Publications

Abstract

Links between HIV and substance use were identified early in the U.S. HIV epidemic. People who use drugs are at risk of HIV infection through shared injection equipment and risky sexual behaviors. In addition, substance use has negative health consequences for people living with HIV. The prescription opioid misuse epidemic, linked to injection drug use, hepatitis C infection, and HIV, poses a new threat to declining HIV rates. We reviewed evidence-based interventions that decrease HIV risk in people who use drugs (needle/syringe programs, medication-assisted treatment, engagement in HIV care, and preexposure prophylaxis/postexposure prophylaxis). The critical roles of nurses in HIV prevention/care for this population are described, including applying the principles of harm reduction, screening for substance use, and undertaking implementation and research efforts. As the nation's largest health care profession, nurses are positioned to contribute to the quality of HIV-related prevention/care for people who use drugs and to lead practice initiatives.

Abstract

Background: Ebstein anomaly (EA) is a rare congenital defect characterized by apical displacement of the septal tricuspid leaflets and atrialization of the right ventricle. The etiology of EA is unclear; however, recurrence in families and the association of EA with genetic syndromes and copy number variants (CNVs) suggest a genetic component. Objective: We performed a population-based study to search for recurrent and novel CNVs in a previously unreported set of EA cases. Methods: We genotyped 60 EA cases identified from all live births (2,891,076) from selected California counties (1991–2010) using the Illumina HumanOmni2.5–8 array. We identified 38 candidate CNVs in 28 (46%) cases and prioritized and validated 11 CNVs based on the genes included. Results: Five CNVs (41%) overlapped or were close to genes involved in early myocardial development, including NODAL, PDLIM5, SIX1, ASF1A and FGF12. We also replicated a previous association of EA with CNVs at 1p34.1 and AKAP12. Finally, we identified four CNVs overlapping or in close proximity to the transcription factors HES3, TRIM71, CUX1 and EIF4EBP2. Conclusions: This study supports the relationship of genetic factors to EA and demonstrates that defects in cardiomyocytes and myocardium differentiation may play a role. Abnormal differentiation of cardiomyocytes and how genetic factors contribute should be examined for their association with EA.

Abstract

We examined the association between maternal characteristics, routinely collected first- and second-trimester biomarkers and the risk of having an infant with a critical congenital heart defect (CCHD). Included were women who participated in the California Prenatal Screening Program who had nuchal translucency (NT) measurement and first- and second-trimester serum screening. All pregnancies ended in a live birth of an infant without aneuploidy or a neural tube defect. Poisson regression analyses were used to estimate the relative risk and 95% confidence interval of a CCHD by maternal characteristics, first- and second-trimester serum biomarkers or NT measurements. The sample included 118,194 mother–infant pairs; 284 infants had a CCHD. Women with preexisting diabetes were three-times as likely to have an infant with a CCHD. After adjusting for preexisting diabetes, women with first-trimester human chorionic gonatotropin (hCG) measurement <10th centile were 1.6-times as likely to have an infant with a CCHD (P = 0.011). Women with a NT measurement ≥95th centile were at two- to threefold higher risk of having an infant with a CCHD (P's = 0.004–0.007). Pregnancies with two risk factors for an infant with a CCHD were 5.6-times more likely to have an infant with a CCHD than women with no identified risk factors (P < 0.001). Despite the increased risk, performance testing demonstrated low sensitivity and specificity for screening use of these risk factors. Of the women with an infant with a CCHD, only 21.8% had an identified risk factor.

Abstract

This chapter discusses contemporary theoretical basis for dietary interventions for disease prevention and management and their applications in practice. This chapter (1) introduces key concepts related to the application of theory in understanding and improving diet and eating-related behaviors, (2) reviews behavioral issues related to adopting healthful diets, (3) discusses dietary interventions, and (4) highlights important issues and constructs that cut across theories. Six theoretical models that are in current use and can be particularly useful for understanding the processes of changing eating habits in clinical and community settings are described: social cognitive theory, the stages of change construct from the transtheoretical model, consumer information processing, the theory of planned behavior, multiattribute utility theory, and the social ecological model. The central elements of each theory and how they can be used to guide dietary interventions are described in this chapter.

Abstract

Objective/background Daytime napping longer than one hour has been associated with an increased risk for all-cause mortality. Associations between cytokine polymorphisms and daytime napping in chronic illnesses such as HIV, however, have not been well described. The purpose of this study was to examine cytokine polymorphisms associated with long daytime napping in adults living with HIV. Methods A cross-sectional analysis was conducted using a convenience sample of 257 adults living with HIV. Daytime napping was assessed with wrist actigraphy data collected over three days. Participants categorized as long nappers (≥60 min) were compared to short nappers and non-nappers (<60 min). Single nucleotide polymorphisms (SNPs) for 15 candidate genes involved in cytokine signaling were analyzed. Genes included: interferon-gamma (IFNG), IFNG receptor 1 (IFNGR1), interleukins (IL1B, IL1R, IL1R2, IL2, IL4, IL6, IL8, IL10, IL13, IL17A), nuclear factors of kappa light polypeptide gene enhancer in B cells (NFKB1 and NFKB2), and tumor necrosis factor alpha (TNFA). Results After adjusting for relevant demographic and clinical characteristics, long daytime napping was associated with 12 SNPs from seven genes: 1) IFNG rs2069728; 2) IL1B rs1143642, rs1143627, and rs16944; 3) IL2 rs2069763; 4) IL6 rs4719714, rs1554606, and rs2069845; 5) IL17A rs3819024 and rs8193036; 6) NFKB1 rs4648110; and 7) NFKB2 rs1056890. Conclusions Cytokine genetic variations may have a role in physiological regulation of daytime napping as well as nocturnal sleep. Cytokine polymorphisms associated with long daytime napping could help identify adults with HIV who may benefit from targeted therapeutic interventions.

Abstract

Background: Numbering close to 300,000 nurse managers represent the largest segment of the health care management workforce. Their effectiveness is, in part, influenced by their job satisfaction. Purpose: We examined factors associated with job satisfaction of novice frontline nurse managers. Methodology/Approach: We used a cross-sectional, correlational survey design. The sample consisted of responders to the fifth wave of a multiyear study of new nurses in 2013 (N = 1,392; response rate of 69%) who reported working as managers (n = 209). The parent study sample consisted of registered nurses who were licensed for the first time by exam 6-18 months prior in 1 of 51 selected metropolitan statistical areas and 9 rural areas across 34 U.S. states and the District of Columbia. We examined bivariate correlations between job satisfaction and 31 personal and structural variables. All variables significantly related to job satisfaction in bivariate analysis were included in a multivariate linear regression model. In addition, we tested the interaction effects of procedural justice and negative affectivity, autonomy, and organizational constraints on job satisfaction. The Cronbach's alphas for all multi-item scales ranged from.74 to.96. Findings: In the multivariate analysis, negative affectivity (β = -.169; p =.006) and procedural justice (β =.210; p =.016) were significantly correlated with job satisfaction. The combination of predictors in the model accounted for half of the variability in job satisfaction ratings (R2 =.51, adjusted R2 =.47; p <. 001). Practice Implications: Health care executives who want to cultivate an effective novice frontline nurse manager workforce can best ensure their satisfaction by creating an organization with strong procedural justice. This could be achieved by involving managers in decision-making processes and ensuring transparency about how decisions that affect nursing are made.

Abstract

Young, heterosexual African American men ages 18 to 24 years continue to be at high risk for HIV and other sexually transmitted infections. However, few interventions have been designed to meet the needs of this “forgotten” population. The article describes the systematic development of a theory-based, culturally-tailored, gender-specific, barbershop-based HIV risk reduction intervention for heterosexual African American men ages 18 to 24. The process included developing a community advisory board, selecting a guiding theoretical framework, incorporating community-based participatory research principles, and conducting formative research with African American males, barbers, and barbershop owners. The result was Shape Up: Barbers Building Better Brothers, a 2-day, HIV risk reduction intervention focused on increasing HIV knowledge and condom use and reducing the number of sexual partners. Intervention sessions were facilitated by barbers who used iPads to deliver the content. As a high-risk population, this intervention has great public health significance for the health of African American men and their sexual partners.

Abstract

Traditional Chinese medicine encompasses many different practices, most notably acupuncture and moxibustion. Traditionally, these modalities are used in combination to augment treatment but seldom are they tested together in clinical studies. Numerous acupuncture studies have been conducted in Asia, Europe, and the United States but there have been few randomized controlled trials utilizing moxibustion outside of East Asia. Limited studies have described the use of a moxibustion control or placebo procedure. The methods for developing an acupuncture and moxibustion protocol used in a randomized controlled trial for irritable bowel syndrome, diarrhea predominant in adults are described here. Our approach conformed to the scientific rigor for a clinical trial and was consistent to the foundations of traditional Chinese medicine.

Abstract

Objective: Adrenergic crises are a cardinal feature of familial dysautonomia (FD). Traditionally, adrenergic crises have been treated with the sympatholytic agent clonidine or with benzodiazepines, which can cause excessive sedation and respiratory depression. Dexmedetomidine is a centrally-acting α2-adrenergic agonist with greater selectivity and shorter half-life than clonidine. We evaluated the preliminary effectiveness and safety of intravenous dexmedetomidine in the treatment of refractory adrenergic crisis in patients with FD. Methods: Retrospective chart review of patients with genetically confirmed FD who received intravenous dexmedetomidine for refractory adrenergic crises. The primary outcome was preliminary effectiveness of dexmedetomidine defined as change in blood pressure (BP) and heart rate (HR) 1 h after the initiation of dexmedetomidine. Secondary outcomes included incidence of adverse events related to dexmedetomidine, hospital and intensive care unit (ICU) length of stay, and hemodynamic parameters 12 h after dexmedetomidine cessation. Results: Nine patients over 14 admissions were included in the final analysis. At 1 h after the initiation of dexmedetomidine, systolic BP decreased from 160 ± 7 to 122 ± 7 mmHg (p = 0.0005), diastolic BP decreased from 103 ± 6 to 65 ± 8 (p = 0.0003), and HR decreased from 112 ± 4 to 100 ± 5 bpm (p = 0.0047). The median total adverse events during dexmedetomidine infusion was 1 per admission. Median hospital length of stay was 9 days [interquartile range (IQR) 3–11 days] and median ICU length of stay was 7 days (IQR 3–11 days). Conclusions: Intravenous dexmedetomidine is safe in patients with FD and appears to be effective to treat refractory adrenergic crisis. Dexmedetomidine may be considered in FD patients who do not respond to conventional clonidine and benzodiazepine pharmacotherapy.

Abstract

Diabetes self-management training (DSMT) improves diabetes health outcomes. However, low numbers of patients receive DSMT. Using virtual environments (VEs) for DSMT is an innovative approach to removing barriers for patients.

Abstract

Breast cancer is the leading cause of cancer death among Hispanic women. Certain dietary factors have been associated with the risk of breast cancer recurrence, but data in Hispanic survivors is scarce. Objective: to examine dietary patterns and diet quality in two groups of Hispanic breast cancer survivors. Methods: 23 Mexican-American (MA) and 22 Puerto Rican (PR) female breast cancer survivors completed a culturally adapted validated food frequency questionnaire. Intake was standardized per 1000 kcal and compared to US Dietary Guidelines and the DASH-style diet adherence score was calculated. Results: Overweight/obese was 70 % in MA and 91 % in PR. PR consumed diets rich in fruit/100 % fruit juices and beans, while MA diets were high in vegetables, beans, and total grains. Both groups consumed high amounts of starchy vegetables, refined grains, animal protein and calories from solid fats and added sugars but low intakes of whole grains, dairy products and nuts and seeds. DASH scores were relatively low. Conclusion: MA and PR female breast cancer survivors have different dietary patterns but both groups had relatively low diet quality. These groups could benefit from culturally tailored interventions to improve diet quality, which could potentially reduce cancer recurrence. ClinicalTrials.gov Identifier NCT01504789.

Abstract

Biological evidence suggests that ethno-racial differences in morning–evening type are possible, whereby Blacks may be more likely to be morning type compared to Whites. However, population-level evidence of ethno-racial difference in morning–evening type is limited. In an earlier study, we reported that morning type was more prevalent in Blacks compared to Whites in the United Kingdom (UK) Biobank cohort (N = 439 933). This study aimed to determine if these ethno-racial differences persisted after accounting for an even broader range of social, environmental and individual characteristics and employing an analytic approach that simulates randomization in observational data, propensity score modeling. Data from UK Biobank participants whose self-identified race/ethnicity was Black/Black British or White; who did not report daytime napping, shift work or night shift work; who provided full mental health information; and who were identified using propensity score matching were used (N = 2044). Each sample was strongly matched across all social, environmental and individual characteristics as indicated by absolute standardized mean differences <0.09 for all variables. The prevalence of reporting nocturnal short, adequate and long sleep as well as morning, intermediate and evening type among Blacks (n = 1022) was compared with a matched sample of Whites (n = 1022) using multinomial logistic regression models. Blacks had a 62% greater odds of being morning type [odds ratio (OR) = 1.620, 95% confidence interval (CI): 1.336–1.964, p <.0001] and a more than threefold greater odds of reporting nocturnal short sleep (OR = 3.453, 95% CI: 2.846–4.190, p <.0001) than Whites. These data indicate that the greater prevalence of morning type and short nocturnal sleep in Blacks compared to Whites is not fully explained by a wide range of social and environmental factors. If sleep is an upstream determinant of health, these data suggest that ethno-racially targeted public health sleep intervention strategies are needed.

Abstract

Purpose: Among young men who have sex with men (YMSM), aged 13-24 years, Blacks/African Americans and Hispanics/Latinos are disproportionately affected by HIV, accounting for 58% and 21%, respectively, of diagnoses of HIV infection in the United States. In the District of Columbia (DC), YMSM of color are also disproportionately affected by HIV. National goals are that 80% of HIV-infected persons be retained in HIV care. We analyzed DC surveillance data to examine retention among YMSM living with HIV infection in DC. Methods: We characterized correlates of retention in HIV care (≥2 clinical visits, ≥3 months apart, within 12 months of diagnosis) among YMSM in DC to inform and strengthen local HIV care efforts. We analyzed data from DC HIV surveillance system for YMSM aged 13-29 years diagnosed between 2005 and 2012 and alive in 2013. We also combined demographic and clinical variables with sociodemographic data from the U.S. American Community Survey (ACS) by census tracts. Results: From 2005 to 2012, 1034 YMSM were diagnosed and living with HIV infection in DC; 83% were Black or Latino. Of the 1034 YMSM, 910 (88%) had census tract data available and were included in analyses (72% Black, 10% Latino, and 17% White); among the 854 (94%) linked to care, 376 (44%) were retained in care. In multivariate analyses, retention in care was less likely among 19-24 year YMSM compared with 13-18-year-old YMSM (adjusted prevalence ratios [aPR] = 0.89, 95% confidence intervals [CI] 0.80-0.99). Conclusion: Retention in HIV care was suboptimal for YMSM. Increased retention efforts are warranted to improve outcomes and reduce age and racial/ethnic disparities.

Abstract

Context Adults with venous leg ulcers frequently experience multiple symptoms that may influence quality of life (QOL). Objectives The objective of this study was to identify patient subgroups based on their experience with a pain-depression-fatigue-sleep disturbance symptom cluster and to identify differences in patient characteristics and wound-healing and QOL outcomes between the subgroups. Methods Secondary data analysis from previous longitudinal studies of 247 patients with venous leg ulcers. Latent class analysis identified subgroups of patients with distinct experiences with the symptom cluster of pain, depression, fatigue, and sleep disturbance. Hierarchical regression analysis identified relationships between the subgroups and QOL outcomes. Survival analysis identified differences between the subgroups and ulcer healing. Results Latent class analysis found 67% of patients were in a mild symptom subgroup (i.e., experiencing no or mild pain, depressive symptoms, fatigue, or sleep disturbance). One-third of the samples were in a severe symptom subgroup, who reported moderate-to-severe levels of these symptoms. Compared with the mild subgroup, patients in the severe subgroup had poorer QOL scores (t = 8.06, P < 0.001). Symptom subgroup membership accounted for 19% of the variance (P < 0.001) within a hierarchical regression model that explained 42% of the variance in QOL (F(7,170) = 16.89, P < 0.001, R2 = 0.42). Cox proportional hazards regression found that at enrollment into the study, patients in the severe symptom subgroup were 1.5 times (95% confidence interval 1.02–2.08) less likely to heal in the following 24 weeks (P = 0.037). Conclusion Significant relationships were found between delayed ulcer healing, decreased QOL, and membership in the severe symptom subgroup. These findings suggest that comprehensive symptom assessment is needed to identify patients at higher risk for poor outcomes and enable early intervention.

Abstract

Background Managing diversity dynamics in academic or clinical settings for men in nursing has unique challenges resulting from their minority status within the profession. Purpose The purpose of this study was to share challenges and lessons learned identified by male scholars in the Robert Wood Johnson Foundation Nurse Faculty Scholars program and suggest strategies for creating positive organizations promoting inclusive excellence. Methods Multiple strategies including informal mentored discussions and peer-to-peer dialogue throughout the program, formal online surveys of scholars and National Advisory Committee members, and review of scholar progress reports were analyzed as part of the comprehensive evaluation plan of the program. Discussion Diversity dynamic issues include concerns with negative stereotyping, microaggression, gender intelligence, and differences in communication and leadership styles. Conclusion Male nurse faculty scholars report experiencing both opportunities and challenges residing in a predominately female profession. This article attempts to raise awareness and suggest strategies to manage diversity dynamics in service of promoting the development of a culture of health that values diversity and inclusive excellence for both men and women in academic, research, and practice contexts.

Abstract

Objective: The purpose of this systematic review and meta-analysis was to examine the effect of health information technology (HIT) diabetes self-management education (DSME) interventions on glycemic control in medically underserved patients. Materials and Methods: Following an a priori protocol, 5 databases were searched. Studies were appraised for quality using the Cochrane Risk of Bias assessment. Studies reporting either hemoglobin A1c pre- and post-intervention or its change at 6 or 12 months were eligible for inclusion in themeta-analysis using random effectsmodels. Results: Thirteen studies met the criteria for the systematic review and 10 for the meta-analysis and represent data from 3257 adults with diabetes (mean age 55 years; 66% female; 74% racial/ethnic minorities). Most studies (n=10) reflected an unclear risk of bias. Interventions varied by HIT type: computer software without Internet (n=2), cellular/automated telephone (n=4), Internet-based (n=4), and telemedicine/telehealth (n=3). Pooled A1c decreases were found at 6 months (-0.36 (95% CI, -0.53 and -0.19]; I2=35.1%, Q=5.0), with diminishing effect at 12 months (-0.27 [95% CI, -0.49 and -0.04]; I2=42.4%, Q=10.4). Discussion: Findings suggest that medically underserved patients with diabetes achieve glycemic benefit following HIT DSME interventions, with dissipating but significant effects at 12 months. Telemedicine/telehealth interventions were the most successful HIT type because they incorporated interaction with educators similar to in-person DSME. Conclusion: These results are similar to in-person DSME in medically underserved patients, showing that welldesigned HIT DSME has the potential to increase access and improve outcomes for this vulnerable group.

Abstract

We conducted a systematic review of the existing empirical studies focusing on Chinese domestic helpers in mainland China and foreign domestic helpers in Hong Kong who provide care for community-dwelling older adults. There are very limited studies specifically focusing on this population. The findings synthesized domestic helpers’ characteristics, acknowledged their contributions to elder care in China, and showed multiple challenges facing them, such as issues related to their physical health and emotional well-being, lack of legal rights protection, difficulties of adapting life in the host city, lack of training, and risk of abuse and sexual harassment. Our findings support the need for developing training and educational programs about legal rights protection and cultural competency for domestic helpers and the need to promote domestic helpers’ access to health care and social welfare and opportunities for career advancement, and provide respectful working conditions.

Abstract

Objective:Accurate outcome prediction is crucial for counseling parents and providing individualized treatment to extremely premature infants. We sought to improve upon existing prediction model by using a diverse population-based cohort of extremely premature live births (1/228 weeks' gestation) for survival and survival without severe neonatal morbidity at different times throughout the first week of life and to evaluate potential differences by race/ethnicity and maternal education.Study design:Retrospective cohort study of all California live births from 2007 through 2011 with linked birth, death and hospital discharge records.Results:A total of 6009 infants were included. In the validation data set at time of delivery, the area under the receiver-operating characteristic curve for the model containing all predictors was 0.863 for survival and 0.789 for survival without severe morbidity. The marginal probability of survival without severe neonatal morbidity of an Asian infant born to a mother with <12 years of education compared with the reference (Caucasian infant, mother with 3/412 years of education) was-0.23 (95% confidence interval (CI)-0.31 to-0.15) for all infants at time of birth and-0.28 (95% CI-0.39 to-0.18) for infants with attempted resuscitation. Notably, no other differences by racial/ethnic category and maternal education emerged.Conclusions:Probabilities of survival and survival without major morbidity change rapidly throughout the first week of life. Extremely premature infants born to Asian mothers with less than a high school education appear to have a lower probability to survive without significant morbidity compared with their Caucasian peers.

Abstract

Background and purpose: The availability of emergency contraception pills (ECP) over the counter (OTC) has the potential to reduce the incidence of unintended pregnancy; however, the increased risk for sexually transmitted infection (STI) acquisition, related to unprotected intercourse, has not been adequately addressed. The purpose of this study is to gain insight into risk perceptions for STIs and subsequent unintended pregnancy in women who have purchased ECP OTC. Methods: Twenty-one women, aged 18–24, attending a private university in an urban setting, who purchased and used ECP OTC participated in 1-h, individual interviews. Conclusions: Narrative, descriptive findings indicated that these women did not consider themselves at risk for STI or unintended pregnancy, despite having used ECP OTC. Pregnancy prevention was paramount for these women, which overshadowed concerns regarding STIs. Implications for practice: Women at risk for unintended consequences of sexual activity are not fully cognizant of those potential outcomes and do not take measures to prevent their occurrence. The availability of ECP OTC offers protection against unintended pregnancy; however, opportunities for health promotion and prevention counseling may be lost.

Abstract

Purpose: Superstorm Sandy forced the evacuation and extended shutdown of New York University Langone Medical Center. This investigation explored how nurses were impacted by the disasters and how they can best be supported in their nursing responsibilities. Design: Sequential mixed methods were used to explore the psychosocial issues nurses experienced throughout the course of this natural disaster and its lingering aftermath. Methods: In-depth interviews were conducted from April to June 2013 with a subsample of nurses who participated in the evacuation deployment (n = 16). An anonymous, Internet-based cross-sectional survey sent to all registered nurses employed at the hospital at the time of the storm explored storm impact and recovery. Between July and September 2013, 528 surveys were completed. Findings: The qualitative data revealed challenges in balancing professional obligations and personal concerns. Accounts described dealing in the immediate recovery period with unexpected job changes and resultant work uncertainty. The storm's lingering aftermath did not signify restoration of their predisaster lifestyle for some, but necessitated coping with this massive storm's long-lasting impact on their personal lives and communal loss. Conclusions: Nurses working under the rapidly changing, uncontrolled, and potentially dangerous circumstances of a weather-related disaster are also experiencing concerns about their families’ welfare and worries about personal loss. These multiple issues increase the psychosocial toll on nurses during a disaster response and impending recovery. Clinical Relevance: Awareness of concerns and competing demands nurses experience in a disaster and aftermath can inform education and services to enable nurses to perform their critical functions while minimizing risk to patients and themselves.

Abstract

Objective To evaluate the incidence, etiology, and 1-year mortality of nonimmune hydrops fetalis (NIHF) and to identify risk factors for mortality in a contemporary population-based dataset. Study design The California Office of Statewide Health Planning and Development maintains a database linking maternal and infant hospital discharge, readmissions, and birth and death certificate date from 1 year before to 1 year after birth. We searched the database (2005-2012) for infants with NIHF (identified by the International Classification of Diseases, 9th Revision, Clinical Modification code). Hazard models were used to identify risk factors for mortality in infants with NIHF; results are presented as hazard ratios (HRs, 95% CI). Results The incidence of NIHF was 2.5 out of 10 000 among live born infants. Neonatal mortality was 35.1% (364 out of 1037) and overall mortality was 43.2% (448 out of 1037) at 1 year of age. Gestational age (GA) was predictive of mortality with a HR of 2.4 (95% CI 1.9-3.2) for preterm compared with term infants. The GA-adjusted HR for mortality was 1.3 (95% CI 1.1-1.6) for polyhydramnios and 1.5 (95% CI 1.2-2.0) for large for gestational age infants compared with appropriate for GA infants. Aneuploid infants with critical congenital heart disease had an adjusted HR of 2.3 (95% CI 1.5-3.6) compared with euploid infants without a structural birth defect. Conclusions In this large, population-based study, prematurity, polyhydramnios, and large for gestational age were predictors of increased mortality. Mortality is highly variable among euploid and aneuploid infants with and without structural birth defects and critical congenital heart disease.