Cohort profile: demographic and clinical characteristics of the MILESTONE longitudinal cohort of young people approaching the upper age limit of their child mental health care service in Europe

PURPOSE

The presence of distinct child and adolescent mental health services (CAMHS) and adult mental health services (AMHS) impacts continuity of mental health treatment for young people. However, we do not know the extent of discontinuity of care in Europe nor the effects of discontinuity on the mental health of young people. Current research is limited, as the majority of existing studies are retrospective, based on small samples or used non-standardised information from medical records. The MILESTONE prospective cohort study aims to examine associations between service use, mental health and other outcomes over 24 months, using information from self, parent and clinician reports.

PARTICIPANTS

Seven hundred sixty-three young people from 39 CAMHS in 8 European countries, their parents and CAMHS clinicians who completed interviews and online questionnaires and were followed up for 2 years after reaching the upper age limit of the CAMHS they receive treatment at.

FINDINGS TO DATE

This cohort profile describes the baseline characteristics of the MILESTONE cohort. The mental health of young people reaching the upper age limit of their CAMHS varied greatly in type and severity: 32.8% of young people reported clinical levels of self-reported problems and 18.6% were rated to be 'markedly ill', 'severely ill' or 'among the most extremely ill' by their clinician. Fifty-seven per cent of young people reported psychotropic medication use in the previous half year.

FUTURE PLANS

Analysis of longitudinal data from the MILESTONE cohort will be used to assess relationships between the demographic and clinical characteristics of young people reaching the upper age limit of their CAMHS and the type of care the young person uses over the next 2 years, such as whether the young person transitions to AMHS. At 2 years follow-up, the mental health outcomes of young people following different care pathways will be compared.

TRIAL REGISTRATION NUMBER

NCT03013595.

A cross-cultural qualitative study of the ethical aspects in the transition from child mental health services to adult mental health services

BACKGROUND

Transitioning from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS) raises novel ethical aspects for healthcare professionals, as well as for young people, their parents and carers.

METHOD

Focus groups were conducted in Croatia, Ireland and the United Kingdom with youth mental health groups and youth representatives with no mental health (MH) remit. One hundred and eleven participants, aged from 16 to 60 years, contributed to discussions.

RESULTS

Perpetuation of stigma, autonomy and decision-making were central themes as both enablers and deterrents of successful transition. The tension between professional (and at times parental) paternalism and young persons' growing autonomy was well captured in the themes; (a) desired practice, (b) who should decide, (c) the process of decision-making and (d) potential harm(s).

CONCLUSIONS

This study provides insight into the ethical values, particularly autonomy and collaboratively working, which people expect to underpin the transition between CAMHS and AMHS.

KEY PRACTITIONER MESSAGE

Engaging young people early in making decisions about their future care can enhance trust between practitioner and the young person. In addition to diagnosis, a number of factors (such as moving home; waiting lists and stigma) may need to be taken into account when considering the direction of future health care. When possible, alternatives to AMHS should be considered if considered by the young person to be a less-stigmatising treatment option.

How do people with eating disorders experience the stigma associated with their condition? A mixed-methods systematic review

BACKGROUND

Public opinion research shows that eating disorders (EDs) are a major target of stigmatisation. To understand the implications of this stigma, research investigating how stigma is experienced by individuals with EDs is critical.

AIM

This paper aims to collate, evaluate and synthesise the extant empirical research illuminating how people with EDs experience the stigma associated with their condition.

METHOD

A systematic mixed-methods literature search was performed. Articles that met a specified set of inclusion criteria underwent a quality assessment and thematic synthesis.

RESULTS

Twenty-nine articles were included in the review. Studies were mostly qualitative and of reasonable methodological quality. The literature was characterised by five research themes, illuminating (i) the nature and prevalence of stigma experienced, (ii) stigma in families, (iii) stigma in healthcare contexts, (iv) self-stigmatisation and illness concealment, and (v) stigma resistance.

CONCLUSIONS

The reviewed research showed that people with EDs have extensive experience of stigma in diverse settings. They report that stigma has negative implications for their psychological wellbeing and likelihood of help-seeking. However, research also shows that people with EDs actively seek to resist and challenge stigma. The review identifies the outstanding gaps and weaknesses in this literature.

Correction to: The interface between child/adolescent and adult mental health services: results from a European 28‑country survey

The original version of this article contained an error in Table 1. The correct table is presented below.

Cortical responses before 6 months of life associate with later autism

Autism spectrum disorder (ASD) is a common, highly heritable, developmental disorder and later-born siblings of diagnosed children are at higher risk of developing ASD than the general population. Although the emergence of behavioural symptoms of ASD in toddlerhood is well characterized, far less is known about development during the first months of life of infants at familial risk. In a prospective longitudinal study of infants at familial risk followed to 36 months, we measured functional near-infrared spectroscopy (fNIRS) brain responses to social videos of people (i.e. peek-a-boo) compared to non-social images (vehicles) and human vocalizations compared to non-vocal sounds. At 4-6 months, infants who went on to develop ASD at 3 years (N = 5) evidenced-reduced activation to visual social stimuli relative to low-risk infants (N = 16) across inferior frontal (IFG) and posterior temporal (pSTS-TPJ) regions of the cortex. Furthermore, these infants also showed reduced activation to vocal sounds and enhanced activation to non-vocal sounds within left lateralized temporal (aMTG-STG/pSTS-TPJ) regions compared with low-risk infants and high-risk infants who did not develop ASD (N = 15). The degree of activation to both the visual and auditory stimuli correlated with parent-reported ASD symptomology in toddlerhood. These preliminary findings are consistent with later atypical social brain responses seen in children and adults with ASD, and highlight the need for further work interrogating atypical processing in early infancy and how it may relate to later social interaction and communication difficulties characteristic of ASD.

Protocol for a cohort study of adolescent mental health service users with a nested cluster randomised controlled trial to assess the clinical and cost-effectiveness of managed transition in improving transitions from child to adult mental health services (the MILESTONE study)

INTRODUCTION

Disruption of care during transition from child and adolescent mental health services (CAMHS) to adult mental health services may adversely affect the health and well-being of service users. The MILESTONE (Managing the Link and Strengthening Transition from Child to Adult Mental Healthcare) study evaluates the longitudinal course and outcomes of adolescents approaching the transition boundary (TB) of their CAMHS and determines the effectiveness of the model of managed transition in improving outcomes, compared with usual care.

METHODS AND ANALYSIS

This is a cohort study with a nested cluster randomised controlled trial. Recruited CAMHS have been randomised to provide either (1) managed transition using the Transition Readiness and Appropriateness Measure score summary as a decision aid, or (2) usual care for young people reaching the TB. Participants are young people within 1 year of reaching the TB of their CAMHS in eight European countries; one parent/carer and a CAMHS clinician for each recruited young person; and adult mental health clinician or other community-based care provider, if young person transitions. The primary outcome is Health of the Nation Outcome Scale for Children and Adolescents (HoNOSCA) measuring health and social functioning at 15 months postintervention. The secondary outcomes include mental health, quality of life, transition experience and healthcare usage assessed at 9, 15 and 24 months postintervention. With a mean cluster size of 21, a total of 840 participants randomised in a 1:2 intervention to control are required, providing 89% power to detect a difference in HoNOSCA score of 0.30 SD. The addition of 210 recruits for the cohort study ensures sufficient power for studying predictors, resulting in 1050 participants and an approximate 1:3 randomisation.

ETHICS AND DISSEMINATION

The study protocol was approved by the UK National Research Ethics Service (15/WM/0052) and equivalent ethics boards in participating countries. Results will be reported at conferences, in peer-reviewed publications and to all relevant stakeholder groups.

TRIAL REGISTRATION NUMBER

ISRCTN83240263; NCT03013595 (pre-results).

Architecture and functioning of child and adolescent mental health services: a 28-country survey in Europe

The WHO Child and Adolescent Mental Health Atlas, published in 2005, reported that child and adolescent mental health services (CAMHS) in Europe differed substantially in their architecture and functioning. We assessed the characteristics of national CAMHS across the European Union (EU), including legal aspects of adolescent care. Using an online mapping survey aimed at expert(s) in each country, we obtained data for all 28 countries in the EU. The characteristics and activities of CAMHS (ie, availability of services, inpatient beds, and clinicians and organisations, and delivery of specific CAMHS services and treatments) varied considerably between countries, as did funding sources and user access. Neurodevelopmental disorders were the most frequent diagnostic group (up to 81%) for people seen at CAMHS (data available from only 13 [46%] countries). 20 (70%) countries reported having an official national child and adolescent mental health policy, covering young people until their official age of transition to adulthood. The heterogeneity in resource allocation did not seem to match epidemiological burden. Substantial improvements in the planning, monitoring, and delivery of mental health services for children and adolescents are needed.

Effect of combined exogenous progesterone with luteotrophic support via equine chorionic gonadotrophin (eCG) on corpus luteum development, circulating progesterone concentrations and embryo development in cattle

The aim was to examine the effect of a single intramuscular (i.m.) injection of equine chorionic gonadotrophin (eCG) on Day 3 after oestrus on corpus luteum (CL) development, circulating progesterone and conceptus development in cross-bred beef heifers. In Experiment 1, heifers received: (1) saline, or a single i.m. injection of eCG on Day 3 at (2) 250 IU (3) 500 IU (4) 750 IU or (5) 1000 IU. Administration of eCG resulted in increased luteal tissue area and progesterone and oestradiol concentrations compared with controls. In Experiment 2, heifers received (1) a progesterone-releasing intravaginal device (PRID Delta) from Day 3 to 5 or (2) a PRID Delta from Day 3 to 5 plus a single injection of 750 IU eCG on Day 3. In vitro-produced blastocysts (n = 10 per recipient) were transferred on Day 7 and heifers were slaughtered on Day 14 to assess conceptus development. Administration of eCG reduced the number of short cycles (6.3% vs 31.3%) and increased mean luteal tissue weight (P = 0.02). Insertion of a PRID Delta on Day 3 resulted in an elevation (P < 0.05) in serum progesterone until removal on Day 5. Administration of eCG at the time of PRID Delta insertion resulted in higher progesterone levels (P < 0.05) from Day 10 onwards. Conceptus dimensions were not affected. In conclusion, a single injection of eCG on Day 3 increased CL size and progesterone concentrations and, when given in conjunction with a progesterone-releasing device, appeared to reduce the number of short cycles, presumably due to its luteotrophic nature. The implications of the elevated oestradiol concentrations for embryo quality require further study.

Pilot study to detect airborne Mycobacterium tuberculosis exposure in a South African public healthcare facility outpatient clinic

BACKGROUND

Airborne transmission of Mycobacterium tuberculosis remains an occupational health hazard, particularly in crowded and resource-limited healthcare settings.

AIM

To quantify airborne M. tuberculosis in a busy outpatient clinic in Gauteng, South Africa.

METHODS

Stationary air samples and samples from healthcare workers (HCWs) were collected in the polyclinic and administrative block. Quantitative real-time polymerase chain reaction (PCR) was used to detect airborne M. tuberculosis. Walkthrough observations and work practices of HCWs were also recorded.

FINDINGS

In total, M. tuberculosis was detected in 11 of 49 (22.4%) samples: nine of 25 (36%) HCW samples and two of 24 (8.3%) stationary air samples. Samples from five of 10 medical officers (50%) and three of 13 nurses (23%) were positive. Repeat measurements on different days showed variable results. Most of the HCWs (87.5%) with positive results had been in contact with coughing patients and had not worn respiratory masks despite training.

CONCLUSION

The use of air sampling coupled with quantitative real-time PCR is a simple and effective tool to demonstrate the risk of M. tuberculosis exposure. The findings provide an impetus for hospital management to strengthen infection prevention and control measures for tuberculosis.

Paradoxical effect of supplementary progesterone between Day 3 and Day 7 on corpus luteum function and conceptus development in cattle

The aim of the present study was to investigate the effect of short-term progesterone (P4) supplementation during the early metoestrous period on circulating P4 concentrations and conceptus development in cattle. The oestrous cycles of cross-bred beef heifers were synchronised using a 7-day P4-releasing intravaginal device (PRID® Delta; 1.55 g P4) treatment with administration of a prostaglandin F2α analogue (Enzaprost; CEVA Sante Animale) the day before PRID® Delta removal. Only those heifers recorded in standing oestrus (Day 0) were used. In Experiment 1, heifers were randomly assigned to one of five groups: (1) control: no treatment; (2) placebo: insertion of a blank device (no P4) from Day 3 to Day 7; (3) insertion of a PRID® Delta from Day 3 to Day 7; (4) insertion of a PRID® Delta from Day 3 to Day 5; or (5) insertion of a PRID® Delta from Day 5 to Day 7. In vitro-produced blastocysts were transferred to each heifer in Groups 2–5 on Day 7 (n = 10 blastocysts per heifer) and conceptuses were recovered when heifers were killed on Day 14. Based on the outcome of Experiment 1, in Experiment 2 heifers were artificially inseminated at oestrus and randomly assigned to one of three treatment groups: (1) placebo; (2) PRID from Day 3 to Day 5; or (3) PRID from Day 3 to Day 7. All heifers were killed on Day 16 and recovered conceptuses were incubated in synthetic oviducal fluid medium for 24 h; spent media and uterine flushes were analysed for interferon-τ (IFNT). In both experiments, daily blood samples were taken to determined serum P4 concentrations. Data were analysed using the PROC MIXED procedure of SAS (SAS Institute, Cary, NC, USA). Insertion of a PRID resulted in an increase (P < 0.05) in serum P4 that declined following removal. In Experiment 1, P4 supplementation from Day 3 to Day 5 (17.0 ± 1.4 mm) or Day 3 to Day 7 (11.3 ± 2.3 mm) increased conceptus length compared with placebo (2.1 ± 1.8 mm). Serum P4 was significantly lower from Day 9 to Day 14 (P < 0.05) and the weight of the Day 14 corpus luteum (CL) was lower in the PRID Day 3–7 group than the placebo or control groups. In Experiment 2, supplementation from Day 3 to Day 5 (94.0 ± 18.8 mm) or Day 3 to Day 7 (143.6 ± 20.6 mm) increased conceptus length on Day 16 compared with placebo (50.3 ± 17.4 mm). Serum P4 was significantly lower in the two supplemented groups following PRID removal compared with placebo (P < 0.05) and was associated with a lower CL weight in the Day 3–7 group. Conceptus length was strongly correlated with the IFNT concentration in the uterine flush (r = 0.58; P = 0.011) and spent culture medium (r = 0.68; P < 0.002). The findings of the present study highlight the somewhat paradoxical effects of P4 supplementation when given in the early metoestrous period in terms of its positive effect on conceptus development and its potentially negative effects on CL lifespan.

Effect of hCG administration during corpus luteum establishment on subsequent corpus luteum development and circulating progesterone concentrations in beef heifers

This study examined the effect of a single administration of human chorionic gonadotrophin (hCG) on Day 1 to 4 after oestrus on corpus luteum (CL) development and circulating progesterone (P4). Oestrus-synchronized heifers (n = 43) were administered a single intramuscular injection of saline on Day 1 (control) or 3000 IU hCG on Day 1, 2, 3 or 4 after oestrus. Administration of hCG on Day 1 had no effect on CL area, on Day 2 increased CL area from Day 6 to 12 (P < 0.05), on Day 3 increased CL area from Day 9 to 11, while on Day 4 increased CL size on Days 9 and 10 (P < 0.05). Administration of hCG on Day 4 induced the formation of an accessory CL in 89% of heifers, resulting in a significant increase in total luteal tissue area on the ovaries compared with all other groups. Consistent with the effects on the CL, hCG on Day 1 did not affect P4 concentrations, on Day 2 significantly increased P4 compared with the control from Day 6 to 11 (P < 0.05), on Day 3 resulted in a non-significant increase in P4 while hCG on Day 4 increased P4 from Day 8 to 13 compared with the control (P < 0.05). In conclusion, administration of hCG as early as Day 2 after oestrus results in increased P4 in circulation from Day 6, which should have beneficial downstream effects in terms of uterine receptivity and conceptus elongation.

76 RELATIONSHIP BETWEEN BLASTOCYST CELL NUMBER AT EMBRYO TRANSFER AND CONCEPTUS ELONGATION ON DAY 14: CAN SUPPLEMENTARY PROGESTERONE RESCUE SMALL EMBRYOS?

Conceptus size on Day 14 following multiple embryo transfer of Day 7 in vitro-produced blastocysts varies greatly within animal. One explanation for this variation may be related to blastocyst cell number at the time of transfer. The aim of this study was to examine the effect of Day 7 blastocyst cell number on Day 14 conceptus size and to examine the effect of progesterone (P4) supplementation on embryo development following the transfer of Day 7 blastocysts containing a low total cell number. The oestrous cycles of crossbred beef heifers were synchronised using an 8-day CIDR (1.38 g of P4) treatment with administration of a prostaglandin F2α analogue (Estrumate™, Merck Animal Health, Summit, NJ, USA) on the day before CIDR removal. Only those heifers recorded in standing oestrus (Day 0) were used. Heifers were randomly assigned to 1 of 4 treatment groups: (1) Control: large blastocysts (high total cell number), (2) Control: small blastocysts (low total cell number), (3) small blastocysts plus a single intramuscular injection of 3000 IU of hCG (Chorulon®, Merck Animal Health) on Day 2 after oestrus, or (4) small blastocysts plus insertion of a vaginal progesterone insert (PRID, 1.55 g of P4) between Days 3 to 5 after oestrus. In vitro-produced blastocysts were transferred to each heifer on Day 7 (n = 10 blastocysts per heifer) and conceptuses were recovered at slaughter on Day 14. A sample of blastocysts was fixed and stained using Hoechst 33342 to determine the mean total cell number per group. Daily blood samples were collected from Day 0 to 14 to measure serum P4 concentrations. Data were analysed using the PROC MIXED procedure of SAS (SAS Institute Inc. Cary, NC, USA). Total cell number on Day 7 was significantly lower in small compared with large blastocysts (72.4 ± 3.93 v. 144.8 ± 3.90; P < 0.05). Conceptus recovery rate was 53.8% overall (140/260) and was highest in the large blastocyst group (68.3%, 41/60) compared with the other groups (45.7–55.0%). Concentrations of serum P4 were similar in the 2 unmanipulated recipient groups but were significantly elevated (P < 0.05) by Day 8 in hCG-treated heifers and on Days 4 and 5 in the PRID group (P < 0.003). In the absence of supplemental P4, Day 14 conceptuses resulting from the transfer of small blastocysts (2.48 ± 0.54 mm) were smaller than those from large blastocysts (3.32 ± 0.52 mm). Administration of hCG on Day 2 approximately doubled conceptus length on Day 14 (4.94 ± 1.15 mm), whereas insertion of a PRID from Day 3 to 5 increased conceptus length ~5-fold (13.09 ± 2.11 mm; P < 0.05) compared with controls. In conclusion, results indicate that supplemental P4 is capable of “rescuing” poor quality blastocysts, presumably via the now well-described actions on the endometrium and consequent effects on uterine lumen fluid composition. Supported by Science Foundation Ireland (07/SRC/B1156).

'It's not a disease, it's a nuisance': controlling diabetes and achieving goals in the context of men with Type 1 diabetes

Despite a steady growth in research into men's health, little is known about how men experience life with a chronic illness like Type 1 diabetes. To address this knowledge gap, we conducted an interview study with 15 men who have Type 1 diabetes. Following grounded theory analysis of the interview transcripts, we generated a number of inter-related themes which were then formulated as a theory of adjustment to life with Type 1 diabetes. This theory indicates that men reduce the seriousness of diabetes by defining it in ways other than a serious illness. By viewing diabetes in this way, men are then able to prioritise the pursuit of their personal goals over adherence to the diabetes regimen. Finally, men reassess their relationship with diabetes in light of diabetes-related complications. The goal of this process is to find the 'best fit' for diabetes in their lives - a place which will allow them to pursue and satisfy their personal goals. As men progress through life, personal goals may change and so too will their relationship with diabetes.

109 EFFECT OF SHORT TERM PROGESTERONE SUPPLEMENTATION ON CIRCULATING PROGESTERONE CONCENTRATION, CORPUS LUTEUM SIZE, AND EARLY EMBRYO DEVELOPMENT IN CATTLE

The aim of this study was to investigate the effect of short term progesterone (P4) supplementation on circulating P4 concentrations, corpus luteum (CL) size, and conceptus development in cattle. The oestrous cycles of crossbred beef heifers were synchronised using a 7-day PRID® Delta (1.55 g P4) treatment with administration of a PGF2α analog (Enzaprost®) the day before PRID® Delta removal. Only those recorded in standing oestrus (Day 0) were used. In Experiment 1, heifers were randomly assigned to 1 of 5 groups: (1) control: no treatment, (2) placebo: insertion of a blank device (no P4) from Day 3 to 7, (3) insertion of a PRID® Delta from Day 3 to 7, (4) insertion of a PRID® Delta from Day 3 to 5, or (v5) insertion of a PRID® Delta from Day 5 to 7. In vitro produced blastocysts were transferred to each heifer on Day 7 (10 blastocysts per heifer) and conceptuses were recovered at slaughter on Day 14. In Experiment 2 heifers were artificially inseminated at oestrus and randomly assigned to 1 of 3 treatment groups (1) placebo, (2) PRID® Delta from Day 3 to 5, or (3) PRID® Delta from Day 3 to 7. All heifers were slaughtered on Day 16, and recovered conceptuses were incubated in synthetic oviduct fluid medium for 24 h; spent media and uterine flushes were analysed for interferon-tau (IFNT). In both experiments, daily blood samples were taken to measure serum P4 concentration. Data were analysed using the PROC MIXED procedure of SAS (SAS Institute Inc., Cary, NC, USA). Insertion of a PRID® Delta resulted in an increase (P < 0.05) in serum P4, which declined following removal. In Experiment 1, serum P4 concentration was significantly lower from Day 9 to 14 (P < 0.05) and Day 14 CL weight was lower in the PRID® Delta Day 3 to 7 group than the placebo or control groups. P4 supplementation from Day 3 to 5 (17.0 ± 1.4 mm) or Day 3 to 7 (11.3 ± 2.3 mm) increased conceptus length compared to the placebo (2.1 ± 1.8 mm). In Experiment 2, serum P4 was significantly lower in the two supplemented groups following PRID® Delta removal compared with the placebo (P < 0.05) and was associated with a lower CL weight in the Day 3 to 7 group. Supplementation from Day 3 to 5 (94.0 ± 18.8 mm) or Day 3 to 7 (143.6 ± 20.6 mm) increased conceptus length on Day 16 compared to the placebo (50.3 ± 17.4 mm). Conceptus length was strongly correlated with the concentration of IFNT in the uterine flush (r = 0.58; P = 0.011) and spent culture medium (r = 0.68; P < 0.002). These findings highlight the somewhat paradoxical effects of P4 supplementation when given in the early metoestrus period in terms of its positive effect on conceptus development and its potentially negative effects on CL lifespan. Supported by CEVA Sante Animale and Science Foundation Ireland (07/SRC/B1156).

110 EFFECT OF HUMAN CHORIONIC GONADOTROPIN (hCG) ADMINISTRATION ON DAYS 1, 2, 3, OR 4 POST-OESTRUS ON CORPUS LUTEUM DEVELOPMENT AND CIRCULATING PROGESTERONE CONCENTRATIONS IN BEEF HEIFERS

The steroid hormone progesterone (P4) plays a key role in the reproductive events associated with the establishment and maintenance of pregnancy. Elevated concentrations of circulating P4 in the immediate post-conception period have been associated with advanced conceptus elongation, increased interferon-tau production, and greater pregnancy rates in cattle. Several strategies have been employed to supplement the endogenous P4 supplied by the corpus luteum (CL). One such strategy is the administration of human chorionic gonadotropin (hCG) during the early luteal phase (typically Day 5) that induces ovulation of the first wave dominant follicle and formation of a functional accessory CL, in turn leading to increased circulating concentrations of P4. In addition to this effect, hCG also stimulates hypertrophy of the original CL, leading to a significant deviation in P4 concentrations 2 days after administration. The aim of this study was to examine whether administration of hCG earlier during the metoestrus period would lead to an earlier rise in P4 by stimulation of the developing endogenous CL. The oestrous cycles of cross-bred beef heifers (n = 50) were synchronised and those recorded in standing oestrus (Day 0) were assigned randomly to one of 5 treatments and administered a single IM injection of saline on Day 1 after oestrus (Control) or 3000 IU hCG on Day 1, 2, 3, or 4 after oestrus. Daily blood samples were collected from Day 0 to 14 by coccygeal venipuncture to measure serum P4 concentration. The dimensions of the original CL and induced CL, when present, were measured by daily ultrasound scanning beginning on Day 3 after oestrus until Day 14. Data were analysed using the PROC MIXED procedure of SAS (SAS Institute Inc., Cary, NC, USA). In terms of effects on the CL, administration of hCG on Day 1 had no effect on CL area. Administration on Day 2 increased CL area from Day 6 to 12 (P ≤ 0.05). hCG on Day 3 increased CL area from Day 9 to 11, while administration on Day 4 increased CL size on Day 9 and 10 (P ≤ 0.05). Administration of hCG on Day 4 induced the formation of an accessory CL in 89% of heifers, resulting in a significant increase in total luteal tissue area on the ovaries compared to all other groups. Consistent with the effects on the CL, hCG on Day 1 did not affect P4 concentrations. Administration on Day 2 significantly increased P4 compared to the control from Day 6 to 11 (P ≤ 0.05). Administration on Day 3 resulted in a nonsignificant increase in P4, while hCG on Day 4 increased P4 from Day 8 to 13 compared to the control (P ≤ 0.05). In conclusion, administration of hCG as early as Day 2 post oestrus results in increased P4 in circulation from Day 6 which should have beneficial downstream effects in terms of uterine receptivity and conceptus elongation. Funded by Science Foundation Ireland (07/SRC/B1156) and the Spanish Ministry of Science and Innovation AGL2009-11810.

Effect of follicular aspiration just before ovulation on corpus luteum characteristics, circulating progesterone concentrations and uterine receptivity in single-ovulating and superstimulated heifers

The aim of this study was to investigate, in unstimulated and superstimulated heifers, the effect of follicle aspiration just before ovulation on corpus luteum (CL) development, circulating progesterone (P4) concentrations and the ability of the uterus to support embryo development. Following follicle aspiration or ovulation timed from GNRH administration, CL development was assessed by daily ultrasonography, and CL function was assessed in terms of the capacity to produce P4 and the expression of genes involved in steroidogenesis in luteal tissue. The capacity of the uterine environment to support conceptus development was assessed following transfer and recovery of in vitro-produced embryos. Follicular aspiration just before the expected time of ovulation leads to a significant reduction in CL diameter, CL area and area of luteal tissue. This was associated with a decrease in circulating P4 in both unstimulated and superstimulated heifers. Follicle aspiration leads to a reduction in conceptus length and area on day 14 in unstimulated heifers only. Follicle aspiration leads to a reduction in the expression of LHCGR in luteal tissue from unstimulated heifers compared with those in which the CL formed after ovulation. Superstimulation significantly reduced the expression of STAR in luteal tissue in both ovulated and follicle-aspirated heifers. In conclusion, in stimulated and unstimulated heifers, aspiration of the preovulatory dominant follicle(s) just before expected ovulation interferes with the subsequent formation and function of the CL, in terms of size and P4 output and this, in turn, is associated with a reduced capacity of the uterus to support conceptus elongation in unstimulated heifers.

156 EFFECT OF DURATION POSTPARTUM ON OOCYTE QUALITY IN LACTATING HOLSTEIN COWS FOLLOWING TRANSVAGINAL FOLLICLE ASPIRATION AND IN VITRO FERTILIZATION

The objective of this study was to examine the effect of duration postpartum on oocyte quality in lactating dairy cows, as assessed by oocyte morphology and development after fertilization and culture in vitro. Holstein-Friesian spring-calving cows were used (n = 16; parity 3.0 ± 0.36, weight at calving 611 ± 16.2 kg, previous 305-day milk yield 6454.0 ± 276.4 kg). Body weight (BW) and body condition score (BCS) were recorded at approximately 2 weeks before the expected calving date, at calving and then weekly until the end of the experiment (approximately 80 days postpartum). Blood plasma samples were collected weekly, beginning 2 weeks before the expected calving date and continuing until the end of the experiment and were analysed for nonesterified fatty acids (NEFA), β-hydroxybutyrate (BHBA), insulin, insulin-like growth factor I (IGF-I) and glucose. There was a linear decline in BW from calving (Day 0) to Day 28, after which it remained stable. The BCS declined from 14 days precalving, reaching a nadir at approximately Day 35 to 42, after which it increased to the end of the period. Nonesterified fatty acids were significantly elevated from the week before calving until Day 42 postcalving, whereas BHBA was significantly elevated from calving to Day 49. The IGF-I declined dramatically from Day –14 to a nadir on Day 7. There was a significant increase in glucose from Day –7 to Day 0, followed by a precipitous decline to Day 7. Based on the assumption that uterine involution (UI) is complete by approximately Day 42 postpartum in most cows, data from Day 0 to 42 postpartum (pre-UI) were compared with corresponding data from Day 42 to 80 (post-UI). Apart from BCS, all the physiological parameters measured (milk yield, BW and blood metabolites) differed significantly between the 2 periods. In particular, IGF-I, insulin and glucose concentrations were higher after Day 42, whereas BHBA and NEFA were lower compared with before Day 42. The number of oocytes recovered per session and oocyte quality grade did not differ between periods. Positive associations of follicles aspirated and insulin, BHBA and NEFA were detected. Number of oocytes recovered was positively associated with milk yield, BW, glucose and NEFA. Number of cleaved oocytes was positively associated with BW and NEFA. In conclusion, the data do not provide evidence of an effect of lactation-induced metabolic stress on oocyte developmental competence in the postpartum dairy cow assessed in terms of morphological quality and ability to develop after IVF. This work was supported by Science Foundation Ireland (07/SRC/B1156).

85 EFFECT OF FOLLICULAR ASPIRATION JUST PRIOR TO OVULATION ON CORPUS LUTEUM CHARACTERISTICS, CIRCULATING PROGESTERONE CONCENTRATIONS AND UTERINE RECEPTIVITY IN SINGLE-OVULATING BEEF HEIFERS

Progesterone (P4) has a crucial impact on the transcriptome of the uterine endometrium and the preparation of the uterus to support implantation. The aim of this study was to investigate the effect of follicle aspiration just before ovulation on corpus luteum (CL) development, circulating P4 concentrations and the ability of the uterus to support embryo development and conceptus elongation. We tested the hypothesis that the unavoidable loss of follicular fluid and some granulosa cells during aspiration of the preovulatory follicle would compromise the development and function of the developing CL and that this would be associated with reduced P4 and a poorer uterine environment. Oestrous cycles of crossbred beef heifers were synchronized using an 8-day CIDR treatment with administration of a prostaglandin F2α analogue on the day before CIDR removal to ensure CL regression. Heifers were checked for signs of oestrus 4 times per day commencing 30 h after CIDR withdrawal and only those recorded in standing oestrus (Day 0, n = 20) were used. All heifers received a gonadotropin-releasing hormone agonist (0.01 mg buserelin) 48 h after CIDR removal to induce an LH surge. Half of the animals underwent follicle aspiration 20 h later, while the remainder underwent ovulation. Daily transrectal ultrasonography was carried out from Day 3 to 13 to record CL development. Daily blood samples were collected from Day 0 to 14 for circulating P4 concentrations. To test the ability of the uterus to support embryo development and conceptus elongation, Day 7 in vitro-produced blastocysts were transferred to the uteri of synchronised recipients (7 to 10 blastocysts per recipient). All recipients were slaughtered on Day 14 to assess embryo survival and conceptus size. CL diameter and CL area were significantly reduced in the follicle aspirated group compared with controls from Day 6 onwards (P ≤ 0.05). Similarly, at slaughter on Day 14, CL weight (4.17 ± 0.48 vs 7.05 ± 1.65 mm), diameter (19.89 ± 1.35 vs 24.64 ± 2.07 mm) and area (321.94 ± 45.01 vs 510.18 ± 69.41 mm2) were lower in aspirated heifers (P ≤ 0.05). Circulating P4 concentrations were lower at all time points from Day 3 to Day 14 but were only significantly lower from Day 12 onwards (P ≤ 0.05). Conceptus length (2.08 ± 0.29, n = 56 vs 4.55 ± 0.78 mm, n = 45) and area (2.52 ± 0.39 vs 5.61 ± 1.12 mm2) were lower (P ≤ 0.05) in heifers undergoing follicular aspiration compared with those undergoing ovulation. In conclusion, aspiration of the preovulatory dominant follicle just before expected ovulation was associated with a compromised CL in terms of size and P4 output and this, in turn, was associated with a reduced capacity of the uterus to support the initiation of conceptus elongation. Supported by Science Foundation Ireland (07/SRC/B1156).

194 EXPRESSION OF STANNIOCALCIN FAMILY GENES DURING PREIMPLANTATION STAGE BOVINE EMBRYO DEVELOPMENT

Stanniocalcins (STC) are a small family of secreted homodimeric glycoprotein hormones consisting of STC1 and STC2. A previous study in Drosophila (Tolias and Stroumbakis 1998 Dev. Genes Evol. 208, 274–282) indicated that maternally derived STC is required during embryogenesis. However, little information is available for mammalian embryos. The aim of this study was to examine the expression of STC and assess their roles during the preimplantation stage of bovine embryo development. Immature cumulus–oocyte complexes were aspirated from follicles of bovine ovaries collected at a local abattoir and matured in vitro for 24 h at 39°C under an atmosphere of 5% CO2 in air with maximum humidity in TCM-199 supplemented with 10% (vol/vol) fetal calf serum and 10 ng mL–1 of epidermal growth factor. Matured cumulus–oocyte complexes were inseminated with fertile bull semen (Day 0). Embryos were cultured in vitro, and subsequently, 4 pools of 10 embryos each at the zygote, 2-cell, 4-cell, 8-cell, 16-cell, morula, and blastocyst stages were collected from 4 different replicate cultures and stored at –80°C until analysis. Total RNA was isolated using an RNeasy Micro Kit and a random primer was used during cDNA synthesis. The expression of STC1, STC2, and reference genes (YWHAZ, PPIA, SDHA) was examined. Quantitative real-time PCR was used to compare transcript abundance, and data were normalized to the geometric averages of the reference genes. The expression levels were analysed using the relative standard curve method, and means were compared using Student’s t-test. Despite being members of the same family and having large sequence similarity, the expression of each gene was unique and stage dependent during embryo development. Expression of STC1 was detected in all the stages examined. Expression was transiently reduced at the 2-cell stage, with no significant change until the 8-cell stage but with a slight increase at the 16-cell stage. In contrast, STC2 was barely detectable before the 8-cell stage. Expression at the 8- and 16-cell stages was significantly (P < 0.0001) higher compared with all other stages, with a peak at the 16-cell stage. This significantly higher expression pattern of STC2 during the critical stages of maternal to zygotic control of development may suggest an important role during this critical period of embryo development. Supported by Science Foundation Ireland (07/SRC/B1156).

Living with type 1 diabetes: a by-person qualitative exploration

Type 1 diabetes is a chronic condition which places enormous demands on the individual diabetic. A strict care routine is necessitated, yet even the most controlled and disciplined diabetic is likely to experience associated health problems and automatically faces a reduced life expectancy. The current study explores the psychological repercussions of this situation via a small scale qualitative study which focuses on the very different viewpoints and experiences of four adults living with Type 1 diabetes. A new and original form of by-person (or by-case) qualitative analysis is employed in order to capture, in a rich and holistic fashion, each participant's current relationship with their condition, their experience of living and dealing with diabetes and the ways in which diabetes is integrated within their lives and identities. The findings have implications for, and are discussed in relation to, issues of control, regimen adherence, and what it means to be a 'good' or 'successful' diabetic. The conclusion is drawn that the satisfaction of personal goals and a focus on psychological as well as physical health may be very important if positive quality of life outcomes are to be attained in the context of Type 1 diabetes.

Temporal expression profiling of the uterine luminal epithelium of the pseudo-pregnant mouse suggests receptivity to the fertilized egg is associated with complex transcriptional changes

BACKGROUND

The molecular basis of changes underlying the altered sensitivity of the uterine luminal epithelium (LE) to the embryo over the peri-implantation period is not fully understood.

METHODS

Microarray analysis was performed on purified LE isolated from the pseudo-pregnant mouse uterus at 12-h intervals from pre-receptivity through the implantation window to refractoriness. The aim was to identify genes whose expression changes in the LE during this period.

RESULTS

A total of 447 transcripts were identified whose abundance changed more than 2-fold in the LE but which did not change in the underlying stroma (S) and glands. Six major patterns of changing expression were noted. Of the 447 genes, 140 were expressed in LE at least 15-fold higher than in S and glandular epithelium (GE) (101 of these more than 20-fold). Detailed spatiotemporal expression profiles were derived for several genes previously implicated in implantation (including Edg7, Ptgs1, Pla2g4a and Alox15).

CONCLUSIONS

Functional changes in LE receptivity are characterized by changing constellations of gene expression. Pre-receptivity has a different molecular footprint to refractoriness. Because we have used the pseudo-pregnant mouse model, these changes are driven solely by endocrine signals rather than events downstream of embryo attachment. Some of these genes have been described in previous microarray studies on endometrium, but for the majority, this is the first time they have been implicated in implantation. The 140 genes enriched in the LE greatly expand the list of epithelial markers and provide many novel candidates for further studies to identify genes playing important roles in receptivity and embryo attachment.

Developmental and reproductive performance in circadian mutant mice

BACKGROUND

Genes underlying circadian rhythm generation are expressed in many tissues. We explore a role for circadian rhythms in the timing and efficacy of mouse reproduction and development using a genetic approach.

METHODS

We compare fecundity in Clock(Delta19) mutant mice (a dominant-negative protein essential for circadian rhythm activity) and in Vipr2-/- null mutant mice (affecting the generation and output of the circadian rhythm of the hypothalamic suprachiasmatic nucleus) with wild type (WT) litter mates under both a 12 h:12 h light:dark cycle and continuous darkness.

RESULTS

Uteri from Clock(Delta19) mice show no circadian rhythm and Vipr2-/- mice show a phase-advanced rhythm compared to WT uteri. In neither mutant line were homozygous or heterozygous fetuses lethal. Sexually mature adults of both mutant lines showed mildly reduced male in vivo (but not in vitro) fertility and irregular estrous cycles exacerbated by continuous darkness. However, pregnancy rates and neonatal litter sizes were not affected. The Clock(Delta19) mutant line was distinguishable from the Vipr2-/- null mutant line in showing more peri-natal delivery problems and very poor survival of offspring to weaning.

CONCLUSIONS

A fully functional central and peripheral circadian clock is not essential for reproduction and development to term, but has critical roles peri-natally and post-partum.

Planning of a community-based approach to injury control and safety promotion in a rural community

This paper describes the planning of a community-based approach to injury control and safety promotion, the Kolan Injury Prevention Program. The process involved the establishment of a local steering committee, 11 months of injury surveillance, a critical review of the evidence base, community consultations and assessment of community resources. There were 412 recorded injury cases during the surveillance period, with higher rates among men, manual workers, those aged 15-34 years, sport/leisure activities and around the home and farm. Salient issues for residents included a lack of access to safety information and skills, particularly with regard to first aid and bush fire for isolated residents and rurally inexperienced new residents. While injury prevention was identified as an important issue for the community, the rapidly changing size and nature of the community and its infrastructure made this a particularly challenging issue. Challenges included limited availability of volunteers from key sectors, lack of formal data collection systems, difficulties in mobilising support for a broad issue like injury, limited communication networks and the negative impact of distance and role uncertainty on community ownership of the program. This case study illustrates the steps involved in an effective community-based needs assessment addressing injury prevention. Such an approach, if carried out systematically, will help ensure that the strategies and programs developed will be both appropriate and likely to obtain the support of the local community.

A Delphi study of self-care in a community population of people with multiple sclerosis

OBJECTIVE

The aim of the study was to obtain the views and priorities of people with multiple sclerosis (MS) to inform the design of a professionally guided self-care programme.

DESIGN

A three-round postal Delphi survey was used as a research tool.

SETTING

The study was conducted at the Centre for Research in Rehabilitation at Brunel University in London.

SUBJECTS

The respondent panel consisted of 200 volunteers with MS of whom 136 responded to the survey (68%). Respondents were recruited through voluntary organizations throughout the UK. The only selection criterion was that the diagnosis of MS was confirmed by the general practitioner.

MAIN OUTCOME MEASURES

The results from each of the three rounds of the Delphi survey were the outcome measures.

RESULTS

One hundred and one people used ten or more self-care strategies (74%). Round 1 data revealed the diversity of practices reported, crossing many domains of life such as daily chores, leisure, relationships and physical and mental health. The top five priorities identified in rounds 2 and 3 concerned coping strategies, social support, independence in daily living, rest and mobility. Complete consensus about priorities was not achieved. However, agreement about priorities approached stability across rounds 2 and 3 and a highly significant Kendall's coefficient of concordance indicated there was good agreement within round 3 group rankings (W= 0.46, chi-squared = 499.37, df = 9, p<0.001, N= 122).

CONCLUSION

Self-care practices were widespread, and those most commonly used could be identified. This survey method allows the views and priorities of this consumer group to be revealed. The information obtained can be used to develop services where the professional guides and encourages appropriate self-management based upon the issues that people with MS consider to be most important.

Report on the prevalence of skin ulcers in a home health agency population

OBJECTIVE

This survey was conducted to assess the presence of skin ulcers within a home health agency population in the United States.

DESIGN

This voluntary survey was conducted by 177 home health agencies. A single observation of each patient within the agency's active caseload formed the cohort examined. Patients deemed to be at low risk (Braden Scale score > 19) were eliminated from further evaluation, while those with skin ulcers were evaluated for wound- and caregiver-related factors. Surveys were conducted between March 1, 1996, and December 31, 1997.

SETTING

Home health agencies in 19 states throughout the United States, with no restrictions on the type or acuity of the patients served.

RESULTS

A total of 21,529 patients were surveyed, with a prevalence of pressure ulcers (inclusive of all stages) of 6.8% (n = 1455). Rates for each agency ranged between 0.5% and 35.7%. The total number of ulcers reported was 2526 (average per patient was 1.7), with 36% (n = 919) found on the sacrum and the buttocks.

CONCLUSION

Pressure ulcers were the most frequently reported reason for admission to the agency's caseload. Survey results are similar to rates reported in other segments of the health care industry. However, among the home health care population, the primary caregiver is unlikely to be a health care professional. This survey found that the patient's spouse was the primary caregiver in 30% (n = 437) of the 1450 responses received regarding the relationship of the primary caregiver to the patient.

Internationalization of multi hospital systems

Much like the manufacturing multinationals of yore, professional service establishments are now going abroad in large numbers. Two factors drive their expansion overseas--the increasing restrictions on their operations domestically, and the inviting opportunities in some of the global markets. A survey of multi hospital corporations both with and without experience in foreign markets was conducted regarding the expansion of their operations overseas. Examined were factors central to the decision-making process including: the various types of foreign health care systems; the entry strategies in penetrating foreign markets (fully owned, joint ventures, etc.); favorable factors and barriers considered in choosing foreign markets; the ability to transfer standardized systems from operations in the U.S.; and the profits from such operations. Respondents provided information regarding the above factors that are critical in determining an overseas expansion strategy.