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PubMed1992

Maternal heat exposure and neural tube defects.

OBJECTIVE: To determine if exposure to hot tub, sauna, fever, or electric blanket during early pregnancy was associated with an increased risk for neural tube defects (NTDs). DESIGN: Prospective follow-up study. SETTING: Mostly private obstetric practices, primarily in New England. PARTICIPANTS: A cohort of 23,491 women having serum alpha-fetoprotein screening or an amniocentesis were identified. Complete exposure and outcome information was available for 97% of these women. OUTCOME MEASURES: Relative risks (RRs) were used to compare incidence of NTD in those exposed to heat with those who were not exposed to any heat. Crude RRs were calculated directly from the data. Unconfounded RRs were calculated using logistic regression. RESULTS: Women reporting any heat exposure (sauna, hot tub, fever, or electric blanket) in early pregnancy had a crude risk of their fetuses developing NTD of 1.6 (95% CI [confidence interval], 0.9 to 2.9). Women reporting exposure to sauna, hot tub, or fever in early pregnancy had a crude risk of their fetuses developing NTD 2.2 times that of women without heat exposure (95% CI, 1.2 to 4.1). For hot tub use, the crude RR was 2.9 (95% CI, 1.4 to 6.3); for sauna, 2.6 (95% CI, 0.7 to 10.1); for fever, 1.9 (95% CI, 0.8 to 4.1); and for electric blanket, 1.2 (95% CI, 0.5 to 2.6). Multivariate adjusted RRs for individual heat sources, after controlling for maternal age, folic acid supplements, family history of NTD, and exposure to other heat sources, were for hot tub use, 2.8 (95% CI, 1.2 to 6.5); sauna, 1.8 (95% CI, 0.4 to 7.9); fever, 1.8 (95% CI, 0.8 to 4.1); and electric blanket, 1.2 (95% CI, 0.5 to 2.6). When only hot tub, sauna, and fever were considered and the women's exposure to each tallied, compared with no heat exposure, the RR for NTDs increased from 1.9 (95% CI, 0.9 to 3.7) after one type of heat exposure to 6.2 (95% CI, 2.2 to 17.2) after two types of heat exposure. CONCLUSIONS: Exposure to heat in the form of hot tub, sauna, or fever in the first trimester of pregnancy was associated with an increased risk for NTDs. Hot tub exposure appeared to have the strongest effect of any single heat exposure. Exposure to electric blanket was not materially associated with increased risk for NTDs.

Cohort Studies↗

PubMed2006

A population-based case-control study of risk factors for neural tube defects in four high-prevalence areas of Shanxi province, China.

Shanxi province in Northern China has one of the highest reported prevalence rates of neural tube defects (NTD) in the world. To explore the risk factors for NTDs in Shanxi province, we carried out a population-based case-control study in four selected counties with prevalence rates >10 per 1000 births during 2003. Using a multi-logistic regression model analysis (alpha = 0.10), 158 NTD cases were compared with 226 control mothers. Maternal factors significantly associated with increased risk for an NTD were a primary school education or lower (adjusted odds ratio [OR] 2.32, 95% confidence interval [CI] 1.09, 4.97); a history of a previous birth defect-affected pregnancy (adjusted OR 5.27, 95% CI 0.98, 28.37); history of a fever or 'cold' (adjusted OR 3.36, 95% CI 1.68, 6.72); use of analgesic and antipyretic drugs (adjusted OR 4.89, 95% CI 0.92, 25.97); daily passive exposure to cigarette smoke (adjusted OR 1.60, 95% CI 0.94, 2.73); poor ventilation during heating (adjusted OR 3.91, 95% CI 0.75, 20.81); and consumption of >or= six meals per week containing pickled vegetables (adjusted OR 3.86, 95% CI 1.11, 13.47) during pregnancy. Factors which appeared to be protective were meat consumption one to three times per week (adjusted OR 0.62, 95% CI 0.37, 1.06), or >or= four times per week (adjusted OR 0.28, 95% CI 0.11, 0.77); and legume consumption >or= six times per week (adjusted OR 0.39, 95% CI 0.17, 0.89). Differences in risk were found between the two most common phenotypes, anencephaly and spina bifida. Most of the environmental factors had stronger positive and negative associations with risk for anencephaly rather than spina bifida, whereas history of a previous birth defect-associated pregnancy, as well as legume consumption, were more strongly associated with the risk for spina bifida than for anencephaly. The findings suggest that aetiological heterogeneity may exist between anencephaly and spina bifida.

Adult↗

PubMed2006

Extremely high prevalence of neural tube defects in a 4-county area in Shanxi Province, China.

BACKGROUND: In the past, northern China's Shanxi Province has reported the highest incidence of neural tube defects (NTDs) in the world. However, little is known about the epidemiology of NTDs in this area in recent years. METHODS: Data were collected from a population-based birth defects surveillance system in 4 counties that captures information on all live births, stillbirths of at least 20 weeks' gestation, and pregnancy terminations at any gestational age resulting from prenatal diagnosis of a birth defect. We also surveyed mothers of NTD case patients to determine their use of folic acid before and during early pregnancy. RESULTS: During 2003, 160 NTD cases were identified among 11,534 births (NTD birth prevalence = 138.7/10,000 births). The rates of anencephaly, spina bifida and encephalocele were 65.9, 58.1, and 14.7 per 10,000, respectively, and a female predominance was observed among anencephaly cases (male-to-female relative risk [RR], 0.49; 95% confidence interval [CI], 0.30-0.79), but not among spina bifida (RR, 0.90; 95% CI, 0.55-1.45) and encephalocele (RR, 1.03; 95% CI, 0.40-2.69) cases. The percentages of pregnancy termination following prenatal diagnosis of anencephaly, spina bifida, and encephalocele were 50%, 41.8%, and 35.3%, respectively. NTD birth prevalence tended to be higher among mothers aged <20 or > or =30 years (P = .06) and was markedly associated with lower levels of maternal education (P < .001). Among 143 NTD mothers, only 6 (4.2%) used folic acid supplements during the periconceptional period. CONCLUSIONS: The NTD birth prevalence rate in the study area is among the highest worldwide. Folic acid deficiency may be one important risk factor.

Abortion, Induced↗

PubMed2002

A nationwide program for the use of preconceptional folic acid to prevent the development of open neural tube defects. Who is really using folic acid?

A nationwide program directed at stimulating the preconceptional use of folic acid (FA) for the prevention of open neural tube defects has been in effect in Puerto Rico for the last 4 years. To evaluate its effectiveness, 479 questionnaires were distributed among pregnant patients. The average age was 27 (range 14-21), and 64.9% of the pregnancies were unplanned. Preconceptional use of FA was 31.5%, despite 87.7% of patients reporting knowledge about the importance of FA use. Only 35.4% of patients who had knowledge about FA used it prior to conception. Among patients who planned their pregnancies and knew about the importance of FA, 92/168 (54.6%) used it prior to pregnancy. With these dismal results, we believe these campaigns should re-evaluate their educational strategies and consider reduction of unplanned pregnancies as part of their goals.

Adolescent↗

PubMed1985

Relationship between timing of posterior neuropore closure and development of spinal neural tube defects in mutant (curly tail) and normal mouse embryos in culture.

The relationship between timing of closure of the posterior neuropore (PNP) and development of spinal neural tube defects (NTD) has been studied in individual mutant curly tail mouse embryos maintained in culture. Moderate delay in PNP closure results in development of tail flexion defects whereas extreme delay of PNP closure is associated with development of open NTD. Experimental enlargement of the PNP at the stage of 25 to 29 somites leads to delayed PNP closure and development of tail flexion defects in 36% and 38% respectively of non-mutant A/Strong embryos. In curly tail embryos, the effect of experimental enlargement of the PNP summates with the genetic predisposition to produce an increased incidence of spinal NTD among which open defects are proportionately more common. These results indicate that a causal relationship exists between delay in PNP closure and development of spinal NTD in mouse embryos. The method described for distinguishing between prospective normal and abnormal curly tail embryos at a stage prior to the appearance of malformations provides an opportunity to study the morphogenetic processes that precede the development of genetically determined spinal NTD.

Animals↗

PubMed2000

Prior spontaneous abortion, prior elective termination, interpregnancy interval, and risk of neural tube defects.

A woman with a history of spontaneous abortion in her immediately prior pregnancy may be at increased risk for a pregnancy affected by a neural tube defect (NTD). A short interpregnancy interval may further increase this risk. Using data from a population-based case-control study (1989-1991), the authors investigated NTD risk resulting from a prior spontaneous abortion or elective termination and a short interpregnancy interval. Of 538 interviewed case mothers and 539 interviewed control mothers, 408 case mothers and 433 control mothers reported having a prior pregnancy. Analysis showed a slightly decreased NTD risk among mothers whose immediately prior pregnancy had ended in a spontaneous abortion or elective termination in comparison with a live birth (odds ratio (OR) = 0.82; 95% confidence interval (CI): 0.61, 1.1). This decreased risk was consistent across strata of short or long interpregnancy intervals. Additional analysis revealed an increased NTD risk for mothers with an interpregnancy interval of < or =6 months compared with >12-< or =24 months (OR = 1.5; 95% CI: 0.93, 2.4). This latter risk was greatest among mothers whose immediately prior pregnancy had resulted in a live birth (OR = 2.0; 95% CI: 1.0, 3.8) rather than a spontaneous abortion or elective termination (OR = 0.96; 95% CI: 0.44, 2.1). Adjustment for potential covariates did not substantially alter observed risk estimates.

Abortion, Induced↗

PubMed2004

Promoter haplotype combinations for the human PDGFRA gene are associated with risk of neural tube defects.

Recent animal studies suggested that deregulated expression of the platelet-derived growth factor receptor alpha (PDGFRalpha) may contribute to the failure of normal neural tube closure (NTC). There is also suggestive evidence that the promoter haplotype of the PDGFRA is associated with genetic susceptibility in human neural tube defects (NTDs). The purpose of our study was to investigate the association between promoter haplotype combinations of the human PDGFRA gene and risk for NTDs in a Hispanic population from the Texas-Mexico border region. This population has a considerably higher prevalence of NTDs (16/10,000 live births) than that generally reported in the United States (8-10/10,000 live births). In the present study, NTDs were defined as spina bifida or anencephaly. The haplotype of PDGFRA gene promoter was determined by direct DNA sequence analysis. Two novel haplotypes, H2epsilon and H1beta, were found. We observed significant differences among variable haplotype groups from in vitro transient transfection studies in U2-OS osteosarcoma cell and two other cell lines (HeLa cell and MCF7 cell). Result from our case-control study demonstrated that the frequencies of haplotypes with low transcription activity were significantly higher in NTD mothers than that observed in control mothers (odds ratio=2.2, 95% CI=1.0-4.6). Infants with at least one low activity allele showed slightly higher risk (odds ratio=1.5, 95%=0.8-3.1). Our study suggests that the reduced transcriptional activity of PDGFRA gene could increase the risk of having an NTD-affected pregnancy.

Adult↗

PubMed2006

Evaluation of the implementation of the folate-neural tube defect health claim and its impact on the availability of folate-fortified food in Australia.

OBJECTIVE: To evaluate the implementation of the folate-neural tube defect (NTD) health claim and its impact on the availability of folate-fortified food in Australia. METHODS: During late 2005, a survey was conducted in 16 supermarkets across all Australian capital cities to identify the use of the folate-NTD health claim on the labels of the 128 food products listed in food standard 1.1A.2: 'Transitional standard--Health claims' and the number of products fortified with folic acid. RESULTS: Seventy-nine per cent of existing listed food products were found and two of these were implementing the folate-NTD health claim. Forty-four per cent of these listed products, previously fortified with folic acid, were no longer fortified. One hundred and seventeen generally available food products were fortified with folic acid, predominantly breakfast cereals (73%). Twenty-seven per cent of these folate-fortified products were listed in the transitional standard. CONCLUSIONS: The health claim was not used widely to inform women of child-bearing age of the importance of periconceptional folate intake. The increased availability of folate-fortified products generally has occurred independently of the health claim. Deficiencies in the verification system of the tested regulatory framework are identified. The voluntary regulatory provisions for both folate fortification and the use of the health claim diminished the States' influence over their implementation of public health tools.

Australia↗

PubMed1993

[Serum screening of pregnant women for fetal neural tube defects and Down syndrome; initial experiences in The Netherlands].

OBJECTIVE: To examine if, and if so, in what way, the maternal serum screening for fetal neural tube defects (NTD) and Down's syndrome (DS) in the Dutch decentralized obstetrical organization would be feasible and effective. DESIGN: Prospective. SETTING: University Hospital Groningen. METHOD: Between October 1st 1990 and December 1st 1991 we determined the likelihood of a baby with a NTD and/or DS in 2580 pregnant women, at 15 to 20 weeks gestation, by serum screening. RESULTS: Five foetuses with DS were detected, as well as two with a NTD, one foetus with an omphalocele, and one with Turner's syndrome. One infant with a NTD and one with DS were not found prenatally. Of all 98 women of 36 years or older, 68 declined amniocentesis because their risk was lower than the age related risk. CONCLUSIONS: Maternal serum screening for NTD and DS is feasible and effective in principle. In a decentralized prenatal care system, special attention has to be paid to the time needed to report the results and to the completion of the follow-up. The detection rate of DS in pregnant women of 36 years or older remains almost the same, but a significant number of them decline prenatal diagnosis. An increased risk of foetal DS, determined by serum screening, should be added to the official list of indications for prenatal diagnosis in the Netherlands.

Adolescent↗

PubMed2006

Folate concentrations and folic acid supplementation among women in their first trimester of pregnancy in a rural area with a high prevalence of neural tube defects in Shanxi, China.

BACKGROUND: Although an information campaign concerning periconceptional folic acid supplementation was launched in 1998 in Shanxi Province, China, the prevalence of neural tube defects in rural areas was reported as high as 140 per 10,000 births in 2002. The blood folate concentrations and the practice of folic acid supplementation among pregnant women in rural areas of the province are described. METHODS: A total of 483 pregnant women (mean gestation, 8.1 weeks) in a rural area of Shanxi were interviewed. Nonfasting blood samples and information on folic acid supplementation were collected. Folate concentrations in plasma and erythrocytes were determined by a microbiological assay. RESULTS: The mean concentrations of plasma and erythrocyte folate for pregnant women was 10.4 nmol/liter and 375.8 nmol/liter, respectively. Deficiencies of plasma and erythrocyte folate were observed in 20.9% and 47.6% of women, respectively. Seasonal variations were noted in the prevalence of folate deficiency, with significantly lower plasma folate concentrations in spring and summer and lower erythrocyte folate concentrations in seasons other than summer. Among pregnant women, <10% reported having taken or currently taking folic acid, and virtually no women (0.6%) took folic acid as recommended. CONCLUSIONS: Women in rural areas had low plasma and erythrocyte folate levels, and folate deficiency was highly prevalent in the area. Few women followed the recommendations regarding folic acid supplementation, and the information campaign in Shanxi was unsuccessful. These findings suggest the urgent need for combined strategies in rural areas to fortify grain with folic acid and promote folic acid supplements for childbearing-age women.

Adult↗

PubMed2000

Neural tube defects: prevention by folic acid and other vitamins.

Folic acid has been demonstrated in clinical trials to reduce significantly the recurrence (and probably occurrence) of neural tube defects (NTD). In the U.K., there has been no decline in prevalence of NTD since the publication of the findings with folic acid. This article examines a series of questions relating to the action of folic acid, with emphasis on the use of mouse models as a source of experimental information which cannot easily be obtained by direct study of humans. Several mouse genetic NTD models exhibit sensitivity to prevention by folic acid, whereas other mice which develop morphologically similar NTD are resistant. Folic acid normalises neurulation in the sensitive mouse strains, providing evidence for a direct effect on the developing embryo, not on the pregnant female: Mouse studies do not support the proposed action of folic acid in encouraging the in utero demise of affected fetuses (i.e. terathanasia). Polymorphic variants of several folate-related enzymes have been shown to influence risk of NTD in humans and an inherited abnormality of folate metabolism has been demonstrated in one mouse NTD model. However, the biochemical basis of the action of folic acid in preventing NTD remains to be determined in detail. NTD in one folate-resistant mouse strain can be prevented by myo-inositol, both in utero and in vitro, raising the possibility of a therapeutic role also in humans. Gene-gene interactions seem likely to underlie the majority of NTD, suggesting that poly-therapy involving folic acid and other agents, such as myo-inositol, may prove more effective in preventing NTD than folic acid treatment alone.

Animals↗

PubMed2003

Folate intakes and awareness of folate to prevent neural tube defects: a survey of women living in Vancouver, Canada.

OBJECTIVE: To estimate folate intake and knowledge in women of childbearing age, in relation to risk of neural tube defects. SUBJECTS/SETTING: One hundred forty-eight women (aged 18 to 45 years) in the Vancouver area of British Columbia, Canada. DESIGN: Using an interviewer-administered survey, we examined women for folate knowledge and the relation of folate knowledge to intake in a random sample. Contribution of folate from food, fortified grain products, and supplements was assessed by validated semiquantitative food frequency questionnaire. STATISTICAL ANALYSIS PERFORMED: Descriptive statistics, t tests, Chi;(2), Pearson correlation analysis. RESULTS: Mean daily folate intake from food, fortified foods, and supplementation was 812+/-710 Dietary Folate Equivalents (DFE)/day. Fortification of bread and grain products contributed 104+/-68 microg synthetic folic acid (SFA)/day (equal to 174+/-114 DFE), and supplements contributed 205+/-388 microg SFA/day. Although 86% of women met the Estimated Average Requirement (320 DFE/day) for folate, only 26% met the recommendation (400 microg SFA/day) for women capable of becoming pregnant. Most (95%) of the women had heard of folate, but only 25% knew that it could prevent birth defects. One-fourth of the women had good or very good knowledge of folate-rich foods. However, folate knowledge was not related to its intake. The most common sources of folate information were magazines/newspapers, doctors, and television/radio. Lack of awareness of the importance of folate was the most common reason given for choosing not to use folic acid supplements before pregnancy. However, 78% of the women indicated that, with knowledge of the benefits of folate, they would use supplemental folic acid daily to reduce the risk of birth defects. APPLICATIONS/CONCLUSIONS: Educational strategies are required to increase folate awareness among women and to promote the benefits of periconceptional folic acid supplementation. Targeting physicians to educate women on the importance of folate could be a potentially successful route. J

Adolescent↗

PubMed1989

The range of neural tube defects in southern India.

During a prospective study of 3500 consecutive births from November 1985 to January 1987 at three hospitals, 40 babies were found to have neural tube defects, an extremely high incidence (11.4/1000 births). The defects comprised anencephaly (n = 18), meningomyelocele (n = 11), Arnold-Chiari deformity (n = 3), encephalocele (n = 3), iniencephaly (n = 2), and one each of occipital meningocele, spina bifida occulta, and anencephaly with rachischisis. There were significant differences in incidence between those with consanguineous and nonconsanguineous parents and those whose mothers had previously given birth to malformed infants or who had had miscarriages, and those who had not. Significantly more defects were found among stillborn and low birthweight babies, among girls, and among those whose mothers were aged between 20 and 30 years. Just over a third (14) were breech presentations, and hydramnios was present in 16 (40%).

Abnormalities, Multiple↗

PubMed1996

Plasma homocysteine and methionine concentrations in children with neural tube defects.

Mild to moderate homocysteinemia in women has been associated with an increased frequency of pregnancies with neural tube defects (NTD). Homocysteinemia is also an independent risk factor for premature vascular disease. In addition to folic acid, supplemental Vitamin B12, Vitamin B6 and betaine may normalize homocysteine metabolism, decrease the risk for NTD formation, and correct related metabolic imbalances in children with NTD. By means of automated amino acid analysis, we assessed total non-fasting homocysteine and methionine in plasma from 24 children with myelomeningocele. This study group (mean age 10.5 +/- 4.9 years) included 12 girls and 12 boys randomly selected from our Birth Defects Clinic. Homocysteine concentrations in our patients (4.7 +/- 1.8 mumol/L) did not differ from those of 20 randomly selected child controls (5.1 +/- 2.6 mumol/L). The mean homocysteine concentration for 36 adult controls (9.3 +/- 3.0 mumol/L) was significantly higher than the mean for either group of children (p < 0.0001). Linear regression analysis revealed negative correlation of total plasma homocysteine with serum folate (r = -0.53; p = 0.01), but not of homocysteine with either methionine or B12. Plasma methionine concentrations from our patients did not differ from adult reference values. Elevated homocysteine in some mothers of children with NTD has been attributed to defective methylation of homocysteine. These preliminary results do not indicate such a defect in the children themselves. A more comprehensive study of homocysteine, methionine and related metabolites in children with NTD and age-matched controls will be required to determine the clinical significance of these findings.

Adolescent↗

PubMed2002

Perturbations in choline metabolism cause neural tube defects in mouse embryos in vitro.

A role for choline during early stages of mammalian embryogenesis has not been established, although recent studies show that inhibitors of choline uptake and metabolism, 2-dimethylaminoethanol (DMAE), and 1-O-octadecyl-2-O-methyl-rac-glycero-3-phosphocholine (ET-18-OCH3), produce neural tube defects in mouse embryos grown in vitro. To determine potential mechanisms responsible for these abnormalities, choline metabolism in the presence or absence of these inhibitors was evaluated in cultured, neurulating mouse embryos by using chromatographic techniques. Results showed that 90%-95% of 14C-choline was incorporated into phosphocholine and phosphatidylcholine (PtdCho), which was metabolized to sphingomyelin. Choline was oxidized to betaine, and betaine homocysteine methyltransferase was expressed. Acetylcholine was synthesized in yolk sacs, but 70 kDa choline acetyltransferase was undetectable by immunoblot. DMAE reduced embryonic choline uptake and inhibited phosphocholine, PtdCho, phosphatidylethanolamine (PtdEtn), and sphingomyelin synthesis. ET-18-OCH3 also inhibited PtdCho synthesis. In embryos and yolk sacs incubated with 3H-ethanolamine, 95% of recovered label was PtdEtn, but PtdEtn was not converted to PtdCho, which suggested that phosphatidylethanolamine methyltransferase (PeMT) activity was absent. In ET-18-OCH3 treated yolk sacs, PtdEtn was increased, but PtdCho was still not generated through PeMT. Results suggest that endogenous PtdCho synthesis is important during neurulation and that perturbed choline metabolism contributes to neural tube defects produced by DMAE and ET-18-OCH3.

Acetylcholine↗

PubMed1998

Description of the characteristics of cases with noncontiguous neural tube defects identified in a series of consecutive births.

Van Allen et al. [(1973) Am. J. Med. Genet. 47:723-743] provided evidence for multisite closure of the neural tube in humans. Reynolds et al. [(1995) Proceedings of the Greewood Genetic Center 14:70-71] and Seller [(1995) J. Med. Genet. 32:205-207] described 13 and seven cases of noncontiguous neural tube defects (NTDs) respectively and concluded that the presence of noncontiguous NTDs cannot be explained on the basis of the model of a single initiation site with bidirectional closure. Here we present a series of 14 consecutive infants with noncontiguous NTDs, describing their characteristics. These show that noncontiguous NTDs are clinically heterogeneous, may have differences in sex ratio, and could have causal heterogeneity. The different combinations of closure failure defects have shown proportions in our population that are different from those in the populations studied by Reynolds et al. and Seller.

Birth Weight↗

PubMed1981

Amniotic fluid cholinesterase measurement as a rapid method for the exclusion of fetal neural tube defects.

Amniotic fluid total cholinesterase (ChE) and acetylcholinesterase (AChE) activities have been measured in 404 pregnancies without fetal malformation and 79 pregnancies associated with open neural-tube defects (NTDs). Neither measurement, either alone or in combination, gave complete separation of the two groups. However, measurement of ChE can be used to assess the probability that a woman is carrying a fetus with an open NTD. Since ChE can be measured within 15 minutes and shows at least 70% of women selected for amniocentesis by serum alpha-fetoprotein screening to have a less than 1 in 100 chance of carrying a fetus with an open NTD, we suggest that this test may be used in an amniocentesis clinic both to reassure women with normal pregnancies and to select probable abnormalities for immediate further investigation.

Acetylcholinesterase↗

PubMed1989

Primary primitive neuroectodermal tumor of the spinal cord associated with neural tube defect.

Certain spinal-cord (SC) neoplasms, principally lipomas and dermoid tumors, have been diagnosed in association with characteristic neuroskeletal malformations thought to result from neural-tube defects (NTD). To our knowledge, no such association has been recognized for primary primitive neuroectodermal tumor of the SC (PNET-SC), an SC malignancy which has been reported in only 3 children and 5 adults. We describe here the occurrence and treatment results of PNET-SC in a boy who exhibited several neuroskeletal malformations suggestive of an underlying NTD. By undertaking a comparative analysis of the literature with respect to both the histology and the clinical presentation of this child's tumor, we document an occurrence of an uncommon malignancy, PNET-SC, and identify PNET-SC as another SC neoplasma which may be associated with NTD.

Abnormalities, Multiple↗