Whole-genome sequencing can identify clinically relevant variants from a single sub-punch of a dried blood spot specimen

The collection of dried blood spots (DBS) facilitates newborn screening for a variety of rare, but very serious conditions in healthcare systems around the world. Sub-punches of varying sizes (1.5–6 mm) can be taken from DBS specimens to use as inputs for a range of biochemical assays. Advances in DNA sequencing workflows allow whole-genome sequencing (WGS) libraries to be generated directly from inputs such as peripheral blood, saliva, and DBS. We compared WGS metrics obtained from libraries generated directly from DBS to those generated from DNA extracted from peripheral blood, the standard input for this type of assay. We explored the flexibility of DBS as an input for WGS by altering the punch number and size as inputs to the assay. We showed that WGS libraries can be successfully generated from a variety of DBS inputs, including a single 3 mm or 6 mm diameter punch, with equivalent data quality observed across a number of key metrics of importance in the detection of gene variants. We observed no difference in the performance of DBS and peripheral-blood-extracted DNA in the detection of likely pathogenic gene variants in samples taken from individuals with cystic fibrosis or phenylketonuria. WGS can be performed directly from DBS and is a powerful method for the rapid discovery of clinically relevant, disease-causing gene variants

Effects of abortion legalization in Nepal, 2001-2010.

Abortion was legalized in Nepal in 2002, following advocacy efforts highlighting high maternal mortality from unsafe abortion. We sought to assess whether legalization led to reductions in the most serious maternal health consequences of unsafe abortion.We conducted retrospective medical chart review of all gynecological cases presenting at four large public referral hospitals in Nepal. For the years 2001-2010, all cases of spontaneous and induced abortion complications were identified, abstracted, and coded to classify cases of serious infection, injury, and systemic complications. We used segmented Poisson and ordinary logistic regression to test for trend and risks of serious complications for three time periods: before implementation (2001-2003), early implementation (2004-2006), and later implementation (2007-2010).23,493 cases of abortion complications were identified. A significant downward trend in the proportion of serious infection, injury, and systemic complications was observed for the later implementation period, along with a decline in the risk of serious complications (OR 0.7, 95% CI 0.64, 0.85). Reductions in sepsis occurred sooner, during early implementation (OR 0.6, 95% CI 0.47, 0.75).Over the study period, health care use and the population of reproductive aged women increased. Total fertility also declined by nearly half, despite relatively low contraceptive prevalence. Greater numbers of women likely obtained abortions and sought hospital care for complications following legalization, yet we observed a significant decline in the rate of serious abortion morbidity. The liberalization of abortion policy in Nepal has benefited women's health, and likely contributes to falling maternal mortality in the country. The steepest decline was observed after expansion of the safe abortion program to include midlevel providers, second trimester training, and medication abortion, highlighting the importance of concerted efforts to improve access. Other countries contemplating changes to abortion policy can draw on the evidence and implementation strategies observed in Nepal

Trend in the percentage of abortion cases with serious complications presenting at four tertiary care hospitals in Nepal, 2001–2010, N = 23,493.

<p>Early implementation, monthly IRR from segmented Poisson regression = 1.002, p<.001; later implementation, monthly IRR = 0.993, p<.001; marginal spline test for slope change, p<.001) Serious complications are those with infection (sepsis or septic shock, peritonitis, endometritis, severe pelvic or peritoneal infection, or body temperature> = 102 F), evidence of foreign body or mechanical injury, systemic complications, such as organ failure, or death. 2002 - Passage of legal abortion legislation 2004 - First trimester services and trainings begin 2007 - Second trimester services and trainings begin 2008 - Midlevel providers trained and legally provide first trimester abortion 2009 - Medication abortion added to safe abortion program.</p

Serious abortion complications as a proportion of all abortion complications presenting at hospitals before and after implementation of legal abortion in Nepal, N = 23,493.

*<p>p<0.05, **p<0.001, ***p<0.001, from Fisher’s Exact statistical test for categorical differences.</p>a<p>Other infections include peritoneal infection and pyoperitoneum, as well as two cases of unspecified infection treated with intravenous antibiotics.</p>b<p>Includes high pulse related to systemic complications, blood loss, and unspecified.</p>c<p>Not including septic shock.</p>d<p>Other systemic complications include deep vein thrombosis, embolism and loss of consciousness.</p

Characteristics of patients abstracted from medical charts for all abortion complication cases, 2001–2010, N = 23,493.

a<p>Information on patient demographics was not consistently available in the medical chart. The percentages are calculated on the non-missing n.</p>b<p>Missing data on the number of births increased at MH and TUTH, and declined at BDH and LZH.</p>c<p>Clinical evidence such as foreign body or injury from instrumentation (e.g., uterine perforation) or free-text chart documentation of induced abortion based upon patient disclosure or provider observation.</p

Multiple variable analysis of factors associated with serious abortion complications, adjusted logistic regression odds ratios^a.

*<p>p<.05, ** p<.01, ***p<.001.</p>a<p>All odds ratios are also adjusted for hospital and season.</p>b<p>Data on the stage of pregnancy was missing in 7.6% of the medical charts. Significance and direction of results were unchanged when the stage of pregnancy variable was excluded from the models.</p>c<p>Clinical evidence such as foreign body or injury from instrumentation (e.g., uterine perforation) or free-text chart documentation of induced abortion based upon patient disclosure or provider observation.</p