Improving Care for Late-Life Depression Through Partnerships With Community-Based Organizations: Results From the Care Partners Project

OBJECTIVES

Collaborative care (CC) has demonstrated effectiveness for improving late-life depression in primary care, but clinics offering this service can find it challenging to address unmet social needs that may be contributing to their patients' depression. Clinics may benefit from better coordination and communication with community-based organizations (CBO) to strengthen depression treatment and to address unmet social needs. We evaluated the feasibility of adding a CBO to enhance standard collaborative care and the impact of such partnered care on older adults.

DESIGN

Multisite, prepost evaluation.

SETTING

Eight (n = 8) partnerships between primary care clinics and community-based organizations in California.

PARTICIPANTS

A total of 707 depressed older adults (60 years or older) as evidenced by having a score of 10 or more on the Patient Health Questionnaire (PHQ-9) received care under the Care Partners project.

INTERVENTION

A CBO partner was added to augment CC for late-life depression in primary care.

MEASUREMENTS

The PHQ-9 was used to identify depressed older adults and to monitor depression symptom severity during a course of care.

RESULTS

At baseline, the average PHQ-9 depression score across the partnerships was 15, indicating moderate depression severity. Participating patients saw an average 7-point reduction in their PHQ-9 score, baseline to last score assessed, with nearly half of all participants (48.4%) experiencing a 50% or greater improvement from their baseline score.

CONCLUSIONS

Our findings suggest that partnering with a community-based organization is a feasible and effective way for primary care clinics to address late-life depression in their patients.

CLEAR - clozapine in early psychosis: study protocol for a multi-centre, randomised controlled trial of clozapine vs other antipsychotics for young people with treatment resistant schizophrenia in real world settings

BACKGROUND

Clozapine is an antipsychotic drug with unique efficacy, and it is the only recommended treatment for treatment-resistant schizophrenia (TRS: failure to respond to at least two different antipsychotics). However, clozapine is also associated with a range of adverse effects which restrict its use, including blood dyscrasias, for which haematological monitoring is required. As treatment resistance is recognised earlier in the illness, the question of whether clozapine should be prescribed in children and young people is increasingly important. However, most research to date has been in older, chronic patients, and evidence regarding the efficacy and safety of clozapine in people under age 25 is lacking. The CLEAR (CLozapine in EARly psychosis) trial will assess whether clozapine is more effective than treatment as usual (TAU), at the level of clinical symptoms, patient rated outcomes, quality of life and cost-effectiveness in people below 25 years of age. Additionally, a nested biomarker study will investigate the mechanisms of action of clozapine compared to TAU.

METHODS AND DESIGN

This is the protocol of a multi-centre, open label, blind-rated, randomised controlled effectiveness trial of clozapine vs TAU (any other oral antipsychotic monotherapy licenced in the British National Formulary) for 12 weeks in 260 children and young people with TRS (12-24 years old).

AIM AND OBJECTIVES

The primary outcome is the change in blind-rated Positive and Negative Syndrome Scale scores at 12 weeks from baseline. Secondary outcomes include blind-rated Clinical Global Impression, patient-rated outcomes, quality of life, adverse effects, and treatment adherence. Patients will be followed up for 12 months and will be invited to give consent for longer term follow-up using clinical records and potential re-contact for further research. For mechanism of action, change in brain magnetic resonance imaging (MRI) biomarkers and peripheral inflammatory markers will be measured over 12 weeks.

DISCUSSION

The CLEAR trial will contribute knowledge on clozapine effectiveness, safety and cost-effectiveness compared to standard antipsychotics in young people with TRS, and the results may guide future clinical treatment recommendation for early psychosis.

TRIAL REGISTRATION

ISRCTN Number: 37176025, IRAS Number: 1004947.

TRIAL STATUS

In set-up. Protocol version 4.0 01/08/23. Current up to date protocol available here: https://fundingawards.nihr.ac.uk/award/NIHR131175# /.

A method for the systematic selection of enzyme panel candidates by solving the maximum diversity problem

Enzymes are being increasingly exploited for their potential as industrial biocatalysts. Establishing a portfolio of useful biocatalysts from large and diverse protein family is challenging and a systematic method for candidate selection promises to aid in this task. Moreover, accurate enzyme functional annotation can only be confidently guaranteed through experimental characterisation in the laboratory. The selection of catalytically diverse enzyme panels for experimental characterisation is also an important step for shedding light on the currently unannotated proteins in enzyme families. Current selection methods often lack efficiency and scalability, and are usually non-systematic. We present a novel algorithm for the automatic selection of subsets from enzyme families. A tabu search algorithm solving the maximum diversity problem for sequence identity was designed and implemented, and applied to three diverse enzyme families. We show that this approach automatically selects panels of enzymes that contain high richness and relative abundance of the known catalytic functions, and outperforms other methods such as k-medoids.

Compositional and surface changes of retrieved stainless-steel hardware and its effects on surrounding soft tissues: A prospective study

Purpose

To evaluate the surface, compositional, and histological changes in the overlying soft tissues of retrieved stainless-steel mini-plates and screws used for rigid internal fixation in the maxillofacial skeleton.

Materials and Method

A prospective study was conducted comprising 60 patients who sustained maxillofacial trauma and underwent ORIF in our unit previously and who required hardware retrieval in the post-operative phase. The retrieved hardware was evaluated for surface and compositional changes with the help of a scanning electron microscope for surface roughness and corrosion changes. Energy-dispersive X-ray study was done to know the composition and metal release from the hardware. The data obtained from these results were compared with a control unused and a sterile stainless-steel mini-plate and screw. The effects of the corrosion changes of this hardware on the adjacent soft tissues were evaluated histologically to assess the cellular changes of the soft tissue cover overlying the stainless-steel mini-plates and screws.

Results

A total of 96 stainless-steel mini-plates and 380 stainless-steel screws were retrieved from 60 patients. The control plate was smooth without any surface and corrosion defects, while the retrieved mini-plates irrespective of the reason for removal have shown surface roughness. Fe and Ni ions were found to be significantly reduced in the retrieved mini-plates. The presence of CrC in the retrieved plates indicates corrosion, which was seen only in hardware retrieved from symptomatic patients. The histological study revealed chronic inflammatory cell infiltrate with hyalinized connective tissue in all the samples irrespective of the reason for the removal of the plate.

Conclusion

Stainless-steel mini-plates and screws act as a potent foreign body material and initiate a localized inflammatory reaction due to its corrosive products with longer duration of stay. Hence, the authors advocate the overall shift in the use of stainless-steel hardware to titanium hardware for ORIF.

Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Perioperative risk assessment

Perioperative risk assessment refers to estimating a patient's risk of adverse outcomes in the perioperative period.

A cluster randomised, 16-week, parallel-group multicentre trial to compare the effectiveness of a digital school-based cognitive behavioural resilience/wellbeing-building intervention targeting emotional and behavioural problems in vulnerable Year 4 primary school children in whole classes, to the usual school curriculum: a study protocol to the "CUES for Schools" trial

BACKGROUND

Around 10% of school-aged children experience mental health difficulties. Many more are 'vulnerable': experiencing emotional and/or behavioural problems reaching clinical levels, and thus at greatest risk of future mental illness. The trial aim is to evaluate the effectiveness of the CUES for schools programme in reducing emotional and behavioural problems in vulnerable children.

METHODS

The "CUES for Schools" study is a multicentre cluster randomised controlled trial in primary schools in south east England. Schools will be randomised to receive the usual school curriculum, or the CUES programme (1:1). We aim to enrol 74 schools (5550 children including 2220 vulnerable children). CUES is a whole-class teacher-facilitated interactive digital cognitive-behavioural intervention, delivered as 24 short (20-min) modules over 12 weeks, targeting emotional/behavioural regulation skills. Children self-report emotional/behavioural problems at baseline, 8, and 16 weeks, and wellbeing and cognitive vulnerability at 0 and 16 weeks. Adverse events are assessed at 8 and 16 weeks. Teachers rate classroom behaviour at baseline and 16 weeks. School senior leadership teams and individual teachers consent to involvement in the study; parents can opt their child out of CUES sessions, assessments, or research. Children can similarly opt out and assent to research participation. The primary objective of this trial is to evaluate the effectiveness of CUES for schools compared to the usual school curriculum in improving emotional/behavioural problems for vulnerable Year 4 (8-9 years old) children at 16 weeks post-randomisation, as measured using a standardised questionnaire designed for primary schools. The secondary objective is to investigate the impact of the CUES for schools programme on both vulnerable and non-vulnerable children on wellbeing and teacher-rated classroom behaviour.

DISCUSSION

The study will show whether CUES for schools is more effective than the usual curriculum in reducing emotional and behavioural problems in vulnerable Year 4 children, and thus reducing the risk of mental health difficulties in later adolescent and adult life. As a digital, teacher-facilitated intervention, CUES for schools can be readily implemented, at minimal cost. If effective, CUES for schools therefore has the potential to reduce the impact of emotional/behavioural difficulties on children's learning, behaviour, and relationships and the burden of future mental health morbidity.

TRIAL REGISTRATION

Trial Registration ISRCTN11445338. Registered on September 12, 2022.

"We are the sun for our community:" Partnering with community health workers/promotores to adapt, deliver and evaluate a home-based collaborative care model to improve equity in access to quality depression care for older U.S. Latino adults who are underserved

Background

While depression is a leading cause of poor health, less than half of older adults receive adequate care. Inequities in both access and outcomes are even more pronounced for socially disadvantaged older adults. The collaborative care model (CCM) has potential to reduce this burden through community-based organizations (CBOs) who serve these populations. However, CCM has been understudied in diverse cultural and resource-constrained contexts. We evaluated the implementation and effectiveness of PEARLS, a home-based CCM adapted with and for community health workers/promotores (CHWs/Ps).

Methods

We used an instrumental case study design. Our case definition is a community-academic partnership to build CHW/P capacity for evidence-based depression care for older U.S. Latino adults in the Inland Empire region of California (2017-2020). We aimed to understand adaptations to fit local context; acceptability, feasibility, and fidelity; clinical effectiveness; and contextual determinants of implementation success or failure. Data sources included quantitative and qualitative administrative and evaluation data from participants and providers. We used descriptive statistics and paired t-tests to characterize care delivery and evaluate effectiveness post-intervention, and deductive thematic analysis to answer other aims.

Findings

This case study included 152 PEARLS participants and nine data sources (N = 67 documents). The CBO including their CHWs/Ps partnered with the external implementation team made adaptations to PEARLS content, context, and implementation strategies to support CHWs/Ps and older adults. PEARLS was acceptable, feasible and delivered with fidelity. Participants showed significant reductions in depression severity at 5 months (98% clinical response rate [mean (SD), 13.7 (3.9) drop in pre/post PHQ-9; p < 0.001] and received support for 2.6 social needs on average. PEARLS delivery was facilitated by its relative advantage, adaptability, and trialability; the team's collective efficacy, buy-in, alignment with organization mission, and ongoing reflection and evaluation during implementation. Delivery was challenged by weak partnerships with clinics for participant referral, engagement, reimbursement, and sustainability post-grant funding.

Discussion

This case study used existing data to learn how home-based CCM was adapted by and for CHWs/Ps to reduce health inequities in late-life depression and depression care among older Latino immigrants. The CBOs and CHWs/Ps strong trust and rapport, addressing social and health needs alongside depression care, and regular internal and external coaching and consultation, appeared to drive successful implementation and effectiveness.

Evaluation of genome skimming to detect and characterise human and livestock helminths

The identification of gastrointestinal helminth infections of humans and livestock almost exclusively relies on the detection of eggs or larvae in faeces, followed by manual counting and morphological characterisation to differentiate species using microscopy-based techniques. However, molecular approaches based on the detection and quantification of parasite DNA are becoming more prevalent, increasing the sensitivity, specificity and throughput of diagnostic assays. High-throughput sequencing, from single PCR targets through to the analysis of whole genomes, offers significant promise towards providing information-rich data that may add value beyond traditional and conventional molecular approaches; however, thus far, its utility has not been fully explored to detect helminths in faecal samples. In this study, low-depth whole genome sequencing, i.e. genome skimming, has been applied to detect and characterise helminth diversity in a set of helminth-infected human and livestock faecal material. The strengths and limitations of this approach are evaluated using three methods to characterise and differentiate metagenomic sequencing data based on (i) mapping to whole mitochondrial genomes, (ii) whole genome assemblies, and (iii) a comprehensive internal transcribed spacer 2 (ITS2) database, together with validation using quantitative PCR (qPCR). Our analyses suggest that genome skimming can successfully identify most single and multi-species infections reported by qPCR and can provide sufficient coverage within some samples to resolve consensus mitochondrial genomes, thus facilitating phylogenetic analyses of selected genera, e.g. Ascaris spp. Key to this approach is both the availability and integrity of helminth reference genomes, some of which are currently contaminated with bacterial and host sequences. The success of genome skimming of faecal DNA is dependent on the availability of vouchered sequences of helminths spanning both taxonomic and geographic diversity, together with methods to detect or amplify minute quantities of parasite nucleic acids in mixed samples.

Evaluation of manuka honey on the microsporidian pathogen Vairimorpha (Nosema) adaliae and its host, the two-spotted lady beetle, Adalia bipunctata L. (Coleoptera: Coccinellidae)

Honey is known for its antibacterial and antifungal properties. Manuka honey was examined for its potential to manage the microsporidium Vairimorpha (Nosema) adaliae infecting Adalia bipunctata larvae. Development time for uninfected larvae fed aphids and water was 13.0 ± 0.2 days, which did not differ significantly from larvae fed aphids and manuka honey. Development of V. adaliae-infected larvae fed aphids and water was 16.3 ± 0.5 days, compared to 15.0 ± 0.2, 15.2 ± 0.3, and 15.6 ± 0.2 days for larvae fed aphids and 5 %, 10 %, or 15 % manuka honey, respectively. Development time was shorter for all honey treatments, but only those fed 5 % manuka differed significantly from the control. Control adults had 19.4 ± 3.0 spores/120 µm², compared to 19.0 ± 2.0, 19.1 ± 2.1, and 14.3 ± 2.2, for adults provided with 5 %, 10 %, and 15 % honey, respectively. Although spore loads did not differ significantly (p > 0.05), lighter infections were observed in the group fed 15 % manuka.

Availability of bereavement support following traumatic pediatric death in a large metropolitan area

Following an unexpected pediatric death, survivors undergo unique trauma. Medical examiners (MEs) evaluate most of these deaths. We evaluated the bereavement support available to survivors in the Chicagoland area following a pediatric death. We had two goals: to characterize the available bereavement support options and compare the locations (by zip code) of support groups with the locations (by zip code) in which pediatric ME cases occurred. We identified 48 organizations that provided bereavement support services at 74 locations in the summer and fall of 2020. Locations by zip codes in which the largest number of ME cases occurred did not have support groups. Locations in which more ME cases occurred generally had lower-income populations and a greater proportion of Black or Hispanic residents. Bereavement support following pediatric death is inadequate and unevenly distributed across the Chicagoland area.

Open-source environmental data as an alternative to snail surveys to assess schistosomiasis risk in areas approaching elimination

Background: Although the presence of intermediate snails is a necessary condition for local schistosomiasis transmission to occur, using them as surveillance targets in areas approaching elimination is challenging because the patchy and dynamic quality of snail host habitats makes collecting and testing snails labor-intensive. Meanwhile, geospatial analyses that rely on remotely sensed data are becoming popular tools for identifying environmental conditions that contribute to pathogen emergence and persistence. Methods: In this study, we assessed whether open-source environmental data can be used to predict the presence of human Schistosoma japonicum infections among households with a similar or improved degree of accuracy compared to prediction models developed using data from comprehensive snail surveys. To do this, we used infection data collected from rural communities in Southwestern China in 2016 to develop and compare the predictive performance of two Random Forest machine learning models: one built using snail survey data, and one using open-source environmental data. Results: The environmental data models outperformed the snail data models in predicting household S. japonicum infection with an estimated accuracy and Cohen’s kappa value of 0.89 and 0.49, respectively, in the environmental model, compared to an accuracy and kappa of 0.86 and 0.37 for the snail model. The Normalized Difference in Water Index (NDWI) within half to one kilometer of the home and the distance from the home to the nearest road were among the top performing predictors in our final model. Homes were more likely to have infected residents if they were further from roads, or nearer to waterways. Conclusion: Our results suggest that in low-transmission environments, investing in training geographic information systems professionals to leverage open-source environmental data could yield more accurate identification of pockets of human infection than using snail surveys. Furthermore, the variable importance measures from our models point to aspects of the local environment that may indicate increased risk of schistosomiasis. For example, households were more likely to have infected residents if they were further from roads or were surrounded by more surface water, highlighting areas to target in future surveillance and control efforts.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

168 AN EXPLORATION OF ATRIAL FIBRILLATION AND ANTICOAGULATION IN STROKE PATIENTS WHO UNDERGO THROMBECTOMY IN A TERTIARY THROMBECTOMY CENTRE

Background

Atrial Fibrillation is a significant cause of ischaemic stroke. Prevalence of atrial fibrillation in patients requiring thrombectomy is approximately 33%. Embolic thrombi which develop due to Atrial fibrillation may become targets for clot removal by thrombectomy in appropriate patients. Anticoagulation is one of the mainstays of treatment for atrial fibrillation.

Methods

A list of patients who had thrombectomy performed for ischaemic stroke in 2021 was compiled. Charts were reviewed to establish the prevalence of atrial fibrillation and the rates of appropriate dosing of anticoagulant. Of those who were not anticoagulated, we aimed to establish if there was a clear reason for this. This was performed in a tertiary referral centre with 24/7 access to thrombectomy.

Results

97 patients had thrombectomy performed for ischaemic stroke in 2021. 34/97(35%) had atrial fibrillation (21/97 pre-existing , 13/97 newly diagnosed on admission). 15/21 were anticoagulated and 6/21 were not anticoagulated at the time of their stroke. 5/6 had a clear reason documented for stopping anticoagulation. One patient had stopped anticoagulation due to cost. Of those with atrial fibrillation who were anticoagulated at the time of their stroke, 11 were anticoagulated with a Direct-Acting AntiCoagulant (DOAC) and four were anticoagulated with Warfarin. Of the Warfarin group, just one patients’ INR was therapeutic at the time of their stroke. Of the DOAC group, all were on the appropriate dose.

Conclusion

Stroke patients requiring thrombectomy are a group who may suffer the largest strokes. Incidence of atrial fibrillation was similar to previous studies. It was encouraging that there was a documented reason for all patients who were not anticoagulated, and that the DOAC dose was appropriate. Issues with therapeutic levels of Warfarin are further highlighted here. This study concludes that we may not be as bad at anticoagulation as we may think.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Integration of probabilistic functional networks without an external Gold Standard

BACKGROUND

Probabilistic functional integrated networks (PFINs) are designed to aid our understanding of cellular biology and can be used to generate testable hypotheses about protein function. PFINs are generally created by scoring the quality of interaction datasets against a Gold Standard dataset, usually chosen from a separate high-quality data source, prior to their integration. Use of an external Gold Standard has several drawbacks, including data redundancy, data loss and the need for identifier mapping, which can complicate the network build and impact on PFIN performance. Additionally, there typically are no Gold Standard data for non-model organisms.

RESULTS

We describe the development of an integration technique, ssNet, that scores and integrates both high-throughput and low-throughout data from a single source database in a consistent manner without the need for an external Gold Standard dataset. Using data from Saccharomyces cerevisiae we show that ssNet is easier and faster, overcoming the challenges of data redundancy, Gold Standard bias and ID mapping. In addition ssNet results in less loss of data and produces a more complete network.

CONCLUSIONS

The ssNet method allows PFINs to be built successfully from a single database, while producing comparable network performance to networks scored using an external Gold Standard source and with reduced data loss.

O-184 The impact of cryopreserved sperm on Intrauterine Insemination (IUI) outcomes: Is frozen as good as fresh?

Study question

Are the outcomes of IUI cycles [with or without ovarian stimulation (OS)] comparable when frozen instead of fresh-ejaculated sperm is utilized?

Summary answer

Overall, clinical outcomes did not differ significantly between frozen and fresh sperm IUI cycles, although specific subgroups might benefit from fresh sperm utilization.

What is known already

At present, data from animal studies point towards less favorable outcomes with frozen sperm utilization, implicating cryopreservation-induced damages to the cytoskeleton, DNA, and acrosome leading to adverse effects on spermatozoa’s motility, viability, and ability to fuse with the oocyte. Assisted Reproductive Technology (ART) data, mostly focusing on severe male factor infertility diagnoses, suggest no major differences between in-vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) cycles utilizing frozen over fresh sperm, often surgically extracted. Nevertheless, contemporary data from IUI(±OS) cycles are still scarce.

Study design, size, duration

Data from 5335 IUI(±OS) cycles (time-period: 01/2004-12/2021) from a large academic fertility center were retrospectively reviewed. Cycles were stratified in two groups based on utilization of frozen instead of fresh-ejaculated sperm for the IUI [FROZEN (n = 1871, all infertility diagnoses), and FRESH (n = 3464, idiopathic infertility diagnosis only), respectively]. Cycle outcomes were compared between groups.

Participants/materials, setting, methods

Participants: women seeking IUI (±OS) treatments.

Outcome Measures: HCG-positivity, clinical pregnancy (CP), spontaneous abortion (SAB) rates. Initial analysis included all cycles irrespective of OS regimen.  Cycles were then stratified by OS regimen into three subgroups [injectable gonadotropins, oral medications (OM): clomiphene-citrate and letrozole, and unstimulated/natural]. Odds ratios (OR) for all relevant outcomes were calculated utilizing logistic regression and adjusted for maternal age, day-3 FSH, and OS regimen. Time-to-pregnancy and first-cycle only analyses were also performed.

Main results and the role of chance

Unadjusted HCG-positivity, and CP were lower in the FROZEN compared to the FRESH group (12.2% vs. 15.6%, p &lt; 0.001; 9.4% vs. 13.0%, p&lt;.001, respectively), which persisted only among OM after stratification (9.9% vs. 14.2% HCG-positivity, p=.030; 8.1% vs. 11.8% CPR, p=.041, for FROZEN compared to FRESH, respectively).

Among all cycles, adjOR(95%CI) for HCG-positivity and CP were respectively: 0.75(0.56-1.02), and 0.77(0.57-1.03), ref: FRESH). Following stratification by OS regimen, adjOR(95%CI) for HCG-positivity and CP showed no difference between groups among gonadotropin and natural cycles but favored the FRESH group in OM cycles [HCG-positivity: 0.55(0.30-0.99); CP: 0.49(0.25-0.95), ref.: FRESH]. SAB odds did not differ between groups among OM and natural cycles but were lower in the FROZEN compared to FRESH group among gonadotropin cycles [adjOR(95%CI): 0.13(0.02-0.98), ref.: FRESH]. However, regarding the latter comparison, numbers were small and the 95%CI wide.  When analysis was limited to first-cycles only and further stratified by OS regimen, the previously noted differences in CP and SAB odds no longer existed within the OS subgroups.

Nevetheless, time-to-conception was slightly longer in the FROZEN compared to the FRESH group (3.84 vs. 2.58 cycles, p&lt;.001).

Limitations, reasons for caution

Study is limited by its retrospective nature. The two groups differed somewhat in age, infertility diagnosis, utilized OS regimen, and as expected in total motile sperm counts. Despite the less favorable characteristics of the FROZEN group, no detrimental effect of sperm cryopreservation on IUI outcomes was noted.

Wider implications of the findings

Our study, the largest to date, showed no significant difference in IUI outcomes between cycles utilizing frozen instead of fresh-ejaculated sperm. Although, specific subgroups might benefit from fresh sperm utilization and time-to-pregnancy might be shorter with fresh over frozen sperm, patients should be counselled about the non-inferiority of frozen sperm.

Trial registration number

Not applicable

P-342 The impact of Clomiphene Citrate (CC) on the endometrium in comparison to gonadotropins (Gn) in intrauterine-insemination treatments (IUI): Is it thinner and does it matter?

Study question

Utilizing patients as their own controls, does endometrial thickness (EMT) differ between CC/IUI and Gn/IUI? Does EMT differ between CC-cycles with and without associated conception?

Summary answer

Within-patient, CC resulted in thinner EMT compared to Gn. CC-cycles associated with conception compared to the ones without it, had thicker endometria.

What is known already

CC, unlike gonadotropins, may have an anti-estrogenic effect on the endometrium. Concerns exist that the thinning of the endometrium might be associated with altered endometrial development and receptivity. However, available data in CC cycles remain inconsistent, probably due to patient and protocol heterogeneity. Currently, it remains unclear whether CC treatments produce a thinner endometrium, compared to gonadotropins, in the same patient. Furthermore, it is uncertain whether such a difference, if one exists, has a consequential effect on IUI cycle outcomes.

Study design, size, duration

Design: retrospective.

Duration: 1/2004-9/2021

Cohort 1 utilized women as their own controls to evaluate CC’s impact on the endometrium and included all cycles from women who sought fertility treatments and initially underwent CC/IUI (CC1, n = 1252) followed by Gn/IUI (Gn1, n = 1307).

Cohort 2 included all cycles from women seeking fertility treatments at the same center that conceived following CC/IUI treatments (CC2, n = 686).

EMT was compared between groups (CC1 vs. Gn1, CC1 vs. CC2).

Participants/materials, setting, methods

Outcome measures:

Primary: EMT (mm).

Secondary: HCG-positivity (pos-HCGR), clinical pregnancy (CPR), and spontaneous abortion rates (SABR).

Statistics:

Regression analysis was used to calculate Odds Ratios (OR) with associated 95% confidence intervals (95%CI), adjusting for potential confounders [maternal age, Body Mass Index (BMI), prior parity, day of EMT measurement relative to trigger). Generalized estimating equations (GEE) model were utilized to account for multiple cycles per patient. P &lt; 0.05 was considered significant.

Main results and the role of chance

In cohort 1, despite CC1 exhibiting non-inferior ovarian response compared to Gn1 (as assessed by preovulatory follicular number), EMT was significantly thinner in CC1 compared to Gn1 [Median(IQR): 7.0(5.7-8.3) vs. 8.9(7.4-10.0), p&lt;.001]. When CC1 was compared to CC2 (CC conceiving), EMT was also thinner [Median(IQR): 7.0(5.7-8.3) vs. 7.5(6.2-9.0), for CC1 vs. CC2, respectively, p&lt;.001]. A higher percentage of CC1 compared to Gn1 cycles resulted in EMT≤7mm (48.9% vs. 16.7% , for CC1 vs. Gn, respectively; p&lt;.001). Most subsequent Gn cycles (82.8%), in the same women, resulted in thicker EMT compared to CC1. AdjOR, in generalized linear mixed models, suggested that CC2 when compared to CC1 cycles had thicker EMT [adjOR(95%CI): 1.81, (1.41,2.35), p&lt;.001].

Interestingly, clinical pregnancies were observed even when EMT was ≤4mm in both CC2 and Gn1 groups and SABR did not differ between cycles with EMT≤4mm and the ones with thicker EMT (2.5% vs. 11.5%, p=.258, in CC2; 0% and 12.3%, p=.544, in Gn1; SABR EMT ≤4 vs. 4 mm, respectively). GEE models suggested an association between EMT and CPR in CC cycles (CC1&CC2), [adjOR(95%CI): 1.12(1.07,1.18), p&lt;.001)] while in Gn1, no such association was observed.

Limitations, reasons for caution

Our study was limited by its retrospective design. Reflecting our selection criterion, in cohort 1, most CC cycles did not result in pregnancy, restricting relevant comparisons. Number of cycles resulting in EMT ≤7mm, and particularly ≤4mm, was limited, and consequently respective results should be interpreted cautiously.

Wider implications of the findings

Utilizing patients as their own controls, we showed that CC compared to gonadotropins resulted in thinner endometrium. Given comparable follicular response, and potentially estradiol levels, thinner endometrium might have resulted from CC’s anti-estrogenic effect. Furthermore, patients conceiving on CC had a thicker endometrium compared to the ones that did not.

Trial registration number

NA

P-434 Is there an association between pre-ovulatory estradiol levels and placental pathology of singleton livebirths conceived with gonadotropins/intrauterine insemination (Gn/IUI) treatments?

Study question

Is pre-ovulatory estradiol level associated with placental weight (PW) and abnormality rates (PAR) in singleton livebirths resulting from gonadotropins/intrauterine insemination (Gn/IUI) treatments?

Summary answer

In Gn/IUI-conceived, singleton-livebirths with available placental pathology, an association was noted between preovulatory estradiol levels and PW, but not between estradiol and PAR.

What is known already

Data suggest an association between ART and placental-mediated pregnancy complications, as well as increased rates of placental pathology. Supraphysiologic levels of preovulatory estradiol have been implicated in abnormal placentation. Whether such an effect is noted in Gn/IUI treatments, where levels of estradiol are lower, nevertheless supraphysiologic, remains unknown.

Study design, size, duration

We retrospectively reviewed data from 560 Gn/IUI-conceived, singleton-livebirths (1/2004-1/2021) recruited from a large academic fertility center. Placental pathology information was available from 218 cycles. These cycles were stratified by pre-ovulatory estradiol levels in quartiles [Q1(lower)-Q4 (higher)]. PW [grams & percentiles (%iles)], and rates of placental abnormalities (classified as anatomic, inflammatory, infectious, and vascular/thrombotic) were compared between groups.

Participants/materials, setting, methods

Participants: Women with Gn/IUI-conceived, singleton-livebirths with available placental pathology.

Outcome Measures: PW and PAR.

Statistics: Regression analysis was utilized to estimate the association of pre-ovulatory estradiol %iles with PW and PAR, adjusting for potential confounders (PW: maternal and gestational age, BMI, infertility diagnosis, medical complications, infant gender; PAR: maternal and gestational age, BMI, race). Adjusted Odds Ratios (OR) with 95%CI were calculated for the latter.

Main results and the role of chance

Mean PW(±SD) in grams were 477.3(±124.1), 445.9(±107.4), 451.2(±113.9), and 438.9(±107.0) in Q1 through Q4 (p=.368). Small placentas (≤10thPW %ile) accounted for more than a third of the total in all estradiol quartiles (37.5%, 49.2%, 37.5%, and 42.2%, p=.539, Q1-Q4, respectively). Similarly, increasingly higher percentages of placentas ≤25th PW %ile were noted with increasing estradiol quartiles (47.9%, 57.6%, 62.5% and 64.5%, in Q1-Q4 respectively, p=.347). After adjusting for potential confounders, we noted a mean 13.7 grams decrease in PW between each subsequent estradiol quartile [ adjβ-coeff (95%CI): -13.7(-27.7-0.3), p=.055]. When estradiol levels were analyzed as a continuous variable, an inverse association with PW [ adjβ-coeff (95%CI): -0.08 (-0.16-(-0.01)), p=.026] was noted. Adjusted ORs for small placenta did not differ between estradiol quartiles or when estradiol was analyzed as a continuous variable [adjORs(95%CI): 1.73(0.74-4.07), 1.10(0.47-2.55), 1.81(0.69-4.72), for Q2-Q4, Q1 as ref.; 1.001(1.000-1.003), p=.167; respectively].

There was no significant association between placental abnormality rates (PAR) and estradiol, either before or after adjustment [adjORs(95%CI): i) Anatomic : 1.16(0.49-2.74), 1.52(0.65-3.59), and 1.17(0.45-3.02); ii) Inflammatory : 0.40(0.13-1.25), 0.79(0.28-2.17), and 1.25(0.42-3.73); iii) Infectious : 0.89(0.35-2.25), 1.67(0.68-4.13), and 0.58(0.20-1.67); iv) Vascular/thrombotic : 0.88(0.37-2.08), 1.87(0.80-4.41), and 0.95(0.36-2.49); for Q2-Q4 vs. Q1].

Limitations, reasons for caution

There are several limitations, including the retrospective design, possible selection bias resulting from the decision to obtain placental pathology. Nonetheless, birth weights did not differ between those with and without placental pathology. Estradiol levels, albeit supraphysiologic, are much lower than those in ART and differences might be masked.

Wider implications of the findings

In Gn/IUI-conceived, singleton-livebirths with available placental pathology, an association was noted between preovulatory estradiol levels and placental weight, but not between estradiol and the rate of specific placental abnormalities (PAR). Since estradiol levels are lower than those observed in ART, an association might have been missed.

Trial registration number

not applicable

P-426 Placental pathology following Intrauterine Insemination (IUI) with or without Ovarian Stimulation (OS)

Study question

Do placental weight percentiles (PW %iles) and abnormality rates (PAR) differ in singleton-livebirths following IUI with or without OS [oral medications (OM), and injectable gonadotropins]?

Summary answer

Following singleton-livebirths, PW did not differ between groups, albeit over half of placentas were ≤25th%ile. Placental anatomic abnormalities were more often seen in OM cycles.

What is known already

ART data suggest a possible association between stimulation-induced supraphysiologic estradiol levels and increased risk of placental abnormalities, as well as subsequent placental-mediated pregnancy complications, such as preeclampsia. Whether there is an association between OS protocols for IUI and placental pathology remains unknown.

Study design, size, duration

Data from 975 IUI(±OS) cycles resulting in singleton livebirths at a large academic fertility center between 01/2004 and 01/2021, were retrospectively reviewed. In 386 cycles a full placental pathologic examination was available. Placentas were stratified by OS regimen into three groups: gonadotropins (n = 222), OM [Clomiphene Citrate (CC)/Letrozole (LTZ); n = 129], and unstimulated / natural (n = 35). PW and PAR were compared between groups.

Participants/materials, setting, methods

Participants: Women delivering a singleton liveborn following IUI(±OS) treatments with placental pathology available.

Outcome Measures: PW (grs & %iles), and PAR (classified as anatomic, inflammatory, infectious, and vascular/thrombotic).

Statistics: Regression analysis was utilized to compare PW and PAR between groups, adjusting for potential confounders (PW: maternal and gestational age, BMI, infertility diagnosis, medical complications, infant gender; PAR: maternal and gestational age, BMI, race). Adjusted Odds Ratios (adjOR, 95%CI) were calculated for the latter.

Main results and the role of chance

Mean(±STDEV) PW (grs) were 451.7(±113.3), 449.2(±102.4), and 481.8(±99.8), for the gonadotropins, OM, and natural groups, respectively. Interestingly, over half of the placentas in all three groups were ≤25th %ile (58.6%, 56.1%, and 52.9%, for gonadotropins, OM, and natural, respectively, p=.249), while 41.8%, 46.4%, and 38.2% were below the 10th %ile (for gonadotropins, OM, and natural, respectively, p=.598). Adjusted PW differences, and adjOR for small placenta (≤10th %ile) did not differ between groups [PW OR(95%CI): 5.6(-17.9-29.2), -28.1(-71.4-15.2), -11.7(-52.6-29.3); small placenta OR(95%CI): 1.04(0.62-1.76); 1.27(0.40-4.01), and 0.96(0.34-2.74) for OM vs. gonadotropins, OM vs. natural, and gonadotropins vs. natural, latter as ref. ].

Regarding PAR, anatomic(43.7%, 52.7%, and 40%, p=.192), inflammatory(20.7%, 27.1%, and 20%, p=.354), infectious(32.9%, 33.3%, and 31.4%, p=.978), and vascular/thrombotic(42.3%, 41.9%, and 42.9%, p=.993) abnormalities rates did not differ between gonadotropins, OM, and natural, respectively. AdjORs(95%CI) for inflammatory, infectious, and vascular/thrombotic abnormalities did not differ significantly between groups. However, anatomic abnormalities were more frequent among OM compared to gonadotropin and natural cycles [adjOR(95%CI): 1.76(1.06-2.91), p=.028, gonadotropins as ref.; 2.52(1.05-6.05), p=.038, natural as ref.].

Limitations, reasons for caution

This study is limited by its retrospective nature. Unfortunately, placental pathology was available only in conceptions clearly identified as resulting from IUI(±OS) treatments. However, birth weights did not differ between those with and without available placental pathology. Natural/IUI cycles were limited in numbers not allowing meaningful conclusions.

Wider implications of the findings

Between IUI-conceived, singleton-livebirths with available placental pathology, mean PW did not differ significantly. However, a higher-than-expected percent of placentas were below the expected %iles, suggesting that IUI(±OS) might be associated with altered placental growth. Placental anatomic abnormalities were more common among OM cycles, compared to gonadotropins, and n atural IUI cycles.

Trial registration number

Not applicable

Development of white matter tracts between and within the dorsal and ventral streams

The degree of interaction between the ventral and dorsal visual streams has been discussed in multiple scientific domains for decades. Recently, several white matter tracts that directly connect cortical regions associated with the dorsal and ventral streams have become possible to study due to advancements in automated and reproducible methods. The developmental trajectory of this set of tracts, here referred to as the posterior vertical pathway (PVP), has yet to be described. We propose an input-driven model of white matter development and provide evidence for the model by focusing on the development of the PVP. We used reproducible, cloud-computing methods and diffusion imaging from adults and children (ages 5-8 years) to compare PVP development to that of tracts within the ventral and dorsal pathways. PVP microstructure was more adult-like than dorsal stream microstructure, but less adult-like than ventral stream microstructure. Additionally, PVP microstructure was more similar to the microstructure of the ventral than the dorsal stream and was predicted by performance on a perceptual task in children. Overall, results suggest a potential role for the PVP in the development of the dorsal visual stream that may be related to its ability to facilitate interactions between ventral and dorsal streams during learning. Our results are consistent with the proposed model, suggesting that the microstructural development of major white matter pathways is related, at least in part, to the propagation of sensory information within the visual system.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

Ways Community-Based Organizations Enhance Late-Life Depression Care in Partnership With Clinics

Late-life depression is a serious public health concern in the U.S., especially as the population ages. To improve care coordination and increase the number of providers working to improve depression outcomes, primary care clinics and community-based organizations (CBOs) can partner and improve care. Addressing social determinants of health is one area CBOs can help respond to but there are other ways CBOs can bring value to these partnerships with primary care clinics. As part of a qualitative evaluation of the Care Partners Project, 84 key informant interviews and 20 focus groups were conducted over five years with selected primary care physicians, care managers, administrators and psychiatric consultants. These data were coded and organized using an inductive and deductive thematic analysis approach. CBOs contributed to care through 1) adding new services that focus on clients’ social needs (e.g., assistance locating affordable housing, reliable transportation, applying for social security benefits) that were foundational to effective depression care; 2) strengthening core aspects of existing care; 3) incorporating a lay health workforce to enhance care; and/or 4) adding home visits that supported deeper understanding of patient’s life context, enhanced trust and improved access to care. CBOs can enhance depression care through increasing access and quality of care. Findings can inform conversations about the value CBOs offer when partnering with health care systems and improve partnership efforts. Such conversations are worth revisiting as organizations deepen their connections and work together over time.

Virtual Parts Repository 2: Model-Driven Design of Genetic Regulatory Circuits

Engineering genetic regulatory circuits is key to the creation of biological applications that are responsive to environmental changes. Computational models can assist in understanding especially large and complex circuits for which manual analysis is infeasible, permitting a model-driven design process. However, there are still few tools that offer the ability to simulate the system under design. One of the reasons for this is the lack of accessible model repositories or libraries that cater to the modular composition of models of synthetic systems. Here, we present the second version of the Virtual Parts Repository, a framework to facilitate the model-driven design of genetic regulatory circuits, which provides reusable, modular, and composable models. The new framework is service-oriented, easier to use in computational workflows, and provides several new features and access methods. New features include supporting hierarchical designs via a graph-based repository or compatible remote repositories, enriching existing designs, and using designs provided in Synthetic Biology Open Language documents to derive system-scale and hierarchical Systems Biology Markup Language models. We also present a reaction-based modeling abstraction inspired by rule-based modeling techniques to facilitate scalable and modular modeling of complex and large designs. This modeling abstraction enhances the modeling capability of the framework, for example, to incorporate design patterns such as roadblocking, distributed deployment of genetic circuits using plasmids, and cellular resource dependency. The framework and the modeling abstraction presented in this paper allow computational design tools to take advantage of computational simulations and ultimately help facilitate more predictable applications.

Male factor infertility and placental pathology in singleton live births conceived with in vitro fertilization

PURPOSE

We sought to determine whether pregnancies conceived in those with male factor infertility have unique placental pathology profiles compared to those undergoing infertility treatments for other indications.

METHODS

This was a retrospective cohort study of placental pathology from 464 live births conceived from autologous fresh IVF cycles at an academic fertility center from 2004 to 2017. Placental pathology was compared between live births arising from patients with male factor infertility alone and those with another infertility diagnosis. Placental outcomes were compared with parametric or non-parametric tests; logistic regression was performed to account for potential confounders.

RESULTS

Compared to cycles performed for a non-male factor diagnosis, male factor infertility cycles had a higher mean paternal age (38.2 years vs. 36.5 years, p < 0.001), a higher female mean BMI (24.3 vs. 23.3 kg/m2, p = 0.01), and a lower day 3 follicle stimulating hormone (FSH) level (6.8 vs. 7.3 IU/mL, p = 0.02). The mean numbers of embryos transferred, and day of transfer were similar between groups, and more cycles used ICSI in the male factor infertility group (90.6% vs. 22.5%, p < 0.001). Placental pathology in our adjusted model was similar between the male factor and non-male factor groups. In our unadjusted subgroup analysis, cycles for male factor using ICSI appeared to lead to more small placentas by weight compared to cycles performed with conventional insemination (45.8% < 10th percentile vs. 18.8%, p = 0.04).

CONCLUSION

Male factor infertility is not associated with significantly different placental pathology compared to other infertility diagnoses.

Women with chronic constipation have more bothersome urogenital symptoms

BACKGROUND

The aim of our study was to characterize urogenital symptoms in women with and without constipation, and by severity of constipation.

METHODS

This was a retrospective cohort study conducted at a pelvic floor disorder center in a tertiary healthcare facility from May 2007 through August 2019 and completed an intake questionnaire were included. We collected demographic, physical exam data and quality of life outcomes. The Urinary Distress Inventory (UDI-6) was used to assess urogenital symptoms. Women with constipation completed the Constipation Severity Instrument (CSI). We excluded women with a history of a bowel resection, inflammatory bowel disease, or pelvic organ prolapse symptoms. The cohort was then divided into two groups, constipated and non-constipated, and the prevalence and severity of urogenital-associated symptoms were compared. A secondary analysis was made among constipated subjects stratified by constipation severity based on CSI scores.

RESULTS

During the study period, 875 women (59.5%) had chronic constipation. Women with chronic constipation were more likely to experience urogenital symptoms, such as dyspareunia, urinary hesitancy, and a sensation of incomplete bladder emptying (all p < 0.05). Moreover, on univariate analysis, women with high CSI scores (75 percentile or higher) were found to have higher UDI-6 scores, increased bladder splinting, pad use, urinary frequency and dyspareunia while on multivariate analysis higher UDI score, increased bladder splinting, urinary frequency and dyspareunia were significantly associated (p < 0.05).

CONCLUSION

We found that the presence and severity of chronic constipation worsened the degree of bother from urogenital symptoms. Given that chronic constipation can modulate urogenital symptoms, our study suggests that pelvic floor specialists should assess the presence and severity of urogenital and bowel symptoms to provide comprehensive care.

The incidence, aetiology, and coagulation management of massive postpartum haemorrhage: a two-year national prospective cohort study

INTRODUCTION

Between 2017 and 2018 a national quality improvement initiative was introduced incorporating point-of-care viscoelastic haemostatic assays (VHA) to guide blood product transfusion. Laboratory coagulation profiles, use and results of VHA, and administration of blood products were investigated.

METHODS

A two-year prospective cohort study of maternal outcomes of women experiencing massive postpartum haemorrhage (PPH) >1000 mL in Wales. In this study, cases of massive PPH (≥2500 mL and/or ≥5 units red blood cell (RBC) transfusion) were identified.

RESULTS

Massive PPH occurred in 349 of 60 914 maternities (rate 5.7 per 1000). There were no deaths from PPH. Intensive care unit admission and/or hysterectomy occurred in 34/311 (10.9%) and 16/347 (4.6%), respectively. The leading cause of massive PPH was genital tract trauma (107/349, 30.6%). Two hundred and seventy-nine (80.6%) required RBC transfusion and 79/345 (22.9%) received at least one blood coagulation product. Results of VHA were recorded in 245/349 (70.2%), with 44/98 (44.9%) women tested in the first six months vs 63/77 (81.8%) in the final six months. Hypofibrinogenaemia (Clauss fibrinogen <2 g/L or FIBTEM A5 <12 mm) was observed in 56/328 (17.1%) of women, thrombocytopaenia (count <75 × 10⁹/L) in 17/334 (5.1%) and either PT or aPTT >1.5×reference range in 10/293 (3.4%).

CONCLUSION

In Wales, the use of VHA in cases of massive PPH increased over time, enabling clinicians to adopt a targeted, patient-specific approach to blood product administration, with only 22.9% of women receiving blood coagulation products and 17.1% having a documented clotting abnormality.

Effect of surgical approach on risk of recurrence after vaginal brachytherapy in early-stage high-intermediate risk endometrial cancer

OBJECTIVE

The objective was to determine if surgical approach affects time to recurrence in early-stage high-intermediate risk endometrial cancer (HIR-EC) treated with adjuvant vaginal brachytherapy (VBT).

METHODS

In this retrospective cohort study, HIR-EC patients treated with VBT between 2005 and 2017 were identified and those who received open or minimally invasive hysterectomies (MIS) were included. Clinical and surgical variables were analyzed and time to recurrence was compared between surgical groups.

RESULTS

We identified 494 patients, of which 363 had MIS hysterectomies, 92.5% had endometrioid histology, 45.7% were stage IA and 48.0% stage IB. Open hysterectomy patients had higher BMIs (p = 0.007), lower rates of lymph node sampling (p < 0.001) and lymphovascular space invasion (LVSI) (p = 0.036), however in patients who recurred, no differences were noted between groups. Overall, 65 patients (13.2%) recurred, 14 in the open group (10.7%) and 51 in the MIS group (14.0%) (p = 0.58), while vaginal recurrences were noted in 4.6% and 6.1% respectively. When compared to the open group, the MIS group had a significantly shorter time to any recurrence (p = 0.022), to pelvic (p = 0.05) and locoregional recurrence (p = 0.021) and to death from any cause (p = 0.039). After adjusting for age, BMI, grade, LVSI and surgery date, the MIS group had a higher risk of any recurrence (HR 2.29 (1.07-4.92), p = 0.034) and locoregional recurrence (HR 4.18 (1.44-12.1), p = 0.008).

CONCLUSIONS

Patients with HIR-EC treated with VBT after MIS hysterectomy have a shorter time to recurrence and higher risk of recurrence when compared to open hysterectomy patients. Further studies into the safety of MIS in high-intermediate risk patients are required.

Complete representation of a tapeworm genome reveals chromosomes capped by centromeres, necessitating a dual role in segregation and protection

BACKGROUND

Chromosome-level assemblies are indispensable for accurate gene prediction, synteny assessment, and understanding higher-order genome architecture. Reference and draft genomes of key helminth species have been published, but little is yet known about the biology of their chromosomes. Here, we present the complete genome of the tapeworm Hymenolepis microstoma, providing a reference quality, end-to-end assembly that represents the first fully assembled genome of a spiralian/lophotrochozoan, revealing new insights into chromosome evolution.

RESULTS

Long-read sequencing and optical mapping data were added to previous short-read data enabling complete re-assembly into six chromosomes, consistent with karyology. Small genome size (169 Mb) and lack of haploid variation (1 SNP/3.2 Mb) contributed to exceptionally high contiguity with only 85 gaps remaining in regions of low complexity sequence. Resolution of repeat regions reveals novel gene expansions, micro-exon genes, and spliced leader trans-splicing, and illuminates the landscape of transposable elements, explaining observed length differences in sister chromatids. Syntenic comparison with other parasitic flatworms shows conserved ancestral linkage groups indicating that the H. microstoma karyotype evolved through fusion events. Strikingly, the assembly reveals that the chromosomes terminate in centromeric arrays, indicating that these motifs play a role not only in segregation, but also in protecting the linear integrity and full lengths of chromosomes.

CONCLUSIONS

Despite strong conservation of canonical telomeres, our results show that they can be substituted by more complex, species-specific sequences, as represented by centromeres. The assembly provides a robust platform for investigations that require complete genome representation.

Protocol-Driven Intensive Outpatient Management of Pregnant Patients With Symptomatic Coronavirus Disease 2019

Background

Reports of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have focused on pregnant women hospitalized due to moderate to severe coronavirus disease 2019 (COVID-19) or asymptomatic women diagnosed through universal screening at the time of obstetric admission. Many pregnant women who have symptomatic SARS-CoV-2 infection may not meet criteria for hospitalization; however, whether and how these women can be managed safely in outpatient setting is not well described.

Methods

We sought to describe the time to symptom and viral clearance and to identify predictors of hospitalization to better understand the safety of monitoring pregnant patients with symptomatic COVID-19 in the outpatient setting. We performed a retrospective cohort study of pregnant patients with symptomatic, confirmed COVID-19 illness at a large, academic medical center. Patients had systematic telehealth follow up by a clinician team to assess for symptoms, provide virtual prenatal care, and arrange in-person visits when appropriate in a dedicated outpatient center. Data were collected via chart abstraction.

Results

Of 180 pregnant patients presenting with symptoms and undergoing reverse-transcription polymerase chain reaction (RT-PCR) testing, 67 patients with confirmed COVID-19 infection were identified during the study period. Nineteen (28%) required acute care given worsening of COVID-19 symptoms, and 95% of these were directed to this acute care setting due to symptom severity telehealth evaluation. Nine women (13%) were admitted to the hospital given worsening symptoms, 3 required intensive care unit care, 2 required ventilatory support, and 2 required delivery. Women with the presenting symptoms of fever, cough, shortness of breath, chest pain, or nausea and vomiting were more likely to require admission. The median duration from initial positive test to RT-PCR viral clearance was 26 days. Disease progression, time to viral clearance, and duration of symptoms did not vary significantly by trimester of infection.

Conclusions

Management of the majority of pregnant women with symptomatic COVID-19 illness can be accomplished in the outpatient setting with intensive and protocol-driven monitoring for symptom progression.

Capturing Multicellular System Designs Using Synthetic Biology Open Language (SBOL)

Synthetic biology aims to develop novel biological systems and increase their reproducibility using engineering principles such as standardization and modularization. It is important that these systems can be represented and shared in a standard way to ensure they can be easily understood, reproduced, and utilized by other researchers. The Synthetic Biology Open Language (SBOL) is a data standard for sharing biological designs and information about their implementation and characterization. Previously, this standard has only been used to represent designs in systems where the same design is implemented in every cell; however, there is also much interest in multicellular systems, in which designs involve a mixture of different types of cells with differing genotype and phenotype. Here, we show how the SBOL standard can be used to represent multicellular systems, and, hence, how researchers can better share designs with the community and reliably document intended system functionality.

Radiation dose tracking in computed tomography: Red alerts and feedback. Implementing a radiation dose alert system in CT

INTRODUCTION

This study investigates instances of elevated radiation dose on a radiation tracking system to determine their aetiologies. It aimed to investigate the impact of radiographer feedback on these alerts.

METHODS

Over two six-month periods 11,298 CT examinations were assessed using DoseWatch. Red alerts (dose length products twice the median) were identified and two independent reviewers established whether alerts were true (unjustifiable) or false (justifiable). During the second time period radiographers used a feedback tool to state the cause of the alert. A Chi-Square test was used to assess whether red alert incidence decreased following the implementation of radiographer feedback.

RESULTS

There were 206 and 357 alerts during the first and second time periods, respectively. These occurred commonly with CT pulmonary angiography, brain, and body examinations. Procedural documentation errors and patient size accounted for 57% and 43% of false alerts, respectively. Radiographer feedback was provided for 17% of studies; this was not associated with a significant change in the number of alerts, but the number of true alerts declined (from 7 to 3) (χ2 = 4.14; p = 0.04).

CONCLUSION

Procedural documentation errors as well as patient-related factors are associated with false alerts in DoseWatch. Implementation of a radiographer feedback tool reduced true alerts.

IMPLICATIONS FOR PRACTICE

The implementation of a radiographer feedback tool reduced the rate of true dose alerts. Low uptake with dose alert systems is an issue; the workflow needs to be considered to address this.

Prevalence and outcome of delirium among acute general medical inpatients in Cape Town, South Africa

BACKGROUND

Delirium is a common, serious, underdiagnosed condition in medical and surgical inpatients with acute conditions. It is associated with increased risk of mortality and morbidity. Data of geriatric cohorts are largely limited to developed countries.

OBJECTIVES

To describe prevalence, risk factors and outcomes of delirium among general medical patients admitted to two hospitals in Cape Town, South Africa.

METHODS

This was a prospective cohort study of patients with acute conditions admitted to a general medical inpatient service in secondary- and tertiary-level public hospitals in the Metro West area of Cape Town. Patients ≥18 years of age were recruited daily from all acute medical admissions. Patients were excluded if they were aphasic or their Glasgow coma scale was &lt;8/15. Delirium was diagnosed using the validated confusion assessment method (CAM) tool and performed by trained neuropsychologists. Demographic data were collected by a clinical team and short- and long-term mortality data were obtained using linkage analysis of hospitalised patients and routinely collected provincial death certification records.

RESULTS

The median age of inpatients was 51 (interquartile range 36 - 65) years, 29% were HIV-infected and the overall prevalence of delirium was 12.3%. Multivariate predictors of delirium included the presence of an indwelling urinary catheter (odds ratio (OR) 4.47; confidence interval (CI) 2.43 - 8.23), admission with a central nervous system disease (OR 4.34; CI 2.79 - 7.90), pre-existing cognitive impairment (OR 3.02; CI 1.22 - 7.43) and immobility (OR 1.88; CI 1.01 - 3.51). HIV infection was not associated with increased risk of delirium. Delirium was associated with an increased risk of inhospital (delirium v. no delirium: 29% v. 12%; p&lt;0.01) and 12-month (30% v. 20%; p&lt;0.01) mortality, as well as increased length of hospital stay (7 days v. 5 days; p&lt;0.01).

CONCLUSIONS

In this cohort of medical inpatients (relatively young and with a high HIV prevalence) 1 of 8 (12.3%) patients was delirious. Delirium was associated with adverse outcomes. Delirium risk factors in this young cohort were similar to those in geriatric cohorts in developed countries, and neither HIV nor opportunistic infections increased risk.

The tapeworm interactome: inferring confidence scored protein-protein interactions from the proteome of Hymenolepis microstoma

Background

Reference genome and transcriptome assemblies of helminths have reached a level of completion whereby secondary analyses that rely on accurate gene estimation or syntenic relationships can be now conducted with a high level of confidence. Recent public release of the v.3 assembly of the mouse bile-duct tapeworm, Hymenolepis microstoma, provides chromosome-level characterisation of the genome and a stabilised set of protein coding gene models underpinned by bioinformatic and empirical data. However, interactome data have not been produced. Conserved protein-protein interactions in other organisms, termed interologs, can be used to transfer interactions between species, allowing systems-level analysis in non-model organisms.

Results

Here, we describe a probabilistic, integrated network of interologs for the H. microstoma proteome, based on conserved protein interactions found in eukaryote model species. Almost a third of the 10,139 gene models in the v.3 assembly could be assigned interaction data and assessment of the resulting network indicates that topologically-important proteins are related to essential cellular pathways, and that the network clusters into biologically meaningful components. Moreover, network parameters are similar to those of single-species interaction networks that we constructed in the same way for S. cerevisiae, C. elegans and H. sapiens, demonstrating that information-rich, system-level analyses can be conducted even on species separated by a large phylogenetic distance from the major model organisms from which most protein interaction evidence is based. Using the interolog network, we then focused on sub-networks of interactions assigned to discrete suites of genes of interest, including signalling components and transcription factors, germline multipotency genes, and genes differentially-expressed between larval and adult worms. Results show not only an expected bias toward highly-conserved proteins, such as components of intracellular signal transduction, but in some cases predicted interactions with transcription factors that aid in identifying their target genes.

Conclusions

With key helminth genomes now complete, systems-level analyses can provide an important predictive framework to guide basic and applied research on helminths and will become increasingly informative as new protein-protein interaction data accumulate.

The gene-rich genome of the scallop Pecten maximus

BACKGROUND

The king scallop, Pecten maximus, is distributed in shallow waters along the Atlantic coast of Europe. It forms the basis of a valuable commercial fishery and plays a key role in coastal ecosystems and food webs. Like other filter feeding bivalves it can accumulate potent phytotoxins, to which it has evolved some immunity. The molecular origins of this immunity are of interest to evolutionary biologists, pharmaceutical companies, and fisheries management.

FINDINGS

Here we report the genome assembly of this species, conducted as part of the Wellcome Sanger 25 Genomes Project. This genome was assembled from PacBio reads and scaffolded with 10X Chromium and Hi-C data. Its 3,983 scaffolds have an N50 of 44.8 Mb (longest scaffold 60.1 Mb), with 92% of the assembly sequence contained in 19 scaffolds, corresponding to the 19 chromosomes found in this species. The total assembly spans 918.3 Mb and is the best-scaffolded marine bivalve genome published to date, exhibiting 95.5% recovery of the metazoan BUSCO set. Gene annotation resulted in 67,741 gene models. Analysis of gene content revealed large numbers of gene duplicates, as previously seen in bivalves, with little gene loss, in comparison with the sequenced genomes of other marine bivalve species.

CONCLUSIONS

The genome assembly of P. maximus and its annotated gene set provide a high-quality platform for studies on such disparate topics as shell biomineralization, pigmentation, vision, and resistance to algal toxins. As a result of our findings we highlight the sodium channel gene Nav1, known to confer resistance to saxitoxin and tetrodotoxin, as a candidate for further studies investigating immunity to domoic acid.

High intrinsic hydrolytic activity of cyanobacterial RNA polymerase compensates for the absence of transcription proofreading factors

The vast majority of organisms possess transcription elongation factors, the functionally similar bacterial Gre and eukaryotic/archaeal TFIIS/TFS. Their main cellular functions are to proofread errors of transcription and to restart elongation via stimulation of RNA hydrolysis by the active centre of RNA polymerase (RNAP). However, a number of taxons lack these factors, including one of the largest and most ubiquitous groups of bacteria, cyanobacteria. Using cyanobacterial RNAP as a model, we investigated alternative mechanisms for maintaining a high fidelity of transcription and for RNAP arrest prevention. We found that this RNAP has very high intrinsic proofreading activity, resulting in nearly as low a level of in vivo mistakes in RNA as Escherichia coli. Features of the cyanobacterial RNAP hydrolysis are reminiscent of the Gre-assisted reaction—the energetic barrier is similarly low, and the reaction involves water activation by a general base. This RNAP is resistant to ubiquitous and most regulatory pausing signals, decreasing the probability to go off-pathway and thus fall into arrest. We suggest that cyanobacterial RNAP has a specific Trigger Loop domain conformation, and isomerises easier into a hydrolytically proficient state, possibly aided by the RNA 3′-end. Cyanobacteria likely passed these features of transcription to their evolutionary descendants, chloroplasts.

The impact of male factor infertility on early and late morphokinetic parameters: a retrospective analysis of 4126 time-lapse monitored embryos

STUDY QUESTION

Is there an effect of male factor infertility (MFI) on either early or late morphokinetic parameters obtained during embryonic culture to blastocyst stage in a time-lapse imaging (TLI) incubator?

SUMMARY ANSWER

Neither mild nor severe MFI had an impact on overall time to blastocyst or duration of individual cleavage stages in the total embryo population.

WHAT IS KNOWN ALREADY

Prior studies have suggested that paternal DNA and sperm quality affect embryo morphokinetic parameters, but the impact of MFI is not fully understood.

STUDY DESIGN, SIZE, DURATION

This retrospective cohort study, at a major academic fertility centre, included 536 couples (women, ≤44 years of age) undergoing IVF between September 2013 and September 2016.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Data from 4126 embryos cultured to the blastocyst stage in a TLI-monitored incubator were retrospectively reviewed. Embryos derived from the sperm of men with MFI were compared with those derived from patients with other infertility diagnoses. Generalized fixed and random effects models, t-test and χ2 were used as appropriate.

MAIN RESULTS AND THE ROLE OF CHANCE

Couples with MFI had a higher rate of ICSI utilization and fewer usable embryos on average, and the men were older compared with couples with other diagnoses. Additionally, the women in MFI couples were younger and had higher antral follicle counts (AFCs) and higher anti-Müllerian hormone (AMH) levels compared with the other women undergoing IVF. When controlling for maternal and paternal ages, AMH and fertilization method (conventional IVF versus ICSI), neither mild nor severe MFI affected duration of individual cleavage stages or overall time to the blastocyst stage, when all or only usable embryos were examined (coefficient 0.44 hours in all embryos, P = 0.57; coefficient 0.39 hours in usable embryos, P = 0.60). Whether the sperm was surgically extracted similarly had no significant effect on embryo morphokinetic parameters. When the fertilization method was assessed independently, ICSI lengthened the overall time to blastocyst stage by 1.66 hours (P = 0.03) on average, primarily due to an increase in duration of the time from 5-cell embryo stage to early blastulation (P5SB).

LIMITATIONS, REASONS FOR CAUTION

This large cohort study avoided embryo selection bias due to random assignment of embryos to the TLI incubators. However, our findings may not be generalizable to groups under-represented in our clinic population. Future studies should also evaluate the impact of male hormonal status and detailed sperm morphology, such as head versus flagellum defects, on embryo morphokinetic development.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings suggest that the fertilization method rather than MFI per se impacts time to early blastulation. The clinical implications of this effect on embryo development warrant further investigation.

STUDY FUNDING/COMPETING INTEREST(S)

There were no sources of funding for this study. There are no competing interests.

TRIAL REGISTRATION NUMBER

N/A