Cardiac arrhythmia in individuals with steroid sulfatase deficiency (X-linked ichthyosis): candidate anatomical and biochemical pathways

Circulating steroids, including sex hormones, can affect cardiac development and function. In mammals, steroid sulfatase (STS) is the enzyme solely responsible for cleaving sulfate groups from various steroid molecules, thereby altering their activity and water solubility. Recent studies have indicated that Xp22.31 genetic deletions encompassing STS (associated with the rare dermatological condition X-linked ichthyosis), and common variants within the STS gene, are associated with a markedly elevated risk of cardiac arrhythmias, notably atrial fibrillation/flutter. Here, we consider emerging basic science and clinical findings which implicate structural heart abnormalities (notably septal defects) as a mediator of this heightened risk, and propose candidate cellular and biochemical mechanisms. Finally, we consider how the biological link between STS activity and heart structure/function might be investigated further and the clinical implications of work in this area.

Menopause age, reproductive span and hormone therapy duration predict the volume of medial temporal lobe brain structures in postmenopausal women

Medial temporal lobe (MTL) atrophy is correlated with risk and severity of Alzheimer disease (AD) pathology and cognitive decline. Increasing evidence suggest that oestrogens affect the aging of MTL structures. Here we investigate the relationship between reproductive hormone exposure, polygenic scores for AD risk and oestradiol concentration, MTL anatomy and cognitive performance in postmenopausal women. To this end, we used data from 10,924 female participants in the UK Biobank from whom brain MRI and genetic data were available. We fitted linear regression models to test whether the volume of structures comprising the MTL were predicted by a) timing related to menopause, b) the use and timing of hormone replacement therapy (HRT) and c) polygenic scores for AD risk and oestradiol concentration. Results showed that longer use of HRT was associated with larger parahippocampal volumes (2.53 mm3/year, p = 0.042). A later age of natural menopause, and a longer reproductive span, was associated with larger hippocampal (6.08 and 5.72 mm3/year, p = 0.0006 and 0.0005), parahippocampal (4.17 mm3 and 4.19 mm3/year, p = 0.00006 and 0.00001), amygdala (2.10 and 2.22 mm3/year, p = 0.028 and 0.01) and perirhinal cortical (2.56 and 2.95 mm3/year, p = 0.028 and 0.008) volumes. Superior prospective memory performance was associated with later age at natural menopause, and a longer reproductive span (ß = 0.05 and 0.05 respectively, p = 0.019 and 0.019). Polygenic scores for AD risk and for oestradiol concentration were not associated with MTL volume and did not interact with menopause-related factors to affect MTL structure. Our results suggest that HRT use did not have any detrimental effects on cognition or brain structure, whilst greater exposure to reproductive hormones across time is associated both with slightly larger volumes of specific MTL structures and marginally superior memory performance, independent of genetic risk for AD and genetic predisposition for higher oestradiol levels. However, the clinical utility of maintenance of oestrogens post-menopause for brain health and protection against cognitive decline is curtailed by the small effect sizes observed.

Characterising heart rhythm abnormalities associated with Xp22.31 deletion

BACKGROUND

Genetic deletions at Xp22.31 are associated with the skin condition X linked ichthyosis (XLI), and with a substantially increased risk of atrial fibrillation/flutter (AF), in males. AF is associated with elevated thrombosis, heart failure, stroke and dementia risk.

METHODS

Through: (a) examining deletion carriers with a diagnosis of AF in UK Biobank, (b) undertaking an online survey regarding abnormal heart rhythms (AHRs) in men/boys with XLI and female carriers of XLI-associated deletions and (c) screening for association between common genetic variants within Xp22.31 and idiopathic AF-related conditions in UK Biobank, we have investigated how AHRs manifest in deletion carriers, and have identified associated risk factors/comorbidities and candidate gene(s). Finally, we examined attitudes towards heart screening in deletion carriers.

RESULTS

We show that AHRs may affect up to 35% of deletion carriers (compared with <20% of age-matched non-carriers), show no consistent pattern of onset but may be precipitated by stress, and typically resolve quickly and respond well to intervention. Gastrointestinal (GI) conditions and asthma/anaemia were the most strongly associated comorbidities in male and female deletion carriers with AHR, respectively. Genetic analysis indicated significant enrichment of common AF risk variants around STS (7 065 298-7 272 682 bp in GRCh37/hg19 genome build) in males, and of common GI disorder and asthma/anaemia risk variants around PNPLA4 (7 866 804-7 895 780 bp) in males and females, respectively. Deletion carriers were overwhelmingly in favour of cardiac screening implementation.

CONCLUSION

Our data suggest AHRs are frequently associated with Xp22.31 deletion, and highlight subgroups of deletion carriers that may be prioritised for screening. Examining cardiac function further in deletion carriers, and in model systems lacking steroid sulfatase, may clarify AF pathophysiology.

X-linked ichthyosis: New insights into a multi-system disorder

Background

X-linked ichthyosis (XLI) is a rare genetic condition almostexclusively affecting males; it is characterised by abnormal desquamation and retentionhyperkeratosis, and presents with polygonal brown scales. Most cases resultfrom genetic deletions within Xp22.31 spanning the STS (steroid sulfatase)gene, with the remaining cases resulting from STS-specific mutations. For manyyears it has been recognised that individuals with XLI are at increased risk ofcryptorchidism and corneal opacities.

Methods

We discuss emerging evidence that such individuals are alsomore likely to be affected by a range of neurodevelopmental and psychiatrictraits, by cardiac arrhythmias, and by rare fibrotic and bleeding-relatedconditions. We consider candidate mechanisms that may confer elevatedlikelihood of these individual conditions, and propose a novel commonbiological risk pathway.

Results

Understanding the prevalence, nature and co-occurrence ofcomorbidities associated with XLI is critical for ensuring early identificationof symptoms and for providing the most effective genetic counselling andmultidisciplinary care for affected individuals.

Conclusion

Future work in males with XLI, and in new preclinical andcellular model systems, should further clarify underlying pathophysiologicalmechanisms amenable to therapeutic intervention.

1069 ESSENTIAL FRAILTY TOOLSET AS A PREDICTOR OF PROLONGED LENGTH OF STAY AND DISCHARGE DESTINATION AFTER TRANSCATHETER AORTIC VALVE IMPLANTATION

Introduction

Frailty is associated with poor outcomes following transcatheter aortic valve implantation (TAVI). Rockwood is the widely used score for this population. In a recent trial, a more objective score, the Essential Frailty Toolset (EFT) outperformed Rockwood’s in predicting mortality and disability 1-year post-TAVI. Whether it predicts in-hospital length of stay (LOS) and discharge destination post-TAVI remains unclear.

Method

A cohort of patients undergoing TAVI for aortic stenosis was recruited, demographic characteristics collected, and frailty assessed with EFT and Rockwood scores. Primary outcomes were LOS post-TAVI, categorised as ‘not prolonged’ (≤2 days) or ‘prolonged’ (&gt;2 days) and discharge destination, characterised as ‘home’ or ‘non-home’.

Results

86 patients were recruited, with median age 82 years (IQR 78–86). 54% were male. EFT identified 35% and Rockwood 11% as frail. 19% were cognitively impaired. 5 chair rises were completed by 70%, with 30% managing under 15 seconds. Median haemoglobin was 121 g/L (IQR 109.5–136). Median albumin was 36 g/L (IQR 33–39). 84% of procedures were transfemoral. 20% had moderate–severe left ventricular systolic dysfunction. Median LOS post-TAVI was 2 days (IQR 2–5). 94% were discharged home, 6% to referring local hospital or rehabilitation centre. 46% were NYHA class III-IV. A model for prolonged LOS including comorbidities, showed frailty determined by EFT (OR 4.80, CI 95% 1.52–15.2, p = 0.008) but not Rockwood (OR 5.00, CI 95% 0.865–29.0, p = 0.072) was the only significant independent predictor for prolonged LOS. A model adjusting for comorbidities also showed EFT to be an independent predictor for non-home discharge destination of borderline significance (OR 2.57 CI 95% 0.994–6.66, p = 0.051) but Rockwood was not (OR 1.38 CI95% 0.485–3.91, p = 0.548).

Conclusion

In a real-world elderly population, EFT score was a stronger, more independent predictor of prolonged LOS and non-home discharge post-TAVI, than Rockwood’s. EFT would be an effective pre-operative assessment tool for LOS and discharge destination for TAVI.

Rewilding the Sea? A Rapid, Low Cost Model for Valuing the Ecosystem Service Benefits of Kelp Forest Recovery Based on Existing Valuations and Benefit Transfers

Kelp forests and seagrasses are important carbon sinks that are declining globally. Rewilding the sea, through restoring these crucial habitats, their related biodiversity and ecosystem contributions, is a movement and concept, gathering pace in the United Kingdom and globally. Yet understanding of the economic costs and benefits for setting areas of the sea aside—and removing some human impacts from them—is not well understood. The potential benefits and distributional impacts on marine users and wider society is critical to make evidence based decisions. Ensuring that areas of the sea recover, and that the impacts (both positive and negative) are understood, requires targeted research to help guide decisions to optimize the opportunity of recovery, while minimizing any negative impacts on sea users and coastal communities. We approach the problem from an ecosystem services perspective, looking at the opportunity of restoring a kelp bed in Sussex by removing fishing activity from areas historically covered in kelp. Development of an ecosystem services valuation model showed restoring kelp to its highest mapped past extent (96% greater, recorded in 1987) would deliver a range of benefits valued at over £ 3.5 million GBP. The application of an ecosystem services approach enabled the full range of benefits from habitat restoration to be assessed. The results and the gaps identified in site specific data and values for this area, have broader implications in fisheries management and natural resource management tools for restoring marine habitats and ecosystems in the United Kingdom.

Sex-linked genetic mechanisms and atrial fibrillation risk

Atrial fibrillation (AF) is a cardiac condition characterised by an irregular heartbeat, atrial pathology and an elevated downstream risk of thrombosis and heart failure, as well as neurological sequelae including stroke and dementia. The prevalence and presentation of, risk factors for, and therapeutic responses to, AF differ by sex, and this sex bias may be partially explained in terms of genetics. Here, we consider four sex-linked genetic mechanisms that may influence sex-biased phenotypes related to AF and provide examples of each: X-linked gene dosage, X-linked genomic imprinting, sex-biased autosomal gene expression, and male-limited Y-linked gene expression. We highlight novel candidate risk genes and pathways that warrant further investigation in clinical and preclinical studies. Understanding the biological basis of sex differences in AF should allow better prediction of disease risk, identification of novel risk/protective factors, and the development of more effective sex-tailored interventions.

Mood symptoms, neurodevelopmental traits, and their contributory factors in X-linked ichthyosis, ichthyosis vulgaris and psoriasis

Background

High rates of adverse mood/neurodevelopmental traits are seen in multiple dermatological conditions, and can significantly affect patient quality of life. Understanding the sex‐specific nature, magnitude, impact and basis of such traits in lesser‐studied conditions like ichthyosis, is important for developing effective interventions.

Aim

To quantify and compare relevant psychological traits in men with X‐linked ichthyosis (XLI, n = 54) or in XLI carrier women (n = 83) and in patients with ichthyosis vulgaris (IV, men n = 23, women n = 59) or psoriasis (men n = 30, women n = 122), and to identify factors self‐reported to contribute most towards depressive, anxious and irritable phenotypes.

Methods

Participants recruited via relevant charities or social media completed an online survey of established questionnaires. Data were analysed by sex and skin condition, and compared with general population data.

Results

Compared with the general population, there was a higher rate of lifetime prevalence of mood disorder diagnoses across all groups and of neurodevelopmental disorder diagnoses in the XLI groups. The groups exhibited similarly significant elevations in recent mood symptoms (Cohen d statistic 0.95–1.28, P < 0.001) and neurodevelopmental traits (d = 0.31–0.91, P < 0.05) compared with general population controls, and self‐reported moderate effects on quality of life and stigmatization. There were strong positive associations between neurodevelopmental traits and recent mood symptoms (r > 0.47, P < 0.01), and between feelings of stigmatization and quality of life, particularly in men. Numerous factors were identified as contributing significantly to mood symptoms in a condition or sex‐specific, or condition or sex‐independent, manner.

Conclusion

We found that individuals with XLI, IV or psoriasis show higher levels of mood disorder diagnoses and symptoms than matched general population controls, and that the prevalence and severity of these is similar across conditions. We also identified a number of factors potentially conferring either general or condition‐specific risk of adverse mood symptoms in the three skin conditions, which could be targeted clinically and/or through education programmes. In clinical practice, recognizing mood/neurodevelopmental problems in ichthyosis and psoriasis, and addressing the predisposing factors identified by this study should benefit the mental health of affected individuals.

Identifying predictive risk factors for permanent pacemaker implantation up to 30 days post-TAVI

Background

Conduction system abnormalities, including AV block, are amongst the most common complications of transcatheter aortic valve implantation (TAVI). Post-TAVI high degree AV block necessitates permanent pacemaker (PPM) implantation.

Purpose

To assess the ability of standardly available pre-, intra- and post-TAVI factors to predict PPM implantation within 30-days post procedure.

Methods

Demographic and clinical (pre-, intra-, and post-procedural) data including ECG parameters were collected from all patients who underwent TAVI at our centre from August 2017 to November 2020. Patients with pre-existing PPM were excluded from the study. Predictive factors were selected through univariate analysis, and selected characteristics were incorporated into a multivariate binomial logistic regression model, in order to create a 30-day PPM risk-prediction model. The Akaike information criterion (AIC) and area under receiver operating curve (AUC/C-statistic) were used to assess discriminative performance.

Results

In total, data from a total of 446 patients were analysed. Of these, 40 (8.97%) received PPM implantation within 30 days of the procedure. The mean age of the patients was 81.5 (±7.3 SD) years; 99 (22.2%) had pre-existing first degree AV block, 55 (12.3%) had pre-existing left bundle branch block (LBBB) and 50 (11.2%) had pre-existing right bundle branch block (RBBB). Intra-procedurally 40 (9.0%) developed LBBB, 21 (4.7%) developed 3rd degree AV block, and 95 (21.3%) patients required temporary pacing wire (TPW) pacing. Post-procedurally, 138 (30.9%) exhibited AV block, 107 (24.0%) LBBB and 50 (11.2%) RBBB.

The following factors met significance at multivariate logistic regression analysis: pre-TAVI RBBB (OR 6.62 [95% CI, 1.37–36.51]), intra-TAVI 3rd degree AV block (OR 12.80 [95% CI, 3.44–53.34]), intra-TAVI LBBB (OR 4.02 [95% CI, 1.28–12.53]), use of TPW pacing (OR 8.58 [95% CI, 3.19–25.12]) and post-TAVI LBBB (OR 7.84 [95% CI, 2.75–24.46]) (Table).

Finally, variables were incorporated into a multivariate logistic regression model with the outcome variable of 30-day PPM implantation (Figure 1a). A model incorporating five factors (pre-TAVI RBBB, intra-TAVI 3rd degree AV block, intra-TAVI LBBB, use of TPW pacing and post-TAVI LBBB) demonstrated excellent discriminative ability (accuracy 0.925 and an AUC of 0.952) at predicting PPM implantation (Figure 1b).

Conclusions

Following variable selection, the best performing model incorporated five factors including pre-TAVI RBBB, intra-TAVI AV block (3rd degree), intra-TAVI LBBB, use of TPW pacing and post-TAVI LBBB. We aim to validate this model using an external cohort.

Funding Acknowledgement

Type of funding sources: None. Table 1Figure 1

Medical and neurobehavioural phenotypes in male and female carriers of Xp22.31 duplications in the UK Biobank

Deletions spanning the STS (steroid sulfatase) gene at Xp22.31 are associated with X-linked ichthyosis, corneal opacities, testicular maldescent, cardiac arrhythmia, and higher rates of developmental and mood disorders/traits, possibly related to the smaller volume of some basal ganglia structures. The consequences of duplication of the same genomic region have not been systematically assessed in large or adult samples, although evidence from case reports/series has indicated high rates of developmental phenotypes. We compared multiple measures of physical and mental health, cognition and neuroanatomy in male (n = 414) and female (n = 938) carriers of 0.8–2.5 Mb duplications spanning STS, and non-carrier male (n = 192, 826) and female (n = 227, 235) controls from the UK Biobank (recruited aged 40–69 from the UK general population). Clinical and self-reported diagnoses indicated a higher prevalence of inguinal hernia and mania/bipolar disorder respectively in male duplication carriers, and a higher prevalence of gastro-oesophageal reflux disease and blistering/desquamating skin disorder respectively in female duplication carriers; duplication carriers also exhibited reductions in several depression-related measures, and greater happiness. Cognitive function and academic achievement did not differ between comparison groups. Neuroanatomical analysis suggested greater lateral ventricle and putamen volume in duplication carriers. In conclusion, Xp22.31 duplications appear largely benign, but could slightly increase the likelihood of specific phenotypes (although results were only nominally-significant). In contrast to deletions, duplications might protect against depressive symptoms, possibly via higher STS expression/activity (resulting in elevated endogenous free steroid levels), and through contributing towards an enlarged putamen volume. These results should enable better genetic counselling of individuals with Xp22.31 microduplications.

342 Rib Fracture Scoring at The Royal Sussex County Hospital, A Major Trauma Centre

Introduction

In April 2017, The Royal Sussex County Hospital introduced rib fracture scoring to help guide the management of rib fractures.

Rib fracture score = (number of fractures x number of sides) + age score1

In this study, we audit our adherence to the scoring system and compare our management of chest trauma before and after its implementation.

Method

All admissions with rib fractures between 1/10/2016- 28/02/2017 (N = 35) and 1/10/2019- 31/01/2020 (N = 41) were recorded. Electronic and written notes were used to retrospectively record multidisciplinary care involvement, analgesics, chest infection and death.

Results

The pre-intervention cohort had an average age of 55.1 years and rib score of 8.8. The post intervention cohort had an average age of 67.2 years and score of 11.3. Following implementation, 45% of patients had a rib score recorded. Post-intervention, anaesthetic involvement increased by 34.5% and 15.4% more patients received a regional block. Inpatient nights fell from 11.2 to 10.1, mortality rate from 7% to 4% but the incidence of chest infection remained similar.

Conclusions

The implementation of a rib fracture scoring system has led to greater multidisciplinary care and higher levels of pain management. A larger study is required to assess patient outcome given the change in sample population over time.

The contribution of Xp22.31 gene dosage to Turner and Klinefelter syndromes and sex-biased phenotypes

Turner syndrome (TS) is a rare developmental condition in females caused by complete, or partial, loss of the second sex chromosome; it is associated with a number of phenotypes including short stature, ovarian failure and infertility, as well as neurobehavioural and cognitive manifestations. In contrast, Klinefelter syndrome (KS) arises from an excess of X chromosome material in males (typical karyotype is 47,XXY); like TS, KS is associated with infertility and hormonal imbalance, and behavioural/neurocognitive differences from gonadal sex-matched counterparts. Lower dosage of genes that escape X-inactivation may partially explain TS phenotypes, whilst overdosage of these genes may contribute towards KS-related symptoms. Here, I discuss new findings from individuals with deletions or duplications limited to Xp22.31 (a region escaping X-inactivation), and consider the extent to which altered gene dosage within this small interval (and of the steroid sulfatase (STS) gene in particular) may influence the phenotypic profiles of TS and KS. The expression of X-escapees can be higher in female than male tissues; I conclude by considering how lower Xp22.31 gene dosage in males may increase their likelihood of exhibiting particular phenotypes relative to females. Understanding the genetic contribution to specific phenotypes in rare disorders such as TS and KS, and to more common sex-biased phenotypes, will be important for developing more effective, and more personalised, therapeutic approaches.

A new molecular risk pathway for postpartum mood disorders: clues from steroid sulfatase-deficient individuals

Postpartum mood disorders develop shortly after childbirth in a significant proportion of women. These conditions are associated with a range of symptoms including abnormally high or low mood, irritability, cognitive disorganisation, disrupted sleep, hallucinations/delusions, and occasionally suicidal or infanticidal ideation; if not treated promptly, they can substantially impact upon the mother's health, mother-infant bonding, and family dynamics. The biological precipitants of such disorders remain unclear, although large changes in maternal immune and hormonal physiology following childbirth are likely to play a role. Pharmacological therapies for postpartum mood disorders can be effective, but may be associated with side effects, concerns relating to breastfeeding, and teratogenicity risks when used prophylactically. Furthermore, most of the drugs that are used to treat postpartum mood disorders are the same ones that are used to treat mood episodes during non-postpartum periods. A better understanding of the biological factors predisposing to postpartum mood disorders would allow for rational drug development, and the identification of predictive biomarkers to ensure that 'at risk' mothers receive earlier and more effective clinical management. We describe new findings relating to the role of the enzyme steroid sulfatase in maternal postpartum behavioural processes, and discuss how these point to a novel molecular risk pathway underlying postpartum mood disorders. Specifically, we suggest that aberrant steroid hormone-dependent regulation of neuronal calcium influx via extracellular matrix proteins and membrane receptors involved in responding to the cell's microenvironment might be important. Testing of this hypothesis might identify novel therapeutic targets and predictive biomarkers.

Medical and neurobehavioural phenotypes in carriers of X-linked ichthyosis-associated genetic deletions in the UK Biobank

BACKGROUND

X-linked ichthyosis (XLI) is an uncommon dermatological condition resulting from a deficiency of the enzyme steroid sulfatase (STS), often caused by X-linked deletions spanning STS. Some medical comorbidities have been identified in XLI cases, but small samples of relatively young patients has limited this. STS is highly expressed in subcortical brain structures, and males with XLI and female deletion carriers appear at increased risk of developmental/mood disorders and associated traits; the neurocognitive basis of these findings has not been examined.

METHODS

Using the UK Biobank resource, comprising participants aged 40-69 years recruited from the general UK population, we compared multiple medical/neurobehavioural phenotypes in males (n=86) and females (n=312) carrying genetic deletions spanning STS (0.8-2.5 Mb) (cases) to male (n=190 577) and female (n=227 862) non-carrier controls.

RESULTS

We identified an elevated rate of atrial fibrillation/flutter in male deletion carriers (10.5% vs 2.7% in male controls, Benjamini-Hochberg corrected p=0.009), and increased rates of mental distress (p=0.003), irritability (p<0.001) and depressive-anxiety traits (p<0.05) in male deletion carriers relative to male controls completing the Mental Health Questionnaire. While academic attainment was unaffected, male and female deletion carriers exhibited impaired performance on the Fluid Intelligence Test (Cohen's d≤0.05, corrected p<0.1). Neuroanatomical analysis in female deletion carriers indicated reduced right putamen and left nucleus accumbens volumes (Cohen's d≤0.26, corrected p<0.1).

CONCLUSION

Adult males with XLI disease-causing deletions are apparently at increased risk of cardiac arrhythmias and self-reported mood problems; altered basal ganglia structure may underlie altered function and XLI-associated psychiatric/behavioural phenotypes. These results provide information for genetic counselling of deletion-carrying individuals and reinforce the need for multidisciplinary medical care.

An Analysis of Cellular Communication Network Factor Proteins as Candidate Mediators of Postpartum Psychosis Risk

Postpartum (or puerperal) psychosis (PP) is a severe psychiatric condition associated with hallucinations, delusions, cognitive disorganization, and mood problems, which affects approximately 1-2 out of every 1,000 mothers shortly after childbirth. While the risk factors for, and co-morbidities of, PP are relatively well-defined, currently, the pathophysiology underlying the disorder is very poorly-specified. Here, I argue, on the basis of multiple lines of new evidence, that altered expression of the Cellular Communication Network (CCN) factor proteins (and of the heterodimerizing CCN2 and CCN3 proteins in particular), may be associated with, and possibly causal for, increased PP risk. Future preclinical and clinical studies should aim to test this hypothesis as empirical support for it would provide much-needed clues regarding the biological substrates of PP, and could point to predictive biomarkers for the condition.

Environmental noise levels in hospital settings: A rapid review of measurement techniques and implementation in hospital settings

BACKGROUND

Hospitals provide treatment to improve patient health and well-being but the characteristics of the care environment receive little attention. Excessive noise at night has a negative impact on in-patient health through disturbed sleep. To address this hospital staff must measure night-time environmental noise levels. Therefore, an understanding of environmental noise measurement techniques is required. In this review, we aim to 1) provide a technical overview of factors to consider when measuring environmental noise in hospital settings; 2) conduct a rapid review on the equipment and approaches used to objectively measured noise in hospitals and identify methodological limitations.

DESIGN

: A rapid review of original research articles, from three databases, published since 2008. Studies were included if noise levels were objectively measured in a hospital setting where patients were receiving treatment.

RESULTS

1429 articles were identified with 76 included in the review. There was significant variability in the approaches used to measure environmental noise in hospitals. Only 14.5% of studies contained sufficient information to support replication of the measurement process. Most studies measured noise levels using a sound level meter positioned closed to a patient's bed area in an intensive care unit.

CONCLUSION

: Unwanted environmental noise in hospital setting impacts negatively on patient and staff health and well-being. However, this literature review found that the approaches used to objectively measure noise level in hospital settings have been inconsistent and poorly reported. Recommendations on best-practice methods to measure noise levels in hospital environments are provided.

Brain Gene Expression in a Novel Mouse Model of Postpartum Mood Disorder

BACKGROUND

Steroid sulfatase (STS) cleaves sulfate groups from steroid hormones; its expression/activity increases in late pregnancy and into the postpartum period. STS-deficient human and mouse mothers display elevated psychopathology and abnormal behaviour respectively; in mice, these effects can be partially normalised by antipsychotic (ziprasidone) administration.

METHODOLOGY

We compared brain gene expression in new mouse mothers administered the STS inhibitor 667-Coumate, or vehicle; significant changes were followed-up with pathway analysis and quantitative polymerase chain reaction (qPCR). Finally, the effects of combined 667-Coumate and ziprasidone administration on expression of the most robustly differentially-expressed genes were examined.

RESULTS

Surprisingly, no between-group gene expression changes were detected at a False Discovery Rate (FDR)-corrected p<0.1. 1,081 unique expression changes were detected at p<0.05, two top hits were verified by qPCR, and pathway analysis indicated enrichment of genes involved in olfactory transduction. The expression of Stoml3 and Cyp2g1 was unaffected by ziprasidone administration.

CONCLUSIONS

Postpartum behavioural abnormalities in STS-deficient mothers are likely to be the culmination of many small gene expression changes. Our data are consistent with the idea that olfactory function is key to maternal behaviour in mice, and suggest that aberrant expression of olfactory system genes may underlie abnormal maternal behaviour in STS-deficient women.

Behavioural and psychiatric phenotypes in female carriers of genetic mutations associated with X-linked ichthyosis

X-linked ichthyosis (XLI) is a rare X-linked dermatological condition arising from deficiency for the enzyme steroid sulfatase (STS). STS is normally expressed in the brain, and males with XLI exhibit personality differences from males in the general population, and are at increased risk of developmental and mood disorders. As the STS gene escapes X-inactivation, female carriers of XLI-associated genetic mutations have reduced STS expression/activity relative to non-carrier females, and could manifest similar behavioural phenotypes to males with XLI. Additionally, as STS activity normally increases in female tissues towards late pregnancy and into the puerperium, carrier females could theoretically present with increased rates of postpartum psychopathology. Using a worldwide online survey comprising custom-designed demographic questionnaires and multiple validated psychological questionnaires, we collected detailed self-reported information on non-postpartum and postpartum behaviour in confirmed adult (>16yrs) female carriers of genetic mutations associated with XLI (n = 94) for statistical comparison to demographically-matched previously-published normative data from female controls (seven independent studies, 98≤n≤2562), adult males with XLI (n = 58), and to newly-obtained online survey data from a general population sample of mothers from the United Kingdom and United States of America (n = 263). The pattern of results in carrier females relative to controls was remarkably similar to that previously observed in males with XLI, with evidence for increased rates of developmental and mood disorders, and elevated levels of inattention, impulsivity, autism-related traits and general psychological distress. Carrier females exhibited a significantly elevated rate of postpartum mental health conditions (notably mild depression) relative to controls which could not be accounted for by social factors. Our data confirm the psychological profile associated with XLI-associated mutations, and suggest that female carriers may be at increased risk of psychopathology, including in the postpartum period. These findings are relevant to families affected by XLI, to clinicians involved in the care of these families, and to genetic counsellors.

Do Defective Immune System-Mediated Myelination Processes Increase Postpartum Psychosis Risk?

Postpartum (or puerperal) psychosis (PP) is a rare, severe psychiatric disorder that affects women shortly after childbirth; risk is particularly high in individuals with a history of bipolar disorder or PP, but the underlying pathophysiology remains poorly understood. Emerging evidence suggests that immune system (dys)function plays an important role in disorder onset. On the basis of new findings from clinical and animal model studies, we hypothesise that the abundance and/or activity of regulatory T cells, and the efficacy of consequent (re)myelination processes in the brain mediated by CCN proteins, is perturbed in PP; this pathway may be modulated by risk and protective/treatment factors for the disorder, and identifying abnormalities within it could signpost novel predictive biomarkers and therapeutic targets.

SULFATION PATHWAYS: The steroid sulfate axis and its relationship to maternal behaviour and mental health

Steroid hormones can exist in functionally dissociable sulfated and non-sulfated (free) forms and can exert profound effects on numerous aspects of mammalian physiology; the ratio of free-to-sulfated steroids is governed by the antagonistic actions of steroid sulfatase (STS) and sulfotransferase (SULT) enzymes. Here, I examine evidence from human and animal model studies, which suggests that STS and its major substrate (dehydroepiandrosterone sulfate, DHEAS) and product (DHEA) can influence brain function, behaviour and mental health, before summarising how the activity of this axis varies throughout mammalian pregnancy and the postpartum period. I then consider how the steroid sulfate axis might impact upon normal maternal behaviour and how its dysfunction might contribute towards risk of postpartum psychiatric illness. Understanding the biological substrates underlying normal and abnormal maternal behaviour will be important for maximising the wellbeing of new mothers and their offspring.

2D:4D digit ratio and religiosity in university student and general population samples

The ratio of index to ring finger length (2D:4D) is used as a proxy for prenatal sex hormone exposure. It has been hypothesised to correlate with religiosity, though no published research has explored this possibility. Here, we initially examined 2D:4D in relation to self-reported religious affiliation and questionnaire measures of general religiosity, spirituality, religious fundamentalism, and religious commitment in male (N = 106) and female (N = 105) university students (Study 1). Although no significant correlations were observed between 2D:4D and the questionnaire measures, females who affiliated with organised religions had higher digit ratios compared to agnostic or atheist females. Study 2 attempted to replicate these findings in an adult general population sample (N = 172 males, N = 257 females), but did not observe significant effects in either sex. Overall, these findings suggest that high 2D:4D may be relatively-specifically associated with religious affiliation in young, highly-educated, females.

X-linked ichthyosis associated with psychosis and behavioral abnormalities: a case report

Background

X-linked ichthyosis is a dermatological condition caused by deficiency for the enzyme steroid sulfatase. Previously, X-linked ichthyosis/steroid sulfatase deficiency has been associated with developmental and neurological phenotypes. Here, we show for the first time, that X-linked ichthyosis may be comorbid with an additional psychiatric phenotype (psychosis).

Case presentation

We report the case of an 11-year-old Saudi Arabian boy with X-linked ichthyosis associated with psychosis, mental retardation, autism spectrum disorder, inattentive attention deficit hyperactivity disorder, and epilepsy. Genetic analysis revealed a 1.68 Mb deletion encompassing STS in 95% of cells while biochemical analysis revealed correspondingly low steroid sulfatase activity consistent with a diagnosis of X-linked ichthyosis. The psychotic symptoms could be reasonably well controlled by administration of an atypical antipsychotic.

Conclusions

This report describes a case of comorbid X-linked ichthyosis and psychosis (most closely corresponding to early-onset schizophrenia) for the first time, and suggests that deficiency for steroid sulfatase and contiguous genes may increase vulnerability to psychosis as well as other psychological disorders.

Attention deficit hyperactivity disorder (ADHD) in phenotypically similar neurogenetic conditions: Turner syndrome and the RASopathies

Background

ADHD (attention deficit hyperactivity disorder) is a common neurodevelopmental disorder. There has been extensive clinical and basic research in the field of ADHD over the past 20 years, but the mechanisms underlying ADHD risk are multifactorial, complex and heterogeneous and, as yet, are poorly defined. In this review, we argue that one approach to address this challenge is to study well-defined disorders to provide insights into potential biological pathways that may be involved in idiopathic ADHD.

Main body

To address this premise, we selected two neurogenetic conditions that are associated with significantly increased ADHD risk: Turner syndrome and the RASopathies (of which Noonan syndrome and neurofibromatosis type 1 are the best-defined with regard to ADHD-related phenotypes). These syndromes were chosen for two main reasons: first, because intellectual functioning is relatively preserved, and second, because they are strikingly phenotypically similar but are etiologically distinct. We review the cognitive, behavioural, neural and cellular phenotypes associated with these conditions and examine their relevance as a model for idiopathic ADHD.

Conclusion

We conclude by discussing current and future opportunities in the clinical and basic research of these conditions, which, in turn, may shed light upon the biological pathways underlying idiopathic ADHD.

Understanding the pathophysiology of postpartum psychosis: Challenges and new approaches

Postpartum psychosis is a severe psychiatric condition which affects 1-2 of every 1000 mothers shortly after childbirth. Whilst there is convincing evidence that the condition is precipitated by a complex combination of biological and environmental factors, as yet the pathophysiological mechanisms remain extremely poorly defined. Here, I critically review approaches that have been, or are being, employed to identify and characterise such mechanisms; I also review a recent animal model approach, and describe a novel biological risk model that it suggests. Clarification of biological risk mechanisms underlying disorder risk should permit the identification of relevant predictive biomarkers which will ensure that “at risk” subjects receive prompt clinical intervention if required.

A genetic variant within STS previously associated with inattention in boys with attention deficit hyperactivity disorder is associated with enhanced cognition in healthy adult males

INTRODUCTION

The enzyme steroid sulfatase (STS) converts sulfated steroids to their non-sulfated forms. Deficiency for this enzyme is associated with inattention but preserved response control. The polymorphism rs17268988 within the X-linked STS gene is associated with inattentive, but not other, symptoms in boys with attention deficit hyperactivity disorder (ADHD).

METHODS

We initially tested whether rs17268988 genotype was associated with attention, response control, and underlying aspects of cognition, using questionnaires and neuropsychological tasks, in two independent cohorts of healthy adult males. In an additional analysis based upon existing data, the performance of mice with genetic or pharmacological manipulations of the STS axis under attentionally demanding conditions was investigated.

RESULTS

G-allele carriers at rs17268988 exhibited reduced reaction time, enhanced attention, and reduced reaction time variability relative to C-allele carriers. Mice with genetic or pharmacological manipulations of the STS axis were shown to have perturbed reaction time variability.

DISCUSSION

Our findings provide additional support for an association between rs17268988 genotype and attention, which may be partially mediated by reaction time variability; they also indicate that, in contrast to the situation in boys with ADHD, in healthy men, the G-allele at rs17268988 is associated with enhanced cognition. As reaction time variability is a predictor of well-being, rs17268988 genotype may represent a biomarker for long-term health.

Ventricular Arrhythmia after Acute Myocardial Infarction: 'The Perfect Storm'

Ventricular tachyarrhythmias (VAs) commonly occur early in ischaemia, and remain a common cause of sudden death in acute MI. The thrombolysis and primary percutaneous coronary intervention era has resulted in the modification of the natural history of an infarct and subsequent VA. Presence of VA could independently influence mortality in patients recovering from MI. Appropriate risk assessment and subsequent treatment is warranted in these patients. The prevention and treatment of haemodynamically significant VA in the post-infarct period and of sudden cardiac death remote from the event remain areas of ongoing study.

A pharmacological mouse model suggests a novel risk pathway for postpartum psychosis

Postpartum psychosis (PP) is a severe psychiatric disorder affecting a small proportion of new mothers shortly after childbirth. The molecular pathophysiology underlying the disorder is currently poorly understood, and there are no amenable animal models for the condition; maternal deficiency for the enzyme steroid sulfatase has been proposed as a potential risk mechanism. Here we show that inhibition of steroid sulfatase with 667-COUMATE (10mg/kg p.o.) in new mouse mothers results in behavioural abnormalities that can be partially alleviated by the administration of the clinically-efficacious antipsychotic ziprasidone (0.3-1.0mg/kg i.p.). The pattern of behavioural abnormalities in 667-COUMATE-treated mice implicated a genetic substrate at 21-23cM on chromosome 15; of the 17 genes within this chromosomal interval, only one (Nov/Ccn3) was significantly differentially expressed in the brains of vehicle and 667-COUMATE-treated mice. Two additional members of the Ccn family (Ccn2/Ctgf and Ccn4/Wisp1) were also significantly differentially expressed between the two groups, as were three further genes co-expressed with Nov/Ccn3 in brain (Arhgdig) or previously implicated in disorder risk by clinical studies (Adcy8 and Ccl2). The expression of Nov/Ccn3, but not of the other differentially-expressed genes, could be normalised by ziprasidone administration (1.0mg/kg). NOV/CCN3 lies directly under a linkage peak for PP risk at 8q24, and the associated protein possesses numerous characteristics that make it an excellent candidate mediator of PP risk. Our data suggest the 667-COUMATE-treated mouse as a model for PP with some degree of face, construct, and predictive validity, and implicate a novel, and biologically-plausible, molecular risk pathway for PP.

Insights into rare diseases from social media surveys

The internet, and social media platforms, are increasingly being used by substantial sectors of the worldwide population. By engaging effectively with online and social media, scientists and clinicians can obtain unprecedented access to relatively large cohorts of individuals with rare diseases, as well as their relatives, carers and professionals involved in their healthcare. Online surveys of these stakeholder groups may provide important new insights into rare conditions and their management relatively quickly and easily, with the possibility of rapid translation into healthcare interventions and policy. Here, I describe our recent positive experience with the online survey approach to a rare disease (X-linked ichthyosis), and review its advantages and limitations.

Behavioural and Psychiatric Phenotypes in Men and Boys with X-Linked Ichthyosis: Evidence from a Worldwide Online Survey

BACKGROUND

X-linked ichthyosis (XLI) is a rare dermatological condition arising from deficiency for the enzyme steroid sulfatase (STS). Preliminary evidence in boys with XLI, and animal model studies, suggests that individuals lacking STS are at increased risk of developmental disorders and associated traits. However, the behavioural profile of children with XLI is poorly-characterised, and the behavioural profile of adults with XLI has not yet been documented at all.

MATERIALS AND METHODS

Using an online survey, advertised worldwide, we collected detailed self- or parent-reported information on behaviour in adult (n = 58) and younger (≤18yrs, n = 24) males with XLI for comparison to data from their non-affected brothers, and age/gender-matched previously-published normative data. The survey comprised demographic and background information (including any prior clinical diagnoses) and validated questionnaires assaying phenotypes of particular interest (Adult ADHD Self-Report Scale v1.1, Barrett Impulsiveness Scale-11, adult and adolescent Autism Quotient, Kessler Psychological Distress Scales, and Disruptive Behaviour Disorder Rating Scale).

RESULTS

Individuals with XLI generally exhibited normal sensory function. Boys with XLI were at increased risk of developmental disorder, whilst adults with the condition were at increased risk of both developmental and mood disorders. Both adult and younger XLI groups scored significantly more highly than male general population norms on measures of inattention, impulsivity, autism-related traits, psychological distress and disruptive behavioural traits.

CONCLUSIONS

These findings indicate that both adult and younger males with XLI exhibit personality profiles that are distinct from those of males within the general population, and suggest that individuals with XLI may be at heightened risk of psychopathology. The data are consistent with the notion that STS is important in neurodevelopment and ongoing brain function, and with previous work suggesting high rates of developmental disorders in boys with XLI. Our results suggest that individuals with XLI may require medical care from multidisciplinary teams, and should help to inform genetic counselling for the condition.

The climate benefits of high-sugar grassland may be compromised by ozone pollution

High sugar ryegrasses (HSG) have been developed to improve the uptake, digestion and nitrogen (N)-utilisation of grazing stock, with the potential to increase production yields and benefit climate by reducing methane (CH4) and nitrous oxide (N2O) emissions from livestock farming. In this study, the effects of tropospheric ozone pollution on the seasonal growth dynamics of HSG pasture mesocosms containing Lolium perenne cv. AberMagic and Trifolium repens cv. Crusader were investigated. Species-specific ozone (O3) dose-response relationships (seasonal means: 35, 41, 47, 51, 59 & 67ppb) based on the Phytotoxic Ozone Dose (PODy) were constructed for above and below ground biomass, injury, N-fixation and forage quality. The dynamics of effects of ozone exposure on HSG pasture changed over the course of a season, with the strongest responses occurring in the first 4-8weeks. Overall, strong negative responses to ozone flux were found for root biomass, root nodule mass and N-fixation rates, and ozone adversely impacted a range of forage quality parameters including total sugar content and relative and consumable food values. These results indicate that increasing ozone pollution could decrease the N-use efficiency and reduce the sugar content of managed pasture, and thereby partially detract from some of the suggested benefits of HSG.

N-fixation in legumes--An assessment of the potential threat posed by ozone pollution

The growth, development and functioning of legumes are often significantly affected by exposure to tropospheric ozone (O3) pollution. However, surprisingly little is known about how leguminous Nitrogen (N) fixation responds to ozone, with a scarcity of studies addressing this question in detail. In the last decade, ozone impacts on N-fixation in soybean, cowpea, mung bean, peanut and clover have been shown for concentrations which are now commonly recorded in ambient air or are likely to occur in the near future. We provide a synthesis of the existing literature addressing this issue, and also explore the effects that may occur on an agroecosystem scale by predicting reductions in Trifolium (clovers) root nodule biomass in United Kingdom (UK) pasture based on ozone concentration data for a "high" (2006) and "average" ozone year (2008). Median 8% and 5% reductions in clover root nodule biomass in pasture across the UK were predicted for 2006 and 2008 respectively. Seasonal exposure to elevated ozone, or short-term acute concentrations >100 ppb, are sufficient to reduce N-fixation and/or impact nodulation, in a range of globally-important legumes. However, an increasing global burden of CO2, the use of artificial fertiliser, and reactive N-pollution may partially mitigate impacts of ozone on N-fixation.

The influence of hypothermia on the management of traumatic cardiac arrest

Post-traumatic hypothermia often occurs as a direct consequence of haemorrhage and shock. Environmental exposure in austere environments may also contribute to its pathogenesis. In those casualties that present in cardiac arrest following injury, coexisting hypothermia may be the primary cause of the arrest, or a marker of the severity of shock. A case of a 25-year-old combat casualty is presented, illustrating some of the technical challenges faced by clinicians while resuscitating hypothermic trauma patients in cardiac arrest.

Evidence-based management of recurrent miscarriages

Recurrent miscarriages are postimplantation failures in natural conception; they are also termed as habitual abortions or recurrent pregnancy losses. Recurrent pregnancy loss is disheartening to the couple and to the treating clinician. There has been a wide range of research from aetiology to management of recurrent pregnancy loss. It is one of the most debated topic among clinicians and academics. The ideal management is unanswered. This review is aimed to produce an evidence-based guidance on clinical management of recurrent miscarriage. The review is structured to be clinically relevant. We have searched electronic databases (PubMed and Embase) using different key words. We have combined the searches and arranged them with the hierarchy of evidences. We have critically appraised the evidence to produce a concise answer for clinical practice. We have graded the evidence from level I to V on which these recommendations are based.

Genetic and pharmacological modulation of the steroid sulfatase axis improves response control; comparison with drugs used in ADHD

Maladaptive response control is a feature of many neuropsychiatric conditions, including attention deficit hyperactivity disorder (ADHD). As ADHD is more commonly diagnosed in males than females, a pathogenic role for sex-linked genes has been suggested. Deletion or point mutation of the X-linked STS gene, encoding the enzyme steroid sulfatase (STS) influences risk for ADHD. We examined whether deletion of the Sts gene in the 39,X(Y*)O mouse model, or pharmacological manipulation of the STS axis, via administration of the enzyme substrate dehydroepiandrosterone sulfate or the enzyme inhibitor COUMATE, influenced behavior in a novel murine analog of the stop-signal reaction time task used to detect inhibitory deficits in individuals with ADHD. Unexpectedly, both the genetic and pharmacological treatments resulted in enhanced response control, manifest as highly specific effects in the ability to cancel a prepotent action. For all three manipulations, the effect size was comparable to that seen with the commonly used ADHD therapeutics methylphenidate and atomoxetine. Hence, converging genetic and pharmacological evidence indicates that the STS axis is involved in inhibitory processes and can be manipulated to give rise to improvements in response control. While the precise neurobiological mechanism(s) underlying the effects remain to be established, there is the potential for exploiting this pathway in the treatment of disorders where failures in behavioral inhibition are prominent.

Sex differences in attention Deficit Hyperactivity Disorder: candidate genetic and endocrine mechanisms

Attention Deficit Hyperactivity Disorder (ADHD) is a developmental condition characterised by severe inattention, pathological impulsivity and hyperactivity; it is relatively common affecting up to 6% of children, and is associated with a risk of long-term adverse educational and social consequences. Males are considerably more likely to be diagnosed with ADHD than females; the course of the disorder and its associated co-morbidities also appear to be sensitive to sex. Here, I discuss fundamental biological (genetic and endocrine) mechanisms that have been shown to, or could theoretically, contribute towards these sexually dimorphic phenomena. Greater understanding of how and why the sexes differ with respect to ADHD vulnerability should allow us to identify and characterise novel protective and risk factors for the disorder, and should ultimately facilitate improved diagnosis, prognosis and treatment.

Highlighting the threat from current and near-future ozone pollution to clover in pasture

Globally, the legume-rhizobia symbiosis, contained within specialised organs called root nodules, is thought to add at least 30 Tg N annually to agricultural land. The growth and functioning of a modern white clover (Trifolium repens cv. Crusader) and red clover (T. pratense cv. Merviot) cultivar were investigated in current and future ozone scenarios in solardomes. Both cultivars developed leaf injury and had significant reductions in root biomass and root nodule number in response to ozone, with Crusader also displaying a reduced size and mass of nodules. In-situ measurements of N-fixation in Crusader by acetylene reduction assay revealed reduced N-fixation rates in a future scenario with an increased background and moderate peaks of ozone. The implications for the sustainability of temperate pasture are discussed.

Altered brain gene expression but not steroid biochemistry in a genetic mouse model of neurodevelopmental disorder

Background

The 39,X^Y*O mouse, which lacks the orthologues of the ADHD and autism candidate genes STS (steroid sulphatase) and ASMT (acetylserotonin O-methyltransferase), exhibits behavioural phenotypes relevant to developmental disorders. The neurobiology underlying these phenotypes is unclear, although there is evidence for serotonergic abnormalities in the striatum and hippocampus.

Methods

Using microarray and quantitative gene expression analyses, and gas chromatography–mass spectrometry, we compared brain gene expression and steroid biochemistry in wildtype (40,XY) and 39,X^Y*O adult mice to identify non-obvious genetic and endocrine candidates for between-group differences in behaviour and neurochemistry. We also tested whether acute STS inhibition by COUMATE in wildtype (40,XY) adult male mice recapitulated any significant gene expression or biochemical findings from the genetic comparison. Data were analysed by unpaired t-test or Mann Whitney U-test depending on normality, with a single factor of KARYOTYPE.

Results

Microarray analysis indicated seven robust gene expression differences between the two groups (Vmn2r86, Sfi1, Pisd-ps1, Tagap1, C1qc, Metap1d, Erdr1); Erdr1 and C1qc expression was significantly reduced in the 39,X^Y*O striatum and hippocampus, whilst the expression of Dhcr7 (encoding 7-dehydrocholesterol reductase, a modulator of serotonin system development), was only reduced in the 39,X^Y*O hippocampus. None of the confirmed gene expression changes could be recapitulated by COUMATE administration. We detected ten free, and two sulphated steroids in 40,XY and 39,X^Y*O brain; surprisingly, the concentrations of all of these were equivalent between groups.

Conclusions

Our data demonstrate that the mutation in 39,X^Y*O mice: i) directly disrupts expression of the adjacent Erdr1 gene, ii) induces a remarkably limited suite of downstream gene expression changes developmentally, with several of relevance to associated neurobehavioural phenotypes and iii) does not elicit large changes in brain steroid biochemistry. It is possible that individuals with STS/ASMT deficiency exhibit a similarly specific pattern of gene expression changes to the 39,X^Y*O mouse, and that these contribute towards their abnormal neurobiology. Future work may focus on whether complement pathway function, mitochondrial metabolism and cholesterol biosynthesis pathways are perturbed in such subjects.

Economical Analysis of Different Clinical Approaches in Pre-Viability Amniorrhexis-A Case Series

Prolonged oligohydramnios following extreme preterm prelabour rupture of membranes (EPPROM) is traditionally associated with a high morbidity and mortality to both the mother and the baby. The clinical maternal evaluation and fetal ultrasound assessment may provide important prognostic information for the clinicians and should be taken into account when counselling the patients so as to provide them with enough information to make decision of continuing or interrupting the pregnancy. Current financial constraints on the National Healthcare Service (NHS) resources make it imperative for clinical decision-makers and budgetary planners to make the right decision of continuing or terminating a second trimester pre-viability amniorrhexis for desperate parents. To assess the economic consequences following EPPROM, the risk of infection to both baby and mother, psychological impact on the parents and associated complications and further disability after delivery on this fragile group of patients to the NHS resources. We review the clinical course, outcome, and the challenges to parents and health care professionals on three pregnancies complicated by EPPROM, occurring before 24 weeks’ gestation with a membrane rupture to delivery interval (latent period) of 14 days or more. The anticipated birth of an extremely premature infant poses many challenges for parents and health care professionals. As parents are faced with difficult decisions that can have a long-term impact on the infant, family and country’s resources, it is critical to provide the type of information and support that is needed by them. Taking all these into consideration with the period of ventilation and respiratory assistance in Neonatal Intensive Care Unit (NICU) is essential to provide maximum chances for survival, minimizing the risk for long term sequelae of the neonate and provides the parents enough time to decide on making the right decision with the associated guidance of the healthcare provider.