O-074 No methylome differences observed in IVF children born after embryo culture in different culture media

Study question

Does human embryo culture in different IVF culture media lead to DNA methylation alterations in IVF offspring?

Summary answer

Genome-wide analyses identified no significant DNA methylation differences between culture medium groups in IVF children (neonates or 9-year olds) from two culture media studies.

What is known already

During in vitro fertilisation (IVF) treatments, embryos undergo preimplantation development in an artificial environment, while concurrently undergoing epigenetic reprogramming. Adversity during this period, such as peri-conception calorie restriction, has been linked to persistent DNA methylation aberrations and increased risk of cardiometabolic disease. Early environmental adversity is suspected in IVF offspring as they are born with lower birthweights and show increased risk of cardiometabolic dysfunction in adulthood as compared to their naturally-conceived counterparts. This is further supported by the observation from two culture media trials (MEDIUM0 and MEDIUM1) that embryo culture in different culture media leads to differences in birthweight.

Study design, size, duration

We recruited singleton offspring from two IVF culture media trials. The MEDIUM0 study, a pseudo-randomized trial comparing G3 (Vitrolife) and K-SICM (Cook), was conducted from 2003-2006. At the 9-year follow-up, saliva was collected (cohort-A). The MEDIUM1 study, a multi-center randomized controlled trial comparing G5 (Vitrolife) and HTF (Lonza), was conducted from 2010-2012. Umbilical cord blood (UCB) was collected at birth (cohort-B).

Participants/materials, setting, methods

DNA methylation was analysed in 120 saliva samples (65 G3, 55 Cook) and 106 UCB samples (47 HTF, 59 G5) using the Infinium MethylationEPIC array (Illumina). Mixed effects linear models, correcting for (gestational) age, sex, sample composition and batch effects alongside maternal age, pregnancy complications and IVF centre for cohort-B, were implemented at single or aggregated sites. Methylation outliers were defined as values over three interquartile ranges below or above 25th and 75th percentiles respectively.

Main results and the role of chance

111 of the 120 saliva samples (60 G3, 51 Cook) and 105 of the 106 UCB samples (47 HTF, 58 G5) passed our quality control criteria. We filtered sites on sex chromosomes, and based on quality, proximity to single-nucleotide polymorphisms, and proportion of missing values, leaving 650,000-700,000 of the 850,000 sites included on the EPIC array for our analyses. To account for heterogeneity in the cellular composition of our samples we estimated their cell compositions using a reference-based approach. First, we investigated individual CpG sites, finding no differentially methylated sites in either cohort after correction for multiple testing (false discovery rate adjusted p. value threshold < 0.1). Sites were then aggregated into regions based on their allocations to genes, promoters and CpG islands. No differentially methylated regions were identified in either cohort. A targeted analysis of DNA methylation of imprinting genes showed no differentially methylated sites or regions. To examine the contribution of stochastic epigenetic alterations we quantified the number of methylation outliers per sample. Although this revealed a predominance of hypomethylation outliers, there was no difference in the total number or distribution of DNA methylation outliers between the two culture media groups of cohort-A and cohort-B.

Limitations, reasons for caution

This analysis is currently limited by the lack of comparison to a naturally-conceived control group. As such, we cannot yet conclude whether IVF embryo culture, in any medium, is associated with DNA methylation aberrations. Additionally, given the large number of comparisons, we may lack power to detect small differences.

Wider implications of the findings

Although there are disparities in birth weight and childhood growth after embryo culture in different media, we observed no DNA methylation alterations preserved postnatally. Whether DNA methylation of these individuals deviates from that of naturally-conceived individuals will be determined in the near future.

Trial registration number

MEDIUM1: NTR 1979 /NL1866 (Netherlands Trial Registry)

[The place of inhaled corticosteroids in COPD]

INTRODUCTION

Clinical trials have provided some evidence of a favorable effect of inhaled corticosteroids on the frequency of exacerbations and on the quality of life of patients with chronic obstructive pulmonary disease (COPD). In contrast, ICS have little or no impact on lung function decline and on mortality.

STATE OF THE ART

Inhaled corticosteroids are recommended only in a minority of COPD patients, those with severe disease and repeated exacerbations and probably those with the COPD and asthma overlap syndrome. However, surveys indicate that these drugs are inappropriately prescribed in a large population of patients with COPD. Overtreatment with inhaled corticosteroids exposes these patients to an increased risk of potentially severe side-effects such as pneumonia, osteoporosis, and oropharyngeal candidiasis. Moreover, it represents a major waste of health-care spending.

CONCLUSION

Primary care physicians as well as pulmonologists should be better aware of the benefits as well as the side-effects and costs of inhaled corticosteroids.

[Miliary cerebral carcinomatosis secondary to EGFR mutation-positive lung adenocarcinoma]

INTRODUCTION

Miliary brain metastases are a rare form of brain metastatic lesions.

CASE REPORT

We report the case of a 58-year-old patient with lung adenocarcinoma and an EGFR mutation, who had metastatic lesions in the bones, pleura and pericardia at the time of diagnosis. The patient was treated with tyrosine kinase inhibitor. A few months later, he presented with progressive neuropsychiatric symptoms, which were attributed to miliary brain metastases based on the radiological pattern (micronodules, some of which were calcified) and the elimination of alternative possible diagnoses. Despite tumour stability in the thorax and metastatic sites other than the brain, his neurological condition deteriorated, even after cerebral radiotherapy, leading to his death eight months after the diagnosis of lung cancer.

CONCLUSION

Miliary brain metastases are a rare form of brain metastases with unusual clinical presentation. The diagnosis is based on the radiological pattern of cerebral miliary dissemination, with sometimes calcified tumor nodules. Despite its rarity, several cases have been reported in lung adenocarcinoma in the presence of EGFR mutations.

Validation of preimplantation genetic diagnosis by PCR analysis: genotype comparison of the blastomere and corresponding embryo, implications for clinical practice

The aim of this study was to validate the overall preimplantation genetic diagnosis (PGD)-PCR procedure and to determine the diagnostic value. Genotyped embryos not selected for embryo transfer (ET) and unsuitable for cryopreservation after PGD were used for confirmatory analysis. The PGD genotyped blastomeres and corresponding embryos were compared, and morphology was scored on Day 4 post fertilization. To establish the validity of the PGD-PCR procedure and the diagnostic value, misdiagnosis rate, false-negative rate and negative predictive value were calculated. Moreover, comparison on the validity was made for the biopsy of one or two blastomeres. For the total embryo group (n = 422), a misdiagnosis rate of 7.1% and a false-negative rate of 3.1% were found. The negative predictive value was 96.1%. Poor morphology Day 4 embryos (Class 1) were over-represented in the embryo group in which the blastomere genotype was not confirmed by the whole embryo genotype. The misdiagnosis rate of Class 1 embryos was 12.5% and the false-negative rate 17.1%. Exclusion of these embryos resulted in a misdiagnosis rate of 6.1%, a false-negative rate of 0.5% and a negative predictive value of 99.3%. The two blastomere biopsies revealed a significant higher positive predictive value, lowering the misdiagnosis rate, whereas the negative predictive value remained the same. In conclusion, the PGD-PCR procedure is a valid diagnostic method to select unaffected embryos for ET. The misdiagnosis and false-negative rates decrease by rejecting Class 1 embryos for ET. The biopsy of a second blastomere improves the positive predictive value, lowering the misdiagnosis rate.

Economic evaluation of a policy change from single-agent treatment for suspected malaria to artesunate-amodiaquine for microscopically confirmed uncomplicated falciparum malaria in the Oussouye District of south-western Senegal

Senegal is changing policy for case management of uncomplicated falciparum malaria, which hitherto is diagnosed clinically and treated with chloroquine or intramuscular quinine. The WHO recommends artemisinin-based combinations for treating falciparum malaria, preferably based on a parasitological diagnosis. There are no economic projections if such a policy were introduced in Senegal. We have conducted a preliminary economic assessment of such a policy change. The study took place in the chloroquine-resistant district of Oussouye in south-western Senegal. We reviewed clinic registers of the district health posts (n=5) from 1996 to 2001, and piloted artesunate combined with amodiaquine (at 4 and 10 mg/kg/day x 3 days respectively) (AS--AQ) for treating slide-proven falciparum malaria during two rainy seasons (2000 and 2001) at one health centre. These data were used to calculate current direct patient costs (clinic visit, diagnosis, drugs) of malaria treatment and project future costs for the district. The robustness of the model was tested by allowing for different drug failure rates and costs of diagnosis. During 1996--2001, the mean number of primary treatments per year was 7654 for a mean, direct cost of 17,452 US dollars to the community. Clinical diagnosis resulted in over-treatment: 56% and 66% in the wet and dry seasons respectively. Current policy leads to substantial drug wastage and excess direct costs for the community. The direct costs of implementing AS-AQ for slide-proven malaria would be 8,150 US dollars (53% less expensive). Studies examining the public health effect and economics of deploying AS--AQ on a wider scale are underway in Senegal.

Sale of drugs and health care utilization in a health care district in Zaire

Health centres of Idjwi district (Zaire) have been self-financed through the selling of drugs since 1985. Medical care is expensive and its use is low (24 visits per year per 100 inhabitants). In 1989 the medical team tried to reduce the cost of visits by changing the prices of drugs and prescriptions. A limited control was set up to assess this intervention. The study showed that although prescribed drug costs were stabilized compared to inflation, there was no increase in the use of medical care. Moreover, the reduction of drug profit margins for health centres seriously affected the health care institution by causing a drop in income. Six months after the intervention the monthly accounts showed a deficit in 6 centres out of 8. The need for health care centres to be self-financing is a major limiting factor in the use of health care in Idjwi district. There are no easy solutions for health centre managers that satisfy both low-cost access to care and health care self-financing. Some minimal financial participation from the state is required. Only then can the concept of financing health care through the selling of drugs be operational.

[Myocardial infarction treated within 4 hrs: comparison of the cost-benefit ratio of 3 thrombolytic treatments: APSAC, rt-PA and streptokinase in 270 patients]

Two hundred and seventy patients under 71 years of age with myocardial infarction less than 4 hours old, defined by clinical and electrocardiographic criteria, were included in this trial and followed up for 1 year: two groups of 89 and 92 patients were randomised to receive APSAC (30 mg i.v. over 5 minutes) or rt-PA (10 mg bolus + 5000 IU of heparin as a bolus, followed by 90 mg rt-PA over 3 hours) and compared with a control series of 89 consecutive patients treated with streptokinase (1.5 MU in 1 hour). Heparin and aspirin (250 mg/day) were prescribed systematically. A score of efficacy was established from the following 4 parameters: patency of the infarct-related artery on coronary angiography at day 6 +/- 2 (N = 252), dyssynergic score on radiological ventriculography, infarct size on resting Thallium myocardial scintigraphy performed between day 15 and 21 (N = 242) and radionuclide ejection fraction performed at the same time. This score (0-24) was respectively 17.8 +/- 6.4 for rt-PA, 17.7 +/- 6.0 for APSAC and 18.1 +/- 6.0 for streptokinase (NS). The costs of hospital treatment were assessed by including: the cost of thrombolytic therapy (ranging from 1.7% of total cost for streptokinase to 16% for rt-PA), the cost of other treatments and biological investigations (10% of total cost); the cost of followed coronary angiography, in 33% of patients, by an angioplasty (21% of total cost), the cost of hospital stay averaging 17 days (49% of total cost in the rt-PA and APSAC groups and 56% in the streptokinase group NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Cost effectiveness of thrombolytic treatment for myocardial infarction: comparison of anistreplase, alteplase and streptokinase in 270 patients treated within 4 hours

Two hundred and seventy patients, under 71 years of age and suffering from a less than 4 h infarction diagnosed according to clinical and electrocardiographic criteria, were included: two 90-patient groups were randomized and then treated with either anistreplase (30 mg iv over 5 min) or alteplase (10 mg bolus injection + 5000 IU heparin bolus injection, followed by 90 mg alteplase over 3 h), and compared with a consecutive control series of 90 patients treated with streptokinase (1.5 million U over 1 h). Intravenous heparin and aspirin (250 mg day-1) were then prescribed routinely. The three groups were comparable as regards age (55.2 +/- 10 years), male/female ratio (10.4), the site of the infarction (42% anterior, 55% inferior) and initial clinical seriousness (Killip I = 90%, II = 8%, III = 2%). The patients were thrombolysed in 17 community hospitals, and then referred to a university hospital with catheterization facilities. An efficacy score was determined, based on four parameters: two obtained from coronary angiography and left ventriculography performed on day 6 +/- 2 (N = 252) (asynergic score and patency of the infarct-related artery), one from Tl-tomography performed at rest (infarct size) and one from radionuclide angiography (global left ventricular ejection fraction) performed between day 15 and day 21 (N = 242). The score (range: 0-24 per patient) was 17.8 +/- 6.4 for alteplase, 17.7 +/- 6.0 for anistreplase and 18.1 +/- 6.0 for streptokinase respectively (NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Representations used for health planning: naivety and crisis in the concepts and methods

This article supports the theory that one of the causes underlying the crisis in the health services in the crisis in the concepts and methods used. Examples from a Third-World country (Congo) and from an industrialized country (France) are given in which problems of the same nature are met. Epidemiology is of little use in defining health action save in the case of accurately-identified diseases for which efficient technical means are available. Detailed epidemiological data is of no use in establishing priorities for larger-scale action, since operational and political criteria are beyond its scope as a discipline. The infra-medical magma which constitutes the bulk of health problems has to be tackled from a point of view broader than the purely medical, since a great number of risk factors must be acted upon. Relations between different administrations and different professions founder on linguistic and power conflicts. Some of the administrative criteria recommended for the organization of the medical side of health care are neither practised nor practicable, since they take no account of the functional logic of such systems, particularly the balance of power between interest groups.