than proactive in their advice-giving on the use of folic acid

Conclusion

Compared with the findings of a similar survey two years ago, it appears that more pharmacists are actively promoting the periconceptional use of folic acid. However, further improvements could still be achieved and pharmacists could become more proactive in their information and advice-giving

'A low risk is still a risk': exploring women's attitudes towards genetic testing for breast cancer susceptibility in order to target disease prevention

BACKGROUND

Population breast cancer screening programs by mammography are offered to women based on age. It has been suggested that a screening program based on genetic risk profile could be more effective by targeting interventions at those at higher genetic risk. This study explores women's attitudes towards genetic testing for breast cancer susceptibility in order to target breast cancer prevention.

METHODS

A qualitative study was conducted using 4 focus groups with 26 women aged 42-73 years. Women were selected irrespective of personal or family history of breast cancer. Discussions were audiotaped and content analyzed.

RESULTS

The results show that in general women are positive towards a breast cancer screening program based on genetic risk profile, provided that in the low-risk group, though less frequent, women are still offered mammography screening (i.e. right to screening (a)). Other themes that women addressed were: (b) value of the genetic risk information (e.g. possibilities for cancer prevention at younger ages, less screening burden for low-risk women), (c) personal autonomy (e.g. free choice to undergo testing), (d) dealing with test results (e.g. burden of risk, motivation to reduce the risk), (e) discrimination, and (f) financial aspects and priority (e.g. with respect to other health care programs).

CONCLUSION

These results suggest that women currently offered breast cancer screening based on age have a positive attitude towards population susceptibility screening for breast cancer, but also identified issues that need to be discussed and studied further, especially if women in the low-risk group were no longer to be offered mammography screening.

[Folic acid fortification of bread recommendable]

Folic acid supplementation was recommended in the Netherlands after it had been demonstrated that periconceptional use of folic acid protected against foetal neural tube defects; this recommendation led to a slight decrease in prevalence only. According to the Dutch Health Council, fortification of bread should now be considered. Policy-making is complicated by uncertainties regarding potential side effects, such as adverse effects in children, for which scientific evidence is lacking however.

[Orphanet: a European database for rare diseases]

Orphanet is a European initiative that aims to improve the management and treatment of rare diseases. It comprises a database dedicated to information on rare diseases and orphan drugs, and offers services adapted to the needs of patients and their families, health professionals, and researchers. The database can be accessed through the website (www.orpha.net) and has some interesting options for searching, for example research projects, support groups or searching by clinical signs. Health professionals are encouraged to add activities concerning rare diseases to the database.

Type 2 diabetes and inheritance: what information do diabetes organizations provide on the Internet?

AIMS

The worldwide epidemic of Type 2 diabetes necessitates preventive actions. Providing information to high-risk populations is key. In an international comparison of websites, we aimed to investigate the presence and quality of information provided by diabetes organizations on inheritance of Type 2 diabetes and the benefits of a healthy lifestyle targeted at those with a family history or belonging to a specific ethnic population.

METHODS

All websites included in the International Diabetes Federation member list in English, German, French, Dutch, Spanish, Portuguese, Swedish, Norwegian, Finnish, Danish and Japanese were included for assessment. Using qualitative content analysis, we reviewed 34 websites which provided health-related information on diabetes.

RESULTS

Most websites mention family history as a risk factor. However, an explanation of the interaction of lifestyle factors and increased genetic susceptibility is lacking. Ethnicity is mentioned in only half of the sites describing risk factors. Although most websites do provide information on the importance of a healthy lifestyle, they do not address specific high-risk groups. Only two websites encourage Type 2 diabetic patients to inform family members of the familial character of diabetes.

CONCLUSIONS

Information on inheritance of Type 2 diabetes and prevention specifically targeted at high-risk groups on the Internet by diabetes organizations is often of poor quality or indeed is lacking. Efforts should be made to disseminate information on heredity of Type 2 diabetes and preventive options to the general public and high-risk populations.

Folic acid--the scientific debate as a base for public health policy

Randomized controlled trials have proven that periconceptional folic acid intake reduces the risk of neural tube defects (NTDs). This lead to different public health policies: fortification of foods in many countries and supplementation in some others. We concentrate here on pro's and con's of fortification policies. Meanwhile, new beneficial but also potential adverse effects are being hypothesized. Highest level evidence is available for the protective effect of folic acid on NTDs. Lower level evidence suggests other protective effects, but also some potential adverse effects, such as masking Vitamin B-12 deficiency, increasing twinning rates and an 'acceleration phenomenon' in pre-existing malignant neoplasms. While observational studies show lower cancer rates associated with increased folate intake, some case reports and animal experiments suggest opposite effects. Thus, public health policy makers are facing the question of balancing beneficial and potential adverse effects repeatedly. We propose that the scientific debate no longer focuses on NTDs alone, but that a comprehensive evaluation be undertaken by a public health authority with experience in complex meta-analyses and technology assessment.

Age at Postnatal Diagnosis of Down Syndrome in the Northern Netherlands for the Period 1981–2000

BACKGROUND

In live-born children with Down syndrome it may be very difficult for the clinician or midwife assisting at the delivery to recognise Down syndrome in newborn babies due to varying physical appearances. Meanwhile more and more therapeutical interventions become available that should start early in life. We were interested in the age at the postnatal diagnosis of Down syndrome, and found no literature on the subject.

METHODS

We studied the age at the diagnosis of Down syndrome for live-born babies born in the period of 1981-2000 and registered by the European Registration of Congenital Anomalies in the northern part of The Netherlands.

RESULTS

For 289 children, data on the age at the postnatal diagnosis were available, in 70.8% of whom there was suspicion of DS on the day of birth. In 1.7% of the cases, the diagnosis was made after 1 year. Place of birth and the specialty of the health worker assisting at the delivery were associated with age at diagnosis. When the child was delivered at hospital, 96.4% of the Down syndrome cases had been diagnosed within 1 month compared to 81.3% following home delivery.

CONCLUSION

In some cases of Down syndrome in live-born babies, the diagnosis is made only after months or a year. The diagnosis was made faster in babies born in hospital compared to those born at home.

Common language for measures of occurrence of congenital anomalies and genetic diseases: incidence or birth prevalence

Scientists involved in the epidemiology of congenital anomalies (including genetic diseases) use many terms to describe the occurrence of these disorders amongst births, such as 'incidence', 'prevalence' and 'rate'. Yet it is clear that often 'prevalence' is the only meaningful measure for the proportion of births affected with a certain congenital or genetic disorder. 'Incidence' and 'rate' are usually inappropriate, as the assessment of the frequency of a disorder is not a matter of following up a cohort of healthy individuals until they fall ill.

[Awareness and periconceptional use of folic acid among non-western and western women in the Netherlands following the 1995 publicity campaign]

OBJECTIVE

To investigate the influence of ethnicity on the awareness and use of folic acid by pregnant women.

DESIGN

Secondary data analysis.

METHOD

Using the data on 1555 women, collected during a cross-sectional study conducted among pregnant women with good knowledge of the Dutch language in 1996, the authors determined what was known about the recommendation to use folic acid around the time of conception and what the actual use was. Women were defined as either 'western' or 'non-western' on the basis of the place of birth of the woman and her parents.

RESULTS

Of the 1555 pregnant women, 74 (5%) were non-western or of non-western descent. Non-western women more often had a lower educational level than western women (51% versus 34%; p = 0.002) and more often had an unintended pregnancy (24% versus 8%; p < 0.0001). 41% of the non-western women had heard of the recommendation to use folic acid before pregnancy, compared to 79% of the western women (p < 0.0001). However, the use of folic acid was not significantly different between non-western and western women (56% versus 69%) if they had been aware of the recommendation to use folic acid before pregnancy. Awareness of the recommendation to use folic acid was higher in older women (OR: 1.46; 95% CI: 1.13-1.89), women of western descent (0.27; 0.16-0.47), women with a higher level of education (0.35; 0.27-0.45) and in case of planned pregnancy (0.45; 0.31-0.67). The use of folic acid, restricted to women who were aware of the recommendation to use folic acid before their pregnancy, was higher in older women (1.37; 1.05-1.80) and lower in those with more previous pregnancies (0.57; 0.43-0.75) and in case of an unplanned pregnancy (0.55; 0.34-0.88).

CONCLUSION

Although non-western women had less knowledge of the recommendation to use folic acid than western women, the use of folic acid was not significantly different from that by western women if they had been aware of the recommendation to use folic acid before pregnancy. Continued education on folic acid targeting non-western and western women is important.

Possibilities and barriers in the implementation of a preconceptional screening programme for cystic fibrosis carriers: a focus group study

OBJECTIVE

This qualitative study aimed to explore possibilities and barriers in the implementation of a nationwide preconceptional cystic fibrosis (CF) carrier screening programme.

METHODS

Sessions were held with two focus groups of CF patients and CF relatives, one focus group of people from the target population (couples planning a pregnancy), and two focus groups of potential providers (general practitioners (GPs) and municipal health service workers).

RESULTS

Important barriers in the implementation of a preconceptional CF carrier screening programme included the problem of reaching the target population, the heavy workload of GPs, the limited public knowledge about CF in general, and the absence of a preconceptional consultation setting. In general, there was a positive attitude among the participants towards CF carrier screening.

CONCLUSION

This study revealed some important barriers in the implementation of CF carrier screening programmes. More research is needed to specify and quantify the importance of the various barriers. Eventually, different intervention strategies should be included in an implementation plan to overcome the most important barriers in the organization and execution of screening.

Three years after the dutch folic acid campaign: growing socioeconomic differences

BACKGROUND

We investigated periconceptional awareness and the use of folic acid tablets 3 years after the 1995 campaign in the northern Netherlands. We studied whether the socioeconomic differences we found in 1996 with respect to awareness and use of folic acid remained in 1998.

METHODS

The present study took place in 1998. Pregnant women were asked to complete a questionnaire.

RESULTS

A total of 452 women completed the questionnaire in 1998. Sixty percent of the women with a lower level of education and 85% of the women with a higher level of education had heard of folic acid before pregnancy. Newspapers and magazines were the most often cited sources of information. Fifty percent of the women with a lower educational level used folic acid, while this figure was 80% for the group with higher education.

CONCLUSION

Awareness and use of folic acid increased after the 1995 campaign. However, socioeconomic differences with respect to awareness of folic acid remained and even increased with respect to knowledge of the advised period. Use of folic acid is also associated with level of education more strongly than in 1996. Therefore, fortification of staple foods is an attractive option.

On the symmetry of limb deficiencies among children with multiple congenital anomalies

In humans, unpaired organs are placed in a highly ordered pattern along the left-right axis. As indicated by animal studies, a cascade of signaling molecules establish left-right asymmetry in the developing embryo. Some of the same genes are involved also in limb patterning. To provide a better insight into the connection between these processes in humans, we analysed the symmetry of limb deficiencies among infants with multiple congenital anomalies. The study was based on data collected by the International Clearinghouse for Birth Defects Monitoring Systems (ICBDMS). Registries of the ICBDMS provided information on infants who, in addition to a limb deficiency, also had at least one major congenital anomaly in other organ systems. We reviewed 815 such cases of which 149 cases (18.3 %) were syndromic and 666 (81.7 %) were nonsyndromic. The comparisons were made within the associated limb deficiencies, considering the information on symmetry, using a comparison group with malformations associated not involved in the index association. Among the non-syndromic cases, the left-right distribution of limb deficiencies did not differ appreciably between limb deficiency subtypes (e.g., preaxial, transverse, longitudinal). The left-right distribution of limb anomalies did not differ among most types of non-limb anomalies, though a predominance of left-sided limb deficiencies was observed in the presence of severe genital defects - odds ratio [OR], 2.6; 95 % CI, 1.1-6.4). Limb deficiencies (LDs) were more often unilateral than bilateral when accompanied by gastroschisis (OR, 0.1) or axial skeletal defects (OR, 0.5). On the contrary, LDs were more often bilateral than unilateral when associated with cleft lip with or without cleft palate (OR, 3.9) or micrognathia (OR, 2.6). Specifically, we found an association between bilateral preaxial deficiencies and cleft lip, bilateral amelia with gastroschisis and urinary tract anomalies, and bilateral transverse deficiencies and gastroschisis and axial skeleton defects. Of 149 syndromic cases, 62 (41.6 %) were diagnosed as trisomy 18. Out of the 30 cases of trisomy 18 with known laterality, 20 cases were bilateral. In the remainder the right and left sides were equally affected. Also, in most cases (74.4 %) only the upper limbs were involved. In conclusion the left-right distribution of limb deficiencies among some non-limb anomalies may suggest a relationship between the development of the limb and the left-right axis of the embryo.

Teratogenic effects of antiepileptic drugs: use of an International Database on Malformations and Drug Exposure (MADRE)

PURPOSE

The study goal was to assess teratogenic effects of antiepileptic drugs (AEDs) through the use of a surveillance system (MADRE) of infants with malformations.

METHODS

Information on all malformed infants (1990-1996) with maternal first-trimester drug exposure was collected by the International Clearinghouse for Birth Defects and Monitoring Systems (ICBDMS). Cases were defined as infants presenting with a specific malformation, and controls were defined as infants presenting with any other birth defect. Exposure was defined by the use of AEDs during the first trimester of pregnancy. The association of AEDs with malformations was then estimated by calculating the odds ratios with 95% confidence intervals and testing their homogeneity among registries.

RESULTS

Among 8005 cases of malformations, 299 infants were exposed in utero to AEDs. Of those exposed to monotherapy, 65 were exposed to phenobarbital, 10 to methylphenobarbital, 80 to valproic acid, 46 to carbamazepine, 24 to phenytoin, and 16 to other AEDs. Associations were found for spina bifida with valproic acid. Infants exposed to phenobarbital and to methylphenobarbital showed an increased risk of oral clefts. Cardiac malformations were found to be associated with phenobarbital, methylphenobarbital, valproic acid, and carbamazepine. Hypospadias was associated with valproic acid. Porencephaly and other specified anomalies of brain, anomalies of face, coarctation of aorta, and limb reduction defects were found to be associated with valproic acid.

CONCLUSIONS

Using the MADRE system, we confirmed known teratogenic effects of AEDs. We also found increased risks for malformations that had never been reported associated with AEDs or for which the association was suggested by case reports.

Trends in live birth prevalence of down syndrome in the Northern Netherlands 1987-96: the impact of screening and prenatal diagnosis

In the Northern Netherlands, we examined the live birth prevalence of Down syndrome (DS) and the impact of maternal serum screening (MSS) and prenatal cytogenetic diagnosis (PCD) during the period 1987-96. In this period the live birth prevalence, based on the maternal age distribution and the age specific risk of delivering a child with DS was expected to increase from 1.26 in 1987 to 1.62 in 1996. The introduction of MSS in 1991 made PCD available to women of all ages. Nevertheless, the utilization of PCD remained very stable. In 1991, 4.7% of pregnant women underwent a diagnostic test. In 1996 this percentage was 6.4%. As a result of MSS and PCD, the live birth prevalence of DS was 19% lower than expected (p<0.01). Despite utilization of PCD based on opting-in and a discouraging government policy regarding the offer of MSS, the percentage of DS cases detected by PCD increased from of 17% during the period 1987-90 to 27% in the period 1991-96 when MSS was available. The percentages have been corrected for spontaneous pregnancy loss. From a medical and financial point of view, MSS was the most cost-effective indication for PCD. However, the potential of reducing the birth prevalence of DS is limited by the low utilization of MSS and PCD by pregnant women.

Limb defects associated with major congenital anomalies: clinical and epidemiological study from the International Clearinghouse for Birth Defects Monitoring Systems

Although limb defects associated with other congenital anomalies are rarely studied, they may provide insights into limb development that may be useful for etiologic studies and public health monitoring. We pooled data from 11 birth defect registries that are part of the International Clearinghouse for Birth Defects Monitoring Systems. We identified 666 infants, born from 1983 through 1993, who had a non-syndromal limb defect plus at least one other major malformation (rate 12.9/100,000 population). We used observed/expected ratios and log-linear models to detect association patterns. We found that specific limb defects occurred with relatively distinct sets of malformations. Preaxial limb defects occurred more frequently with microtia, esophageal atresia, anorectal atresia, heart defects, unilateral kidney dysgenesis, and some axial skeleton defects; postaxial defects with hypospadias; transverse defects with craniofacial defects, micrognathia, ring constrictions, and muscular defects; intercalary defects with omphalocele; split hand/foot with encephalocele; and amelia with anorectal atresia, omphalocele, severe genitalia defects, unilateral kidney dysgenesis, gastroschisis, and ring constriction. Log-linear modeling identified higher order associations among some of these same malformations.

Additional information from parental questionnaires and pharmacy records for registration of birth defects. EuroMAP-group

EUROCAT Northern Netherlands registers children born with a birth defect in the Northern Netherlands. Data used to be collected via a notification form, which is filled out by the notifier and, if necessary, completed by the general practitioner. To increase the amount of information, EUROCAT started using new methodology in July 1997. The new procedure consists of three additional steps. Firstly, a parental questionnaire with 43 questions concerning pregnancy and medical history is sent to the parents. Also, the pharmacist is approached to provide information on the drugs that were dispensed to the mother in the period from three months before until the end of the pregnancy. The last step is a telephone interview with the mother. In this study the old and new method are compared with respect to response, quality and quantity of the data. Of the 198 parental questionnaires included in this study, 179 (90.4%) were returned. The pharmacists returned 173 out of 179 requests for information (96.6%). The parental information is more complete for ethnicity and serum screening. The quality of the drug exposure data is much better using the new methodology. The general practitioner's input is still necessary for specification and verification of the diagnosis.

Lower limb deficient children in The Netherlands: epidemiological aspects

Information on the characteristics of children with limb deficiencies and amputations in The Netherlands is largely lacking. The present study aimed to collect data about the prevalence of congenital deficiencies, the ratio of congenital to acquired limb deficiencies, types of lower leg deficiency or amputation and male/female ratios. Data were obtained from a regional birth defects registry for the northern part of The Netherlands (EUROCAT-NNL) and from a national survey. Inclusion criteria for the selection of the EUROCAT data were: children/foetuses with lower leg deficiencies born in 1981-1986. Inclusion criteria for the survey data were: children aged 1-18 years with congenital deficiencies or acquired amputations of the leg, excluding toe deficiencies/amputations. Both the regional birth defects registry and the national survey only yielded small numbers of children, which limits the validity of the authors' findings. The Eurocat data show a prevalence of lower leg deficiencies at birth of 2.07/10,000. Fifty-five (55) children/foetuses were included in the present study. The male/female ratio was 1:1. Of the live-born children, 30% also had defects of the upper limbs, while 38% had bilateral lower limb deficiencies. The national survey included 89 children, of whom 73% had congenital deficiencies, while the others had undergone amputations: of which 37% were due to malignancies, 29% to traumata, 13% to infections and 21% to other pathology. The male/female ratio was 7:3 for the children with congenital deficiencies versus 6:4 for the children with acquired amputations. In the group of congenital deficiencies, fibula deficiency was most frequently seen (36%), while in the group with acquired amputations trans-femoral amputation, knee disarticulation and trans-tibial amputation were seen with equal frequency (21%). In 40% of the children with congenital deficiency and in 8% of the children with acquired amputations the arm was also affected. Both legs were affected in 37% of the children with congenital deficiencies and in 8% of the children with acquired amputations.

The Dutch 'Folic Acid Campaign'--have the goals been achieved?

Periconceptional folic acid use considerably reduces the risk of neural tube defects. The aim of this study was to measure the effect of the national and the local 'Folic Acid Campaign' on periconceptional folic acid use. Before (1995 survey) and 1 year after the campaign (1996 survey), the awareness and use of folic acid was measured among pregnant women in four regions of the Netherlands. To this end, pregnant women who visited the midwife, general practitioner or obstetrician for the first or second prenatal visit were asked to complete a questionnaire. The results showed that use of folic acid for any period around conception increased from 25.1% in 1995 to 53.5% in 1996. Appropriate use (4 weeks before until 8 weeks after conception) increased from 4.8% in 1995 to 21.0% in 1996. No additional effect of the local Folic Acid Campaign was found (adjusted odds ratio= 1.0; 95% confidence interval = 0.7, 1.4). It was possible to conclude that folic acid use at the recommended time increased considerably as a result of the national and the local Folic Acid Campaign, but the target (use in 46% of women wishing to conceive) was not achieved. New health education programmes are needed to increase further its use at the appropriate times.

Birth Defect and Risk Factor Surveillance in the Northern and Southwestern Netherlands

OBJECTIVE

To survey the associations between several risk factors and birth defects, in order to detect potential new teratogens.

METHODS

Data of the two Dutch European Registration of Congenital Anomalies (EUROCAT) registries collected before January 1, 1998 were used to perform chi2 tests for a large number of risk factors and birth defects. Defects caused by chromosomal or monogenic disorders were analyzed separately.

RESULTS

Cross-tabulations of 80 groups of birth defects with 303 risk factors were studied. Of these, 126 combinations had a p value under 0.05, and 34 had a p value under 0.001. Of these 34 associations, some are known in the literature, some were found before in the same databases and some were new associations.

CONCLUSIONS

This is a good method for generating new hypotheses for associations between risk factors and birth defects. It can be a start for new, more in-depth studies of potential teratogens.

Accuracy of family history of cancer: clinical genetic implications

Family medical history is the cornerstone of clinical genetic diagnosis and management in cases of familial cancer. The soundness of medical decisions can be compromised if reports by the family on affected relatives are inaccurate. Although very time consuming, family medical histories are therefore routinely verified. To investigate whether such verification is clinically justified, we retrospectively analysed the accuracy of a consecutive series of 383 tumour reports from counsellees on 120 families in our clinic. We evaluated these families for the impact of verification on clinical genetic diagnosis and management. Accuracy according to cancer type showed marked variation, ranging from 93% and 89% for breast cancer and colorectal cancer, respectively, to 42% and 37% for extra-colorectal alimentary tract cancer and uterine cancer. Accuracy was related to the degree of kinship of the affected relative, but not to age and gender of the counsellee, nor to the reason for referral or personal history of cancer. Age at diagnosis and multiple primary tumours were reported accurately in 97% and 94% of cases, respectively. In six out of 120 families verification data changed clinical genetic management, in five of these the genetic risk was reduced. Although verification of all reported cancer cases in a family remains the 'gold standard' for clinical as well as research purposes, verification of reports on breast cancer can be limited without seriously compromising medical decision making. In cases where verification is impossible because medical records are unavailable, findings from studies such as ours may help in interpreting family histories.

Improvement of drug exposure data in a registration of congenital anomalies. Pilot-study: pharmacist and mother as sources for drug exposure data during pregnancy. EuroMAP Group. Europen Medicine and Pregnancy Group

We examined the possibilities of improving the retrospective collection of data on drug use during pregnancy. The European Registration of Congenital Anomalies (EUROCAT) has registered information on maternal drug exposure in the northern Netherlands through a question on the notification form for the registration of birth defects, filled out by physicians or midwives since 1981. Furthermore, hospital records are used and general practitioners are asked to add information on drug use. The present pilot study used pharmacy records and maternal questionnaires as well as maternal interview data to complete the data on drug exposure in the EUROCAT registration. Combined information from pharmacies, questionnaires, and interviews with the mother were used as the reference standard. Pharmacy records provided detailed data on 57% of drugs used (prescription drugs, mainly). Mothers were able to report 76% of drug groups used, but when only data on the exact name of the drug were studied, this figure was 52%. Of the drugs dispensed by the pharmacy, 6% were not used (false positives). We conclude that pharmacy records and maternal interviews are both indispensable sources of information on maternal drug exposure that provide much added value.

Artefactual increasing frequency of omphaloceles in the Northern Netherlands: lessons for systematic analysis of apparent epidemics

BACKGROUND

While monitoring birth defects in a registry, statistically significant increases in prevalence occasionally occur. In the European Registration Of Congenital Anomalies (EUROCAT) in the Northern Netherlands 20000 births are monitored every year. For omphaloceles, a steady increase in the prevalence from 0.86 per 10000 live- and stillbirths in 1981-1983 to 3.11 per 10000 live- and stillbirths in 1994 was seen in the three northern provinces of The Netherlands.

METHODS

A stepwise enquiry into this increase, which included checking for misclassification and change in coding and ascertainment when necessary, was done. All cases of omphalocele and associated or similar birth defects registered at the EUROCAT registry were retrieved and if necessary recoded.

RESULTS

This study showed that the increase reported previously was not a true time trend. A few cases of e.g. diastasis recti and trisomy 18 were misclassified. The prevalence in more recent years is comparable with that in the rest of Europe, whereas it used to be lower. There was an increase in isolated omphalocele, but the numbers are small.

CONCLUSIONS

The stepwise enquiry described should be a standard procedure after noticing an increasing prevalence in a registry. A better subdivision, e.g. in isolated cases versus children with multiple congenital anomalies, before monitoring can contribute to a lower number of false positive signals.