Timing of Testicular Biopsy in Relation to Oocyte Retrieval and the Outcomes of Intracytoplasmic Sperm Injection

PURPOSE

We evaluate microscopic (micro) testicular sperm extraction (TESE) timing relative to oocyte retrieval on intracytoplasmic sperm injection outcome.

MATERIALS AND METHODS

Couples with nonobstructive azoospermia who underwent intracytoplasmic sperm injection with freshly retrieved spermatozoa were analyzed based on whether micro-TESE was performed at least 1 day prior to oocyte retrieval (TESE-day-before group) or on the day of oocyte retrieval (TESE-day-of group). Embryology and clinical outcomes were compared.

RESULTS

The percentage of patients who underwent a successful testicular sperm retrieval was significantly lower in the TESE-day-before cohort (62%) than in the TESE-day-of cohort (69%; odds ratio [OR] 1.4, 95% CI [1.1, 1.7], P < .001). The fertilization rate was also found to be significantly lower in the TESE-day-before group (45%) than in the TESE-day-of group (53%; OR 1.4, 95% CI [1.2, 1.7], P = .01). Although the association between the cleavage rate and TESE timing was not statistically significant, the implantation rate was found to be significantly higher in the day-before cohort (28%) than in the day-of cohort (22%; OR 0.7, 95% CI [0.6, 0.9], P = .01). Nevertheless, it was found that the clinical pregnancy and delivery rates were not statistically significantly associated with the TESE timing.

CONCLUSIONS

Although sperm retrieval and fertilization rates were lower in the TESE-day-before cohort, the 2 cohorts showed comparable embryologic and clinical outcomes. Micro-TESE can be performed before oocyte harvesting to provide physicians ample time to decide between cancelling oocyte retrieval or retrieving oocytes for cryopreservation.

Genetic profiling of azoospermic men to identify the etiology and predict reproductive potential

PURPOSE

To identify germline mutations related to azoospermia etiology and reproductive potential of surgically retrieved spermatozoa, and to investigate the feasibility of predicting seminiferous tubule function of nonobstructive azoospermic men by transcriptomic profiling of ejaculates.

MATERIALS AND METHODS

Sperm specimens were obtained from 30 men (38.4 ± 6 years) undergoing epididymal sperm aspiration for obstructive azoospermia (OA, n = 19) acquired by vasectomy, or testicular biopsy for nonobstructive azoospermia (NOA, n = 11). To evaluate for a correlation with azoospermia etiology, DNAseq was performed on surgically retrieved spermatozoa, and cell-free RNAseq on seminal fluid (n = 23) was performed to predict spermatogenesis in the seminiferous tubule.

RESULTS

Overall, surgically retrieved sperm aneuploidy rates were 1.7% and 1.8% among OA and NOA cohorts, respectively. OA men carried housekeeping-related gene mutations, while NOA men displayed mutations on genes involved in crucial spermiogenic functions (AP1S2, AP1G2, APOE). We categorized couples within each cohort according to ICSI clinical outcomes to investigate genetic causes that may affect reproductive potential. All OA-fertile men (n = 9) carried mutations in ZNF749 (sperm production), whereas OA-infertile men (n = 10) harbored mutations in PRB1, which is essential for DNA replication. NOA-fertile men (n = 8) carried mutations in MPIG6B (stem cell lineage differentiation), whereas NOA-infertile individuals (n = 3) harbored mutations in genes involved in spermato/spermio-genesis (ADAM29, SPATA31E1, MAK, POLG, IFT43, ATG9B) and early embryonic development (MBD5, CCAR1, PMEPA1, POLK, REC8, REPIN1, MAPRE3, ARL4C). Transcriptomic assessment of cell-free RNAs in seminal fluid from NOA men allowed the prediction of residual spermatogenic foci.

CONCLUSIONS

Sperm genome profiling provides invaluable information on azoospermia etiology and identifies gene-related mechanistic links to reproductive performance. Moreover, RNAseq assessment of seminal fluid from NOA men can help predict sperm retrieval during testicular biopsies.

Thyroid hormone-regulated chromatin landscape and transcriptional sensitivity of the pituitary gland

Thyroid hormone (3,5,3'-triiodothyronine, T3) is a key regulator of pituitary gland function. The response to T3 is thought to hinge crucially on interactions of nuclear T3 receptors with enhancers but these sites in pituitary chromatin remain surprisingly obscure. Here, we investigate genome-wide receptor binding in mice using tagged endogenous thyroid hormone receptor β (TRβ) and analyze T3-regulated open chromatin using an anterior pituitary-specific Cre driver (Thrbb2Cre). Strikingly, T3 regulates histone modifications and chromatin opening primarily at sites that maintain TRβ binding regardless of T3 levels rather than at sites where T3 abolishes or induces de novo binding. These sites associate more frequently with T3-activated than T3-suppressed genes. TRβ-deficiency blunts T3-regulated gene expression, indicating that TRβ confers transcriptional sensitivity. We propose a model of gene activation in which poised receptor-enhancer complexes facilitate adjustable responses to T3 fluctuations, suggesting a genomic basis for T3-dependent pituitary function or pituitary dysfunction in thyroid disorders.

Sperm centriolar factors and genetic defects that can predict pregnancy

The human sperm centrosome, comprising the two morphologically distinct centrioles and associated pericentriolar materials, plays a crucial role in fertilization and early embryonic development after fertilization. Once inside the oocyte, the sperm centrosome serves as a microtubule-organizing center, orchestrating mitotic spindle formation, chromosome segregation, and syngamy. Abnormalities of the sperm centrosome can lead to abnormal embryonic development and embryonic chromosomal instability, and are associated with pregnancy loss. Recent research has shed light on the molecular composition, regulation, and function of this vital organelle. Understanding the intricacies of the sperm centrosome is crucial for elucidating the mechanisms underlying successful fertilization and early embryonic development, as well as addressing infertility and developmental disorders associated with centrosomal defects.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Biphasic expression of thyroid hormone receptor TRβ1 in mammalian retina and anterior ocular tissues

The retina is increasingly recognized as a target of thyroid hormone. We previously reported critical functions for thyroid hormone receptor TRβ2, encoded by Thrb, in cones, the photoreceptors that mediate color vision. TRβ1, another Thrb receptor isoform, is widely expressed in other tissues but little studied in the retina. Here, we investigate these N-terminal isoforms by RNA-sequencing analysis and reveal a striking biphasic profile for TRβ1 in mouse and human retina. In contrast to the early TRβ2 peak, TRβ1 peaks later during retinal maturation or later differentiation of human retinal organoids. This switch in receptor expression profiles was confirmed using lacZ reporter mice. TRβ1 localized in cones, amacrine cells and ganglion cells in contrast to the restricted expression of TRβ2 in cones. Intriguingly, TRβ1 was also detected in the retinal pigmented epithelium and in anterior structures in the ciliary margin zone, ciliary body and iris, suggesting novel functions in non-retinal eye tissues. Although TRβ1 was detected in cones, TRβ1-knockout mice displayed only minor changes in opsin photopigment expression and normal electroretinogram responses. Our results suggest that strikingly different temporal and cell-specific controls over TRβ1 and TRβ2 expression may underlie thyroid hormone actions in a range of ocular cell types. The TRβ1 expression pattern suggests novel functions in retinal and non-neural ocular tissues.

Transcriptional control of cone photoreceptor diversity by a thyroid hormone receptor

Cone photoreceptor diversity allows detection of wavelength information in light, the first step in color (chromatic) vision. In most mammals, cones express opsin photopigments for sensitivity to medium/long (M, "green") or short (S, "blue") wavelengths and are differentially arrayed over the retina. Cones appear early in retinal neurogenesis but little is understood of the subsequent control of diversity of these postmitotic neurons, because cone populations are sparse and, apart from opsins, poorly defined. It is also a challenge to distinguish potentially subtle differences between cell subtypes within a lineage. Therefore, we derived a Cre driver to isolate individual M and S opsin-enriched cones, which are distributed in counter-gradients over the mouse retina. Fine resolution transcriptome analyses identified expression gradients for groups of genes. The postnatal emergence of gradients indicated divergent differentiation of cone precursors during maturation. Using genetic tagging, we demonstrated a role for thyroid hormone receptor β2 (TRβ2) in control of gradient genes, many of which are enriched for TRβ2 binding sites and TRβ2-regulated open chromatin. Deletion of TRβ2 resulted in poorly distinguished cones regardless of retinal location. We suggest that TRβ2 controls a bipotential transcriptional state to promote cone diversity and the chromatic potential of the species.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

National audit of non-melanoma skin cancer excisions performed by plastic surgery in the UK

A national, multi-centre audit of non-melanoma skin cancer excisions by plastic surgery.

A comparison of the kinematics and kinetics of barefoot and shod running in children with cerebral palsy

BACKGROUND

The biomechanics of barefoot and shod running are different for typically developing children but unknown for children with cerebral palsy (CP). Such differences may have implications for injury and performance.

AIMS

The primary aims of this study were to compare the lower limb biomechanics of barefoot and shod running in children with CP, and to determine whether any differences were the same in GMFCS levels I and II.

METHODS

This cross-sectional study examined 38 children with CP (n = 24 (GMFCS) level I; n = 14 GMFCS II), running overground at 3 speeds (jog, run, sprint) in barefoot and shod conditions. Marker trajectories and force plate data were recorded, and lower limb kinematics, kinetics and spatiotemporal variables were derived. Differences between barefoot and shod running were analysed using linear mixed models.

RESULTS

For both GMFCS levels, barefoot running resulted in higher loading rates, but smaller impact peaks at all speeds. Barefoot running was associated with greater hip and knee power; less ankle dorsiflexion and hip flexion at initial contact, and less ankle and knee range of motion during stance, compared to shod running, at all speeds. Barefoot stride length was shortened, and cadence increased compared to shod during jogging and running but not sprinting. For GMFCS level I only, barefoot running involved a higher incidence of forefoot strike, greater ankle power generation and less hip range of motion during stance.

SIGNIFICANCE

Running barefoot may facilitate running performance by increasing power generation at the ankle in children with CP, GMFCS level I. Higher barefoot loading rates may have implications for performance and injury.

O-251 Defining the exclusive role of male genome integrity on conceptus development

Study question

To determine the effect of sperm DNA fragmentation on embryo development by ruling out a female factor component.

Summary answer

By utilizing healthy donor oocytes, it is possible to quantify the sole deleterious effect of sperm DNA fragmentation and explore the ooplasmic repair mechanism.

What is known already

In approximately 50% of couples with unexplained ART failure, a subtle male factor is present that is missed in a conventional semen analysis assessing concentration, motility, and morphology. Additional information on male gamete competence can be acquired by assessing Sperm Chromatin Fragmentation (SCF). Indeed, a fragmented male genome can give rise to poorly developing embryos, leading to impaired implantation, lower pregnancy, and higher miscarriage rates. It has been previously seen that an oocyte, according to its age, can repair the damaged DNA contributed by the male gamete.

Study design, size, duration

In last decade, 316 couples, who have an elevated SCF, underwent ICSI cycles and resulted in disappointing clinical outcomes. To exclude an eventual confounding female factor, couples who utilized donor oocytes were identified and clinical outcome was compared to a control. To measure the role of an impaired sperm genome and a concurrent oocyte repair mechanism, we compared clinical outcomes between cycles in the same couples who used their own and subsequently donor oocytes.

Participants/materials, setting, methods

We included 381 couples screened for SCF; 65 underwent ICSI cycles with donor oocytes; of these, 46 underwent a previous ICSI cycle with their own oocytes. Fertilization, implantation, clinical pregnancy, and delivery rates were compared between above-mentioned groups. A TUNEL assay was used to measure SCF (≥500 spermatozoa were assessed/sample at a 15% threshold). Paired t and Chi-square tests were used to compare ages and clinical outcomes, respectively.

Main results and the role of chance

We included 381 couples (maternal age, 37.8 ± 4.2; paternal age, 41.8 ± 8.2), whose male partners had the following semen parameters: average volume of 2.5 mL, concentration of 25.4x106/mL, 33% motility, and normal morphology of 1.7. Of these, 316 had elevated average DNA fragmentation of 25.5% and utilized their own oocytes in 683 ICSI cycles, resulting in a 67.5% fertilization, 12.2% implantation, 27.9% clinical pregnancy, and a 22.5% ongoing/delivery. Of the 381 couples, 65 underwent ICSI utilizing donor oocytes (SCF of 24.3%) resulting in a significantly higher fertilization (78.4%) (P &lt; 0.00001) and embryo implantation rates (34.2%) (P &lt; 0.0001). Similarly, albeit not statistically significant, the clinical pregnancy and ongoing/delivery rates increased from 27.9% to 37.1% and from 22.5% to 30.0%, respectively.

To further explore the exclusive role of the male gamete in embryo development, we identified a cohort of patients (n = 46), with an elevated average DNA fragmentation of 23.6%, who underwent an ICSI cycle using their own oocytes and a subsequent cycle using donor oocytes. Compared to cycles where couples used their own oocytes, fertilization, embryo implantation, clinical pregnancy, and ongoing/delivery rates rose from 67.5% to 76.6% (P &lt; 0.0001), 2.8% to 24.7% (P &lt; 0.00001), 8.4% to 38.8% (P &lt; 0.0001), and 1.2% to 28.6% (P &lt; 0.00001), respectively.

Limitations, reasons for caution

Although this study attempts to control for a concurrent confounding female factor, it cannot be completely excluded. It is difficult to assess the extent and contribution of the ooplasmic repair mechanisms on the male genome.

Wider implications of the findings

Ooplasmic repair mechanisms of healthy female gametes appear to repair or improve the deleterious impact of sperm DNA fragmentation on ART outcomes.

Trial registration number

not applicable

An animal model for Pierpont syndrome; a mouse bearing the Tbl1xr1Y446C/Y446C mutation

Pierpont syndrome is a rare disorder characterized mainly by global developmental delay, unusual facial features, altered fat distribution in the limbs and hearing loss. A specific mutation (p.Tyr446Cys) in TBL1XR1, encoding a WD40 repeat-containing protein, which is a component of the SMRT/NCoR (silencing mediator retinoid and thyroid hormone receptors/nuclear receptor corepressors), has been reported as the genetic cause of Pierpont syndrome. Here, we used CRISPR-cas9 technology to generate a mutant mouse with the Y446C mutation in Tbl1xr1, which is also present in Pierpont syndrome. Several aspects of the phenotype were studied in the mutant mice: growth, body composition, hearing, motor behavior, thyroid hormone state and lipid and glucose metabolism. The mutant mice (Tbl1xr1^Y446C/Y446C) displayed delayed growth, altered body composition with increased relative lean mass and impaired hearing. Expression of several genes involved in fatty acid metabolism differed in white adipose tissue, but not in liver or muscle of mutant mice compared to wild-type mice (Tbl1xr1^+/+). No difference in thyroid hormone plasma concentrations was observed. Tbl1xr1^Y446C/Y446C mice can be used as a model for distinct features of Pierpont syndrome, which will enable future studies on the pathogenic mechanisms underlying the various phenotypic characteristics.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Cochlear Fibrocyte and Osteoblast Lineages Expressing Type 2 Deiodinase Identified with a Dio2CreERt2 Allele

Type 2 deiodinase (Dio2) amplifies levels of 3,5,3'-L-triiodothyronine (T3), the active form of thyroid hormone, and is essential for cochlear maturation and auditory development. However, cellular routes for endocrine signaling in the compartmentalized, anatomically complex cochlea are little understood. Dio2 generates T3 from thyroxine (T4), a more abundant thyroid hormone precursor in the circulation, and is dramatically induced in the cochlea before the onset of hearing. The evidence implies that specific Dio2-expressing cell types critically mediate T3 signaling but these cell types are poorly defined because Dio2 is expressed transiently at low levels. Here, using a Dio2CreERt2 knockin that activates a fluorescent reporter, we define Dio2-expressing cochlear cell types at high resolution in male or female mice. Dio2-positive cells were detected in vascularized supporting tissues but not in avascular internal epithelia, indicating segregation of T3-generating and T3-responding tissues. In the spiral ligament and spiral limbus, Dio2-positive fibrocytes clustered around vascular networks that convey T4 into cochlear tissues. In the otic capsule, Dio2-positive osteoblasts localized at cartilage surfaces as the bony labyrinth matures. We corroborated the identities of Dio2-positive lineages by RNA-sequencing of individual cells. The results suggest a previously unrecognized role for fibrocytes in mediating hormonal signaling. We discuss a model whereby fibrocytes mediate paracrine-like control of T3 signaling to the organ of Corti and epithelial target tissues.

Thyroid Hormone Deiodinases: Dynamic Switches in Developmental Transitions

Thyroid hormones exert pleiotropic, essential actions in mammalian, including human, development. These actions depend on provision of thyroid hormones in the circulation but also to a remarkable extent on deiodinase enzymes in target tissues that amplify or deplete the local concentration of the primary active form of the hormone T3 (3,5,3'-triiodothyronine), the high affinity ligand for thyroid hormone receptors. Genetic analyses in mice have revealed key roles for activating (DIO2) and inactivating (DIO3) deiodinases in cell differentiation fates and tissue maturation, ultimately promoting neonatal viability, growth, fertility, brain development, and behavior, as well as metabolic, endocrine, and sensory functions. An emerging paradigm is how the opposing activities of DIO2 and DIO3 are coordinated, providing a dynamic switch that controls the developmental timing of a tissue response, often during neonatal and maturational transitions. A second paradigm is how cell to cell communication within a tissue determines the response to T3. Deiodinases in specific cell types, often strategically located near to blood vessels that convey thyroid hormones into the tissue, can regulate neighboring cell types, suggesting a paracrine-like layer of control of T3 action. We discuss deiodinases as switches for developmental transitions and their potential to influence tissue dysfunction in human thyroid disorders.

Spigelian hernia: Our total extraperitoneal approach and a systematic review of the literature

INTRODUCTION

Spigelian hernia is a rare lateral ventral hernia traditionally repaired through open incision with extensive dissection. Three laparoscopic techniques have been reported in the literature: intraperitoneal onlay mesh (IPOM), transabdominal preperitoneal (TAPP), and total extraperitoneal (TEP). TEP is less popular than the other approaches. We evaluated TEP's safety and effectiveness and compared different laparoscopic techniques.

METHODS

All patients with Spigelian hernia who had undergone extended TEP (eTEP) repair with mesh in our center from January 2007 to February 2020 were studied. A three-port technique with a preperitoneal space created by telescope at the midline was adopted. A systematic review on laparoscopic mesh repair was performed by searching for "Spigelian hernia" and "laparoscopic" from 1999 to 2019 in the MEDLINE database.

RESULTS

Seven patients underwent eTEP repair for Spigelian hernia. Five presented with abdominal mass and underwent preoperative imaging. Two were diagnosed incidentally during TEP for inguinal hernia. The mean operative duration was 65 minutes (range, 40-93 minutes). There were no open conversions or intraoperative complications. The mean length of hospital stay was 1.4 days (range, 1-3 days). The mean follow-up period was 44.3 months. One patient developed seroma. There was no recurrence or chronic pain. We identified 197 laparoscopic mesh repairs reported in 41 articles. IPOM (n = 91) was the most popular approach, followed by TAPP (n = 70) and TEP (n = 36). Laparoscopic mesh repair of Spigelian hernia is safe and offers excellent outcomes.

CONCLUSION

We found the eTEP approach safe and effective for Spigelian hernia repair. IPOM, TAPP, and TEP are comparable.

Dio2-CreErt2 Knockin Model to Identify T3-Generating Cells That Express Type 2 Deiodinase in Tissues

Background: Thyroid hormone promotes many developmental and homeostatic functions. Apart from adequate circulating levels, the concentration of the active hormone T3 within tissues may be amplified by type 2 deiodinase (Dio2) by conversion from the precursor T4. Dio2 is critical in auditory development, bone maturation, brain function and control of the hypothalamic-pituitary-thyroid axis. Despite its crucial role, an obstacle to studying Dio2 is that the protein has a short half-life, is at low levels and is often transiently expressed, making it difficult to identify Dio2 in tissues at cellular resolution. Methods: We derived a Dio2-CreERt2 knockin mouse that expresses tamoxifen-dependent Cre recombinase from the endogenous Dio2 gene. When crossed onto Ai6 reporter mice, following tamoxifen treatment, Dio2-CreERt2 expression is detected as fluorescent signal in specific cells in brain regions, pituitary, and other tissues. We showed previously that Dio2 is essential for hearing with rising expression levels in the cochlea prior to onset of hearing. The Dio2-CreERt2 model identified positive cell types in the cochlear spiral ligament, septal divisions and modiolus around the sensory epithelium. Dio2-positive fibrocytes were adjacent to and extended projections around blood capillary networks, the source of T4 supply. Transcriptome analysis of isolated positive cells revealed bone lineage-related origins for many of these cells. Conclusion: The Dio2-CreERt2 model detects Dio2 expression sensitively at cellular resolution. In the cochlea, Dio2-positive cell types reside in vascularized support tissues, suggesting combined endocrine and paracrine-like control of the T3 supply. Analysis of cell origins suggests novel interactions between endocrine and skeletal systems in promoting T3 action required for hearing.

eLearning in Physical Therapy: Lessons Learned From Transitioning a Professional Education Program to Full eLearning During the COVID-19 Pandemic

OBJECTIVE

The objectives of this cross-sectional qualitative study were to explore the perspectives of students enrolled in one physical therapist undergraduate education program in Australia about their experience with transitioning to full eLearning and student recommendations to improve the learning experience during the COVID-19 pandemic.

METHODS

Seven focus groups with 28 undergraduate physical therapist students were conducted following the transitioning to full eLearning as a result of strict physical distancing measures. Focus group questions explored the students' experiences of the transition from face-to-face to full eLearning approach and the students' recommendations for improving future eLearning experiences. Data were analyzed using inductive thematic analysis.

RESULTS

The 3 themes identified were: (1) students presenting heightened negative feelings such as anxiety, stress, and reduced motivation to study; (2) students continuing to value the face-to-face learning, as it provided social support and facilitated feedback from peers and tutors; (3) student recommendations for eLearning included having online lectures and supplementary videos but face-to-face practical classes and developing healthy learning habits such as scheduled times for studying, exercise, and other activities that regulate stress.

CONCLUSIONS

The transition to a full eLearning approach in an undergraduate physical therapist education program during the COVID-19 pandemic revealed that students had heightened negative emotions due to the pandemic. Students valued face-to-face practical classes to learn and receive social support from peers and tutors. Student recommendations to future eLearning suggested changes to curriculum development geared toward a greater blended approach to learning. Blended learning may include using online lectures instead of face-to-face lectures and online resources to supplement student learning of practical skills.

IMPACT

As higher education moves toward a more blended approach, lessons learned from this study can help educators design future physical therapist education programs. The findings can also assist programs in delivering a full eLearning approach as the COVID-19 pandemic continues.

Tension-free mesh repair of inguinal hernia in patients on continuous ambulatory peritoneal dialysis

BACKGROUND

Peritoneal dialysis (PD) is the first-line renal replacement therapy for end-stage renal failure patients in Hong Kong. Abdominal wall hernia is a common mechanical complication of PD, and early surgical repair has been advocated to reduce complications. This study aims to review the outcomes of tension-free mesh repair of inguinal hernia in PD patients.

METHODS

All PD patients who underwent elective repair of inguinal hernia from 2009 to 2015 were identified from a single centre for retrospective analysis. Primary outcomes included surgical complications, perioperative dialysis technique and recurrence.

RESULTS

Twenty-one patients with a total of 26 inguinal hernia repairs were included in this 7-year retrospective study. All were males, and the mean age was 68 ± 10 years. Diabetic nephropathy (n = 9, 42.9%) and glomerulonephritis (n = 7, 33.3%) were the two most common causes of renal failure. All hernias were detected after the initiation of PD, and the mean duration of PD to hernia detection was 16 months (range 1-65 months). Lichtenstein open mesh repair was performed in all patients. Complications included seroma (n = 3, 11.5%) and ischaemic orchitis (n = 1, 3.8%). There were no mesh infection or recurrence. Twenty patients (95.2%) received intermittent peritoneal dialysis post-operatively and returned to continuous ambulatory PD in 15 to 30 days. Only one patient (4.8%) required bridging haemodialysis due to Tenckhoff catheter blockage.

CONCLUSIONS

Tension-free mesh repair is associated with low morbidity and low recurrence rates in PD patients. Timely management and close collaboration with renal physicians are essential to continue PD after repair.

Laparoscopic Total Extraperitoneal Groin Hernia Repair in Females: Comparison of Outcomes Between Preservation or Division of the Uterine Round Ligament

Background: Laparoscopic repair has been recommended as the method-of-choice of groin hernia repair among women. Whether the round ligament of uterus should be divided to facilitate mesh placement remains controversial. This study aims to review the outcomes of laparoscopic total extraperitoneal (TEP) groin hernia repair in women and to evaluate the impact of division of round ligament. Methods: Consecutive female patients with inguinal or femoral hernias who underwent elective laparoscopic TEP repair at a single institution from 2006 to 2017 were included for retrospective analysis. Primary outcomes were postoperative pain, genital prolapse, and recurrence. Outcomes of patients who had the round ligament divided were further compared with those with round ligament preserved and multivariable adjusted analysis was performed. Results: Sixty-eight patients with a total of 77 TEP repairs were included in the 12-year study period. The mean age was 45 ± 16 years old. Incidental femoral hernia was identified in 4 patients (5.9%). There was 1 (1.3%) recurrence upon mean follow-up of 42.9 ± 37.3 months. The round ligament was divided in 67.5% of patients, and upon multivariable adjusted analysis, there were no statistically significant differences in outcomes in terms of chronic pain (odds ratio [OR] = 2.210, P = .357), paresthesia (OR = 0.241, P = .149), and genital prolapse (OR = 0.327, P = .415) when compared with patients with preserved round ligament. Conclusion: Laparoscopic groin hernia repair in women is associated with low recurrence. Division of round ligament intraoperatively facilitates mesh placement and has minimal impact on clinical outcomes.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Emilin 2 promotes the mechanical gradient of the cochlear basilar membrane and resolution of frequencies in sound

The detection of different frequencies in sound is accomplished with remarkable precision by the basilar membrane (BM), an elastic, ribbon-like structure with graded stiffness along the cochlear spiral. Sound stimulates a wave of displacement along the BM with maximal magnitude at precise, frequency-specific locations to excite neural signals that carry frequency information to the brain. Perceptual frequency discrimination requires fine resolution of this frequency map, but little is known of the intrinsic molecular features that demarcate the place of response on the BM. To investigate the role of BM microarchitecture in frequency discrimination, we deleted extracellular matrix protein emilin 2, which disturbed the filamentous organization in the BM. Emilin2 ^-/- mice displayed broadened mechanical and neural frequency tuning with multiple response peaks that are shifted to lower frequencies than normal. Thus, emilin 2 confers a stiffness gradient on the BM that is critical for accurate frequency resolution.

0365 Sleep Quality Associated with Perceived Stress and Autonomic Nervous System Measures: Implications for Sleep and Health Disparities

Introduction

It is not known whether the restorative nature of sleep mediates the effects of perceived stress on the autonomic nervous system (ANS).This study explored the relationships between stress and autonomic biomarkers, and aimed to assess potential mediation by sleep quality.

Methods

A secondary data analysis was performed using data from the Midlife in the United States (MIDUS, MIDUS II & Milwaukee). Multiple regression models examined the association between perceived stress using the Perceived Stress Scale (PSS) and two autonomic biomarkers-heart rate variability(HRV) (n=888) and urine catecholamines (n=1,058). The roles of sleep quality (using the Pittsburg Sleep Quality Index (PSQI)) and race/ethnicity were explored in post-hoc analyses.

Results

No statistically significant relationships were found between PSS and autonomic stress measures. However, perceived stress (b=0.09;p&lt;0.01; 95% CI=0.06,0.13) and the covariate Likert stress scale at baseline (b=0.13;p=&lt;0.04;95% CI=0.005,0.26) were significantly related to PSQI. Post hoc analyses explored racial differences. Baseline stress, PSS, depressive symptoms and PSQI scores were significantly higher in Blacks/African-Americans than Non-Hispanic Whites. Yet, Blacks/African-Americans had lower sympathetic responses (epinephrine means 1.56 vs 2.00;t=-4.82;p&lt;0.01, norepinephrine means, 24.15 vs 27.30;t=3.14;p&lt;0.01) and higher parasympathetic responses (lnHF, natural log of High Frequency HRV means 5.48 vs 4.75; t=6.17;p&lt;0.01), compared to Non-Hispanic Whites.

Conclusion

Blacks/African-Americans and Non-Hispanic Whites had significant differences in their sleep quality and ANS biomarkers. Sleep quality may play a role in the effect of discrimination on mental and physical health. Different stress sources may lead to variable expression in biomarkers of autonomic tone. Future prospective studies incorporating longitudinal biomarkers and alternative statistical models will help elucidate the relationships among stress, sleep, and the pathways linking these factors to poor health, and effect targeted treatments.

Support

The MIDUS I study was supported by the John D. and Catherine T. MacArthur Foundation Research Network. MIDUS II was supported by the NIA(P01-AG020166), M01-RR023942(Georgetown), M01-RR00865(UCLA) and 1UL1RR025011(UW) grants. Many thanks to Dr. James McNally, Dr. Barry Radler, Dr. Gayle Love and Suzanne Hodge for access to the Milwaukee dataset.

Cyanotic Congenital Heart Disease Modes of Presentation and Prenatal Detection

Prenatal detection of structural congenital heart disease (CHD) optimises cardiovascular stability pre-operatively and post-operative outcomes. We compared prenatal detection rates of critical CHD in units offering universal fetal anomaly scans with those offering imaging to selected women. One hundred and thirteen infants met inclusion criteria. The overall pre-natal detection rate for critical CHD was 57% of liveborn infants. It was 71% (57/80) in hospitals who offered a universal anomaly scan and 29% (9/31) in centres offering a limited service. Postnatal diagnosis was associated with PICU admission (p=0.016) and preoperative mechanical ventilation (p=0.001). One-year mortality was 10 fold higher in the postnatally diagnosed group 15% vs 1.55% (p=0.0066). There is a significant disparity between centres offering universal anomaly versus selective screening. Prenatal detection confers advantage in terms of pre-operative stability and one year survival. Failure to deliver an equitable service exposes infants with CHD to avoidable risk.

First Measurement of Near-Threshold J/ψ Exclusive Photoproduction off the Proton

We report on the measurement of the γp→J/ψp cross section from E_{γ}=11.8  GeV down to the threshold at 8.2 GeV using a tagged photon beam with the GlueX experiment. We find that the total cross section falls toward the threshold less steeply than expected from two-gluon exchange models. The differential cross section dσ/dt has an exponential slope of 1.67±0.39  GeV^{-2} at 10.7 GeV average energy. The LHCb pentaquark candidates P_{c}^{+} can be produced in the s channel of this reaction. We see no evidence for them and set model-dependent upper limits on their branching fractions B(P_{c}^{+}→J/ψp) and cross sections σ(γp→P_{c}^{+})×B(P_{c}^{+}→J/ψp).

Laparoscopic versus open repair for small paraumbilical hernia: A retrospective review

INTRODUCTION

The advantages of laparoscopic surgery for ventral hernia repairs are well documented, but its application for small paraumbilical hernias has been less studied. There is no consensus regarding the best technique.

METHODS

All patients who had open (suture or mesh) and laparoscopic repair of primary paraumbilical hernia between September 2007 and September 2017 in a single center were identified. Hernial defects of 2 cm or less were included; recurrent hernias were excluded. Primary outcomes included operative time, length of hospital stay, and surgical complications.

RESULTS

Seventy-seven patients were recruited: 54 (70.1%) had open repair and 23 (29.9%) had laparoscopic repair. Forty-six patients (85%) in the open group had primary suture repair. The mean operative time was significantly shorter in the open group than in the laparoscopic group (27.2 vs 56.1 min, P < 0.05). The length of hospital stay in the open group was significantly shorter than in the laparoscopic group (0.8 vs 1.4 days, P = 0.00). Early complications rates were similar, with wound complications in 5.6% (3/54) of open repair patients and 4.3% (1/23) of laparoscopic repair patients (P = 1.0). Among open repair patients, 19 patients (35.2%) were successfully discharged within 12 h after operation. Two patients (3.7%) in the open simple suture group developed recurrence, but no recurrence was identified in the laparoscopic group; this was not statistically significant (P = 1.0).

CONCLUSION

The laparoscopic approach is comparable to the open approach in the repair of small paraumbilical hernias. For small paraumbilical hernias, we recommend that laparoscopic repair be reserved for obese patients or those with suspected multiple hernial defects.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Elective laparoscopic totally extraperitoneal repair for Spigelian hernia: A case series of four patients

INTRODUCTION

Spigelian hernia (SH) is uncommon. Clinical diagnosis may be difficult, but computed tomography (CT) can help to establish the diagnosis. Laparoscopic repair is increasingly performed because it is associated with low morbidity rates. Laparoscopic approaches include transabdominal preperitoneal (TAPP), intraperitoneal onlay mesh (IPOM), and totally extraperitoneal (TEP). Here, we report our experiences of TEP repair for SH.

METHODS

A retrospective review was performed on all patients with SH who underwent elective laparoscopic TEP repair from 2007 to 2017 at Tung Wah Hospital, Hong Kong.

RESULTS

Four patients with SH were identified in the study period: three with a preoperative diagnosis of SH confirmed by CT scan and one diagnosed incidentally during TEP repair for inguinal hernia. The patients' mean age was 66.8 years (range, 55.0-82.0 years). The mean BMI was 22.8 kg/m² (range, 20.8-23.6 kg/m² ). The mean size of the SH defect was 2.0 cm (range, 0.5-3.0 cm). The mean operative time was 59 min (range, 40-86 min). Concomitant direct inguinal hernia was found in one patient and repaired simultaneously. All patients were discharged on postoperative day 1. One patient developed seroma, which subsided on conservative management. At a mean follow-up of 36 months (range, 2-108 months), there was no recurrence.

CONCLUSION

Laparoscopic repair for SH is preferred over the open approach as it is associated with a low morbidity rate and a short hospital stay. In our experience, TEP technique is safe and effective in laparoscopic SH repair.

Posttraumatic stress disorder in the World Mental Health Surveys

BACKGROUND

Traumatic events are common globally; however, comprehensive population-based cross-national data on the epidemiology of posttraumatic stress disorder (PTSD), the paradigmatic trauma-related mental disorder, are lacking.

METHODS

Data were analyzed from 26 population surveys in the World Health Organization World Mental Health Surveys. A total of 71 083 respondents ages 18+ participated. The Composite International Diagnostic Interview assessed exposure to traumatic events as well as 30-day, 12-month, and lifetime PTSD. Respondents were also assessed for treatment in the 12 months preceding the survey. Age of onset distributions were examined by country income level. Associations of PTSD were examined with country income, world region, and respondent demographics.

RESULTS

The cross-national lifetime prevalence of PTSD was 3.9% in the total sample and 5.6% among the trauma exposed. Half of respondents with PTSD reported persistent symptoms. Treatment seeking in high-income countries (53.5%) was roughly double that in low-lower middle income (22.8%) and upper-middle income (28.7%) countries. Social disadvantage, including younger age, female sex, being unmarried, being less educated, having lower household income, and being unemployed, was associated with increased risk of lifetime PTSD among the trauma exposed.

CONCLUSIONS

PTSD is prevalent cross-nationally, with half of all global cases being persistent. Only half of those with severe PTSD report receiving any treatment and only a minority receive specialty mental health care. Striking disparities in PTSD treatment exist by country income level. Increasing access to effective treatment, especially in low- and middle-income countries, remains critical for reducing the population burden of PTSD.

SKP2 Activation by Thyroid Hormone Receptor β2 Bypasses Rb-Dependent Proliferation in Rb-Deficient Cells

Germline RB1 mutations strongly predispose humans to cone precursor-derived retinoblastomas and strongly predispose mice to pituitary tumors, yet shared cell type-specific circuitry that sensitizes these different cell types to the loss of RB1 has not been defined. Here we show that the cell type-restricted thyroid hormone receptor isoform TRβ2 sensitizes to RB1 loss in both settings by antagonizing the widely expressed and tumor-suppressive TRβ1. TRβ2 promoted expression of the E3 ubiquitin ligase SKP2, a critical factor for RB1-mutant tumors, by enabling EMI1/FBXO5-dependent inhibition of SKP2 degradation. In RB1 wild-type neuroblastoma cells, endogenous Rb or ectopic TRβ2 was required to sustain SKP2 expression as well as cell viability and proliferation. These results suggest that in certain contexts, Rb loss enables TRβ1-dependent suppression of SKP2 as a safeguard against RB1-deficient tumorigenesis. TRβ2 counteracts TRβ1, thus disrupting this safeguard and promoting development of RB1-deficient malignancies. Cancer Res; 77(24); 6838-50. ©2017 AACR.

Deletion of the Thyroid Hormone-Activating Type 2 Deiodinase Rescues Cone Photoreceptor Degeneration but Not Deafness in Mice Lacking Type 3 Deiodinase

Type 2 deiodinase amplifies and type 3 deiodinase depletes levels of the active form of thyroid hormone, triiodothyronine. Given the opposing activities of these enzymes, we tested the hypothesis that they counteract each other's developmental functions by investigating whether deletion of type 2 deiodinase (encoded by Dio2) modifies sensory phenotypes in type 3 deiodinase-deficient (Dio3-/-) mice. Dio3-/- mice display degeneration of retinal cones, the photoreceptors that mediate daylight and color vision. In Dio2-/- mice, cone function was largely normal but deletion of Dio2 in Dio3-/- mice markedly recovered cone numbers and electroretinogram responses, suggesting counterbalancing roles for both enzymes in cone survival. Both Dio3-/- and Dio2-/- strains exhibit deafness with cochlear abnormalities. In Dio3-/-;Dio2-/- mice, deafness was exacerbated rather than alleviated, suggesting unevenly balanced actions by these enzymes during auditory development. Dio3-/- mice also exhibit an atrophic thyroid gland, low thyroxine, and high triiodothyronine levels, but this phenotype was ameliorated in Dio3-/-;Dio2-/- mice, indicating counterbalancing roles for the enzymes in determining the thyroid hormone status. The results suggest that the composite action of these two enzymes is a critical determinant in visual and auditory development and in setting the systemic thyroid hormone status.