1. Ukraine Clinical Study: U01
Christina Chambers, PhD
Carl Keen, PhD
Claire Coles, PhD
Julie Kable, PhD
Kenneth Lyons Jones, MD
Wladimir Wertelecki, MD
Rajesh Miranda, PhD
Kelly Frazer, PhD
Rhongui Xu, PhD
Lyubov Yevtushok, MD
Natalya Zymak, MD

2. Specific Aim 1
Determine if the beneficial effects of a prenatal multivitamin/mineral supplement in alcohol-exposed children persists to pre-school age
Does the effect of the nutrient supplements persist in children who are years of age?
Do measures previously collected in infancy correlate with preschool measures?

3. Specific Aim 2
Determine if prenatal alcohol exposure affects child nutritional status, and determine to what extent that affects child growth and performance
Does prenatal exposure affect current child nutritional status in context of child’s dietary intake as measured between 2 and 5 years of age?
Does child’s current nutritional status predict neurodevelopmental performance and/or growth through 5 years of age in the context of prenatal alcohol exposure?

4. Specific Aim 3
Determine if a miRNA biomarker for alcohol exposure is useful as a marker of recent or distant exposure to alcohol in the human
Can an alcohol-related maternal circulating miRNA profile be identified among drinking women?
Does that profile (or another) persist in 3rd trimester maternal plasma, and/or in the child?
Do any miRNA profiles identified in mother or child relate to FASD (growth and performance)?

5. Specific Aim 4
Explore genetic and epigenetic risk factors for FASD, effect of maternal/child nutrition on 3D facial images, and telemedicine approaches to earlier diagnosis
Do genetic variants suggested by other CIFASD collaborators occur more frequently in heavily exposed mother/child pairs?
Is variance in methylation status associated with heavily exposed mother/child pairs in context of nutritional status?
Is 3D imaging an effective diagnostic aid in infants/young children?Does pre or postnatal nutrition impact image classification?
Can telemedicine approaches in remote areas aid in earlier/accurate diagnosis of FASD?

6. Sample
Retain and test ~300 children from original sample with preschool battery
Continue to perform Bayleys and heart rate monitoring for children up to12 months of age
Recruit and follow 120 new pregnant women with no MVM intervention
Continue blood sampling 2x in pregnancy for nutritional status, and prenatal ultrasounds for newly recruited women

7. Progress
2 U.S. (Emory and Davis) and 1 foreign subcontract all in place
1 U.S. subcontract for Year 2 (Texas A&M) in progress
Collaborator’s agreement terms negotiated for administrators at both foreign sites
Purchase of and translation into Ukrainian of preschool neurobehavioral testing battery
Training in person for both psychologists in Ukraine initiated October, 2011
Purchase of new (portable) heart rate monitoring setup in progress; replacement of existing non-functional equipment at the same time; both to be delivered March, 2013

8. Progress
Obtained IRB approval to use archived maternal blood samples for de-identified analysis (Pediatric Genomics at UCSD; Rutgers; Texas A&M)
Selecting appropriate samples
Oragene kits for saliva collection delivered to Ukraine
Protocol for child blood and urine collection reviewed with Ukrainian partners and modified to add a third visit to reduce per visit blood quantity required and to improve retention
Adding a local test to provide immediate feedback to participants
Customs process for 3D camera to be initiated Jan, 2013
Created 15 minute training video for new sample preparation

10. Progress
Informatics group working with U.S. Data Manager and Julie Kable to finalize the neurobehavioral input tool
Created an Access database for complex scheduling of visits and a user manual; trained Khmelnytsky Data Manager on this in December

11. Enrollment Data
Shows the entire history of the subject, e.g. group, due date, exam date, any LTF

12. Criteria for eligible subject
current age greater than 3 years old but less than 6yr &11mo
not LTF/drop
Status on 12 month (and previous visits)

13. Preschool evaluation eligible subject list
Setting the criteria from the previous slide will give us this list

14. Preschool cumulative list
An overview of all subjects who have reached testing age and the test status (Status)

15. Cumulative counts by ETOH/Vit group
Can look at the cumulative number of subjects eligible and/or tested by ETOH group and by Vit group
ETOH Group (0,1,2)
Row sum
Counts of subjects by Status, site, ETOH Group, and Vit Group

16. Progress: data analysis
DSMB met in 2012 and approved formal interim data analysis
Revised statistical analysis plan (approved by the DSMB) called for nominal p-value cutoff of <0.005 with sample tested at 12 months (50 each in the no MVM intervention and yes MVM intervention alcohol-exposed group); and revised nominal p-value cutoff for final analysis of in order to ensure an overall 2-sided Type I error rate of 0.05
Due to 3 sets of twin pairs in the MVM intervention group, sample had to be reduced by randomly selecting one of each set

17. Progress: interim analysis BSID scores at 12m by nutrition intervention in alcohol exposed
Group
Vitamin No
N=50
Yes
P-value
PDI
95.1 (16.5)
98.5 (12.7)
0.255
MDI
88.0 (14.4)
93.7 (11.6)
0.032

18. Progress: Interim analysis: balanced by randomization groups
Vitamin No
Vitamin Yes
Mean Age Years 25
Mean GA Weeks 20 17
Mean Parity
.96
.91
Mean Years Education 13
Intervention Randomization
None
46% MVM only
54% MVM+choline
Smoker (%)
Never
Previous
Quit in Pregnancy
Continued in Pregnancy 27 8 42 23 34 10 30 26
Other Vitamin Use
Some 73 32 68

19. Progress: final analysis
Expect to have required 150 subjects tested at 12 months and data entered by Feb. 1
Will allow for all subsequent analyses pending publication of the primary analysis to proceed.

20. Progress: PRAMS publication: analysis of multivitamin supplement use and alcohol consumption
Phase 5 core questionnaire
111,644 women from 39 states who completed questions on
Alcohol consumption in the 3 months before pregnancy
Multivitamin or prenatal vitamin supplement use in the month before pregnancy

21. Progress: PRAMS analysis of multivitamin supplement use and alcohol consumption
Drinks 3 Mo Before Pregnancy
Multivitamin Use
Adjusted OR
95% CI
None
1.00
reference
Up to 3 per week
0.76
0.72, 0.80
4-6 per week
0.60
0.56, 0.66
7-13 per week
0.49
0.44, 0.55
14 or more per week
0.39
0.32, 0.47
P-for-trend <0.001
Adjusted for maternal education, race/ethnicity, household income, age, parity

22. Progress: PRAMS analysis of multivitamin supplement use and alcohol consumption
Number Binges 5 or more in 3 Mo Before Pregnancy
Multivitamin Use
Adjusted OR
95% CI
None
1.00
reference
1 time
0.76
0.71, 0.81
2-3 times
0.66
0.62, 0.70
4-5 times
0.56
6+ times
0.50
0.44, 0.56
P-for-trend <0.001
Adjusted for maternal education, race/ethnicity, household income, age, parity

23. Progress: PRAMS analysis of multivitamin supplement use and alcohol consumption

24. Progress: PRAMS analysis of multivitamin supplement use and alcohol consumption

25. Prenatal ultrasound brain measures - Ukraine sample
Transverse Cerebellar Diameter
Occipital Frontal Diameter
Caval-Calvarial Distance
Frontothalamic Distance
Outer Orbital Distance
Interorbital Distance
Orbital Distance
TCD T
CCD
OOD
FTD

26. Progress: ultrasound papers (1): ultrasound measures at 4-6 months gestation as predictors of exposure
Exposed
N = 104
Unexposed
N = 135
P-value*
Frontothalamic distance
37.7 (5.4)
39.1 (4.7)
0.026
Caval calvarial distance
24.0 (3.1)
24.8 (3.0)
0.006
*Adjusted for gestational age, smoking, and vitamin use

27. Progress: ultrasound papers (1): ultrasound measures at 4-6 months gestation as predictors of physical features
Feature
U/S Measure
Direction of U/S Measure
Short pf’s
Inter-orbital distance
wider
Thin vermillion
narrower
Smooth philtrum
Occipital frontal diameter
longer
Maxillary arc
Orbital diameter
shorter
Mandibular arc

28. Progress: ultrasound papers (2): ultrasound measures at 4-6 months gestation as predictors of Bayley score
Examined MDI and PDI at 6 and 12 months in relation to the following measures (standardized for gestational age at measure), adjusted for alcohol group, vitamin group, alc x vit interaction, use of non-study vitamins, smoking status, and prepregnancy BMI
TCD
CCD
OFD
FTD
OOD
IOD OD

29. Progress: ultrasound papers (2): ultrasound measures at 4-6 months gestation as predictors of Bayley score
U/S Measure
6M MDI
(p-value)
12M MDI
6M PDI
12M PDI
CCD --
+0.87 (0.02)
FTD
+0.63 (<0.001)
+1.06 (< )
+0.87 (0.001)
+0.73 (<0.01)
IOD
-1.14 (<0.001)
-2.00 (<0.0001)
-1.58 (<0.001)
-1.14 (<0.01)

30. Other activities Submitted 2 UC Global Health Fellowship applications
1 Ukrainian OB/ultrasonographer for 11 month-fellowship to
Describe range of defects diagnosed by prenatal ultrasound in relation to post-natal diagnosis
Link to women screened for alcohol and look at prevalence of specific malformations by dose of alcohol reported
Describe other malformations in all children in the Eurocat Ukraine register who have an FAS diagnosis
1 U.S. 2nd year medical student from Ukraine for 11 month fellowship to
Conduct family interviews with 30 families of an FAS child in Ukraine to describe natural history, recurrence and compare to similar number of families identified through FASD study with high alcohol use but apparently unaffected child
Possible collaboration on 2 women in science fellowship applications for K. Sulik