Plasma cells are not restricted to the CD27+ phenotype: characterization of CD27-CD43+ antibody-secreting cells

Circulating antibody-secreting cells are present in the peripheral blood of healthy individuals reflecting the continued activity of the humoral immune system. Antibody-secreting cells typically express CD27. Here we describe and characterize a small population of antibody-secreting class switched CD19+CD43+ B cells that lack expression of CD27 in the peripheral blood of healthy subjects. In this study, we characterized CD27-CD43+ cells. We demonstrate that class-switched CD27-CD43+ B cells possess characteristics of conventional plasmablasts as they spontaneously secrete antibodies, are morphologically similar to antibody-secreting cells, show downregulation of B cell differentiation markers, and have a gene expression profile related to conventional plasmablasts. Despite these similarities, we observed differences in IgA and IgG subclass distribution, expression of homing markers, replication history, frequency of somatic hypermutation, immunoglobulin repertoire, gene expression related to Toll-like receptors, cytokines, and cytokine receptors, and antibody response to vaccination. Their frequency is altered in immune-mediated disorders.

Conclusion

we characterized CD27-CD43+ cells as antibody-secreting cells with differences in function and homing potential as compared to conventional CD27+ antibody-secreting cells.

POS0442 GLPG4399: SELECTIVE SIK3 INHIBITION AS A NOVEL MODE OF ACTION FOR THE TREATMENT OF INFLAMMATORY ARTHRITIC DISEASES (PRECLINICAL)

Background

Salt-inducible kinases (SIKs) is a family of kinases with immunomodulatory function identified using a proprietary adenoviral shRNA knockdown target discovery platform. Moreover, SIK inhibition has previously been shown to have a role in inflammatory signalling.1–3 These findings suggest a therapeutic potential for SIK inhibition in inflammatory indications. A medicinal chemistry effort resulted in the development of a first-in-class, oral, selective SIK3 inhibitor: GLPG4399. This compound may be beneficial in inflammatory diseases such as rheumatoid and psoriatic arthritis which are chronic disorders characterized by impaired joint synovial inflammation.

Objectives

Our research aimed to characterize GLPG4399 and explore its impact in arthritis-relevant inflammatory in vitro phenotypic cell assays, and to evaluate the therapeutic potential of selective SIK3 inhibition in in vivo experimental models of arthritis.

Methods

The selectivity and potency of GLPG4399 was profiled using biochemical and target-based cell assays. The mode of action of selective SIK3 inhibition in inflammation was explored in an in vitro panel of innate (monocytes, macrophages, dendritic cells) and adaptive (B and T lymphocytes) immune phenotypic assays and in a lipopolysaccharide (LPS)-stimulated human whole blood assay by measuring the production of inflammatory cytokines. In vivo target engagement was evaluated in an acute LPS-stimulated cytokine release mouse model by measuring plasma tumour necrosis factor (TNF) α levels. The therapeutic efficacy of GLPG4399 was evaluated in vivo in collagen-induced arthritis (CIA) and IL-23-induced psoriatic arthritis mouse models by assessing disease activity endpoints.

Results

GLPG4399 was shown to be a SIK3 inhibitor with high selectivity against a panel of 370 kinases. The wide effect of SIK3 inhibition on key immune cell types was demonstrated by GLPG4399’s reduction of pro-inflammatory cytokines produced by monocytes, macrophages, dendritic cells, B and T lymphocytes in a panel of in vitro innate and adaptive immune phenotypic assays. The biological activity and target engagement of GLPG4399 was further demonstrated by dose-dependent inhibition of TNFα production in vitro in LPS-stimulated human whole blood and in vivo in the blood of LPS-challenged mice. Oral treatment with GLPG4399 in mice resulted in a significant and dose-dependent improvement of disease activity score in both CIA and the psoriatic arthritis disease model. Moreover, bone erosion in CIA and new bone formation in the psoriatic arthritis disease model were significantly reduced.

Conclusion

Our preclinical findings demonstrate the strong immunomodulatory effect of SIK3 inhibition in arthritis-relevant inflammatory cell assays and highlight the significant preclinical efficacy of GLPG4399 in two experimental arthritis mouse models. The novel mechanisms of action of GLPG4399 represents a promising approach for the treatment of arthritis.

References

[1]Sundberg TB et al. PNAS 2014;111:12468–73.

[2]Lombardi MS et al. J Leukoc Biol 2016;99:711–21.

[3]Wein MN et al. Trends Endocrinol Metab 2018;29:723–35.

Acknowledgements

These studies were funded by Galapagos NV (Mechelen, Belgium). Editorial and publications management support was provided by PharmaGenesis London, London, UK, and funded by Galapagos NV.

Disclosure of Interests

Stephanie Lavazais Employee of: Employee of Galapagos., Anna Pereira-Fernandes Employee of: Employee of Galapagos., Carole Delachaume Employee of: Employee of Galapagos., Catherine Jagerschmidt Employee of: Employee of Galapagos., Michael Drennan Employee of: Employee of Galapagos., Didier Merciris Employee of: Employee of Galapagos., Christophe Peixoto Employee of: Employee of Galapagos., Monica Borgonovi Employee of: Employee of Galapagos., Nicolas Desroy Employee of: Employee of Galapagos., David Amantini Employee of: Employee of Galapagos., Steve De Vos Employee of: Employee of Galapagos., Kris Nys Employee of: Employee of Galapagos.

Biopsy-derived Intestinal Epithelial Cell Cultures for Pathway-based Stratification of Patients With Inflammatory Bowel Disease

BACKGROUND

Endoplasmic reticulum [ER] stress was shown to be pivotal in the pathogenesis of inflammatory bowel disease. Despite progress in inflammatory bowel disease [IBD] drug development, not more than one-third of patients achieve steroid-free remission and mucosal healing with current therapies. Furthermore, patient stratification tools for therapy selection are lacking. We aimed to identify and quantify epithelial ER stress in a patient-specific manner in an attempt towards personalised therapy.

METHODS

A biopsy-derived intestinal epithelial cell culture system was developed and characterised. ER stress was induced by thapsigargin and quantified with a BiP enzyme-linked immunosorbent assay [ELISA] of cell lysates from 35 patients with known genotypes, who were grouped based on the number of IBD-associated ER stress and autophagy risk alleles.

RESULTS

The epithelial character of the cells was confirmed by E-cadherin, ZO-1, and MUC2 staining and CK-18, CK-20, and LGR5 gene expression. Patients with three risk alleles had higher median epithelial BiP-induction [vs untreated] levels compared with patients with one or two risk alleles [p = 0.026 and 0.043, respectively]. When autophagy risk alleles were included and patients were stratified in genetic risk quartiles, patients in Q2, Q3, and Q4 had significantly higher ER stress [BiP] when compared with Q1 [p = 0.034, 0.040, and 0.034, respectively].

CONCLUSIONS

We developed and validated an ex vivo intestinal epithelial cell culture system and showed that patients with more ER stress and autophagy risk alleles have augmented epithelial ER stress responses. We thus presented a personalised approach whereby patient-specific defects can be identified, which in turn could help in selecting tailored therapies.

ATG16L1: A multifunctional susceptibility factor in Crohn disease

Genetic variations in the autophagic pathway influence genetic predispositions to Crohn disease. Autophagy, the major lysosomal pathway for degrading and recycling cytoplasmic material, constitutes an important homeostatic cellular process. Of interest, single-nucleotide polymorphisms in ATG16L1 (autophagy-related 16-like 1 [S. cerevisiae]), a key component in the autophagic response to invading pathogens, have been associated with an increased risk of developing Crohn disease. The most common and well-studied genetic variant of ATG16L1 (rs2241880; leading to a T300A conversion) exhibits a strong association with risk for developing Crohn disease. The rs2241880 variant plays a crucial role in pathogen clearance, resulting in imbalanced cytokine production, and is linked to other biological processes, such as the endoplasmic reticulum stress/unfolded protein response. In this review, we focus on the importance of ATG16L1 and its genetic variant (T300A) within the elementary biological processes linked to Crohn disease.

Therapeutic innovations in inflammatory bowel diseases

Inflammatory bowel disease (IBD) is a spectrum of complex multifactorial immune disorders characterized by chronic inflammation of the gut. Significant advances have been made in unraveling the pathogenesis of this disease spectrum, which have spurred the discovery of new therapeutic targets and strategies. In this review, we highlight the emerging new classes of IBD therapeutics under clinical evaluation and their method of action, including JAK inhibitors, anti-SMAD7 oligonucleotides, and cell-based therapies. Moreover, we discuss how an approach based on unique molecular insights in a given patient will, in the future, lead to a truly individualized/tailored disease management, starting at diagnosis, aiding in prognosis, and resulting in a personalized therapeutic approach.

Impact of T300A Variant of ATG16L1 on Antibacterial Response, Risk of Culture Positive Infections, and Clinical Course of Crohn's Disease

OBJECTIVES:

Autophagy-related 16-like 1 (ATG16L1) deficiency leads to impaired cellular autophagy and bacterial degradation as well as an altered cytokine production. The single-nucleotide polymorphism rs2241880 (T300A) is associated with an increased risk for Crohn's disease (CD). ATG16L1 polymorphisms could therefore have an impact on the risk of infectious complications and disease course in CD. We examined the impact of the T300A genotype on the antibacterial response toward a panel of pathogenic bacteria in vitro, as well as clinical infectious complications in vivo and the disease course in a Danish cohort of patients with CD.

METHODS:

A total of 236 CD patients were genotyped for ATG16L1^T300A; their clinical records were reviewed, and microbial, radiological, and surgical data were scrutinized. Peripheral blood mononuclear cells (PBMCs) were isolated from healthy controls and CD patients carrying the different ATG16L1 genotypes, and the production of tumor necrosis factor (TNF)-α and interleukin (IL)-1β was measured by enzyme-linked immunosorbent assay after stimulation with a panel of pathogenic bacteria of clinical relevance for the gastrointestinal tract, e.g., enteroinvasive Escherichia coli (EIEC), Listeria monocytogenes, Salmonella typhimurium, Staphylococcus aureus, or Mycobacterium avium paratuberculosis.

RESULTS:

Fifty-seven healthy controls (15, 29, 13) and 236 patients with CD (50, 108, 78) were genotyped for the T300A ATG16L1 polymorphism (AA homozygous, GG homozygous risk variant, AG heterozygous variant, respectively). The median duration of disease was 128 months (range, 30–175). The cumulative follow-up of this cohort was 2,366 patient-years. ATG16L1 gene variations interfered with the production of IL-1β, which was significantly increased in PBMCs from GG patients in response to all tested bacteria, whereas the TNF-α production was decreased in PBMCs from GG patients stimulated with EIEC, L. monocytogenes, and S. typhimurium, but unaffected by the other bacteria tested. Moreover, the GG variant showed a nonsignificant increase in the risk of bowel resections (P=0.07) and postsurgical infections (P=0.08), whereas the risk of non-disease-related infections was unaffected by genotype in the observation period. In addition, patients with AA and AG variants had a higher frequency of complicated fistulizing disease (P=0.03) with an overall more aggravated disease course with an increased number of surgical procedures for fistulous disease from a median 6.5 operations (2.0 in GG patients; P=0.002). This risk was independent on disease phenotype (penetrating vs. non-penetrating) and immunomodulating medication.

CONCLUSIONS:

The T300A variant in patients with CD strongly increases the risk for complicated fistulizing disease, and significantly affects antibacterial responses in vitro, but the latter effect seems to have a minor role for the infectious risk in CD.

ATG16L1: A multifunctional susceptibility factor in Crohn disease

Genetic variations in the autophagic pathway influence genetic predispositions to Crohn disease. Autophagy, the major lysosomal pathway for degrading and recycling cytoplasmic material, constitutes an important homeostatic cellular process. Of interest, single-nucleotide polymorphisms in ATG16L1 (autophagy-related 16-like 1 [S. cerevisiae]), a key component in the autophagic response to invading pathogens, have been associated with an increased risk of developing Crohn disease. The most common and well-studied genetic variant of ATG16L1 (rs2241880; leading to a T300A conversion) exhibits a strong association with risk for developing Crohn disease. The rs2241880 variant plays a crucial role in pathogen clearance, resulting in imbalanced cytokine production, and is linked to other biological processes, such as the endoplasmic reticulum stress/unfolded protein response. In this review, we focus on the importance of ATG16L1 and its genetic variant (T300A) within the elementary biological processes linked to Crohn disease.

Tumor vessel normalization by chloroquine independent of autophagy

Chloroquine (CQ) has been evaluated as an autophagy blocker for cancer treatment, but it is unknown if it acts solely by inhibiting cancer cell autophagy. We report that CQ reduced tumor growth but improved the tumor milieu. By normalizing tumor vessel structure and function and increasing perfusion, CQ reduced hypoxia, cancer cell invasion, and metastasis, while improving chemotherapy delivery and response. Inhibiting autophagy in cancer cells or endothelial cells (ECs) failed to induce such effects. CQ's vessel normalization activity relied mainly on alterations of endosomal Notch1 trafficking and signaling in ECs and was abrogated by Notch1 deletion in ECs in vivo. Thus, autophagy-independent vessel normalization by CQ restrains tumor invasion and metastasis while improving chemotherapy, supporting the use of CQ for anticancer treatment.

Genetic association and functional role of Crohn disease risk alleles involved in microbial sensing, autophagy, and endoplasmic reticulum (ER) stress

Genome-wide association studies have identified several genes implicated in autophagy (ATG16L1, IRGM, ULK1, LRRK2, and MTMR3), intracellular bacterial sensing (NOD2), and endoplasmic reticulum (ER) stress (XBP1 and ORMDL3) to be associated with Crohn disease (CD). We studied the known CD-associated variants in these genes in a large cohort of 3451 individuals (1744 CD patients, 793 ulcerative colitis (UC) patients and 914 healthy controls). We also investigated the functional phenotype linked to these genetic variants. Association with CD was confirmed for NOD2, ATG16L1, IRGM, MTMR3, and ORMDL3. The risk for developing CD increased with an increasing number of risk alleles for these genes (P<0.001, OR 1.26 [1.20 to 1.32]). Three times as many (34.8%) CD patients carried a risk allele in all three pathways, in contrast to 13.3% of the controls (P<0.0001, OR = 3.46 [2.77 to 4.32]). For UC, no significant association for one single nucleotide polymorphism (SNP) was found, but the risk for development of UC increased with an increasing total number of risk alleles (P = 0.001, OR = 1.10 [1.04 to 1.17]). We found a genetic interaction between reference SNP (rs)2241880 (ATG16L1) and rs10065172 (IRGM) in CD. Functional experiments hinted toward an association between an increased genetic risk and an augmented inflammatory status, highlighting the relevance of the genetic findings.

Autophagy: a new target or an old strategy for the treatment of Crohn's disease?

In the past 5 years much progress has been made in understanding the molecular basis of Crohn's disease, a multifactorial chronic inflammatory disease of the gastrointestinal tract. Data suggest that hampered autophagy--the major lysosomal pathway for recycling of cytoplasmic material--might contribute to an increased susceptibility to Crohn's disease. Consequently, intense investigations have started to evaluate the potential value of autophagy as a therapeutic target and as a highly needed diagnostic tool. Interestingly, as well as the promising introduction of direct autophagic modulators, several drugs already used in the treatment of Crohn's disease might exert at least part of their effect through the regulation of autophagy. However, whether this phenomenon contributes to or rather counteracts their therapeutic use, remains to be determined and might prove to be highly compound-specific. Here we review the complex and emerging role of autophagy modulation in the battle against Crohn's disease. Moreover, we discuss the potential benefits and deleterious effects of autophagic regulation by both new and clinically used drugs.

Skin mild hypoxia enhances killing of UVB-damaged keratinocytes through reactive oxygen species-mediated apoptosis requiring Noxa and Bim

The naturally occurring skin hypoxia has emerged as a crucial host factor of the epidermal microenvironment. We wanted to systematically investigate how reduced oxygen availability of the epidermis modulates the response of keratinocytes and melanocytes to noxious ultraviolet B radiation (UVB). We report that the exposure of normal human keratinocytes (NHKs) or melanocytes (NHEMs) to mild hypoxia drastically impacts cell death responses following UVB irradiation. The hypoxic microenvironment favors survival and reduces apoptosis of UVB-irradiated NHEMs and their malignant counterparts (melanoma cells). In contrast, NHKs, but not the transformed keratinocytes, under hypoxic conditions display increased levels of reactive oxygen species (ROS) and are significantly sensitized to UVB-mediated apoptosis as compared to NHKs treated under normoxic conditions. Prolonged exposure of UVB-treated NHKs to hypoxia triggers a sustained and reactive oxygen species-dependent activation of the stress kinases p38(MAPK) and JNKs, which in turn, engage the activation of Noxa and Bim proapoptotic proteins. Combined silencing of Noxa and Bim significantly inhibits UVB-mediated apoptosis under hypoxic conditions, demonstrating that hypoxia results in an amplification of the intrinsic apoptotic pathway. Physiologically occurring skin hypoxia, by facilitating the specific removal of UVB-damaged keratinocytes, may represent a decisive host factor impeding important steps of the photocarcinogenesis process.

The major secreted protein Msp1/p75 is O-glycosylated in Lactobacillus rhamnosus GG

BACKGROUND

Although the occurrence, biosynthesis and possible functions of glycoproteins are increasingly documented for pathogens, glycoproteins are not yet widely described in probiotic bacteria. Nevertheless, knowledge of protein glycosylation holds important potential for better understanding specific glycan-mediated interactions of probiotics and for glycoengineering in food-grade microbes.

RESULTS

Here, we provide evidence that the major secreted protein Msp1/p75 of the probiotic Lactobacillus rhamnosus GG is glycosylated. Msp1 was shown to stain positive with periodic-acid Schiff staining, to be susceptible to chemical deglycosylation, and to bind with the mannose-specific Concanavalin A (ConA) lectin. Recombinant expression in Escherichia coli resulted in a significant reduction in molecular mass, loss of ConA reactivity and increased sensitivity towards pronase E and proteinase K. Mass spectrometry showed that Msp1 is O-glycosylated and identified a glycopeptide TVETPSSA (amino acids 101-108) bearing hexoses presumably linked to the serine residues. Interestingly, these serine residues are not present in the homologous protein of several Lactobacillus casei strains tested, which also did not bind to ConA. The role of the glycan substitutions in known functions of Msp1 was also investigated. Glycosylation did not seem to impact significantly on the peptidoglycan hydrolase activity of Msp1. In addition, the glycan chain appeared not to be required for the activation of Akt signaling in intestinal epithelial cells by Msp1. On the other hand, examination of different cell extracts showed that Msp1 is a glycosylated protein in the supernatant, but not in the cell wall and cytosol fraction, suggesting a link between glycosylation and secretion of this protein.

CONCLUSIONS

In this study we have provided the first evidence of protein O-glycosylation in the probiotic L rhamnosus GG. The major secreted protein Msp1 is glycosylated with ConA reactive sugars at the serine residues at 106 and 107. Glycosylation is not required for the peptidoglycan hydrolase activity of Msp1 nor for Akt activation capacity in epithelial cells, but appears to be important for its stability and protection against proteases.

Bcl-2 family members: essential players in skin cancer

Skin cancer has reached epidemic proportions and is considered to be a direct consequence of ultraviolet (UV) radiation exposure. Excessive exposure of epidermal cells to UV results in apoptosis of irreparably damaged cells to avoid malignant transformation. The Bcl-2 family of proteins is emerging as a crucial regulator of epidermal homeostasis and cell's fate in the stressed skin. Not surprisingly, deregulation of Bcl-2 family members is also chiefly involved in skin carcinogenesis and response to cancer therapy. Here we discuss the physiopathological role of epidermal Bcl-2 family members, their implications in skin carcinogenesis and as potential targets in cancer therapy.

Uncovering the role of hypoxia inducible factor-1α in skin carcinogenesis

The hypoxia inducible factor-1α (HIF-1α) is a pleiotropic transcription factor typically activated in response to low oxygen tension as well as other stress factors in normoxic conditions. Upon activation HIF-1α mediates the transcriptional activation of target genes involved in a variety of processes comprising stress adaptation, metabolism, growth and invasion, but also apoptotic cell death. The molecular mechanisms, signaling pathways and downstream targets evoked by the activation of HIF-1α in epidermal cells are becoming increasingly understood and underscore the participation of HIF-1α in crucial processes including malignant transformation and cancer progression. Recent studies have implicated HIF-1α as an integral part of the multifaceted signal transduction initiated by the exposure of keratinocytes to ultraviolet radiation B (UVB), which represents the most ubiquitous hazard for human skin and the principal risk factor for skin cancer. HIF-1α activation by UVB exposure contributes to either repair or the removal of UVB-damaged keratinocytes by inducing apoptosis, thus revealing a tumor suppressor role for HIF-1α in these cells. On the other hand, the constitutive expression of HIF-1α evoked by the mild hypoxic state of the skin has been implicated as a positive factor in the transformation of normal melanocytes into malignant melanoma, one of the most aggressive types of human cancers. Here we review the uncovered and complex role of HIF-1α in skin carcinogenesis.

Apoptosis signal regulating kinase-1 connects reactive oxygen species to p38 MAPK-induced mitochondrial apoptosis in UVB-irradiated human keratinocytes

The p38 MAPK pathway controls critical premitochondrial events culminating in apoptosis of UVB-irradiated human keratinocytes, but the upstream mediators of this stress signal are not completely defined. This study shows that in human keratinocytes exposed to UVB the generation of reactive oxygen species (ROS) acts as a mediator of apoptosis signal regulating kinase-1 (Ask-1), a redox-sensitive mitogen-activated protein kinase kinase kinase (MAP3K) regulating p38 MAPK and JNK cascades. The NADPH oxidase antagonist diphenylene iodonium chloride and the EGFR inhibitor AG1487 prevent UVB-mediated ROS generation, the activation of the Ask-1-p38 MAPK stress response pathway, and apoptosis, evidencing the link existing between the early plasma membrane-generated ROS and the activation of a lethal cascade initiated by Ask-1. Consistent with this, Ask-1 overexpression considerably sensitizes keratinocytes to UVB-induced mitochondrial apoptosis. Although the JNK pathway is also stimulated after UVB, the killing effect of Ask-1 overexpression is reverted by p38 MAPK inhibition, suggesting that Ask-1 exerts its lethal effects mainly through the p38 MAPK pathway. Moreover, p38alpha(-/-) murine embryonic fibroblasts are protected from UVB-induced apoptosis even if JNK activation is fully preserved. These results argue for an important role of the UVB-generated ROS as mediators of the Ask-1-p38 MAPK pathway that, by culminating in apoptosis, restrains the propagation of potentially mutagenic keratinocytes.

Triple Test Screening for Down Syndrome: Looking Back on a False-Positive Result and Having or Not Having a Triple Test in Subsequent Pregnancies

Objectives: It was the main aim of the present retrospective study carried out in Flanders to evaluate how women with a false-positive triple test result look back on their experience and decision making and how many of them make use of the triple test in subsequent pregnancies. Methods: All 508 women tested in the Centre for Human Genetics in Leuven in 1995 who had a positive triple test result followed by a normal amniocentesis outcome were invited to participate in a mailed questionnaire study with open and multiple choice questions in 1998. The response rate was 68%. Results: The answers to the multiple choice question assessing how they look back on their initial expectations regarding the exact meaning of the triple test revealed that less than one half reported that it concerned the identification of 'a higher risk of carrying a child with Down syndrome (DS)'. Reporting correct initial expectations was significantly associated with a higher education level. The same holds for indecisiveness regarding pregnancy termination should the amniocentesis have detected a fetus with DS. As expected, a large majority of the women reported a high level of distress or worry after the communication of the positive triple test result. Overall the findings show that retrospectively most women had the feeling that the decision to have amniocentesis was their own decision rather than a professional's. Of the subgroup with one or more subsequent pregnancies 70% had another triple test. Conclusions: The overall results of this study clearly reveal a need for a systematic approach aimed at better informing and counselling pregnant women about the implications and limitations of the triple test. Notwithstanding the reported high level of distress caused by a positive triple test result, a large majority of the women with subsequent pregnancies had another triple test; they represent a clearly higher percentage than in another recent study. Copyright 2001 S. Karger AG, Basel

Parenting stress and psychosocial well-being among parents with twins conceived naturally or by reproductive technology

This study compared parenting stress and psychosocial well-being among parents with 1 year old twins conceived in three different ways: (i) spontaneously without any medical assistance (54 families), (ii) spontaneously following hormonal treatment (25 families) and (iii) following in-vitro fertilization (IVF) or artificial insemination (AI) with the semen of the social father (24 families). The investigation included the Parenting Stress Index (PSI) and the General Health Questionnaire (GHQ-30). Since the presence of older children differed significantly between the three groups, this factor was included in the statistical analysis. Overall, no significant differences were found between the three study groups, either for the mothers or for the fathers. Nevertheless, we found a main effect of the presence of older children and an interaction effect of the presence of older children and the conception mode on some of the scales for the mothers: first-time mothers showed significantly higher stress related to parental competence, health and the partner relationship compared with mothers who had older children. First-time mothers with a history of infertility obtained significantly higher stress scores for parental competence and health and showed lower psychosocial well-being compared with naturally conceiving first-time mothers and mothers with a history of infertility who already had children.

Feelings and the need for information and counselling of expectant parents of twins

In this study, expectant parents of twins were questioned about their feelings and need for information and counselling on the parenting of twins. Data were obtained from self-rating questionnaires and an interview with the expectant mother. From the results it is argued that expectant parents of twins need specific information and counselling about the medical, emotional and parenting issues of having twins. Guidelines for organising this counselling are proposed.