Longitudinal changes of swallowing safety and efficiency in infants with spinal muscular atrophy who received disease modifying therapies

BACKGROUND

Dysphagia is a common feature of the natural history of patients with spinal muscular atrophy (SMA). Literature regarding swallowing safety and efficiency is scarce in patients with SMA, particularly in the era of newborn screening programs and disease-modifying therapies.

OBJECTIVE

To describe the longitudinal changes of swallowing safety and efficiency in children with SMA who received one or more disease modifying therapies METHODS: Case series of patients with SMA followed at the University of Florida from 1 May 2019 to 31 December 2022 who had two or more videofluoroscopy swallowing studies (VFSS), with the first being within 30 days of their first treatment. Data extracted from the electronic health record included: neuromotor outcomes, VFSS penetration aspiration scores (PAS), presence of abrnormal oral or pharyngeal residue, clinical history, and timing of disease-modifying therapies administration.

RESULTS

Seven subjects were included (five male); three were diagnosed via newborn screen. Median age at diagnosis was 10 days (range: 4-250). Median age at initial VFSS was 29 days (range: 9-246), and age at the last VFSS was 26.1 months (range: 18.2-36.2). All subjects received onasemnogene-abeparvovec (OA); four received additional therapies. PAS at diagnosis was abnormal in four subjects. Six subjects required feeding modifications after VFSS results. Of these, three had silent aspiration (PAS 8) and three of them improved after treatment.

CONCLUSIONS

Swallowing safety and efficiency can be impaired in patients with SMA despite early treatment. Larger, prospective studies are needed to define optimal timiing of longitudinal instrumental evaluations.

Therapeutic Play Gym: Feasibility of a Caregiver-Mediated Exercise System for NICU Graduates with Neuromuscular Weakness-A Case Series

PURPOSE

To describe the feasibility and effect of caregiver-mediated exercise training using a novel Therapeutic Play Gym in 3 neonatal intensive care unit (NICU) graduates with rare neuromuscular diseases.

SUMMARY OF KEY POINTS

Caregivers of 3 medically complex, technology-dependent NICU graduates could not access community-based rehabilitation services after discharging from lengthy initial hospitalizations. These children, diagnosed with spinal muscular atrophy type 0, untreated X-linked myotubular myopathy, and untreated nemaline myopathy 3 (NEM3), completed monthly consultations with a pediatric clinical specialist and 3 assessment appointments. The caregivers agreed to administer a progressive Therapeutic Play Gym home exercise program at a minimum frequency of 3×/wk for 6 months.

CONCLUSION

A monthly consultative approach was both feasible and effective to safely progress caregiver-mediated home exercise training using a novel Therapeutic Play Gym. Positive training effects emerged in fitness, function, and caregiver-reported quality of life domains.

RECOMMENDATIONS FOR CLINICAL PRACTICE

A strong therapist-caregiver alliance can empower families to perform guided training when community resources are limited. More research is needed to see whether this training model is feasible for children with other conditions; for use in hospital, outpatient, or educational settings; and as an adjuvant exercise treatment for children receiving disease-modifying interventions.

Developmental-stage specific single-cell human embryo dissociation

Isolation of individual cells ensures detailed analysis of human embryos and promotes our understanding of molecular mechanisms driving embryo development and cell specification. Here, we present a protocol for the processing of human embryos for single-cell analysis. We describe steps for growing embryos and individualizing cells from the polar and the mural parts of trophectoderm at the blastocyst stage using laser dissection. We then detail embryo dissociation followed by steps to pick, wash, and dispense cells in plates.

Adeno-associated virus-mediated gene therapy in a patient with Canavan disease using dual routes of administration and immune modulation

Gene replacement therapy is a rational therapeutic strategy and clinical intervention for neurodegenerative disorders like Canavan disease, a leukodystrophy caused by biallelic mutations in the aspartoacylase (ASPA) gene. We aimed to investigate whether simultaneous intravenous (i.v.) and intracerebroventricular (i.c.v.) administration of rAAV9-CB6-ASPA provides a safe and effective therapeutic strategy in an open-label, individual-patient, expanded-access trial for Canavan disease. Immunomodulation was given prophylactically prior to adeno-associated virus (AAV) treatment to prevent an immune response to ASPA or the vector capsid. The patient served as his own control, and change from baseline was assessed by clinical pathology tests, vector genomes in the blood, antibodies against ASPA and AAV capsids, levels of cerebrospinal fluid (CSF) N-acetylaspartate (NAA), brain water content and morphology, clinical status, and motor function tests. Two years post treatment, the patient's white matter myelination had increased, motor function was improved, and he remained free of typical severe epilepsy. NAA level was reduced at 3 months and remained stable up to 4 years post treatment. Immunomodulation prior to AAV exposure enables repeat dosing and has prevented an anti-transgene immune response. Dual-route administration of gene therapy may improve treatment outcomes.

Polysomnography findings in children with spinal muscular atrophy after onasemnogene-abeparvovec

BACKGROUND

Sleep disordered breathing (SDB) is common in patients with neuromuscular diseases, including spinal muscular atrophy (SMA). While polysomnography (PSG) findings have been described in natural history studies of patients with SMA, reports regarding PSG in treated children are limited to nusinersen. We aim to describe the sleep characteristics in a cohort of children treated with Onasemnogene-abeparvovec.

METHODS

We conducted a cross-sectional cohort study of children with SMA followed at the University of Florida Center for neuromuscular and rare diseases and had a diagnostic or split night PSG after SMA treatment.

RESULTS

Eight children were included in the cohort (four female), aged 5-250 days at diagnosis. Five children had two survival motor neuron 2 (SMN2) copies, two had three SMN2 copies and one subject had four SMN2 copies. Median age at the time of treatment was 46.5 days (range 20-257). All children received onasemnogene-abeparvovec (OA) before their PSG; in addition to OA, one received nusinersen and one received risdiplam. Apnea hypopnea index (AHI) ranged from 3.6 to 24.1/h. REM AHI was higher than NREM AHI. Median Children's Hospital of Philadelphia Infant test of neuromuscular disorders (CHOP-Intend) score at the time of PSG was 55 (range 33-64). There was no correlation between age at treatment, CHOP-Intend score and AHI.

CONCLUSION

SDB is common in treated children with SMA, regardless of age at diagnosis, treatment and neuromotor scores. While AHI may not be the only indicator of SDB in this population, indications, timing of PSG in this cohort remain unknown.

P-539 Effects of gender of chromosomal translocation's carrier on pre-implantation genetic testing for structural rearrangement (PGT-SR) outcomes

Study question

Do the outcomes of PGT-SR cycles vary according to the gender of chromosomal translocation’s carrier?

Summary answer

The rate of balanced embryos was significantly higher when translocation carrier was a male as compared to female, but clinical outcomes were not significantly different.

What is known already

It has been well described that chromosomal translocations lead to very high rate of unbalanced embryos, and have a subsequent negative impact on blastulation, implantation, miscarriage and live birth rates.PGT-SR allows selecting balanced embryos and increases the chances of pregnancy, while decreasing the risk of micarriage in couples with chromosomal translocations. However, whether the gender of translocation carrier is associated with significantly different impact on PGT-SR outcomes is not known.

Study design, size, duration

This is a monocentric retrospective cross-sectional study conducted in all PGT-SR cycles performed between 2015 and 2020.

A total of 603 cycles, carried out in 283 couples, were included in the analysis.

Participants/materials, setting, methods

Two groups have been formed according to the gender of translocation carrier, Group 1 for female carriers (107 couples, 229 cycles), and group 2 for male (175 couples, 373 cycles).

The rate of balanced embryos, ovarian stimulation parameters, number of oocytes, biopsy rate, clinical pregnancy rate and live birth rate were compared between both groups.

Main results and the role of chance

Female age and infertility etiologies were comparable between both groups.

Mean total dose of gonadotrophin and peak E2 levels were not significantly different in both groups (2422± 895 units vs 2290 ± 858 respectively, p > 0.05) (2460± 1346 pg/ml vs 2497 ± 1397, p > 0.05). There was no significant difference in the number of oocytes and biopsied embryos rate between Group 1 and Group 2.

The rate of balanced embryo after PGT-SR was significantly lower in group 1 (female carriers) than in group 2 (21.1% vs 24.8% respectively, p = 0.036). Finally, biochemical pregnancy rate and live birth rate per transfer were not statistically different between both groups (46.2% vs 43.2% and 20.3% vs 18.5% respectively, p > 0.05).

Limitations, reasons for caution

The retrospective nature of the study was its main limitation. PGT-A was not used, preventing from concluding on embryo euploidy rate.

Wider implications of the findings

Further fundamental studies should be performed to explore the respective mechanisms involved in chromosomal rearrangements according to gender. Our study suggests that a higher number of oocytes could be targeted in female translocation carriers in order to increase the probability of obtaining at least one balanced embryo.

Trial registration number

2

Human blastoids model blastocyst development and implantation

One week after fertilization, human embryos implant into the uterus. This event requires the embryo to form a blastocyst consisting of a sphere encircling a cavity lodging the embryo proper. Stem cells can form a blastocyst model that we called a blastoid¹. Here we show that naive human pluripotent stem cells cultured in PXGL medium² and triply inhibited for the Hippo, TGF-β and ERK pathways efficiently (with more than 70% efficiency) form blastoids generating blastocyst-stage analogues of the three founding lineages (more than 97% trophectoderm, epiblast and primitive endoderm) according to the sequence and timing of blastocyst development. Blastoids spontaneously form the first axis, and we observe that the epiblast induces the local maturation of the polar trophectoderm, thereby endowing blastoids with the capacity to directionally attach to hormonally stimulated endometrial cells, as during implantation. Thus, we propose that such a human blastoid is a faithful, scalable and ethical model for investigating human implantation and development^3,4.

P–665 Influence of premature progesterone elevation on embryo development

Study question

Does a serum progesterone level higher than 1.3 ng/mL on the day of ovulation trigger have an impact on blastocyst development?

Summary answer

Elevated progesterone level has no significant impact on top blastocyst rate, usable blastocyst rate and on morphokinetics.

What is known already

Premature elevation of progesterone level on the day of ovulation trigger prior to IVF is common and causes a decrease in endometrial receptivity. A freeze all strategy is then recommended. However, cumulative live birth rates have also been described as lower in cases of high progesterone levels.

Study design, size, duration

This was a retrospective bicentric cohort follow-up study, including 1150 IVF/ICSI cycles performed between 2016 and 2018 with at least 1 day–5 blastocyst available for transfer or freezing. Among these cycles, 524 were performed with use of a time-lapse system (Embryoscope). Serum Progesterone level was measured on the day of ovulation trigger, and a value >1.3 ng/ml was used to identify premature progesterone elevation.

Participants/materials, setting, methods

The cycles were divided into 2 groups according to serum progesterone level: 1335 cycles were allocated in the normal progesterone group (P < 1,3) and 215 in the progesterone premature elevation group (P > 1.3). Patient’s characteristics, ovarian stimulation characteristics, IVF cycles characteristics and embryology parameters were anonymously recorded and compared between the 2 groups.

Main results and the role of chance

Female age, smoking status, AFC and AMH levels were comparable between the 2 groups. Female BMI was significantly higher in the P < 1,3 than in the P > 1.3 group (26.1 versus 24.7 kg/m² respectively). Total FSH dose, estradiol level, number of follicles >11mm and number of retrieved oocytes were significantly higher in the P > 1.3 group than in P < 1.3 group No difference was observed between the 2 groups in terms of top blastocyst rate per mature oocyte and usable blastocyst rate per mature oocyte. When morphokinetic analysis was available, time to blastulation was the only significantly different parameter between the 2 groups (110.4 hours in P < 1.3 versus 107.9 hours in P > 1.3, p = 0.04). Cumulative live birth rate per cycle was not statistically different between the two groups (23.1% for P < 1.3 versus 28.7% for P > 1.3) (p > 0.05).

Limitations, reasons for caution

The retrospective design of the study should lead to careful analysis of the results. The progesterone threshold refers to a specific assay, and should not be generalized to other assays.

Wider implications of the findings: Premature elevation of serum progesterone level on the day of ovulation trigger does not seem to affect embryo developmental competence. This further supports the relevance of freeze all strategy in this situation.

Trial registration number

Not applicable

Integrated pseudotime analysis of human pre-implantation embryo single-cell transcriptomes reveals the dynamics of lineage specification

Understanding lineage specification during human pre-implantation development is a gateway to improving assisted reproductive technologies and stem cell research. Here we employ pseudotime analysis of single-cell RNA sequencing (scRNA-seq) data to reconstruct early mouse and human embryo development. Using time-lapse imaging of annotated embryos, we provide an integrated, ordered, and continuous analysis of transcriptomics changes throughout human development. We reveal that human trophectoderm/inner cell mass transcriptomes diverge at the transition from the B2 to the B3 blastocyst stage, just before blastocyst expansion. We explore the dynamics of the fate markers IFI16 and GATA4 and show that they gradually become mutually exclusive upon establishment of epiblast and primitive endoderm fates, respectively. We also provide evidence that NR2F2 marks trophectoderm maturation, initiating from the polar side, and subsequently spreads to all cells after implantation. Our study pinpoints the precise timing of lineage specification events in the human embryo and identifies transcriptomics hallmarks and cell fate markers.

Time-lapse technology improves total cumulative live birth rate and shortens time to live birth as compared to conventional incubation system in couples undergoing ICSI

PURPOSE

The improvement of clinical outcome provided by time-lapse technology (TLT) in IVF over conventional incubation (CI) still remains controversial. This study aimed at evaluating whether the exclusive use of time-lapse technology (TLT) during whole IVF care improves total cumulative live birth rate (TCLBR) and shortens time to live birth (TTLB) as compared to the use of CI in couples undergoing ICSI.

METHODS

This retrospective cohort study was conducted in couples with male infertility undergoing their first ICSI cycle in 2014-2015 and for whom embryo culture system remained the same during their whole IVF care, i.e., TLT or CI. Couples were followed up up to 2020, including all following frozen-embryo transfers and ICSI cycles (if any). Survival analysis was used to compare clinical outcome and time-related endpoints between both groups.

RESULTS

A total of 151 and 250 couples underwent their whole IVF care with the exclusive use of TLT and CI, respectively. Survival analysis showed that TCLBR after whole IVF care was significantly higher in TLT than in CI group (66.9 vs 56.4%, p=0.02, log-rank test). Median live birth time was significantly shorter in TLT than CI group (464 vs 596 days, p=0.01).

CONCLUSIONS

We found that TCLBR and TTLB were significantly improved with TLT over CI in couples undergoing ICSI for male factor. This study fuels the debate on the clinical benefit of using TLT. The use of time-related endpoints adds important information for both patients and practitioners.

Time-lapse technology improves total cumulative live birth rate and shortens time to live birth as compared to conventional incubation system in couples undergoing ICSI

PURPOSE

The improvement of clinical outcome provided by time-lapse technology (TLT) in IVF over conventional incubation (CI) still remains controversial. This study aimed at evaluating whether the exclusive use of time-lapse technology (TLT) during whole IVF care improves total cumulative live birth rate (TCLBR) and shortens time to live birth (TTLB) as compared to the use of CI in couples undergoing ICSI.

METHODS

This retrospective cohort study was conducted in couples with male infertility undergoing their first ICSI cycle in 2014-2015 and for whom embryo culture system remained the same during their whole IVF care, i.e., TLT or CI. Couples were followed up up to 2020, including all following frozen-embryo transfers and ICSI cycles (if any). Survival analysis was used to compare clinical outcome and time-related endpoints between both groups.

RESULTS

A total of 151 and 250 couples underwent their whole IVF care with the exclusive use of TLT and CI, respectively. Survival analysis showed that TCLBR after whole IVF care was significantly higher in TLT than in CI group (66.9 vs 56.4%, p=0.02, log-rank test). Median live birth time was significantly shorter in TLT than CI group (464 vs 596 days, p=0.01).

CONCLUSIONS

We found that TCLBR and TTLB were significantly improved with TLT over CI in couples undergoing ICSI for male factor. This study fuels the debate on the clinical benefit of using TLT. The use of time-related endpoints adds important information for both patients and practitioners.

Comparison of two automated sperm analyzers using 2 different detection methods versus manual semen assessment

PURPOSE

The exploration of male infertility is mainly based on semen analysis, but its evaluation might be affected by the operator's competence and subjectivity. This led to the development of automated semen analyzing systems. Despite continuous improvement, the precision and correlation of these automated systems with manual sperm assessment performed strictly according to WHO guidelines remains variable in the literature, and their role in daily practice is debated.

METHODS

In this double blind prospective study, we compared the results provided by 2 automated systems based on different concepts (CASA and electro-optical signal) with manual sperm assessment. Sperm concentration, motility and morphology were performed simultaneously and independently by different operators, blinded to each other.

RESULTS

A total of 102 unselected men attending the andrology department for routine sperm analysis were included in the study. We found no significant difference between each automated method and manual assessment for all sperm parameters, except for sperm morphology assessment where the electro-optical system gave higher results and performed slightly poorer than CASA. Correlation was moderate to high between manual assessment and each automated methods for all sperm parameters, with randomly distributed differences.

CONCLUSIONS

Overall, these results show that both types of automated systems can be implemented in andrology laboratory for routine sperm analysis.

[Pre-implantation genetic testing: Comparison between cleavage stage and blastocyst biopsy]

OBJECTIVES

Preimplantation genetic testing (PGT) refers to the set of techniques for testing whether embryos obtained through in vitro fertilization have genetic defect. There is a lack of global standardization regarding practices between countries or even from one center to another. In ours, biopsies are preferably performed on day 3 embryos, but also at the blastocyst stage on day 5. The blastocyst biopsy often requires systematic freezing of the embryos before obtaining the genetic results, whereas day 3 biopsy allows fresh embryo transfer of the healthy or balanced embryo after getting the genetic results. We wanted to compare the chances of success for couples performing PGT in our center according to the day of the biopsy.

METHODS

For this, we carried out a retrospective monocentric study including all PGT cycles performed between 2016 and 2019 divided into two groups: day 3 or day 5 biopsy.

RESULTS

There was no significant difference in terms of live birth rate (P=0.7375) after fresh embryo transfers, as well for pregnancy rates, clinical pregnancy rates, implantation rates and miscarriage rates. On the other hand, we observed higher live birth rates after frozen-thawed embryo transfer when the biopsy was performed on day 5 rather on day 3 (P=0.0001). We also wanted to assess what was the most efficient biopsy strategy in our laboratory. Our rates of useful embryos were similar regardless of the day of the biopsy (34% in D3 and 37.7% in D5, P=0.244). No statistical difference was found in the number of unnecessarily biopsied embryos in the two groups. But still, the percentage of embryos biopsied on D5 and immediately frozen was 42.8% (118 blastocysts), while no embryo biopsied on D3 led to this case.

CONCLUSION

Therefore, our results are in favor of generalization of the D5 biopsy as the international standard. However, the organizational, financial and logistical implications that this technic would impose make it unsystematic in our center.

Modification of late human embryo development after blastomere removal on day 3 for preimplantation genetic testing

The purpose of our study was to use a time-lapse monitoring (TLM) system to determine if day 3 blastomere biopsy for preimplantation genetic testing (PGT) had an impact on subsequent morphokinetic parameters at the morula and blastocyst stages. In this retrospective monocentric study conducted between May 2013 and August 2017, we compared late morphokinetic parameters in embryos undergoing day 3 blastomere biopsy for PGT and in control non-biopsied embryos obtained in intracytoplasmic sperm injection (ICSI) cycles for male infertility. All embryos in both groups were cultured in a TLM system. The biopsy group was composed of 1691 embryos (386 PGT cycles). The control group was composed of 2578 embryos (786 ICSI cycles). Early morphokinetic parameters up to day 3 were similar in both groups. Concerning late morphokinetic parameters, the onset of compaction (tSC), fully-compacted morula stage (tM), onset of cavitation/early blastulation (tSB), and blastocyst stages (tB and tEB) appeared significantly earlier in the biopsy group than in the control group. We found that late morphokinetic events at the morula and the blastocyst stages occurred significantly earlier in biopsied embryos than in control non-biopsied-embryos. The mechanisms underlying these modifications of embryo development after biopsy should be investigated in order to determine precisely, and this phenomenon could be associated with embryo, fetal, and offspring development.Abbreviations: TLM: time-lapse monitoring; PGT: preimplantation genetic testing; ICSI: intracytoplasmic sperm injection; tSC: the onset of compaction; tM: fully-compacted morula stage; tSB: onset of cavitation/early blastulation; tB and tEB: blastocyst stages; OHSS: ovarian hyperstimulation syndrome.

Development of automated annotation software for human embryo morphokinetics

STUDY QUESTION

Is it possible to develop an automated annotation tool for human embryo development in time-lapse devices based on image analysis?

SUMMARY ANSWER

We developed and validated an automated software for the annotation of human embryo morphokinetic parameters, having a good concordance with expert manual annotation on 701 time-lapse videos.

WHAT IS KNOWN ALREADY

Morphokinetic parameters obtained with time-lapse devices are increasingly used for the assessment of human embryo quality. However, their annotation is time-consuming and can be slightly operator-dependent, highlighting the need to develop fully automated approaches.

STUDY DESIGN, SIZE, DURATION

This monocentric study was conducted on 701 videos originating from 584 couples undergoing IVF with embryo culture in a time-lapse device. The only selection criterion was that the duration of the video must be over 60 h.

PARTICIPANTS/MATERIALS, SETTING, METHODS

An automated morphokinetic annotation tool was developed based on gray level coefficient of variation and detection of the thickness of the zona pellucida. The detection of cellular events obtained with the automated tool was compared with those obtained manually by trained experts in clinical settings.

MAIN RESULTS AND THE ROLE OF CHANCE

Although some differences were found when embryos were considered individually, we found an overall concordance between automated and manual annotation of human embryo morphokinetics from fertilization to expanded blastocyst stage (r2 = 0.92).

LIMITATIONS, REASONS FOR CAUTION

These results should undergo multicentric external evaluation in order to test the overall performance of the annotation tool. Getting access to the export of 3D videos would enhance the quality of the correlation with the same algorithm and its extension to the 3D regions of interest. A technical limitation of our work lies within the duration of the video. The more embryo stages the video contains, the more information the script has to identify them correctly.

WIDER IMPLICATIONS OF THE FINDINGS

Our system paves the way for high-throughput analysis of multicentric morphokinetic databases, providing new insights into the clinical value of morphokinetics as a predictor of embryo quality and implantation.

STUDY FUNDING/COMPETING INTEREST(S)

This study was partly funded by Finox-Gedeon Richter Forward Grant 2016 and NeXT (ANR-16-IDEX-0007). We have no conflict of interests to declare.

TRIAL REGISTRATION NUMBER

N/A

Performance of Day 5 KIDScore™ morphokinetic prediction models of implantation and live birth after single blastocyst transfer

PURPOSE

While several studies reported the association between morphokinetic parameters and implantation, few predictive models were developed to predict implantation after day 5 embryo transfer, generally without external validation. The objective of this study was to evaluate the respective performance of 2 commercially available morphokinetic-based models (KIDScore™ Day 5 versions 1 and 2) for the prediction of implantation and live birth after day 5 single blastocyst transfer.

METHODS

This monocentric retrospective study was conducted on 210 ICSI cycles with single day 5 embryo transfer performed with a time-lapse imaging (TLI) system between 2013 and 2016. The association between both KIDScore™ and the observed implantation and live birth rates was calculated, as well as the agreement between embryologist's choice for transfer and embryo ranking by the models.

RESULTS

Implantation and live birth rate were both 35.7%. A significant positive correlation was found between both models and implantation rate (r = 0.96 and r = 0.90, p = 0.01) respectively. Both models had statistically significant but limited predictive power for implantation (AUC 0.60). There was a fair agreement between the embryologists' choice and both models (78% and 61% respectively), with minor differences in case of discrepancies.

CONCLUSIONS

KIDScore™ Day 5 predictive models are significantly associated with implantation rates after day 5 single blastocyst transfer. However, their predictive performance remains perfectible. The use of these predictive models holds promises as decision-making tools to help the embryologist select the best embryo, ultimately facilitating the implementation of SET policy. However, embryologists' expertise remains absolutely necessary to make the final decision.

Parallel derivation of isogenic human primed and naive induced pluripotent stem cells

Induced pluripotent stem cells (iPSCs) have considerably impacted human developmental biology and regenerative medicine, notably because they circumvent the use of cells of embryonic origin and offer the potential to generate patient-specific pluripotent stem cells. However, conventional reprogramming protocols produce developmentally advanced, or primed, human iPSCs (hiPSCs), restricting their use to post-implantation human development modeling. Hence, there is a need for hiPSCs resembling preimplantation naive epiblast. Here, we develop a method to generate naive hiPSCs directly from somatic cells, using OKMS overexpression and specific culture conditions, further enabling parallel generation of their isogenic primed counterparts. We benchmark naive hiPSCs against human preimplantation epiblast and reveal remarkable concordance in their transcriptome, dependency on mitochondrial respiration and X-chromosome status. Collectively, our results are essential for the understanding of pluripotency regulation throughout preimplantation development and generate new opportunities for disease modeling and regenerative medicine.

[Smoking and young people; effectiveness of smoking prevention and cessation programmes]

- In this article, we discuss the scientific knowledge on the effects of interventions that help young people to quit smoking and interventions that should prevent young people from starting to smoke.- We also describe the interventions in the Netherlands that, after a quality assessment, have been included in the database of the National Institute for Public Health and the Environment (RIVM) Centre for Healthy Living.- Interventions have varying degrees of success in helping young people to quit smoking. There are only indications of a modest effect of behavioural interventions.- Preventive interventions mostly occur in a school setting and are making a modest contribution to the reduction of the number of young people that start smoking.- There are preliminary indications of the effectiveness of interventions in a medical setting. However, research into this is rare and there is no insight in long-term effects.- The database of the RIVM Centre for Healthy Living includes mainly preventive interventions in a school setting and only one smoking cessation intervention.

Effectiveness of a brief school-based intervention on depression, anxiety, hyperactivity, and delinquency: a cluster randomized controlled trial

Problematic substance use and mental health problems often co-occur in adolescents. Effective school-based interventions that are brief and target multiple problems are promising in the field of health promotion. Preventure is a brief, school-based, selective preventive intervention, tailored to four personality profiles. Preventure has already proved effective on alcohol outcomes. Previous trials also reveal effects on several mental health outcomes, yet the evidence for these outcomes is limited. This study presents the results of the Dutch Preventure Trial, on a range of mental health outcomes. In a cluster RCT, including 699 high risk students (mean age 14 years), the intervention effects on mental health problems at 2, 6, and 12 months post intervention were tested in the total high risk population and in four specific personality groups. No significant intervention effects were found on 22 from the 24 tests. A positive intervention effect on anxiety was found in the anxiety sensitivity personality group at 12-month follow-up, and a negative intervention effect on depression was found at 12-month follow-up in the negative thinking group. In post hoc growth curve analyses these effects were not found. This study found no convincing evidence for the effectiveness of Preventure in The Netherlands on mental health problems. This finding is not in line with the results of an earlier effectiveness study in the UK. This highlights the need for more research into the knowledge transfer model of interventions, to ensure that interventions are effective in a variety of circumstances.

Does sperm origin affect embryo morphokinetic parameters?

PURPOSE

The purpose of our study was to use time-lapse in order to evaluate the impact of sperm origin (fresh ejaculate or surgically retrieved) on embryo morphokinetic parameters and clinical outcome in intracytoplasmic sperm injection (ICSI) cycles.

METHODS

This retrospective monocentric study was conducted in 485 unselected couples undergoing 604 ICSI cycles with embryo culture in the Embryoscope®. Among them, 445 couples underwent ICSI cycle with fresh ejaculated sperm and 40 with surgically retrieved sperm (26 with testicular sperm and 14 with epididymal sperm). Embryo morphokinetic parameters and clinical cycle outcome were compared between fresh ejaculated sperm and surgically retrieved sperm. A subgroup analysis was also conducted between testicular and epididymal sperm ICSI cycles.

RESULTS

Clinical outcome was comparable between groups according to sperm origin. Although most early morphokinetic parameters were comparable between ejaculated and surgical sperm groups, a few parameters were significantly different between both groups, but with a considerable overlap in their distribution. Late cellular events occurred significantly later in the surgical sperm group than in the ejaculated sperm group.

CONCLUSIONS

Morphokinetic analysis did not allow us to identify clinically relevant differences between fresh ejaculate and surgically retrieved sperm groups. Further studies are needed, especially concerning the relationship between sperm origin and late morphokinetic parameters, such as blastocyst development.

Consumer participation in mental health services: looking from a consumer perspective

Widespread changes to the structure and delivery of mental health services have effected considerable change in the role of the service user or consumer. The view of consumers of mental health services as passive recipients of care and treatment is gradually undergoing a significant shift, in light of an increasing expectation that consumers be provided with opportunities to become actively involved in all aspects of their care. Consumer participation is now broadly reflected in government policy; however, to date there has been little exploration of the extent to which the policy is being realized in practice. To provide a greater understanding of these experiences and opinions, in-depth interviews were conducted with consumers of mental health services (n = 15). The interview transcripts were analysed through the identification and explication of major themes. The findings reinforce the need to view consumers as heterogeneous and respond to individual needs and interests regarding consumer participation. Despite variations in experience there is a clear need to develop mechanisms to support consumer involvement and to influence the attitudes of health professions to become more valuing of a consumer perspective. Nurses are in an ideal position to lead this process.

Biofeedback and electrical stimulation therapy for treating urinary incontinence and voiding dysfunction: one center's experience

Urinary incontinence affects 13 million Americans at a cost of $11.2 billion annually to the community. With an aging population, these numbers are expected to increase substantially in coming years. At the Bladder Control Center in Cincinnati, staff have completed over 3,600 biofeedback sessions with encouraging results.

Minimal platelet deposition and activation in models of injured vessel wall ensure optimal neutrophil adhesion under flow conditions

Platelets at injured vessel wall form an adhesive surface for leukocyte adhesion. The precise relation between platelet adhesion and activation and leukocyte adhesion, however, is not known. We therefore used various models of injured vessel wall to form different patterns of platelet adhesion. The interaction of polymorphonuclear neutrophils (PMNs) was subsequently studied under flow conditions. In the absence of platelets, not only endothelial cell, smooth muscle cell, and fibroblast matrices but also purified matrix proteins (fibrinogen, collagen, and fibronectin) barely support PMN adhesion. The presence of platelets, however, strongly enhances PMN adhesion. PMN adhesion shows a proportional increase with platelet coverage up to 15%. Although PMNs roll over the scarcely scattered platelets, they speed up again when encountering surfaces without platelets. This "hopping" interaction of PMNs vanishes with platelet coverage >15%. Unobstructed rolling of PMNs is than observed and soon leads to a maximal adhesion of 1000 to 1200 cells/mm2. The mean rolling velocity of PMNs continues to decrease with higher platelet coverage. Platelet aggregate formation is an accepted indicator of platelet activation. The presence of platelet aggregates instead of contact or spread platelets, however, does not increase PMN adhesion. Also, additional stimulation of surface-associated platelets by thrombin fails to influence PMN adhesion. Moreover, indomethacin as an inhibitor of platelet activation and aggregation does not change the subsequent PMN interaction. In conclusion, approximately 15% of platelet coverage is sufficient for optimal PMN adhesion. Increasing platelet coverage increases the availability of platelet-associated receptors that lower PMN rolling velocity. Additional activation of adherent platelets makes no difference in the expression of relevant adhesion receptors. Therefore, minimal vascular damage in vivo and only scarce platelet adhesion will already evoke significant colocalization of leukocytes.

The IPCS Collaborative Study on Neurobehavioral Screening Methods: IV. Control data. Steering Group

The goal of the International Programme on Chemical Safety (IPCS) Collaborative Study on Neurobehavioral Screening Methods was to determine the intra- and inter-laboratory reliability of a functional observational battery (FOB) and an automated assessment of motor activity in eight laboratories worldwide. The control data were crucial to the outcome of the studies in terms of sensitivity and reliability of the test measures, which in turn impact on the between-laboratory comparisons of chemical effects. In addition, analyses of control data can aid in determining endpoints that may require modification to improve their sensitivity and reliability. The control data from the eight laboratories were examined in terms of the following parameters: 1) control variability within studies for each laboratory; 2) within-laboratory replicability of control values across studies; 3) within-laboratory stability of control values over the course of testing for a given study; and 4) between-laboratory comparisons of parameters (1), (2), and (3). The analyses indicated considerable differences across endpoints, wherein some measures showed high variability and little replicability, while others were extremely reproducible. Generally, there were similar ranges of variability and replicability of control data across laboratories, although in some cases one or two laboratories were markedly different from the others. The physiological (weight, body temperature) and neuromuscular (grip strength, landing foot splay) endpoints exhibited the least variability, whereas the subjective assessments of reactivity varied the most. These data indicate a reasonable degree of comparability in the data generated in the participating laboratories.

The IPCS Collaborative Study on Neurobehavioral Screening Methods: V. Results of chemical testing. Steering Group

The IPCS Collaborative Study on Neurobehavioral Screening Methods was undertaken to determine the intra- and inter-laboratory reliability of a functional observational battery (FOB) and an automated assessment of motor activity in eight laboratories world-wide. Following the training phase and the conduct of proficiency studies in all laboratories, participants proceeded to test the effects of seven chemicals in both single dose and four-week repeated dosing scenarios. The chemicals studied were acrylamide, bisacrylamide, p,p'-DDT, lead acetate, parathion, toluene, and triethyl tin. Participants received coded samples from a common source. In order to judge the general utility of these procedures in a diversity of testing situations, laboratories conducted the studies under their standard conditions, using their choice of rat strain and test equipment. Chemical does and time of peak effect for acute testing were determined by each laboratory: these parameters were quite similar for some chemicals, but varied greatly for others. The results of the chemical tests indicated that while there was some variability in the data on specific endpoints, all laboratories detected and characterized the effects of all but one of the known neurotoxicants. The one exception (toluene) was probably due to other factors (e.g., dose level, route of administration) rather than lack of sensitivity of the test methods. This study provides extensive data regarding the use of neurobehavioral screening methods over a range of laboratory conditions as well as the reliability, sensitivity, and robustness of the tests to detect neurotoxic potential of chemicals.

The IPCS Collaborative Study on Neurobehavioral Screening Methods: III. Results of proficiency studies. Steering Group

The goal of the IPCS Collaborative Study on Neurobehavioral Screening Methods was to determine the intra- and inter-laboratory reliability of a functional observational battery (FOB) and an automated assessment of motor activity in eight laboratories world-wide. The first phase of the Collaborative Study involved training the participants: evidence of training was then evaluated using positive-control compounds. The positive-control studies required the laboratories to identify, using the FOB, specific neurotoxic syndromes produced by acute exposure to p,p'-DDT, parathion, and by short-term repeated dosing with acrylamide. For the sake of expediency, only one dose of each chemical was used instead of collecting dose-response data. Motor activity test chambers were not of uniform design. The laboratories were therefore required to demonstrate adequate sensitivity by the ability to detect statistically-significant activity increases and decreases produced by triadimefon and chlorpromazine, respectively, following acute administration of a range of doses. The resulting FOB and motor activity data showed variability in the magnitude of effects obtained: some of these differences were attributed to miscommunications, difficulties with the techniques or protocol, or the limitations of having only one dose. All laboratories, however, successfully met the criteria set forth by the Study Steering Committee.

Evaluation of the VA's Pilot Program in Institutional Reorganization Toward Primary and Ambulatory Care: Part II, A study of organizational stresses and dynamics

BACKGROUND

Many academically affiliated hospitals are moving from an inpatient, subspecialty orientation in their patient care and educational programs toward a greater emphasis on ambulatory and primary care. Few studies have focused on the organizational, staffing, and management issues involved in implementing these changes.

METHOD

The authors carried out a qualitative evaluation of the process of change in an academic Department of Veterans Affairs hospital during implementation of a major ambulatory primary care program. They interviewed four top managers individually and 59 top and middle managers, house officers, and patients in focus groups in the spring of 1992, nine months after implementation of the key components of the program. Four raters independently evaluated written transcripts of focus-group sessions and identified themes.

RESULTS

The main problems identified were difficulty with administrative integration between inpatient and outpatient services; need for training, retraining, and orientation; tensions due to changes in roles and organizational culture; and inefficiency due to the need for frequent negotiations in daily work life. These four problems reflected tensions associated with new demands imposed by matrix management, changing job descriptions, policies and procedures, and changing patterns of communication and record keeping.

CONCLUSION

During the process of implementation of a primary care focus throughout a medical center, extra demands upon staff are inevitable and should be anticipated and planned for. Twelve key factors for successful organizational change are discussed.

A profile of reported skunk rabies in Arkansas: 1977-1979

Skunk rabies in Arkansas increased from 90 laboratory confirmed cases in 1977 to 140 in 1978 and 297 in 1979. In 1979, the Arkansas Department of Health declared a skunk rabies epizootic in Arkansas. Skunk rabies accounted for 90% of the total rabies cases in 1978 and 1979. March, April and May had the highest incidence in each year. SYMVU computer analysis illustrated the distribution and spread of rabies. In general, rabies was confined to the upland areas of the state. Regression analysis of 16 density-independent variables revealed no correlation with the distribution of rabies, indicating the primary determinants to be biotic.