Intellectual Developmental Disabilities Research Articles

Assessment of Isokinetic Strength of Knee Extension/Flexion of Individuals With Intellectual Developmental Disabilities—Systematic Review With Protocol Proposal

ABSTRACT Muscle performance is a crucial determinant of physical function in the daily lives of individuals with intellectual developmental disabilities (IDD), with lower strength levels often leading to loss of independence. The isokinetic dynamometer has been established as a reliable method for assessing muscle performance in this population. This article outlines the design of a protocol to be adopted to assess isokinetic knee strength in individuals with IDD. Using systematic review methodology, electronic searches were conducted in PubMed, Scopus, SPORTDiscus, and Web of Science databases, including articles published between January 1990 and September 2022. The key terms were combined with the Boolean operator “AND” or “OR”. After the methodological process, 23 studies were included for analysis. The protocol proposal consists of 8 phases, covering previous considerations: (a) warm-up, (b) familiarization; (c) equipment adjustment, choosing the limb to evaluate and in what type of action (concentric and/or eccentric); (d) number of repetitions and sets; (e) the rest duration; (f) angular velocity to be tested; and (g) parameters for analysis. It is intended that this article provide insights into the development of a useful tool for the various stakeholders interested in assessing the isokinetic knee strength of individuals with IDD.

Teaching Physician Assistant Students to Care for People With Intellectual and Developmental Disabilities.

The purposes of this educational activity were to instill in students a greater empathy for patients with intellectual developmental disabilities, give students a better understanding of how to obtain a medical history for patients with communication limitations, teach students practical tips for obtaining a medical history and physical examination to increase competence in their future practice, and to build a relationship with a local organization that serves people with intellectual disabilities. An experiential learning activity was added to the curriculum of two courses for first-year PA students to accomplish these goals. The course instructors engaged in several planning meetings with a local residential facility for people with intellectual disabilities, including choosing patients that the students would assess. The students made 3 visits to the facility. The visits included interactive lectures by a physical therapist, occupational therapist, nurse practitioner, medical doctor, and dentist. Two of the facility involved patient visits at designated homes on campus. The students then wrote comprehensive visit notes with patient identifying information removed and submitted them for grading. Students expressed feeling better prepared to assess people with intellectual disabilities and having an increased appreciation for obtaining quality medical histories. The partner facility also reported they received positive feedback from staff participants and indicated they would like to continue this partnership.

Identification and educational placement of students with intellectual disability in Ontario, Canada

BackgroundLittle is known about the identification and educational placement of students considered to have intellectual disability in the Canadian context and, specifically, the province of Ontario. AimsThe purpose of this study was to describe trends in the school-based identification of students with mild intellectual disability and developmental disability based on the Ontario criteria over a 14-year period, as well as current patterns characterizing classroom placement. MethodsUsing data provided by the Ontario Ministry of Education, a doubly multivariate analysis of variance and profile analysis were performed. ResultsFindings revealed a statistically significant decrease in the number of students identified with mild intellectual disability over time, and that students identified with developmental disability per the provincial criteria accessed their education in specialized settings at a significantly higher rate than their peers with mild intellectual disability. ConclusionsReasons for differences in the identification and placement of the two groups of students are explored relative to the research context.

An Examination of the Effectiveness of Ballet on Gross Motor Function in Children with Intellectual Developmental Disabilities

The purpose of this study was to examine how ballet could be used as a form of therapy to improve gross motor function in children with intellectual developmental disabilities (IDDs). Fourteen participants (ages 4-12, 10 males, 4 females) who were enrolled in Monday and Friday camp days at ABC Educational Services, Inc. Stimulation School Summer Camp were included in the study. Participants completed the Bruininks-Oseretsky Test of Motor Proficiency, 2nd Edition (BOT-2) during the first week of the intervention. For the following six weeks, participants engaged in thirty-minute ballet classes twice a week. During week eight of the intervention participants completed the BOT-2 test a second time. The results indicated that children with a suspected IDD did not consistently score below average on the BOT-2. Additionally, statistically significant correlations between ballet instruction and gross motor proficiency were not found. Further studies should be done to continue to examine the relationship between ballet and gross motor function.

The impact of social-environmental factors on IQ in syndromic intellectual developmental disabilities.

Despite having the same underlying genetic etiology, individuals with the same syndromic form of intellectual developmental disability (IDD) show a large degree of interindividual differences in cognition and IQ. Research indicates that up to 80% of the variation in IQ scores among individuals with syndromic IDDs is attributable to nongenetic effects, including social-environmental factors. In this narrative review, we summarize evidence of the influence that factors related to economic stability (focused on due to its prevalence in existing literature) have on IQ in individuals with syndromic IDDs. We also highlight the pathways through which economic stability is hypothesized to impact cognitive development and drive individual differences in IQ among individuals with syndromic IDDs. We also identify broader social-environmental factors (e.g., social determinants of health) that warrant consideration in future research, but that have not yet been explored in syndromic IDDs. We conclude by making recommendations to address the urgent need for further research into other salient factors associated with heterogeneity in IQ. These recommendations ultimately may shape individual- and community-level interventions and may inform systems-level public policy efforts to promote the cognitive development of and improve the lived experiences of individuals with syndromic IDDs.

Burden and Epidemiology of Mental Disorders in the Middle East and North Africa from 1990 to 2019: Findings from the Global Burden of Disease Study

Previous studies have mainly focused on individual mental disorders, and there is no study addressing the total burden of mental disorders in the Middle East and North Africa (MENA). To evaluate the burden of mental disorders in the MENA region from 1990 to 2019. A cross-sectional study. We utilized global burden of disease data to examine the burden of 12 mental disorders from 1990 to 2019 across age groups, genders, and the 21 MENA countries. We collected data on prevalence, incidence, mortality, years of life lost, years lived with disability, and disability-adjusted life-years (DALY), including both crude and age-standardized rates per 100,000 people. The DALY rate of mental disorders in MENA countries increased by 13.88% from 1,747.92 per 100,000 people in 1990 to 1990.5 per 100,000 people in 2019. The highest percentage increases in the DALY rates of mental disorders were observed for bulimia nervosa (35.69%), other mental health disorders (34.58%), and schizophrenia (33.02%) from 1990 to 2019. However, the DALY rates for idiopathic developmental intellectual disability (-26.48%), conduct disorder (-23.91%), attentiondeficit/ hyperactivity disorder (-16.46%), and autism spectrum disorders (-4.12%) decreased in the MENA region from 1990 to 2019. In 2019, the highest DALY rates for idiopathic developmental intellectual disability, anxiety disorders, and major depressive disorder were observed in age groups ≤ 4 years, 5-19 years, and ≥ 20 years, respectively. The age-standardized DALY rate of mental disorders was the highest in Palestine (2,396.9 per 100,000), Iran (2,295.8 per 100,000), and Lebanon (2,126.0 per 100,000) compared with other MENA countries in 2019. There has been a slight increase in the burden of mental disorders in the MENA region between 1990 and 2019. National policies should prioritize evidence-based preventive measures and ensure accessible treatment options for mental health disorders in the population, especially in the MENA region.

Barriers to Utilizing National Trust Act Programmes: A Qualitative Study of Caregivers of Children with Intellectual Developmental Disability (IDD)

Barriers to Utilizing National Trust Act Programmes: A Qualitative Study of Caregivers of Children with Intellectual Developmental Disability (IDD)

Population Level Mental Health Diagnoses for Youth with Intellectual/Developmental Disabilities Compared to Youth without Intellectual/Developmental Disabilities.

There is evidence in the literature that youth with intellectual/developmental disabilities (IDD) experience mental health issues to a greater extent compared to youth without IDD. In addition, transition from pediatric to adult services may be a period of increased anxiety and mental health problems for these youth. This study used a retrospective cohort design using population level administrative health data to compare mental health diagnoses between youth with IDD and youth without IDD; particularly examining the period when youth transition from pediatric health services to adult health services. In addition, this study compared the mental health of youth with various types of IDD (Down syndrome, autism, fetal alcohol syndrome and other rarer diagnoses). Results showed that at the population level youth with IDD have greater odds of anxiety/depression or psychotic illness than youth without IDD. Adjusted odds of anxiety/depression or psychotic illness also varied with age, income level, sex, and type of IDD. Youth with fetal alcohol syndrome had the greatest odds of both anxiety/depression and a psychotic illness. Odds of anxiety/depression increased from age 15-19 years old. Odds of a psychotic illness increased from age 15 to age 24 years old.

Cognitive reserve proxies for individuals with intellectual developmental disability: A scoping review

AbstractBackgroundCognitive reserve (CR) has not been studied in people with Intellectual Developmental Disability, a population with a high incidence of dementia. Commonly adopted CR proxies should be adapted to reflect more specifically the experiences of people with Intellectual Developmental Disability.MethodThis scoping review intended to identify CR proxies relevant to people with this condition.ResultsSome of these were the same already detected in a population without intellectual disabilities (education, occupation, physical activity, leisure, community and social activities); others were found to be specifically relevant for this population: type of schooling, parental educational level, environmental stimulation and living place.ConclusionsThese proxies need to be considered in studies on CR and Intellectual Developmental Disability and in clinical practice. Research on the protective effect of CR aims to encourage policies promoting lifestyle‐based educational and preventive interventions and overcome participation barriers for people with Intellectual Developmental Disability.

Norwegian perspectives on health care for people with intellectual and developmental disabilities

AbstractThe Norwegian health care system is built on individual rights and the principles of universal access, decentralization, and free choice of provider. Norway has universal health coverage, funded primarily by general taxes and by payroll contributions shared by employers and employees. Local authorities at the municipal level organize and finance primary health care services according to local demand and within national frameworks. Habilitation services are offered both in the primary health care and as a part of the specialist health services. They offer both inpatient and outpatient services for people with intellectual/developmental disabilities (IDD). National guidelines, known as Good health and care services for people with IDD, have recently (2021) been launched after various reports over the years of serious breaches and challenges in the health and care services provided to people with IDD.

Differences in Telemedicine Use Between People With and Without an Intellectual or Other Developmental Disability During the COVID-19 Pandemic.

Telemedicine utilization of people with an Intellectual or Other Developmental Disability (IDD) during the COVID-19 Pandemic is not well known. This study compares telemedicine utilization of those with and without IDD prior to the pandemic to after it began. Using the Utah All Payers Claims Database from 2019 to 2021, the study identified telemedicine utilization of adults aged 18 to 62 years old in 2019. Propensity score matching was used to minimize observed confounders of subjects with and without IDD in 2019. Negative binomial regression was used to identify factors that were associated with telemedicine utilization. The final number of subjects in the analysis was 18 204 (IDD: n = 6068, non-IDD: n = 12 136 based on 1:2 propensity score matching). The average (SD) age of the subjects was 31 (11.3) years old in 2019. Forty percent of the subjects were female, about 70% of subjects were covered by Medicaid in 2019. Average (SD) number of telemedicine use in 2020 (IDD: 1.96 (5.97), non-IDD: 1.18 (4.90); P < .01) and 2021 (IDD: 2.24 (6.78) vs 1.37 (5.13); P < .01) were higher for the IDD group than the non-IDD group. The regression results showed that the subjects with IDD had 56% more telemedicine encounters than those in the non-IDD group (Incidence Rate Ratio (IRR) = 1.56, P < .01). The growth of telemedicine during the COVID-19 pandemic has the potential to reduce persistent healthcare disparities in individuals with IDD. However, quality of telemedicine should be considered when it is provided to improve health of subjects with IDD.

Identification of two novel and one rare mutation in DYRK1A and prenatal diagnoses in three Chinese families with intellectual Disability-7.

Background and purpose: Intellectual disability-7 (MRD7) is a subtype disorder of intellectual disability (MRD) involving feeding difficulties, hypoactivity, and febrile seizures at an age of early onset, then progressive intellectual and physical development deterioration. We purposed to identify the underlying causative genetic factors of three individuals in each Chinese family who presented with symptoms of intellectual disability and facial dysmorphic features. We provided prenatal diagnosis for the three families and genetic counseling for the prevention of this disease. Methods: We collected retrospective clinical diagnostic evidence for the three probands in our study, which included magnetic resonance imaging (MRI), computerized tomography (CT), electroencephalogram (EEG), and intelligence tests for the three probands in our study. Genetic investigation of the probands and their next of kin was performed by Trio-whole exome sequencing (WES). Sanger sequencing or quantitative PCR technologies were then used as the next step to verify the variants confirmed with Trio-WES for the three families. Moreover, we performed amniocentesis to explore the state of the three pathogenic variants in the fetuses by prenatal molecular genetic diagnosis at an appropriate gestational period for the three families. Results: The three probands and one fetus were clinically diagnosed with microcephaly and exhibited intellectual developmental disability, postnatal feeding difficulties, and facial dysmorphic features. Combining probands' clinical manifestations, Trio-WES uncovered the three heterozygous variants in DYRK1A: a novel variant exon3_exon4del p.(Gly4_Asn109del), a novel variant c.1159C>T p.(Gln387*), and a previously presented but rare pathogenic variant c.1309C>T p.(Arg437*) (NM_001396.5) in three families, respectively. In light of the updated American College of Medical Genetic and Genomics (ACMG) criterion, the variant of exon3_exon4del and c.1159C>T were both classified as likely pathogenic (PSV1+PM6), while c1309C>T was identified as pathogenic (PVS1+PS2_Moderate+PM2). Considering clinical features and molecular testimony, the three probands were confirmed diagnosed with MRD7. These three discovered variants were considered as the three causal mutations for MRD7. Prenatal diagnosis detected the heterozygous dominant variant of c.1159C>T p.(Gln387*) in one of the fetuses, indicating a significant probability of MRD7, subsequently the gestation was intervened by the parents' determination and professional obstetrical operation. On the other side, prenatal molecular genetic testing revealed wild-type alleles in the other two fetuses, and their parents both decided to sustain the gestation. Conclusion: We identified two novel and one rare mutation in DYRK1A which has broadened the spectrum of DYRK1A and provided evidence for the diagnosis of MRD7 at the molecular level. Besides, this study has supported the three families with MRD7 to determine the causative genetic factors efficiently and provide concise genetic counseling for the three families by using Trio-WES technology.

EFFECTIVENESS OF PARENTING SKILL PROGRAM ON CHILDS ADAPTIVE BEHAVIORAMONG PARENTS OF CHILDREN WITH INTELLECTUAL DEVELOPMENTAL DISABILITY

Background: A child brings happiness, love and joy in the family and society and if a child born with Intellectual Developmental Disability (IDD), then parenting of IDD children requires a huge amount of liability, accountability, commitment and dedication. Children with intellectual disability are having debilitate physical and mental health conditions, lower longevity1. As parents are the primary caregivers, but lives of parents of children with IDD are much more complicated and stressful as compared to the lives of non-disabled childrens parents. Methodology: Quasi-experimental Time Series Research Design was used to assess the effectiveness of Parenting Skill Program on childs adaptive behavior among parents of children with Intellectual developmental disability in selected Special Schools of Delhi NCR.The tools used for data collection included a socio-demographic proforma and the Vineland Social Maturity Scale (VSMS). Structured interviews and pre-assessment tools, such as socio-demographic proforma and the Vineland Social Maturity Scale (VSMS), were administered to both experimental and control groups in the first month. Subsequently, the parenting skills program, consisting of 12 sessions, was implemented over a three-month period, with one session per week for parents in the experimental group. At the 6th, 9th, and 12th months, structured interviews using post-assessment tools were conducted with parents from both groups. Results: The findings of the study revealed thatthere was an improvement in the mean posttest score of childs adaptive behavior over the time. Specifically, at 6th month, it increased to (53.425±8.95), followed by (52.850±9.77) at 9th month and (55.288±8.87) at 12th month when compared to baseline score (46.362±8.09).This increase was found to be statistically significant within the group (F= 163.040, p 0.001).However, the control group, showed no significant change in the mean score of childs adaptive behavior and it remained same in 6th month, 9th month and 12th month as baseline, and no significant difference was observed within the group (F= 6.00, p 0.112). Hence, it could be interpreted that parenting skill program was effective in improving the childs adaptive behavior score of children with IDD in experimental group than in control group. Conclusion:It was concluded thatparenting skill program was effective in improving the childs adaptive behavior of children with IDD.

Our Lives, Our Voices: Impact of Self-Advocacy Program on Persons with Intellectual Developmental Disability

Our Lives, Our Voices: Impact of Self-Advocacy Program on Persons with Intellectual Developmental Disability

Effectiveness of L-serine supplementation in children with a GRIN2B loss-of-function mutation: Rationale and protocol for single patient (n-of-1) multiple cross-over trials

RationaleLoss-of-function (LoF) mutations in GRIN2B result in neurologic abnormalities due to N-methyl-D-aspartate receptor (NMDAR) dysfunction. Affected persons present with various symptoms, including intellectual developmental disability (IDD), hypotonia, communication deficits, motor impairment, complex behavior, seizures, sleep disorders and gastrointestinal disturbance. Recently, in vitro experiments showed that D-serine mitigates function to GluN2B (mutation)-containing NMDARs. 11 previous case reports are published on (experimental) L-serine treatment of patients between 1.5 and 12 years old with GRIN2B missense or null mutations, some of whom showed notable improvement in motor and cognitive performance, communication, behavior and abnormalities on electro encephalography (EEG). Our objective is to further evaluate the effectiveness of L-serine for GRIN2B-related neurodevelopmental disorder (GRIN2B-NDD), using an n-of-1 trial design, increasing the level of evidence. Methods/designThese n-of-1 trials, consisting of 2 cycles of 6 months, will be performed to evaluate the effect of L-serine compared to placebo in 4 patients with a GRIN2B LoF mutation. The aggregation of multiple n-of-1 trials will provide an estimate of the average treatment effects.The primary outcome is the Perceive-Recall-Plan-Perform of Task Analysis, assessing developmental skills. Secondary outcomes include Goal Attainment Scaling, seizure log books, EEGs, sleep log books, the irritability subscale of the Aberrant Behavior Checklist, the Bristol Stool Scale and the Pediatric Quality of Life Inventory. ConclusionThis study employs an innovative methodological approach to evaluate the effectiveness of L-serine for patients with a GRIN2B LoF mutation. The results will establish a foundation for implementing L-serine as a disease-modifying treatment in GRIN2B-NDD.

DDX3X Syndrome Behavioral Manifestations with Particular Emphasis on Psycho-Pathological Symptoms-A Review.

(1) Background: Identification of typical behavioral manifestations in patients with DEAD-Box Helicase 3 X-linked gene (DDX3X) variants plays a crucial role in accurately diagnosing and managing the syndrome. The objective of this paper was to carry out a review of medical and public databases and assess the behavioral features of the DDX3X syndrome (DDX3X), with a particular focus on psycho-pathological symptoms. (2) Methods: An extensive computerized search was conducted in various databases, including PubMed, Medline Complete, Science Direct, Scopus, and Web of Science. Specific keywords and Medical Subject Headings were used to ensure the inclusion of relevant studies. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were applied to assess the methodological quality of the manuscripts. (3) Results: Only nine papers out of the 272 assessed met the inclusion criteria. These articles revealed various psycho-pathological manifestations in patients with the DDX3X syndrome. Intellectual disability (ID) or developmental disability (DD), speech delay, autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), generalized anxiety disorder (GAD), self-injurious behaviors (SIBs), sensory symptoms and sleep disturbance were demonstrated to be the most common psycho-pathological behavior manifestations. (4) Conclusions: Patients with the DDX3X syndrome manifest a wide spectrum of psycho-pathological symptoms. A comprehensive investigation of these symptoms in patients is essential for early diagnosis and effective therapy.

THU168 PRMT7 Gene Mutation—A Rare Genetic Syndrome With Novel Endocrine Associations

Abstract Disclosure: K. Nutakki: None. S. Nalla: None. P. Deb: None. A. Vulpala: None. Background: Causes of short stature in children include pathologic causes (genetic diseases, underlying systemic disease, or growth hormone deficiency) and non-pathological variants such as familial and constitutional short stature. Genetic causes include Turner’s syndrome, SHOX mutations, Noonan’s syndrome and Silver- Russel syndrome besides others. Homozygous/compound heterozygous mutations in Protein Arginine Methyltransferase 7 (PRMT7) can result in Short Stature, Brachydactyly, Intellectual Developmental Disability and Seizures syndrome (SBIDDS) . Here, we report a child with SBIDDS syndrome who has associated endocrine manifestations of growth hormone deficiency and primary hypothyroidism. Case report: A 9-year-old male child, twin A of dichorionic diamniotic gestation, presented to the Endocrine OPD with short stature. There was a history of developmental delay, seizure disorder and mild intellectual deficit. Excessive weight gain was observed since 4 years of age. On examination, he was short with abdominal obesity, brachydactyly, simian crease and macroglossia. Height was below 3rd centile and weight at the 97th percentile. SMR was pre-pubertal. Investigations confirmed primary hypothyroidism.GH deficiency (peak GH after clonidine stimulation was less than 4 microgram/L) and reduced IGF-I levels were also found. Twin B was noted to have a normal height percentile. In both, skeletal maturation was consistent with chronological age. Twin A was treated with rGH and levothyroxine and responded well to rGH treatment. Whole exome sequencing revealed homozygosity for PRMT7 mutation in twin A with both parents heterozygous for the same gene mutation. His twin sibling, twin B was also found to be homozygous for the mutation, but he did not display any characteristics of the syndrome. Discussion: To the best of our knowledge, this is only the second reported case of SBIDDS syndrome (PRMT7 mutation) with documented growth hormone deficiency and only case with documented primary hypothyroidism. Height gain observed over the period of rGH treatment is suggestive of a possible role of GH/IGF-I axis alterations as contributors of growth impairment in these children. PRMT7 encodes for an arginine methyltransferase, involved in several biological processes, such as DNA transcription and repairing, RNA splicing, cell differentiation. We would like to propose that children with SBIDDS syndrome may be tested for GH deficiency as part of their overall assessment. Likewise, it should be further explored if PRMT7 gene mutation testing should be recommended in a child presenting with short stature and one or more manifestations of SBIDDS syndrome. Presentation: Thursday, June 15, 2023

Quality of life of families with children with intellectual and developmental disabilities: Family health domain

Introduction: The most general definition of quality of life states that “quality of life is the degree of what makes life good.” Contemporary disability research increasingly relies on examining the quality of life of the whole family. Health and developmental outcomes are affected by the health of children and their environment. The objective of this study is to determine the difference in quality of life between families with children with disabilities and families with children without disabilities in the area of family health. Methods: The Family Quality of Life Questionnaire was used to assess quality of life. The test group consisted of 41 families of children with intellectual disabilities and developmental disabilities who use day care centers. The control group consisted of 69 families of children without disabilities whose members are employed in day care centers. Results: A statistically significant difference was found in the quality of life of families of children with disabilities and families of children without disabilities in the area of family health within the concept of satisfaction with family health (p = 0.0001), with respondents in the test group reporting a lower mean score of 3.1 ± 0.86 compared to subjects in the control group 3.94 ± 0.62. None of the respondents in the test group reported being very satisfied with family health, while for most respondents in both groups, 38 (92.8%) in the test group and 66 (95.7%) in the control group, family health was very important for quality of life. Conclusion: A statistically significant difference was found in the quality of life of families of children with disabilities and families of children without disabilities within the concept of achievement, the concept of satisfaction with family health and the determination is a statistically significant difference in relation to the existence of health services in the place of residence.

Health policy narratives contributing to health inequities experienced by people with intellectual/developmental disabilities: New evidence from COVID-19

This paper discusses three cultural narratives that threaten the health of people with intellectual/developmental disabilities (IDD) and which have become more evident during the COVID-19 pandemic. These meta-narratives are the medical model of health/disability; the population health approach to health inequalities; and policies premised on the assumption of the importance of national economic growth as an incentive for reducing health inequalities. Evidence exists that health research is more likely to become policy if it fits within a medical model and addresses national economic growth. These two criteria are particularly problematic for people who have IDD. The paper also proposes a research model to facilitate the inclusion of IDD related issues in future policy regarding health inequalities.

School-based prevention education for children and youth with intellectual developmental disabilities

Children with intellectual developmental disabilities (IDD) are at a heightened risk of experiencing child maltreatment (CM) when compared to their peers without IDD. Despite expanding evidence supporting the efficacy of school-based CM prevention programs, there are limited programs that tailor their lessons to the unique needs of children with IDD. This discussion first presents information regarding the prevalence and risk factors of CM among children with IDD. We then present existing peer-reviewed CM programs that have been developed for children with IDD. Finally, based on the latest research of CM prevention and special education, we present our considerations for a comprehensive school-based CM prevention program for children with IDD. Prevention programs for children with IDD may increase risk awareness among children with IDD and their parents, equip children with IDD with the protective skills necessary to navigate unsafe situations, and decrease the overall incidence of CM against this population.