Medicine in the marketplace: clinician and patient views on commercial influences on assisted reproductive technology

RESEARCH QUESTION

What are the views and experiences of patient and expert stakeholders on the positive and negative impacts of commercial influences on the provision of assisted reproductive technology (ART) services, and what are their suggestions for governance reforms?

DESIGN

Semi-structured interviews were conducted with 31 ART industry experts from across Australia and New Zealand and 25 patients undergoing ART from metropolitan and regional Australia, between September 2020 and September 2021. Data were analysed using thematic analysis.

RESULTS

Expert and patient participants considered that commercial forces influence the provision of ART in a number of positive ways - increasing sustainability, ensuring consistency in standards and providing patients with greater choice. Participants also considered commercial forces to have a number of negative impacts, including increased costs to government and patients; the excessive use of interventions that lack sufficient evidence to be considered part of standard care; inadequately informed consent (particularly with regard to financial information); and threats to patient-provider relationships and patient-centred care. Participants varied in whether they believed that professional self-regulation is sufficient. While recognizing the benefits of commercial investment in healthcare, many considered that regulatory reforms, as well as organizational cultural initiatives, are needed as means to ensure the primacy of patient well-being.

CONCLUSIONS

The views expressed in this study should be systematically and critically examined to derive insights into how best to govern ART. These insights may also inform the design and delivery of other types of healthcare that are provided in the private sector.

Going the Distance : Ethics of Space and Location on Accessing Reproductive Services in Australia

Qualitative studies on assisted reproductive technology commonly focus on the perspectives of participants living in major metropolises. In doing so, the experiences of those living outside major cities, and the unique way conditions of spatiality shape access to treatment, are elided. In this paper, we examine how location and regionality in Australia impact upon access and experience of reproductive services. We conducted twelve qualitative interviews with participants residing in regional areas across Australia. We asked participants to discuss their experience with assisted reproduction services and the impacts of location on access, service choice, and experience of care, and analysed the data using reflexive thematic analysis, as outlined by Braun and Clarke (2006, 2019). Participants in this study reported that their location impacted the services available to them, required considerable time in travel, and reduced continuity of care. We draw on these responses to examine the ethical implications of uneven distribution of reproductive services in commercial healthcare settings which rely on market-based mechanisms.

Human SLFN5 is a transcriptional co-repressor of STAT1-mediated interferon responses and promotes the malignant phenotype in glioblastoma

We provide evidence that the IFN-regulated member of the Schlafen (SLFN) family of proteins, SLFN5, promotes the malignant phenotype in glioblastoma multiforme (GBM). Our studies indicate that SLFN5 expression promotes motility and invasiveness of GBM cells, and that high levels of SLFN5 expression correlate with high grade gliomas and shorter overall survival in patients suffering from GBM. In efforts to uncover the mechanism by which SLFN5 promotes GBM tumorigenesis, we found that this protein is a transcriptional co-repressor of STAT1. Type-I IFN treatment triggers the interaction of STAT1 with SLFN5, and the resulting complex negatively controls STAT1-mediated gene transcription via interferon stimulated response elements (ISRE). Thus, SLFN5 is both an IFN-stimulated response gene and a repressor of IFN-gene transcription, suggesting the existence of a negative-feedback regulatory loop that may account for suppression of antitumor immune responses in glioblastoma.

The effect of body position on developing ultrasound criteria for the assessment of the internal jugular vein

Recent studies investigating chronic cerebrospinal venous insufficiency highlighted that intracranial venous return has not yet been routinely investigated by ultrasound in the normal population. This creates an absence of a reference standard and raises concerns that the approach introduces variations into the results. The primary objective of this study was to develop reference standards for the assessment of the internal jugular vein in a normal population. A prospective small-scale study was conducted. Internal jugular veins of 31 normal candidates were examined using B-Mode and PW Doppler. Measurements at proximal and mid-point internal jugular vein were taken in sitting (90°) and supine (0°) positions. Area measurements were taken during passive respiration in cm(2). Time average velocity measurements were taken during passive respiration over a 3-second period. Reflux measurements were taken after apnoea and reflux was recorded from any reversed flow. Measurements were taken three times; an average was calculated and statically analysed. Of the 31 participants, one was excluded from the study and 30 were suitable. The Mann-Whitney U test was used to analyse the results; all results (area, time average velocity and reflux) showed that there was a significant difference between the two positions with p < 0.05 (two-tailed). This pilot study does suggest that there is a significant difference in area, time average velocity and reflux measurements of the internal jugular vein when taken in the sitting and supine position, which could affect the outcome of chronic cerebrospinal venous insufficiency. A further large-scale study is required to validate and standardise the assessment of the internal jugular vein.

Regulation of pathways downstream of mTOR by imatinib mesylate in CML cells

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Background: The differential regulation of signaling pathways downstream of the BCR-ABL tyrosine kinase are being defined in an effort to improve therapeutic strategies for patients with CML. We have previously shown that imatinib mesylate suppressed p70 S6 kinase activity, consistent with inhibition of BCR-ABL-mediated activation of the mTOR/p70 S6 kinase pathway. In this study we examined the effects of imatinib mesylate on other target proteins downstream of mTOR. Methods: BCR-ABL expressing cell lines (K562, KT1 and BV173) were treated with 1μM of imatinib mesylate for 30, 60 and 90 minutes, and then lysed in phosphorylation lysis buffer. Immunoblotting was done using standard enhanced chemiluminescence (ECL) methods. In the experiments in which the pharmacologic inhibitor of mTOR, rapamycin was used, the cells were pretreated for 60 minutes with the inhibitor and subsequently treated with imatinib. Results: The translational repressor 4E-BP1 is constitutively phosphorylated in CML cells. In the presence of imatinib mesylate in concentrations as low as 1μM, the phosphorylation of 4E-BP1 on threonine sites 37 and 46 is decreased. The phosphorylation of eIF-4G on serine site 1108 is also inhibited by imatinib mesylate treatment as early as 60 minutes. The combination of the mTOR inhibitor rapamycin and imatinib mesylate was more potent in suppressing phosphorylation of 4E-BP1 than imatinib alone, suggesting a mechanism for the enhancing effects of rapamycin on imatinib mesylate-dependent inhibition of growth of BCR-ABL cells. Conclusions: Our results further suggest the potential development of future clinical-translational studies utilizing rapamycin in combination with imatinib for the treatment of patients with CML.

No significant financial relationships to disclose.

The combination of arsenic trioxide and rapamycin has potent inhibitory effects on acute myeloid leukemia (AML) cells

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Background: Arsenic trioxide (As2O3) exhibits potent growth inhibitory and pro-apoptotic effects against a variety of neoplastic cells, but the precise mechanisms by which it mediates such effects are not known. The mammalian target of rapamycin (mTOR) is a key cellular regulator of multiple signaling events that control initiation of mRNA translation in leukemia cells. We examined the effects of As2O3 on the activation of mTOR-dependent pathways that regulate initiation of mRNA translation in acute myeloid leukemia (AML) cells. We also determined the effects of the combination of As2O3 with the mTOR inhibitor rapamycin on the growth of AML cell lines. Methods: The human leukemia cell lines, KG-1, U937, and MM6, were incubated and cultured with increasing concentrations of As2O3, in the presence or absence of the mTOR inhibitor rapamycin. Cell lysates were immunoprecipitated with an anti-p70 S6 kinase antibody, and immune-complex kinase assays to detect p70 S6 kinase activity were performed. In addition, cell proliferation assays were carried out in cells treated with or without rapamycin (10 or 20 nM) and increasing concentrations of AS2O3 (0 to 5 uM). Results: As2O3-treatment of U937 cells resulted in strong induction of p70 S6 kinase activity, which was inhibited by concomitant treatment of cells with rapamycin. In cell proliferation assays, we found that rapamycin alone significantly inhibited the growth of U937, KG-1, and MM6 cells. The addition of As2O3 further enhanced the inhibitory effects of rapamycin, in a dose-dependent manner, indicating that the combination of these agents is more potent in inhibiting the growth of AML cell lines than each agent alone. Conclusions: During treatment of AML cell lines with As2O3, the p70 S6 kinase pathway is activated, apparently in a negative feedback regulatory manner. Pharmacological inhibition of mTOR with rapamycin has potent antileukemic properties, which are further enhanced by As2O3. Therefore, the use of As2O3 and rapamycin in combination may be a promising strategy for the treatment of AML.

No significant financial relationships to disclose.

Determinants of carotid plaque instability: echoicity versus heterogeneity

OBJECTIVE

to identify the echoicity and heterogeneity of carotid plaques associated with ipsilateral symptomatic and asymptomatic neurovascular presentations.

DESIGN

cross-sectional study.

MATERIALS

a total of 113 patients, with 127 symptomatic and asymptomatic plaques, were studied.

METHODS

the duplex images of the plaques were analysed echoically in a computer by means of Grey Scale Median (GSM) [hypoechoic (low GSM), hyperechoic (high GSM)]. The presence or absence of at least two plaque regions within the plaque area being echoically uniform (no variation of echoicity), occupying each at least 10% of the plaque area and having GSM difference greater than the plaque GSM was evaluated to distinguish the heterogeneous (presence of this pattern) from the homogeneous (absence of this pattern) plaques.

RESULTS

the symptomatic status was associated with plaques of low median GSM (10.5) and 88% prevalence of the homogeneous pattern as contrasted with the asymptomatic status that was associated with high median GSM (28) and 65% prevalence of the homogeneous pattern [(p=0.001 (GSM), p=0.003 (heterogeneity)].

CONCLUSIONS

symptomatic plaques were associated with hypoechoic and predominant homogeneous echo-pattern whereas the asymptomatic ones were associated with hyperechoic and less predominant homogeneous pattern.