A Systematic Review of Psycho-Spiritual Interventions in the NICU: Supporting Parents' Mental Health and Psychological Well-Being.

BACKGROUND: The presence of psychospiritual supports and interventions for neonatal intensive care unit (NICU) parents is unclear. PURPOSE: This systematic review examines the psychological and medical literature for psychospiritual interventions designed to support parents' mental health and psychological well-being during or after the NICU experience. DATA SOURCES: Data sources include PubMed, PsycINFO, and Cochrane Library (Cochrane Database of Systemic Reviews, Cochrane Central Register of Controlled Trials) with peer-reviewed studies published between 2013 and 2023. STUDY SELECTION: Peer-reviewed studies that included spiritual and psychological intervention components focused on supporting parents during or after the NICU were included for this systematic review. There were 42 records located in 3 databases ultimately yielding 4 peer-reviewed studies that met inclusion criteria. Articles must have been written in English and evaluate parents'/caregivers' mental health/psychological well-being in relation to a psychospiritual intervention. DATA EXTRACTION: Because of the small number of studies, article summaries are provided within the results section and were written by the first author with approval by the second and third authors. RESULTS: Results indicated that when psychological (focus on coping) and spiritual components were included psychological and well-being outcomes were better for NICU parents. IMPLICATIONS FOR PRACTICE AND RESEARCH: The inclusion of psychological and spiritual aspects of coping and supportive care is necessary for the best family-centered NICU care. More work needs to be done to develop psychospiritual supports and include fathers in these endeavors as most work occurs with mothers. Nurses need support and training to facilitate family-centered care with a focus on parents' psychospiritual needs.

Fathers' Heightened Stress Responses to Recounting their NICU Experiences Months after Discharge: A Mixed Methods Pilot Study.

OBJECTIVE: The acute and traumatic events associated with having a newborn who requires admission to the neonatal intensive care unit (NICU) may elicit long-term concerns for parents postdischarge. Cognitive processing of taxing events influences recurring stress responses, which can be inferred via biomarkers such as salivary cortisol (sCort) and skin conductance (SC). In addition, personal narratives provide an important insight into individual perceptions and coping strategies. The current pilot study aimed to (1) test the hypotheses that fathers' sCort and SC would peak in response to stress induction and decrease during recovery, (2) examine associations among stress biomarkers and stress perceptions, (3) explore fathers' narratives using thematic analysis, and (4) integrate fathers' narrative themes with their stress responsivity. STUDY DESIGN: Using a convergent mixed methods approach, we enrolled 10 fathers of infants formerly cared for in NICU who underwent a Trier Social Stress Test including recounting their NICU experience months postdischarge. Stress responsivity was measured via sCort and SC, while stress perceptions were identified by using the Perceived Stress Scale and Distress Thermometer-Parent. Personal narratives were explored by using thematic analysis. RESULTS: The significant rise in fathers' sCort and SC in response to stress induction was reflected in narrative themes including loss, worry, and role strain. Subsequently, fathers' sCort and SC returned to baseline, which was illustrated by themes such as role strength, coping, and medical staff interactions. Fathers' stress measured by PSS was lower than that required for mental health referral, and did not correlate with stress biomarkers. CONCLUSION: Salivary cortisol and skin conductance are useful biomarkers of paternal stress responsivity and recovery. Thematic analysis identified fathers' NICU stressors and coping strategies that mirrored their stress responsivity patterns. Further studies are needed to more broadly examine the sociodemographic variables that influence stress reactivity and perceptions in parents of infants formerly cared for in NICU. KEY POINTS: · Stress associated with NICU stay is impactful on fathers and may have long-term implications.. · Salivary cortisol and skin conductance are useful noninvasive stress biomarkers.. · Fathers' coping strategies included infant bonding, partner relationship, and trust building..

Family-Integrated Neonatal Music Therapy: A Descriptive Pilot Study of Parental Perceptions on Music Therapy Participation and Long-Term Influences.

Purpose: Following a family-integrated music therapy (MT) approach, describe parental perceptions on the use of music with maternal voice to soothe and connect with the infant and the long-term influence of this approach on parents' integration of music postdischarge. Design: In this descriptive, observational within-subjects pilot cohort study, board-certified music therapists instructed and recorded mothers in singing selected songs of kin. Infants received the recorded sessions weekly from enrollment to discharge. Parents were surveyed at 1- and 6-year postdischarge. Sample: Medically stable preterm infants (n = 12) and their English-speaking parents (n = 17). Main Outcome Variable: Parent perceptions on participation and long-term influence on family integration of music during hospitalization and postdischarge. Results: Parents reported knowledge of soothing and interacting with their children as the highest benefit of MT. They also perceived the effects of an easier transition home, enhanced learning and child development, and personal benefits of positive mood and enhanced relaxation.

Results and lessons from dual extraction of DNA and RNA from formalin-fixed paraffin-embedded breast tumor tissues for a large Cancer epidemiologic study.

BACKGROUND: The use of archived formalin-fixed paraffin-embedded (FFPE) tumor tissues has become a common practice in clinical and epidemiologic genetic research. Simultaneous extraction of DNA and RNA from FFPE tissues is appealing but can be practically challenging. Here we report our results and lessons learned from processing FFPE breast tumor tissues for a large epidemiologic study. METHODS: Qiagen AllPrep DNA/RNA FFPE kit was adapted for dual extraction using tissue punches or sections from breast tumor tissues. The yield was quantified using Qubit and fragmentation analysis by Agilent Bioanalyzer. A subset of the DNA samples were used for genome-wide DNA methylation assays and RNA samples for sequencing. The QC metrices and performance of the assays were analyzed with pre-analytical variables. RESULTS: A total of 1859 FFPE breast tumor tissues were processed. We found it critical to adjust proteinase K digestion time based on tissue volume to achieve balanced yields of DNA and RNA. Tissue punches taken from tumor-enriched regions provided the most reliable output. A median of 1475 ng DNA and 1786 ng RNA per sample was generated. The median DNA integrity number (DIN) was 3.8 and median DV200 for RNA was 33.2. Of 1294 DNA samples used in DNA methylation assays, 97% passed quality check by qPCR and 92% generated data deemed high quality. Of the 130 RNA samples with DV200 ≥ 20% used in RNA-sequencing, all but 5 generated usable transcriptomic data with a mapping rate ≥ 60%. CONCLUSIONS: Dual DNA/RNA purification using Qiagen AllPrep FFPE extraction protocol is feasible for clinical and epidemiologic studies. We recommend tissue punches as a reliable source material and fine tuning of proteinase K digestion time based on tissue volume. IMPACT: Our protocol and recommendations may be adapted by future studies for successful extraction of archived tumor tissues.

Vagal Tone and Proinflammatory Cytokines Predict Feeding Intolerance and Necrotizing Enterocolitis Risk.

BACKGROUND: Necrotizing enterocolitis (NEC) is the leading cause of death due to gastrointestinal disease in preterm neonates; yet, clinicians lack reliable and noninvasive predictive tools. PURPOSE: We aimed to test that diminished high-frequency heart rate variability (HF-HRV) and elevated levels of proinflammatory cytokines would have utility in NEC prediction. METHODS: In this multisite prospective study, we enrolled 250 preterm (26-34 weeks' postmenstrual age [PMA]) neonates with physiological stability at 72 hours of life. HRV was measured noninvasively using electrocardiograhic data from standardized cardiorespiratory monitors at postnatal week 1 of life and weekly thereafter until 35 weeks' PMA or discharge; blood was collected for cytokines at postnatal weeks 1 and 3. NEC was diagnosed via Modified Bell's Staging Criteria. RESULTS: HF-HRV was decreased at weeks 1 and 2 in neonates (47% females) who developed feeding intolerance or stage 2+ NEC. In addition, these neonates displayed elevated levels of IL-8 at week 1 and increased levels of IL-1ß, IL-6, TNF-α, and IL-8 at week 3 of life. Low HF-HRV was associated with elevated IL-6 or IL-8 levels at weeks 1 and 3 of life. Logistic regression indicated that only HF-HRV was a significant predictor of feeding intolerance or NEC development. IMPLICATIONS FOR PRACTICE AND RESEARCH: HRV is a promising noninvasive modality for NEC risk detection. The association of low HF-HRV with elevated proinflammatory cytokines provides evidence for a putative role of the vagal cholinergic pathway in NEC pathogenesis. Future studies should focus on application of these techniques to test clinical therapeutics.Video Abstract available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=54.

Increased early enteral zinc intake improves weight gain in hospitalised preterm infants.

AIM: To test the hypothesis that enteral zinc intake is associated with improved preterm infant growth during neonatal intensive care unit (NICU) hospitalisation. METHODS: This prospective cohort study enrolled 105 preterm infants at a tertiary referral centre. Enteral zinc intake was calculated at day of life 14, and growth was measured as change in weight, length and head circumference from birth to discharge. Nonparametric tests assessed the contribution of breast milk vs formula and enteral zinc intake on weight, length and head circumference growth. Partial correlations evaluated the impact of baseline health status and caloric intake on growth. Multiple regression analysis was then completed to determine the unique contribution of zinc intake to weight gain and head circumference growth. RESULTS: Total enteral zinc intake was positively associated with weight gain (r = 0.4, p < 0.01) and head circumference growth (r = 0.3, p < 0.01) during NICU hospitalisation. Further, multiple regression analysis showed higher zinc intake is linked to weight gain during NICU hospitalisation after accounting for postmenstrual age at birth. CONCLUSION: Increased early enteral zinc intake is linked to weight gain during NICU hospitalisation, highlighting the importance of enteral zinc intake in early infant nutrition.

Increased Frequency of Skin-to-Skin Contact Is Associated with Enhanced Vagal Tone and Improved Health Outcomes in Preterm Neonates.

OBJECTIVE: An estimation of the individual's ability to cope with environmental adversity, that is, stress resiliency, can be extrapolated by measuring cardiac vagal tone, that is, high-frequency heart rate variability (HF-HRV); indeed, higher HF-HRV is associated with health and developmental advantages for preterm neonates. Previous studies show skin-to-skin contact (SSC) improves stress resiliency; however, linkages between SSC and HF-HRV on outcomes have not been assessed. We aimed to test the hypothesis that increased SSC frequency would enhance HF-HRV, reduce neonatal morbidity, and improve developmental outcomes. STUDY DESIGN: Weekly electrocardiograms and clinical data were obtained from 101 preterm neonates. SSC frequency was determined from the electronic medical record. RESULTS: At postnatal week 1, frequency of SSC and HF-HRV were positively correlated (p =.02); further, multiple stepwise regressions showed higher HF-HRV and SSC predicted reduced days on ventilation and oxygen, and shorter hospital stay (p < 0.001). Higher HF-HRV predicted lower postmenstrual age (PMA) at discharge (p < 0.01). CONCLUSION: Higher SSC frequency was associated with increased HF-HRV during the first postnatal week. SSC and HF-HRV uniquely predicted diminished neonatal morbidity throughout hospitalization. Additionally, HF-HRV uniquely predicted earlier PMA at discharge. Augmenting SSC early in life enhances stress resiliency and improves health outcomes.

Preterm Stress Behaviors, Autonomic Indices, and Maternal Perceptions of Infant Colic.

BACKGROUND: While biological and behavioral stress response systems are intact in early gestation, preterm infants' behaviors are often more subtle and difficult to interpret compared with full-term infants. They are also more vulnerable for regulatory issues (ie, colic) that are known to impact caregiver-infant interactions. Biobehavioral measures such as behavioral responsivity and heart rate variability (HRV), particularly cardiac vagal tone, may help elucidate preterm infants' stress/regulatory systems. PURPOSE: To test the hypotheses that preterm infants' consoling behaviors and high-frequency (HF) HRV in the first week of life are significantly associated and they are inverse correlates of future colic risk. METHODS/SEARCH STRATEGY: Thirty preterm (mean ± SE = 32.7 ± 0.3 weeks postmenstrual age [PMA]) infants underwent direct NIDCAP (Newborn Individualized Development and Assessment Program) observation during routine care and had HRV measurements during their first week postbirth. Sixty-three percent of mothers completed the Infant Colic Scale at 6 to 8 weeks adjusted postnatal age. Nonparametric tests were used to determine associations among behaviors, HRV, and maternal perceptions of infant colic. FINDINGS/RESULTS: Self-consoling behaviors were positively associated with HF-HRV (vagal tone). In addition, stress behaviors were positively associated with low-frequency/high-frequency HRV (sympathetic dominance). Infants who displayed more stress behaviors also demonstrated more self-consoling behaviors. No significant associations were found with colic. IMPLICATIONS FOR PRACTICE: HF-HRV provides information on the infant's capacity to modulate stress and is a useful, noninvasive measure when behaviors are more difficult to discern. IMPLICATIONS FOR RESEARCH: Further study in a larger sample is needed to determine whether behavioral stress measures and HF-HRV may be useful to determine colic risk.

Physiological functioning moderates infants' sensory sensitivity in higher conflict families.

Children exposed to parent conflict may be at risk for emotional and behavioral disorders by becoming sensitized to conflict cues in their environments. This study explored possible precursors to negative child outcomes associated with parent conflict by examining the relation between parent conflict and infants' (N = 36; 23-42 weeks; 44% female) behavioral sensitivity to general sensory stimuli (e.g., loud noises, physical touch). To determine whether infants' characteristic autonomic arousal and regulation moderated this association, infant baseline skin conductance (SC) and respiratory sinus arrhythmia (RSA) were measured. Parents reported levels of parent conflict, and mothers reported infants' behavioral sensory sensitivity. The association between parent conflict and lower threshold for sensory sensitivity was strongest for infants with higher physiological arousal (higher SC) and lesser capacity for physiological regulation (lower RSA). Children may become more sensitive to environmental stimuli as a function of parent conflict during infancy, though this appears to depend on characteristic physiological arousal and regulation.

Skin conductance at baseline and postheel lance reflects sympathetic activation in neonatal opiate withdrawal.

AIM: Skin conductance (SC) provides an objective measure of autonomic system regulation through sympathetic-mediated filling of sweat glands. This study aimed to test the utility of SC to detect sympathetic activation in neonatal abstinence syndrome (NAS). METHODS: Fourteen term (mean, SE: 38.8 ± 0.35 weeks gestational age) neonates with chronic prenatal opiate exposure were enrolled. SC (peaks/seconds and mean of peaks) was measured at baseline, during heel lance/squeeze (HLS) and recovery from HLS at 24-48 (mean 38) hours of life prior to treatment for NAS. Blinded coders with established reliability assessed neonates using the Modified Finnegan Neonatal Scoring System (MFNSS). Nonparametric tests were used to determine group differences, phase differences from baseline to HLS and HLS to recovery, and associations between MFNSS and SC measures. RESULTS: Neonates that would later require morphine treatment for NAS (n = 6) had higher baseline SC mean of peaks than those that did not require treatment (n = 8) (p < 0.05). Moreover, there were unique phase differences between groups and SC positively correlated with MFNSS (p < 0.05). CONCLUSION: SC provides early identification of NAS severity. However, a larger sample is needed to determine sensitivity and specificity of SC for early identification of NAS and treatment effectiveness.

Sacred Spaces: Religious and Secular Coping and Family Relationships in the Neonatal Intensive Care Unit.

BACKGROUND: Preterm birth is an unanticipated and stressful event for parents. In addition, the unfamiliar setting of the intensive care nursery necessitates strategies for coping. PURPOSE: The primary study objective of this descriptive study was to determine whether secular and religious coping strategies were related to family functioning in the neonatal intensive care unit. METHODS: Fifty-two parents of preterm (25-35 weeks' gestation) infants completed the Brief COPE (secular coping), the Brief RCOPE (religious coping), and the Family Environment Scale within 1 week of their infant's hospital admission. FINDINGS: This descriptive study found that parents' religious and secular coping was significant in relation to family relationship functioning. Specifically, negative religious coping (ie, feeling abandoned or angry at God) was related to poorer family cohesion and use of denial. IMPLICATIONS FOR PRACTICE: These findings have relevance for interventions focused toward enhancing effective coping for families. IMPLICATIONS FOR RESEARCH: Further study of religious and secular coping strategies for neonatal intensive care unit families is warranted in a larger more diverse sample of family members.

Implementing and Sustaining Evidence Based Practice Through a Nursing Journal Club.

BACKGROUND: The outcomes based emphasis in nursing and health care delivery requires identification of best available evidence in order to produce quality, safe, and effective patient care. Finding, critiquing, and ultimately implementing the best available evidence for practice is a formidable task for many clinical nurses. Development and implementation of a nursing journal club (NJC) became one organization's successful attempt to help clinical nurses better understand and use best available evidence in actual practice. METHODS: The process and structure for the NJC evolved from an additional activity scheduled outside of work to a fully established endeavor of Nursing Research and Evidence Based Practice Council (NR&EBP). The Nursing Professional Practice Model was foundational to establishing the NJC as a formal component within the NR&EBP Council shared governance structure. Efforts to embed the NJC included taking advantage of resources available at an academic medical center and incorporating them into the council structure. RESULTS: Successful outcomes of the NJC include a quarterly schedule, with topics selected in advance that are based on nursing department as well as organizational driven goals and initiatives. The structure and process in place has eliminated frequently mentioned deterrents to evidence based practice such as not enough time, lack of knowledge, or no immediate application to practice. CONCLUSIONS: Incorporating the NJC as a component of NR&EBP Council has provided clinical nurses time away from clinical care that supports scholarship for nursing practice. Committed leadership and garnering of available resources have been key factors for success.

Religious and Spiritual Journeys: Brief Reflections from Mothers and Fathers in a Neonatal Intensive Care Unit (NICU).

The birth of a child is often accompanied by elation and celebration, but when a birth results in admittance to the Neonatal Intensive Care Unit (NICU), the typical emotions of joy and celebration may be tempered with anxiety and fear. Parents with a religious and spiritual worldview may find their faith and spiritual lens is an important aspect of coping with their NICU experience. There is a dearth of literature on this issue, and thus a pilot study was implemented that included eight mothers and fathers of babies admitted to the NICU. Parents responded to a brief interview 4 to 6 weeks after discharge that focused on how their religious or spiritual worldview changed as a result of their NICU experience, how they coped with their premature newborn after discharge, and the perceived impact on their spousal/partner relation-ship. Results indicated that parents who presented to the NICU with a religious or spiritual background indicated their faith grew as a result of their experience in the NICU. Parents without a religious or spiritual worldview also reported being able to adequately manage their NICU experience and reported little to no change in their religious or spiritual lives. Further, parents reported they coped well after their babies' discharge from the NICU and had supportive spousal relationships. This pilot study supported assessment of religious and spiritual experiences as a salient aspect in NICU parents' lives. Further study is necessary to elucidate how religiosity and spirituality can be strengthened for families during this challenging time.

Genome-wide association study identifies novel loci predisposing to cutaneous melanoma.

We performed a multistage genome-wide association study of melanoma. In a discovery cohort of 1804 melanoma cases and 1026 controls, we identified loci at chromosomes 15q13.1 (HERC2/OCA2 region) and 16q24.3 (MC1R) regions that reached genome-wide significance within this study and also found strong evidence for genetic effects on susceptibility to melanoma from markers on chromosome 9p21.3 in the p16/ARF region and on chromosome 1q21.3 (ARNT/LASS2/ANXA9 region). The most significant single-nucleotide polymorphisms (SNPs) in the 15q13.1 locus (rs1129038 and rs12913832) lie within a genomic region that has profound effects on eye and skin color; notably, 50% of variability in eye color is associated with variation in the SNP rs12913832. Because eye and skin colors vary across European populations, we further evaluated the associations of the significant SNPs after carefully adjusting for European substructure. We also evaluated the top 10 most significant SNPs by using data from three other genome-wide scans. Additional in silico data provided replication of the findings from the most significant region on chromosome 1q21.3 rs7412746 (P = 6 × 10(-10)). Together, these data identified several candidate genes for additional studies to identify causal variants predisposing to increased risk for developing melanoma.

Performance assessment of copy number microarray platforms using a spike-in experiment.

MOTIVATION: Changes in the copy number of chromosomal DNA segments [copy number variants (CNVs)] have been implicated in human variation, heritable diseases and cancers. Microarray-based platforms are the current established technology of choice for studies reporting these discoveries and constitute the benchmark against which emergent sequence-based approaches will be evaluated. Research that depends on CNV analysis is rapidly increasing, and systematic platform assessments that distinguish strengths and weaknesses are needed to guide informed choice. RESULTS: We evaluated the sensitivity and specificity of six platforms, provided by four leading vendors, using a spike-in experiment. NimbleGen and Agilent platforms outperformed Illumina and Affymetrix in accuracy and precision of copy number dosage estimates. However, Illumina and Affymetrix algorithms that leverage single nucleotide polymorphism (SNP) information make up for this disadvantage and perform well at variant detection. Overall, the NimbleGen 2.1M platform outperformed others, but only with the use of an alternative data analysis pipeline to the one offered by the manufacturer. AVAILABILITY: The data is available from http://rafalab.jhsph.edu/cnvcomp/. CONTACT: pevsner@jhmi.edu; fspencer@jhmi.edu; rafa@jhu.edu SUPPLEMENTARY INFORMATION: Supplementary data are available at Bioinformatics online.

No observed association for mitochondrial SNPs with preterm delivery and related outcomes.

BACKGROUND: Preterm delivery (PTD) is the leading cause of neonatal morbidity and mortality. Epidemiologic studies indicate recurrence of PTD is maternally inherited, creating a strong possibility that mitochondrial variants contribute to its etiology. This study examines the association between mitochondrial genotypes and PTD and related outcomes. METHODS: This study combined, through meta-analysis, two case-control, genome-wide association studies: one from the Danish National Birth Cohort Study and one from the Norwegian Mother and Child Cohort Study (MoBa) conducted by the Norwegian Institute of Public Health. The outcomes of PTD (≤36 wk), very PTD (≤32 wk), and preterm prelabor rupture of membranes (PPROM) were examined. A total of 135 individual single-nucleotide polymorphism (SNP) associations were tested using the combined genome from mothers and neonates (case vs. control) in each population and then pooled via meta-analysis. RESULTS: After meta-analysis, there were four SNPs for the outcome of PTD below P ≤ 0.10 and two below P ≤ 0.05. For the additional outcomes of very PTD and PPROM, there were three and four SNPs, respectively, below P ≤ 0.10. CONCLUSION: Given the number of tests, no single SNP reached study-wide significance (P = 0.0006). Our study does not support the hypothesis that mitochondrial genetics contributes to the maternal transmission of PTD and related outcomes.

Autonomic measures identify stress, pain, and instability associated with retinopathy of prematurity ophthalmologic examinations.

Background: Retinopathy of prematurity (ROP) ophthalmologic examinations cause stress and pain. Infants' stress and pain can be measured non-invasively using skin conductance (SC) and high frequency heart rate variability (HF-HRV), reflecting sympathetic-mediated sweating and parasympathetic activity, respectively. Objectives: To test the utility of SC to detect sympathetic activation during ROP examination, and the contribution of HF-HRV to predict stability post-examination. Methods: In this prospective, single center study, we measured SC continuously pre-, during, and post-examination, and HRV at 24 h pre-ROP examination. Clinical data included stability [apneas, bradycardias, and desaturations (A/B/Ds)], and interventions post-examination. Results: SC increased 56% above baseline during ROP examination (p = 0.001) and remained elevated post-examination (p = 0.02). Post-hoc analysis showed higher illness acuity, represented by need for respiratory support, was associated with lower HF-HRV at 24 h pre-ROP examination (p = 0.001). Linear regression indicated lower HF-HRV at 24 h pre-examination contributed to the need for higher intervention (i.e., stimulation to breathe, oxygen support) particularly among infants with higher illness acuity [F(1, 15) = 5.05, p = 0.04; ß = -1.33, p = 0.04]. Conclusion: ROP examination induced a 2-fold increase in sympathetic activation which remained above baseline in recovery. Also, we propose that the low parasympathetic tone associated with autonomic imbalance contributes to instability and need for higher intervention to assure stabilization with A/B/D events. Our findings provide insight into the underestimation of adverse events associated with ROP examination and identification of infants who may be more vulnerable to potential sequelae following ROP examinations.

Identification of Two Genetic Loci Associated with Leukopenia after Chemotherapy in Patients with Breast Cancer.

PURPOSE: To identify molecular predictors of grade 3/4 neutropenic or leukopenic events (NLE) after chemotherapy using a genome-wide association study (GWAS). EXPERIMENTAL DESIGN: A GWAS was performed on patients in the phase III chemotherapy study SUCCESS-A (n = 3,322). Genotyping was done using the Illumina HumanOmniExpress-12v1 array. Findings were functionally validated with cell culture models and the genotypes and gene expression of possible causative genes were correlated with clinical treatment response and prognostic outcomes. RESULTS: One locus on chromosome 16 (rs4784750; NLRC5; P = 1.56E-8) and another locus on chromosome 13 (rs16972207; TNFSF13B; P = 3.42E-8) were identified at a genome-wide significance level. Functional validation revealed that expression of these two genes is altered by genotype-dependent and chemotherapy-dependent activity of two transcription factors. Genotypes also showed an association with disease-free survival in patients with an NLE. CONCLUSIONS: Two loci in NLRC5 and TNFSF13B are associated with NLEs. The involvement of the MHC I regulator NLRC5 implies the possible involvement of immuno-oncological pathways.

FOXE1 association with both isolated cleft lip with or without cleft palate, and isolated cleft palate.

Nonsyndromic orofacial clefts are a common complex birth defect caused by genetic and environmental factors and/or their interactions. A previous genome-wide linkage scan discovered a novel locus for cleft lip with or without cleft palate (CL/P) at 9q22-q33. To identify the etiologic gene, we undertook an iterative and complementary fine mapping strategy using family-based CL/P samples from Colombia, USA and the Philippines. Candidate genes within 9q22-q33 were sequenced, revealing 32 new variants. Concurrently, 397 SNPs spanning the 9q22-q33 2-LOD-unit interval were tested for association. Significant SNP and haplotype association signals (P = 1.45E - 08) narrowed the interval to a 200 kb region containing: FOXE1, C9ORF156 and HEMGN. Association results were replicated in CL/P families of European descent and when all populations were combined the two most associated SNPs, rs3758249 (P = 5.01E - 13) and rs4460498 (P = 6.51E - 12), were located inside a 70 kb high linkage disequilibrium block containing FOXE1. Association signals for Caucasians and Asians clustered 5' and 3' of FOXE1, respectively. Isolated cleft palate (CP) was also associated, indicating that FOXE1 plays a role in two phenotypes thought to be genetically distinct. Foxe1 expression was found in the epithelium undergoing fusion between the medial nasal and maxillary processes. Mutation screens of FOXE1 identified two family-specific missense mutations at highly conserved amino acids. These data indicate that FOXE1 is a major gene for CL/P and provides new insights for improved counseling and genetic interaction studies.