Critical overview on the use of hydrophobic (deep) eutectic solvents for the extraction of organic pollutants in complex matrices

During the last decades, many efforts have been devoted to the adaptation of sample preparation techniques and methods to the principles of Green Analytical Chemistry. Among them, this article review focusses on those aimed to green the solvents involved in sample treatment. Research in this field started in the late 1990s with the synthesis of room temperature ionic liquids, which were later replaced by the deep eutectic solvents (DESs). During the last years, a subclass of DESs, the so-called hydrophobic deep eutectic solvents (HDESs) have attracted attention. HDESs have contributed to circumventing some of the limitations of early-synthesised hydrophilic DESs regarding the cost of raw materials, the simplicity of synthesis, and the biocompatibility and, apparently, the biodegradability of the mixtures. In addition, these mixtures allowed the treatment of aqueous samples and the extraction of non-polar analytes. This article discusses fundamental aspects regarding the nomenclature used concerning HDESs, summarises the main physicochemical properties of these mixtures, and through discussion of key application studies, describes current progress in the use of these green solvents for the extraction of trace organic contaminants from a variety of matrices. Remaining gaps and possible lines of future development in this emerging, active and attractive research area are also identified and critically discussed.

Explainable artificial intelligence for the automated assessment of the retinal vascular tortuosity

Retinal vascular tortuosity is an excessive bending and twisting of the blood vessels in the retina that is associated with numerous health conditions. We propose a novel methodology for the automated assessment of the retinal vascular tortuosity from color fundus images. Our methodology takes into consideration several anatomical factors to weigh the importance of each individual blood vessel. First, we use deep neural networks to produce a robust extraction of the different anatomical structures. Then, the weighting coefficients that are required for the integration of the different anatomical factors are adjusted using evolutionary computation. Finally, the proposed methodology also provides visual representations that explain the contribution of each individual blood vessel to the predicted tortuosity, hence allowing us to understand the decisions of the model. We validate our proposal in a dataset of color fundus images providing a consensus ground truth as well as the annotations of five clinical experts. Our proposal outperforms previous automated methods and offers a performance that is comparable to that of the clinical experts. Therefore, our methodology demonstrates to be a viable alternative for the assessment of the retinal vascular tortuosity. This could facilitate the use of this biomarker in clinical practice and medical research.

Contact sensitization in pediatric patients with atopic dermatitis: a purpose for a new patch testing series for the Portuguese population

Summary

Background. Atopic dermatitis is a prevalent condition in the pediatric population, with affected children exhibiting a susceptibility to cutaneous sensitization due to skin barrier dysfunction and immune dysregulation. Recent studies have highlighted an increased prevalence of certain allergens, which identifi-cation may be clinically relevant, with direct implications for the management of atopic dermatitis. Methods. We retrospective reviewed pediatric patients patch tested due to suspected contact dermatitis. Patients were divided according the diagnosis of AD, with subsequent comparison of positive results for both groups. Results. A total of 145 pediatric patch testing were analyzed, 44.1% (n = 63) with the diagnosis of atopic dermatitis. There were notable differences in sensitization rates of relevant allergens between groups and when compared to other European studies. Based on the most prevalent and relevant allergens, we proposed an adapted hapten series for assessing portuguese pediatric patients with AD and suspicion of concomitant allergic contact dermatitis. Conclusions. Our findings confirmed the geograph-ic sensitization variability and emphasize the need for pediatric adaptation and "individualized baseline series".

Neddylation of phosphoenolpyruvate carboxykinase 1 controls glucose metabolism

Neddylation is a post-translational mechanism that adds a ubiquitin-like protein, namely neural precursor cell expressed developmentally downregulated protein 8 (NEDD8). Here, we show that neddylation in mouse liver is modulated by nutrient availability. Inhibition of neddylation in mouse liver reduces gluconeogenic capacity and the hyperglycemic actions of counter-regulatory hormones. Furthermore, people with type 2 diabetes display elevated hepatic neddylation levels. Mechanistically, fasting or caloric restriction of mice leads to neddylation of phosphoenolpyruvate carboxykinase 1 (PCK1) at three lysine residues-K278, K342, and K387. We find that mutating the three PCK1 lysines that are neddylated reduces their gluconeogenic activity rate. Molecular dynamics simulations show that neddylation of PCK1 could re-position two loops surrounding the catalytic center into an open configuration, rendering the catalytic center more accessible. Our study reveals that neddylation of PCK1 provides a finely tuned mechanism of controlling glucose metabolism by linking whole nutrient availability to metabolic homeostasis.

Three-year efficacy of switching to dolutegravir plus lamivudine: A real-world study

BACKGROUND

Dolutegravir (DTG) plus lamivudine (3TC) has proven highly efficacious as a switching strategy in virologically suppressed people with HIV (PWH). As this strategy was introduced relatively recently, real-world, long-term durability studies are lacking.

METHODS

We performed a retrospective review of treatment-experienced patients who started DTG + 3TC in a cohort of PWH. HIV-RNA <50 copies/mL was analysed at 144 weeks in an intention-to-treat (ITT) analysis (missing = failure) and a per-protocol (PP) analysis (patients with missing data or changes for reasons other than virological failure were excluded).

RESULTS

The study population comprised 358 PWH (19% women). Median age and time with HIV infection were 51.7 and 13.4 years, respectively. The median number of previous antiretroviral combinations was three. Previous virological failure was reported in 27.1% of patients, and the M184V resistance mutation was detected in 17 patients. At 144 weeks, the percentage of individuals with HIV-RNA <50 copies/mL was 77.4% (277/358) in the ITT analysis and 95.5% (277/290) in the PP analysis. A total of 68 participants were excluded from the PP analysis (data missing, 25, discontinuation due to toxicity, 19; other, 16; death, 8). Two people with virological failure selected resistance-associated mutations (M184V and M184V + R263K). HIV-RNA remained undetectable in 17 patients with a previous history of the M184V mutation.

CONCLUSION

Our results confirm the real-world, long-term efficacy, tolerability and high genetic barrier of DTG + 3TC in treatment-experienced PWH. Although scarce, mutations causing resistance to nucleosides and integrase can emerge.

Non-target analysis of organohalogenated contaminants in deep-sea fishes from the Mediterranean Sea by comprehensive two-dimensional gas chromatography-time-of-flight mass spectrometry

The enhanced separation power and identification capabilities make comprehensive two-dimensional gas chromatography-time-of-flight mass spectrometry (GC × GC - ToF MS) a valuable instrumental alternative for non-target analysis (NTA). In the present study, GC × GC - ToF MS has been used for the NTA of chlorine- and bromine-containing compounds in composite livers of two scarcely investigated Mediterranean deep-sea fish species, hollowsnout grenadier (Coelorinchus caelorhincus) and roughsnout grenadier (Trachyrhinchus trachyrhinchus). Attention focused on the identification of organohalogenated compounds with structural characteristics similar to those of persistent organic pollutants (POPs). In total, 116 Cl-, Br- and mixed Cl/Br-compounds were either positively or tentatively identified in the analyzed liver samples. Up to 88 of these compounds were legacy POPs, being polychlorinated biphenyls (PCBs) and organochlorinated pesticides (OCPs) the most abundant and frequently detected families. The other 28 identified POP-like compounds were analytes not considered by current regulation and environmental monitoring programs, including, among others, degradation products of specific OCPs, naturally produced organohalogen compounds and several perchlorinated diethyldiphenylmethane-derivatives whose presence in the investigated species is reported here for the first time. The presence of other naturally occurring brominated and mixed halogenated compounds in these fish species is also described for the first time. Our results also showed differences in the accumulation profile of the identified compounds in both species. Thereby, anthropogenic POPs showed higher relative abundances in the livers of roughsnout grenadiers than those in hollowsnout grenadiers, while for naturally occurring compounds the opposite trend or similar levels were found in both species.

Clinical outcomes of uninterrupted embryo culture with or without time-lapse-based embryo selection versus interrupted standard culture (SelecTIMO): a three-armed, multicentre, double-blind, randomised controlled trial

BACKGROUND

Time-lapse monitoring is increasingly used in fertility laboratories to culture and select embryos for transfer. This method is offered to couples with the promise of improving pregnancy chances, even though there is currently insufficient evidence for superior clinical results. We aimed to evaluate whether a potential improvement by time-lapse monitoring is caused by the time-lapse-based embryo selection method itself or the uninterrupted culture environment that is part of the system.

METHODS

In this three-armed, multicentre, double-blind, randomised controlled trial, couples undergoing in-vitro fertilisation or intracytoplasmic sperm injection were recruited from 15 fertility clinics in the Netherlands and randomly assigned using a web-based, computerised randomisation service to one of three groups. Couples and physicians were masked to treatment group, but embryologists and laboratory technicians could not be. The time-lapse early embryo viability assessment (EEVA; TLE) group received embryo selection based on the EEVA time-lapse selection method and uninterrupted culture. The time-lapse routine (TLR) group received routine embryo selection and uninterrupted culture. The control group received routine embryo selection and interrupted culture. The co-primary endpoints were the cumulative ongoing pregnancy rate within 12 months in all women and the ongoing pregnancy rate after fresh single embryo transfer in a good prognosis population. Analysis was by intention to treat. This trial is registered on the ICTRP Search Portal, NTR5423, and is closed to new participants.

FINDINGS

1731 couples were randomly assigned between June 15, 2017, and March 31, 2020 (577 to the TLE group, 579 to the TLR group, and 575 to the control group). The 12-month cumulative ongoing pregnancy rate did not differ significantly between the three groups: 50·8% (293 of 577) in the TLE group, 50·9% (295 of 579) in the TLR group, and 49·4% (284 of 575) in the control group (p=0·85). The ongoing pregnancy rates after fresh single embryo transfer in a good prognosis population were 38·2% (125 of 327) in the TLE group, 36·8% (119 of 323) in the TLR group, and 37·8% (123 of 325) in the control group (p=0·90). Ten serious adverse events were reported (five TLE, four TLR, and one in the control group), which were not related to study procedures.

INTERPRETATION

Neither time-lapse-based embryo selection using the EEVA test nor uninterrupted culture conditions in a time-lapse incubator improved clinical outcomes compared with routine methods. Widespread application of time-lapse monitoring for fertility treatments with the promise of improved results should be questioned.

FUNDING

Health Care Efficiency Research programme from Netherlands Organisation for Health Research and Development and Merck.

Dimorphic frataxin and its gene regulation by sex steroids in hamsters

The role of frataxin (FXN) has been studied extensively in Friedreich ataxia patients, however, the molecular bases underlining the sex steroid-dependent gene expression profiles of FXN in adult tissues are unknown. I describe the molecular characterization of hamster FXN by examining the sexually dimorphic expression and its regulation by sex steroids. Sequence analysis of FXN cDNA showed 630 bp-long ORF encoding 209 amino acids. qPCR analysis revealed that FXN is detected in a wide range of tissues, with the highest expression in the heart, liver, and epididymis, and the weakest expression in the lung, spleen, uterus, and gut. In the male Harderian gland (HG), castration decreased FXN expression, while dihydrotestosterone (DHT) administration reestablished levels. FXN expression levels were higher in the male HG than the female HG. Expression levels in endocrine tissues showed a certain degree of sexual dimorphism; the transcript in the testis was significantly higher than those in the ovary. The effects of the estrous cycle on FXN expression remained unchanged in the HG, ovary, and adrenal glands; however, in the pancreas, the FXN mRNA was overexpressed during proestrus and exhibited sexual dimorphism as compared to the male pancreas. The mRNA expression results indicated that Harderian FXN may play a dynamic role in intracellular Fe of heme required for processing cytochromes and other hemeproteins, also suggesting that the moderate sexual dimorphism present in the HG and gonads could be regulated by androgens, while sexually dimorphic expression of FXN in the female pancreas may be controlled by sex steroids.

Using digital chatbots to close gaps in healthcare access during the COVID-19 pandemic

INTRODUCTION

Chatbots have emerged as a first link to care in recent years. The COVID-19 pandemic, and consequent health system disruptions, expanded their use. Socios En Salud (SES) introduced chatbots in Peru, which experienced one of the highest excess COVID mortalities in the world.

METHODS

SES and the government identified unmet population health needs, which could be amenable to virtual interventions. Chatbots were developed to screen individuals for these conditions; we describe the period of deployment, number of screenings, and number of people who received services.

RESULTS

Between April 2020 and May 2021, SES deployed nine ChatBots: four for mental health, two for maternal and child health, and three for chronic diseases: breast cancer, hypertension, diabetes mellitus, and obesity. Mental health services were provided to 42,932 people, 99.99% of those offered services. The other ChatBots reached fewer people. Overall, more than 50% of eligible people accepted chatbot-based services.

DISCUSSION

ChatBot use was highest for mental health. Chatbots may increase connections between a vulnerable population and health services; this is likely dependent on several factors, including condition, population, and penetration of smart phones. Future research will be critical to understand user experience and preferences and to ensure that chatbots link vulnerable populations to appropriate, high-quality care.

Clinical Validation and Extension of an Automated, Deep Learning-Based Algorithm for Quantitative Sinus CT Analysis

BACKGROUND AND PURPOSE

Sinus CT is critically important for the diagnosis of chronic rhinosinusitis. While CT is sensitive for detecting mucosal disease, automated methods for objective quantification of sinus opacification are lacking. We describe new measurements and further clinical validation of automated CT analysis using a convolutional neural network in a chronic rhinosinusitis population. This technology produces volumetric segmentations that permit calculation of percentage sinus opacification, mean Hounsfield units of opacities, and percentage of osteitis.

MATERIALS AND METHODS

Demographic and clinical data were collected retrospectively from adult patients with chronic rhinosinusitis, including serum eosinophil count, Lund-Kennedy endoscopic scores, and the SinoNasal Outcomes Test-22. CT scans were scored using the Lund-Mackay score and the Global Osteitis Scoring Scale. CT images were automatically segmented and analyzed for percentage opacification, mean Hounsfield unit of opacities, and percentage osteitis. These readouts were correlated with visual scoring systems and with disease parameters using the Spearman ρ.

RESULTS

Eighty-eight subjects were included. The algorithm successfully segmented 100% of scans and calculated features in a diverse population with CT images obtained on different scanners. A strong correlation existed between percentage opacification and the Lund-Mackay score (ρ = 0.85, P < .001). Both percentage opacification and the Lund-Mackay score exhibited moderate correlations with the Lund-Kennedy score (ρ = 0.58, P < .001, and ρ = 0.58, P < .001, respectively). The percentage osteitis correlated moderately with the Global Osteitis Scoring Scale (ρ = 0.48, P < .001).

CONCLUSIONS

Our quantitative processing of sinus CT images provides objective measures that correspond well to established visual scoring methods. While automation is a clear benefit here, validation may be needed in a prospective, multi-institutional setting.

Real-world efficacy of switching to bictegravir/ emtricitabine/tenofovir alafenamide in pretreated patients with triple therapy containing rilpivirine

Objetivo

Analizar la eficacia y tolerabilidad de la estrategia de cambio desde regímenes basados en rilpivirina (RPV) a bictegravir/emtricitabina/tenofovir alafenamida (B/F/TAF) en la vida real.

Métodos

Estudio unicéntrico, observacional y retrospectivo. Se seleccionaron pacientes que cambiaron de un régimen con RPV a B/F/TAF antes de febrero del 2020 analizándose los resultados después de 24 y 48 semanas. Se determinó el porcentaje que permanecía con carga viral indetectable, así como los cambios en linfocitos CD4+, parámetros metabólicos y función renal.

Resultados

Se incluyeron en el estudio 42 pacientes. 32 de los 35 (91,4%) que completaron las 48 semanas de seguimiento tenían carga viral indetectable. El recuento de linfocitos CD4+ permaneció estable a las 24 y a las 48 semanas. El tipo de análogos recibidos previamente no influyó en la respuesta

Conclusión

El cambio desde una triple terapia con RPV a B/F/TAF es una estrategia segura y eficaz en la vida real.

Womens’ preferences concerning IVF treatment: a discrete choice experiment with particular focus on embryo transfer policy

STUDY QUESTION

What outcomes are important for women to decide on the day of embryo transfer (ET) in IVF?

SUMMARY ANSWER

The highest cumulative live birth rate (cLBR) per treatment was the most important treatment outcome for women undergoing an IVF treatment, regardless of the number of transfers needed until pregnancy and impact on quality of life.

WHAT IS KNOWN ALREADY

Cleavage stage (Day 3) and blastocyst stage (Day 5) ETs are common transfer policies in IVF. The choice for one or the other day of ET differs between clinics. From the literature, it remains unclear whether the day of transfer impacts the cLBR. Patient preferences for the day of ET have not been examined yet.

STUDY DESIGN, SIZE, AND DURATION

A discrete choice experiment (DCE) was performed to investigate female patients’ preferences and their values concerning various aspects of an IVF treatment, with a particular focus on ET policy. A multicenter DCE was conducted between May 2020 and June 2020 in which participants were asked to choose between different treatments. Each treatment was presented using hypothetical scenarios containing the following attributes: the probability of a healthy live birth per IVF treatment cycle, the number of embryos available for transfer (for fresh and frozen-thawed ET), the number of ETs until pregnancy and the impact of the treatment on the quality of life.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women (n = 445) were asked to participate in the DCE at the start of an IVF treatment cycle in 10 Dutch fertility clinics. Participating women received an online questionnaire. The attributes’ relative importance was analyzed using logistic regression analyses.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 164 women participated. The most important attribute chosen was the cLBR. The total number of embryos suitable for transfer also influenced women’s treatment preferences. Neither the number of transfers needed until pregnancy, nor the impact on quality of life influenced the treatment preferences in the aggregated data. For women in the older age group (age ≥36 years) and the multipara subgroup, the impact on quality of life was more relevant. Naive patients (patients with no prior experience with IVF treatment) assigned less value to the number of ETs needed until pregnancy and assigned more value to the cLBR than the patients who had experienced IVF.

LIMITATIONS REASONS FOR CAUTION

An important limitation of a DCE study is that not all attributes can be included, which might be relevant for making choices. Patients might make other choices in real life as the DCE scenarios presented here are hypothetical and might not exactly represent their personal situation. We tried to avoid potential bias by selecting the attributes that mattered most to the patients obtained through patient focus groups. The final selection of attributes and the assigned levels were established using the input of an expert panel of professionals and by performing a pilot study to test the validity of our questionnaire. Furthermore, because we only included women in our study, we cannot draw any conclusions on preferences for partners.

WIDER IMPLICATIONS OF THE FINDINGS

The results of this study may help fertility patients, clinicians, researchers and policymakers to prioritize the most important attributes in the choice for the day of ET. The present study shows that cLBR per IVF treatment is the most important outcome for women. However, currently, there is insufficient information in the literature to conclude which day of transfer is more effective regarding the cLBR. Randomized controlled trials on the subject of Day 3 versus Day 5 ETs and cLBR are needed to allow evidence-based counseling.

STUDY FUNDING/COMPETING INTEREST(S)

This work received no specific funding and there are no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

P-044 Abnormal sperm morphology, so what? The clinical outcome of medical assisted reproduction is not affected by 100% teratospermic semen samples

Study question

What is the success rate (clinical outcome) in medical assisted reproduction (MAR) when 0% normal spermatozoa forms are observed using strict morphology criteria (SMC)?

Summary answer

Strict criteria morphology has no predictive value for the clinical outcome of MAR. Absence of normal morphology spermatozoa does not preclude high cumulative pregnancy rates.

What is known already

Many studies have questioned the clinical value of sperm morphology since no effect on treatment outcome is apparent when sperm samples with &lt;4% normal forms are used. However, data evaluating treatment outcome when 0% normal sperm at diagnose (evaluated by strict morphology criteria, WHO 2010) scarce. While teratozoospermia values are known to have a negative correlation with fertilization per cycle, data on cumulative ongoing pregnancy rates (COPR) or live birth rates (LBR) are missing in this selected group.

Study design, size, duration

This is a retrospective analysis (January 2010-June 2021) of the clinical outcome for couples when the male partner presents with 0% normal morphology (WHO 2010) at diagnostic semen analysis. Cases with 100% globozoospermia, cilia abnormalities or other MMAF phenotypes were excluded. Depending on the total progressively motile sperm count (TPMSC), couples were referred for MAR. The primary outcome presented is COPR/treatment and LBR/couple. Secondary outcomes were total fertilization failure (TFF) and mean fertilization rate (FR).

Participants/materials, setting, methods

All 193 cases included in this study presented with 100% teratozoospermia, as evaluated by two independent technicians following WHO 2010 manual recommendations. Couples were treated with IUI,IVF or ICSI depending on TPMSC at diagnosis. A total of 17 couples underwent 68 IUI treatments, 20 couples underwent 36 IVF ovum-pickups (OPU) (with respectively fresh embryo transfer (ET) and frozen ET, FET); 156 couples underwent 394 ICSI-OPU (with respectively fresh-ET and FET). Cumulative-OPR per treatment/couple is presented.

Main results and the role of chance

From the 17 couples undergoing IUI (mean 4 IUI cycles/couple; with or without mild ovarian stimulation) 3 ongoing pregnancies were reported (all singletons; 18% LBR per couple). Twenty IVF couples (mean 1.8 OPUs/couple) resulted in a total of 13 ongoing pregnancies (12 singletons, 1 twin pregnancy), therefore, the LBR per IVF-couple was 65%. In six cycles a TFF was observed even with sufficient motile sperm during insemination (5x with TPMSC &gt;5 x 10^6/ml). If TFF was observed after IVF cycle, then ICSI was performed in the next cycle. The IVF mean %FR using 100% teratozoospermic samples was 54%, compared to 58% in cases with &gt;1% normal forms.

Regarding ICSI, 156 couples underwent a total of 377 cycles (mean of 2.4 OPUs/couple). These treatments resulted in a total of 357 fresh-ET and 458 FET. A total of 103 couples achieved 154 ongoing pregnancies (146 singletons, 7 twins), therefore the COPR was 39%/cycle and LBR was 66%/couple. In 13 cycles (3.4%) TFF was observed and in 15 cases the fertilization rate was &lt;20%. The mean FR with ICSI using teratozoospermic samples was 55%. Comparingly, using samples with &gt;1% normal morphology, the laboratory mean for FR is 68% and 3.7% for TFF.

Limitations, reasons for caution

This is a retrospective study and not matched case-control cohort was used in this analysis. Not all couples have completed 3 complete IVF/ICSI cycles. As not all frozen embryos have been transferred, cumulative pregnancy rates might be higher than the rates reported here.

Wider implications of the findings

The data presented here confirms the limited value of the actual strict criteria for sperm morphology evaluation. Morphology is important for identification of sporadic sperm samples with atypical malformations such as globozoospermia, MMAF and other aberrant forms of a genetic origin, however SMC evaluation and interpretation should be reconsidered

Trial registration number

N.A.

O-003 The SelecTIMO study - clinical outcomes of uninterrupted embryo culture with or without time-lapse based embryo selection versus interrupted standard culture: a randomized controlled trial

Study question

Does uninterrupted embryo culture with or without the application of a time-lapse monitoring (TLM) selection algorithm lead to higher (cumulative) ongoing pregnancy rates?

Summary answer

Uninterrupted embryo culture with or without a TLM selection algorithm and interrupted culture with morphological embryo selection all resulted in comparable (cumulative) ongoing pregnancy rates.

What is known already

The application of TLM for embryo development has been claimed to improve success rates of IVF and ICSI treatments. Systematic reviews, however, show that evidence supporting the routine clinical use of TLM in IVF laboratories is limited and well-designed RCTs are needed to assess its clinical value. The uninterrupted and stable culture conditions in a TLM incubator may cause an increase of the clinical success rate independent from a possible improvement mediated by TLM based embryo selection procedures. Therefore, three study groups were needed to distinguish these two mechanisms.

Study design, size, duration

In this multicenter, double-blind, superiority RCT, women were prospectively randomized in three groups between 2017-2020: 1) TLE (Time-Lapse Eeva): embryo selection based on the Eeva® Test (a day three TLM algorithm, used adjunctively with morphology) and uninterrupted culture. 2) TLR (Time-Lapse Routine): routine morphological embryo selection and uninterrupted culture. 3) CON (Control): routine morphological embryo selection and interrupted culture. Embryos were cultured in Geri+ incubators. Randomization was stratified for laboratory-site and ovum pickup number.

Participants/materials, setting, methods

Women scheduled for day three single embryo transfer (SET) during their first, second or third ovum pickup were included. Primary endpoints were: 1) cumulative ongoing pregnancy rate (cOPR) including fresh SET and associated cryo transfers within 12 months of all women; 2) ongoing pregnancy rate (OPR) after fresh SET in a good-prognosis population: women &lt;41.0 years, ≥5 oocytes, ≥4 fertilized oocytes. Odds ratios (OR) with 95% CI were adjusted for laboratory-site and ovum pickup number.

Main results and the role of chance

A total of 1731 women were randomly assigned to TLE (577), TLR (579) or CON (575). The 12 month cOPR did not differ significantly between the groups (p = 0.85) with a cOPR of 50.8% (293/577) in TLE, 50.9% (295/579) in TLR and 49.4% (284/575) in CON (TLE vs TLR: OR 0.99, 95% CI 0.79 – 1.25; TLE vs CON: OR 1.06, 95% CI 0.84 – 1.33; CON vs TLR: OR 0.94, 95% CI 0.75 – 1.19). In the good-prognosis population, the OPR after fresh SET was 38.2% (125/327) in TLE, 36.5% (118/323) in TLR and 37.8% (123/325) in CON (p = 0.90). Consistent results were found for pregnancy and live birth rates after fresh embryo transfer and cumulatively within one year. A planned subgroup analysis of three female age groups revealed interaction between age group and treatment on cOPR (p = 0.02). In women of 39 years and older (n = 245), the cOPR was higher in TLE compared to TLR (40.0% vs 23.7%: OR 2.10, 95% CI 1.05-4.21) with no difference between TLE vs CON (40.0% vs 31.5%: OR 1.44, 95% CI 0.76-2.71).

Limitations, reasons for caution

This study investigated embryo culture in the Geri+ incubator and the Eeva® Test algorithm, which predicts blastocyst formation on day three and was used in combination with morphology for embryo selection, while more TLM systems and algorithms are currently available.

Wider implications of the findings

Neither embryo selection based on a TLM selection algorithm in combination with morphology (TLE) nor the uninterrupted culture conditions in the Geri+ incubator (TLR) improved (cumulative) ongoing pregnancy and live birth rates after IVF or ICSI. Widespread application for fertility treatments with the promise of improved outcomes should be questioned.

Trial registration number

NL5314

De novo mutations in children born after medical assisted reproduction

STUDY QUESTION

Are there more de novo mutations (DNMs) present in the genomes of children born through medical assisted reproduction (MAR) compared to spontaneously conceived children?

SUMMARY ANSWER

In this pilot study, no statistically significant difference was observed in the number of DNMs observed in the genomes of MAR children versus spontaneously conceived children.

WHAT IS KNOWN ALREADY

DNMs are known to play a major role in sporadic disorders with reduced fitness such as severe developmental disorders, including intellectual disability and epilepsy. Advanced paternal age is known to place offspring at increased disease risk, amongst others by increasing the number of DNMs in their genome. There are very few studies reporting on the effect of MAR on the number of DNMs in the offspring, especially when male infertility is known to be affecting the potential fathers. With delayed parenthood an ongoing epidemiological trend in the 21st century, there are more children born from fathers of advanced age and more children born through MAR every day.

STUDY DESIGN, SIZE, DURATION

This observational pilot study was conducted from January 2015 to March 2019 in the tertiary care centre at Radboud University Medical Center. We included a total of 53 children and their respective parents, forming 49 trios (mother, father and child) and two quartets (mother, father and two siblings). One group of children was born after spontaneous conception (n = 18); a second group of children born after IVF (n = 17) and a third group of children born after ICSI combined with testicular sperm extraction (ICSI-TESE) (n = 18). In this pilot study, we also subdivided each group by paternal age, resulting in a subgroup of children born to younger fathers (<35 years of age at conception) and older fathers (>45 years of age at conception).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Whole-genome sequencing (WGS) was performed on all parent-offspring trios to identify DNMs. For 34 of 53 trios/quartets, WGS was performed twice to independently detect and validate the presence of DNMs. Quality of WGS-based DNM calling was independently assessed by targeted Sanger sequencing.

MAIN RESULTS AND THE ROLE OF CHANCE

No significant differences were observed in the number of DNMs per child for the different methods of conception, independent of parental age at conception (multi-factorial ANOVA, f(2) = 0.17, P-value = 0.85). As expected, a clear paternal age effect was observed after adjusting for method of conception and maternal age at conception (multiple regression model, t = 5.636, P-value = 8.97 × 10-7), with on average 71 DNMs in the genomes of children born to young fathers (<35 years of age) and an average of 94 DNMs in the genomes of children born to older fathers (>45 years of age).

LIMITATIONS, REASONS FOR CAUTION

This is a pilot study and other small-scale studies have recently reported contrasting results. Larger unbiased studies are required to confirm or falsify these results.

WIDER IMPLICATIONS OF THE FINDINGS

This pilot study did not show an effect for the method of conception on the number of DNMs per genome in offspring. Given the role that DNMs play in disease risk, this negative result is good news for IVF and ICSI-TESE born children, if replicated in a larger cohort.

STUDY FUNDING/COMPETING INTEREST(S)

This research was funded by the Netherlands Organisation for Scientific Research (918-15-667) and by an Investigator Award in Science from the Wellcome Trust (209451). The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Real-world use of mycophenolate mofetil in inflammatory bowel disease: Results from the ENEIDA registry

BACKGROUND

Studies to evaluate the use of mycophenolate mofetil (MMF) in inflammatory bowel disease (IBD) are limited after the appearance of biological treatments.

AIMS

Our primary objective was to evaluate the effectiveness and safety of MMF in IBD.

METHODS

IBD patients who had received MMF were retrieved from the ENEIDA registry. Clinical activity as per the Harvey-Bradshaw Index (HBI), partial Mayo score (pMS), physician global assessment (PGA) and C-reactive protein (CRP) were reviewed at baseline, at 3 and 6 months, and at final follow-up. Adverse events and causes of treatment discontinuation were documented.

RESULTS

A total of 83 patients were included (66 Crohn's disease, 17 ulcerative colitis), 90% of whom had previously received other immunosuppressants. In 61% of patients systemic steroids were used at initiation of MMF, and in 27.3% biological agents were co-administered with MMF. Overall clinical effectiveness was observed in 64.7% of the population. At the end of treatment, 45.6% and 19.1% of subjects showed remission and clinical response, respectively. MMF treatment was maintained for a median of 28.9 months (IQR: 20.4-37.5).

CONCLUSION

Our study suggests, in the largest cohort to date, that MMF may be an effective alternative to thiopurines and methotrexate in IBD.

Controlling the volume fraction of glass-forming colloidal suspensions using thermosensitive host "mesogels"

The key parameter controlling the glass transition of colloidal suspensions is φ, the fraction of the sample volume occupied by the particles. Unfortunately, changing φ by varying an external parameter, e.g., temperature T as in molecular glass formers, is not possible, unless one uses thermosensitive colloidal particles, such as the popular poly(N-isopropylacrylamide) (PNiPAM) microgels. These, however, have several drawbacks, including high deformability, osmotic deswelling, and interpenetration, which complicate their use as a model system to study the colloidal glass transition. Here, we propose a new system consisting of a colloidal suspension of non-deformable spherical silica nanoparticles, in which PNiPAM hydrogel spheres of ∼100-200μm size are suspended. These non-colloidal "mesogels" allow for controlling the sample volume effectively available to the silica nanoparticles and hence their φ, thanks to the T-induced change in mesogels' volume. Using optical microscopy, we first show that the mesogels retain their ability to change size with T when suspended in Ludox suspensions, similarly as in water. We then show that their size is independent of the sample thermal history such that a well-defined, reversible relationship between T and φ may be established. Finally, we use space-resolved dynamic light scattering to demonstrate that, upon varying T, our system exhibits a broad range of dynamical behaviors across the glass transition and beyond, comparable with those exhibited by a series of distinct silica nanoparticle suspensions of various φ.

Validation of a New Software Application for Tear Breakup Measurement

SIGNIFICANCE

Tear film instability has been recognized as one key mechanism on dry eye disease. There is a need for new instruments, methods, or protocols to improve the repeatability and reproducibility of the tear film stability to facilitate its clinical evaluation use as a rapid and reliable primary diagnostic test.

PURPOSE

The present pilot study aimed to validate a method to automatically measure the tear film breakup time (BUT).

METHODS

A total of 264 videos of BUT were randomly selected among the clinical history of subjects attending the optometry clinic. Videos were stored in a backup server through a secure file transfer protocol and analyzed by three different examiners: two masked observers (subjective evaluation) and a third investigator using the automatic software application (objective evaluation). Subjective evaluation was conducted only once on an online software designed for this protocol where videos were presented in random masked order. Automatic evaluation based on color and texture analysis was performed by (1) automatic localization of sequences of interest in the video, (2) extraction of the region of interest within each frame, and (3) automatic BUT measurement from evolution curves in the region of interest as time elapsed from the beginning of the sequence of interest until the curve exceeds a threshold.

RESULTS

Substantial correlation was observed among the examiners (intraclass correlation coefficient, 0.752). There was a statistical difference between observer 1 and 2 evaluations (t test, P < .001), whereas data provided by the software showed no significant differences from those of the observers (t test, P ≥ .26). Similar results to the whole data set analysis were obtained when the sample was reassessed only considering mean BUT values ≤15 seconds.

CONCLUSIONS

The present pilot study showed acceptable clinical results for the software application designed to objectively measure the BUT.

Dupilumab for atopic dermatitis: a real-world portuguese multicenter retrospective study

Introduction: Atopic dermatitis (AD) is a difficult-to-treat inflammatory skin disease with a high impact on patients' quality of life. Dupilumab, an IL-4 and IL-13 inhibitor, was the first monoclonal antibody approved for the treatment of moderate-to-severe AD and is currently approved in patients aged 6 or older.Methods: This is a nationwide, multicenter, retrospective, 48-week study designed by the Portuguese Group of AD to assess real-world efficacy and safety of dupilumab for the treatment of AD.Results: A total of 169 patients were enrolled, with a mean disease duration of 22.75 (±11.98) years. The percentage of patients achieving an improvement of at least 75% in Eczema Area and Severity Index (EASI) compared to baseline (EASI75 response) at weeks 12 and 48 was 67.6% and 74.1%, respectively. In the same timepoints, 25.0% and 44.1% achieved an EASI90 response. Patient-reported outcome measures also improved throughout the study period. Regarding safety, 32.0% of the patients developed adverse events, with conjunctivitis (26.6%), persistent facial erythema (4.7%), and arthritis/arthralgia (3.6%) as the more frequently reported.Conclusion: Data from real-world populations are crucial to guide clinicians in their daily decisions. This study provides data demonstrating that dupilumab is an effective and safe therapeutic option for AD.

High fat diet-induced obesity prolongs critical stages of the spermatogenic cycle in a Ldlr-/-.Leiden mouse model

Obesity can disturb spermatogenesis and subsequently affect male fertility and reproduction. In our study, we aim to elucidate at which cellular level of adult spermatogenesis the detrimental effects of obesity manifest. We induced high fat diet (HFD) obesity in low-density lipoprotein receptor knock-out Leiden (Ldlr^−/−.Leiden) mice, and studied the morphological structure of the testes and histologically examined the proportion of Sertoli cells, spermatocytes and spermatids in the seminiferous tubules. We examined sperm DNA damage and chromatin condensation and measured plasma levels of leptin, testosterone, cholesterol and triglycerides. HFD-induced obesity caused high plasma leptin and abnormal testosterone levels and induced an aberrant intra-tubular organisation (ITO) which is associated with an altered spermatids/spermatocytes ratio (2:1 instead of 3:1). Mice fed a HFD had a higher level of tubules in stages VII + VIII in the spermatogenic cycle. The stages VII + VII indicate crucial processes in spermatogenic development like initiation of meiosis, initiation of spermatid elongation, and release of fully matured spermatids. In conclusion, HFD-induced obese Ldlr^−/−.Leiden mice develop an aberrant ITO and alterations in the spermatogenic cycle in crucial stages (stages VII and VII). Thereby, our findings stress the importance of lifestyle guidelines in infertility treatments.

A de novo paradigm for male infertility

De novo mutations are known to play a prominent role in sporadic disorders with reduced fitness. We hypothesize that de novo mutations play an important role in severe male infertility and explain a portion of the genetic causes of this understudied disorder. To test this hypothesis, we utilize trio-based exome sequencing in a cohort of 185 infertile males and their unaffected parents. Following a systematic analysis, 29 of 145 rare (MAF < 0.1%) protein-altering de novo mutations are classified as possibly causative of the male infertility phenotype. We observed a significant enrichment of loss-of-function de novo mutations in loss-of-function-intolerant genes (p-value = 1.00 × 10^-5) in infertile men compared to controls. Additionally, we detected a significant increase in predicted pathogenic de novo missense mutations affecting missense-intolerant genes (p-value = 5.01 × 10^-4) in contrast to predicted benign de novo mutations. One gene we identify, RBM5, is an essential regulator of male germ cell pre-mRNA splicing and has been previously implicated in male infertility in mice. In a follow-up study, 6 rare pathogenic missense mutations affecting this gene are observed in a cohort of 2,506 infertile patients, whilst we find no such mutations in a cohort of 5,784 fertile men (p-value = 0.03). Our results provide evidence for the role of de novo mutations in severe male infertility and point to new candidate genes affecting fertility.

Hamster DAX1: Molecular insights, specific expression, and its role in the Harderian gland

DAX1 plays an essential role in the differentiation and physiology of the Hypothalamic-Pituitary-Adrenal-Gonadal (HPAG) axis during embryogenesis. However, in adult tissues, in addition to the HPAG axis, evidence has not been found for its differential expression and function. We isolated the DAX1 cDNA to analyze its tissue localization and gene expression profiles in male and female hamsters' Harderian glands (HGs), Mesocricetus auratus. The isolated cDNA clone contains 1848 base pairs (bp), and a 1428-bp open reading frame (ORF) encodes a 476 amino acid protein. Sequence alignments and the phylogenetic tree display a relevant percentage of similarity with human (66%), rat (81%), and mouse (84%) sequences. In adult tissues, the mRNA distribution demonstrated that DAX1 is present in testis, ovaries, and male and female HGs. The highest expression profiles were identified in the adrenal glands, where females exhibit higher mRNA levels than males. The sexually dimorphic expression of DAX1 in adrenals suggests that its presence could be associated with regulating, functioning, and maintaining this endocrine tissue. These findings indicate that the DAX1 gene is limitedly expressed in adult tissues. In the HGs, we demonstrate the absence of sexually dimorphic gene expression. Our results suggest that DAX1 might have an additional physiological function outside of the HPAG axis, specifically in the HG, which may be required for the regulation of intracrine steroidogenesis, secretion, and maintenance of exocrine tissue.

Detailed Morphological Analysis of Cryoinjury in Human Ovarian Tissue Following Vitrification or Slow Freezing

Cryopreservation of human ovarian tissue represents a key procedure for fertility preservation. The two most widely used cryopreservation methods for human ovarian cortex samples are slow freezing\thawing (SF\T) and vitrification\warming (V\W). The aim of the present study was to analyze the effects of SF\T and V\W using a metal chamber, on specific follicle and oocyte structures and on the stromal organization post-cryopreservation. We did histology analysis of SF\T and V\W ovarian fragments from nine healthy subjects. Overall results showed that cryopreserved tissues presented significant rates of damage in primordial and primary follicles. Altered nuclear structure of primordial follicles and cell detachment from primordial and primary follicles were the main injuries observed after V/W and SF/T. The stromal components were similarly well preserved after cryopreservation. We conclude that both cryopreservation methods may be used for fertility preservation purposes with similar outcomes in terms of follicular and stromal integrity. Detachment of follicle cells from basal membrane represents an important cryoinjury that deserves further investigation.

P–133 Monopronuclear (1PN) embryos can derive in healthy pregnancies

Study question

Should 1PN embryos be considered suitable for transfer when normal development is observed at day 3 or day 5?

Summary answer

In IVF/ICSI cycles, 1PN zygotes are encountered in 2.7% of inseminated oocytes. Transfer of 1PN-embryos should be considered in the absence of suitable 2PN embryos.

What is known already

During in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI) zygotes containing only a single pronucleus (monopronuclear, 1PN) are encountered in 1–7.7% of cases, while the display of two pronuclei is expected in a normally fertilised oocyte. A 1PN zygote can be of gynogenetic or androgenetic origin, but it can also be biparental. Gynogenetic and androgenetic 1PN embryos can be haploid or diploid, so a diploid 1PN embryo is not guaranteed to be normally fertilised. Generally, 1PN are discarded, as they have an increased risk for aneuploidy. However, sporadically they can develop into healthyl babies.

Study design, size, duration

1PN-zygotes (n = 1287, 2.7% from all inseminated oocytes) from 1–1–2016 up to 15–12–2020 were retrospectively evaluated. The development and fate (discarded/transferred/cryopreserved) of all embryos were recorded. Embryos were evaluated at day 2, 3 or 5 of development. The policy of our unit is that, in absence of 2PN embryos, normal developed 1PN-embryos can be transferred on day 3. Supernumerary 1PN embryos can be cryopreserved at blastocyst stage. Ongoing pregnancies from fresh embryo transfers (ET) were analysed.

Participants/materials, setting, methods

In 946 IVF/ICSI cycles, at least one 1PN zygote was observed (total 1287 embryos). ICSI with ejaculated, PESA or TESE sperm counted for a total of 795 embryos, IVF cycles for 494 embryos. Embryo evaluation was performed using a home-made numerical algorithm: A (top embryo; 150–200 points), B (regular embryo; 100–149 points) or C (poor embryo; 0–99 points). Monopronuclear embryos always scored lower than equal developed 2PN embryos. Blastocyst evaluation was according to Gardner score.

Main results and the role of chance

From the 795 ICSI embryos, 49 (6.1%) were used for fresh ET (26 scored quality A or B), and a total of 60 embryos developed to blastocyst and were cryopreserved. From these 49 ICSI transfers, 4 (8.1%) ongoing pregnancies were obtained, all 4 from DET (1PN+2PN embryo), from which one twin pregnancy was confirmed. From the 494 IVF embryos, 41 (8.3%) were used for fresh ET (24 scored A or B), and 62 blastocysts were cryopreserved. A total of 9/41 (22%) ongoing pregnancies were obtained: 5 from SET (1PN) and 4 from DET (1PN+ 2PN embryo). Therefore, in only five IVF cycles a confirmed pregnancy was observed from a 1PN embryo (all A-quality embryos).

Considering six ongoing pregnancies with complete certainty of monopronuclear origin from fresh tranfers could be confirmed from our retrospective data, we can conclude that although the live birth rate of these embryos is very low (around 0,5- 1.0%), they should not be discarded when development is normal and no dipronuclear embryos are present.

Limitations, reasons for caution

Cryo-thawing data is missing as these embryos were not differentially marked at freezing. Therefore, the cumulative pregnancies from monopronuclear embryos could be higher. Embryos were not evaluated in a time lapse system, so asynchronicity of PN formation could explain missing the right moment for evaluation, while normal fertilized.

Wider implications of the findings: Notably, IVF monopronuclear embryos display a higher developmental potential than those derived from ICSI. We suggest that, in absence of dipronuclear embryos, culture to blastocyst stage before considering fresh ET or cryopreservation will help differentiate viable 1PN embryos, reducing the higher chance of genetic anomalies and miscarriages.

Trial registration number

N.A.

Exhaustive characterization of (semi-)volatile organic contaminants in car dust using comprehensive two-dimensional gas chromatography ‒ Time-of-flight mass spectrometry

This work represents the first reported effort to build an extensive database of the organic volatile and semi-volatile contaminants present in car dust as a result of migration from materials used in auto-manufacturing. Untargeted analysis of car dust samples has been performed using comprehensive two-dimensional gas chromatography combined with time-of-fight mass spectrometry (GC×GC ‒ToF MS) after generic sample preparation. The enhanced separation power and structural confirmation capabilities provided by this technique have been used for the either positive or tentative identification of 245 GC-amenable compounds, a number of them being identified for the first time in this type of matrix. Information concerning 5 compounds remaining unidentified has also been provided. Results have been summarised in a searchable database containing chromatographic, mass spectral and normalised abundances calculated for the detected analytes in the ten investigated car dusts used to discuss the main findings of the study. Results are expected to serve other researcher to take decisions concerning priority analytes for further evaluation in this research field and for car manufacturers who might search for safer materials.

Exome sequencing reveals variants in known and novel candidate genes for severe sperm motility disorders

STUDY QUESTION

What are the causative genetic variants in patients with male infertility due to severe sperm motility disorders?

SUMMARY ANSWER

We identified high confidence disease-causing variants in multiple genes previously associated with severe sperm motility disorders in 10 out of 21 patients (48%) and variants in novel candidate genes in seven additional patients (33%).

WHAT IS KNOWN ALREADY

Severe sperm motility disorders are a form of male infertility characterised by immotile sperm often in combination with a spectrum of structural abnormalities of the sperm flagellum that do not affect viability. Currently, depending on the clinical sub-categorisation, up to 50% of causality in patients with severe sperm motility disorders can be explained by pathogenic variants in at least 22 genes.

STUDY DESIGN, SIZE, DURATION

We performed exome sequencing in 21 patients with severe sperm motility disorders from two different clinics.

PARTICIPANTS/MATERIALS, SETTING, METHOD

Two groups of infertile men, one from Argentina (n = 9) and one from Australia (n = 12), with clinically defined severe sperm motility disorders (motility <5%) and normal morphology values of 0–4%, were included. All patients in the Argentine cohort were diagnosed with DFS-MMAF, based on light and transmission electron microscopy. Sperm ultrastructural information was not available for the Australian cohort. Exome sequencing was performed in all 21 patients and variants with an allele frequency of <1% in the gnomAD population were prioritised and interpreted.

MAIN RESULTS AND ROLE OF CHANCE

In 10 of 21 patients (48%), we identified pathogenic variants in known sperm assembly genes: CFAP43 (3 patients); CFAP44 (2 patients), CFAP58 (1 patient), QRICH2 (2 patients), DNAH1 (1 patient) and DNAH6 (1 patient). The diagnostic rate did not differ markedly between the Argentinian and the Australian cohort (55% and 42%, respectively). Furthermore, we identified patients with variants in the novel human candidate sperm motility genes: DNAH12, DRC1, MDC1, PACRG, SSPL2C and TPTE2. One patient presented with variants in four candidate genes and it remains unclear which variants were responsible for the severe sperm motility defect in this patient.

LARGE SCALE DATA

N/A

LIMITATIONS, REASONS FOR CAUTION

In this study, we described patients with either a homozygous or two heterozygous candidate pathogenic variants in genes linked to sperm motility disorders. Due to unavailability of parental DNA, we have not assessed the frequency of de novo or maternally inherited dominant variants and could not determine the parental origin of the mutations to establish in all cases that the mutations are present on both alleles.

WIDER IMPLICATIONS OF THE FINDINGS

Our results confirm the likely causal role of variants in six known genes for sperm motility and we demonstrate that exome sequencing is an effective method to diagnose patients with severe sperm motility disorders (10/21 diagnosed; 48%). Furthermore, our analysis revealed six novel candidate genes for severe sperm motility disorders. Genome-wide sequencing of additional patient cohorts and re-analysis of exome data of currently unsolved cases may reveal additional variants in these novel candidate genes.

STUDY FUNDING/COMPETING INTEREST(S)

This project was supported in part by funding from the Australian National Health and Medical Research Council (APP1120356) to M.K.O.B., J.A.V. and R.I.M.L., The Netherlands Organisation for Scientific Research (918-15-667) to J.A.V., the Royal Society and Wolfson Foundation (WM160091) to J.A.V., as well as an Investigator Award in Science from the Wellcome Trust (209451) to J.A.V. and Grants from the National Research Council of Argentina (PIP 0900 and 4584) and ANPCyT (PICT 9591) to H.E.C. and a UUKi Rutherford Fund Fellowship awarded to B.J.H.

Effect of parental and ART treatment characteristics on perinatal outcomes

STUDY QUESTION

Do parental characteristics and treatment with ART affect perinatal outcomes in singleton pregnancies?

SUMMARY ANSWER

Both parental and ART treatment characteristics affect perinatal outcomes in singleton pregnancies.

WHAT IS KNOWN ALREADY

Previous studies have shown that singleton pregnancies resulting from ART are at risk of preterm birth. ART children are lighter at birth after correction for duration of gestation and at increased risk of congenital abnormalities compared to naturally conceived children. This association is confounded by parental characteristics that are also known to affect perinatal outcomes. It is unclear to which extent parental and ART treatment characteristics independently affect perinatal outcomes.

STUDY DESIGN, SIZE, DURATION

All IVF clinics in the Netherlands (n = 13) were requested to provide data on all ART treatment cycles (IVF, ICSI and frozen-thawed embryo transfers (FET)), performed between 1 January 2000, and 1 January 2011, which resulted in a pregnancy. Using probabilistic data-linkage, these data (n = 36 683) were linked to the Dutch Perinatal Registry (Perined), which includes all children born in the Netherlands in the same time period (n = 2 548 977).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Analyses were limited to singleton pregnancies that resulted from IVF, ICSI or FET cycles. Multivariable models for linear and logistic regression were fitted including parental characteristics as well as ART treatment characteristics. Analyses were performed separately for fresh cycles and for fresh and FET cycles combined. We assessed the impact on the following perinatal outcomes: birth weight, preterm birth below 37 or 32 weeks of gestation, congenital malformations and perinatal mortality.

MAIN RESULTS AND THE ROLE OF CHANCE

The perinatal outcomes of 31 184 out of the 36 683 ART treatment cycles leading to a pregnancy were retrieved through linkage with the Perined (85% linkage). Of those, 23 671 concerned singleton pregnancies resulting from IVF, ICSI or FET. Birth weight was independently associated with both parental and ART treatment characteristics. Characteristics associated with lower birth weight included maternal hypertensive disease, non-Dutch maternal ethnicity, nulliparity, increasing duration of subfertility, hCG for luteal phase support (compared to progesterone), shorter embryo culture duration, increasing number of oocytes retrieved and fresh embryo transfer. The parental characteristic with the greatest effect size on birth weight was maternal diabetes (adjusted difference 283 g, 95% CI 228–338). FET was the ART treatment characteristic with the greatest effect size on birth weight (adjusted difference 100 g, 95% CI 84–117) compared to fresh embryo transfer. Preterm birth was more common among mothers of South-Asian ethnicity. Preterm birth was less common among multiparous women and women with ‘male factor’ as treatment indication (compared to ‘tubal factor’).

LIMITATIONS, REASONS FOR CAUTION

Due to the retrospective nature of our study, we cannot prove causality. Further limitations of our study were the inability to adjust for mothers giving birth more than once in our dataset, missing values for several variables and limited information on parental lifestyle and general health.

WIDER IMPLICATIONS OF THE FINDINGS

Multiple parental and ART treatment characteristics affect perinatal outcomes, with birth weight being influenced by the widest range of factors. This highlights the importance of assessing both parental and ART treatment characteristics in studies that focus on the health of ART-offspring, with the purpose of modifying these factors where possible. Our results further support the hypothesis that the embryo is sensitive to its early environment.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by Foreest Medical School, Alkmaar, the Netherlands (grants: FIO 1307 and FIO 1505). B.W.M. reports grants from NHMRC and consultancy for ObsEva, Merck KGaA, iGenomics and Guerbet. F.B. reports research support grants from Merck Serono and personal fees from Merck Serono. A.C. reports travel support from Ferring BV. and Theramex BV. and personal fees from UpToDate (Hyperthecosis), all outside the remit of the current work. The remaining authors report no conflict of interests.

TRIAL REGISTRATION NUMBER

N/A.

Harderian SOX9: Molecular characterization and its dimorphic expression in hamster

The molecular action of SOX9 can promote lipogenesis. Because the hamster Harderian gland (HG) synthesizes lipids and exhibits sexual dimorphism, this study aimed to identify and characterize Harderian SOX9. We examined the tissue distribution and expression profiles of SOX9 in hamster Mesocricetus auratus HGs. The full-length SOX9 cDNA sequence [3649-base pairs (bp)] contains an 81-bp 5' untranslated region (UTR), a 3' UTR of 2044-bp, an open reading frame (ORF) of 1524-bp, and a polyadenylation signal (AATAAA) at 19-bp upstream of poly(A) tail. The cDNA encodes a 507 amino acid protein containing the potential DNA-binding domain known as the HMG box. BLAST analysis revealed 99%, 99%, and 97% identity with the SOX9 of mouse, rat, and human, respectively. High expression levels were also observed in the testis, cerebellum, and hypothalamus. qPCR analysis demonstrated that SOX9 is expressed more abundantly in the HGs of males than in females. Sexually dimorphic expression of SOX9 suggests that differential expression between male and female HGs could be under the regulation of sex steroids. SOX9 might play a similar role in regulating exocrine secretions of lipids; these could occur downstream of FGF signaling - as found during embryogenesis - and/or androgen signaling.

Exome sequencing reveals novel causes as well as new candidate genes for human globozoospermia

STUDY QUESTION

Can exome sequencing identify new genetic causes of globozoospermia?

SUMMARY ANSWER

Exome sequencing in 15 cases of unexplained globozoospermia revealed deleterious mutations in seven new genes, of which two have been validated as causing globozoospermia when knocked out in mouse models.

WHAT IS KNOWN ALREADY

Globozoospermia is a rare form of male infertility characterised by round-headed sperm and malformation of the acrosome. Although pathogenic variants in DPY19L2 and SPATA16 are known causes of globozoospermia and explain up to 70% of all cases, genetic causality remains unexplained in the remaining patients.

STUDY DESIGN, SIZE, DURATION

After pre-screening 16 men for mutations in known globozoospermia genes DPY19L2 and SPATA16, exome sequencing was performed in 15 males with globozoospermia or acrosomal hypoplasia of unknown aetiology.

PARTICIPANTS/MATERIALS, SETTING, METHOD

Targeted next-generation sequencing and Sanger sequencing was performed for all 16 patients to screen for single-nucleotide variants and copy number variations in DPY19L2 and SPATA16. After exclusion of one patient with DPY19L2 mutations, we performed exome sequencing for the 15 remaining subjects. We prioritised recessive and X-linked protein-altering variants with an allele frequency of <0.5% in the population database GnomAD in genes with an enhanced expression in the testis. All identified candidate variants were confirmed in patients and, where possible, in family members using Sanger sequencing. Ultrastructural examination of semen from one of the patients allowed for a precise phenotypic characterisation of abnormal spermatozoa.

MAIN RESULTS AND ROLE OF CHANCE

After prioritisation and validation, we identified possibly causative variants in eight of 15 patients investigated by exome sequencing. The analysis revealed homozygous nonsense mutations in ZPBP and CCDC62 in two unrelated patients, as well as rare missense mutations in C2CD6 (also known as ALS2CR11), CCIN, C7orf61 and DHNA17 and a frameshift mutation in GGN in six other patients. All variants identified through exome sequencing, except for the variants in DNAH17, were located in a region of homozygosity. Familial segregation of the nonsense variant in ZPBP revealed two fertile brothers and the patient’s mother to be heterozygous carriers. Paternal DNA was unavailable. Immunohistochemistry confirmed that ZPBP localises to the acrosome in human spermatozoa. Ultrastructural analysis of spermatozoa in the patient with the C7orf61 mutation revealed a mixture of round heads with no acrosomes (globozoospermia) and ovoid or irregular heads with small acrosomes frequently detached from the sperm head (acrosomal hypoplasia).

LIMITATIONS, REASONS FOR CAUTION

Stringent filtering criteria were used in the exome data analysis which could result in possible pathogenic variants remaining undetected. Additionally, functional follow-up is needed for several candidate genes to confirm the impact of these mutations on normal spermatogenesis.

WIDER IMPLICATIONS OF THE FINDINGS

Our study revealed an important role for mutations in ZPBP and CCDC62 in human globozoospermia as well as five new candidate genes. These findings provide a more comprehensive understanding of the genetics of male infertility and bring us closer to a complete molecular diagnosis for globozoospermia patients which would help to predict the success of reproductive treatments.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by The Netherlands Organisation for Scientific Research (918–15-667); National Health and Medical Research Council of Australia (APP1120356) and the National Council for Scientific Research (CONICET), Argentina, PIP grant 11220120100279CO. The authors have nothing to disclose.

Dutasteride combined with androgen receptor antagonists inhibit glioblastoma U87 cell metabolism, proliferation, and invasion capacity: Androgen regulation

Glioblastoma (GB) is the most common and aggressive primary brain tumor in adult humans. Therapeutic resistance and tumor recurrence after surgical resection contributes to a poor prognosis for glioblastoma patients. Men are known to be more likely than women to develop an aggressive form of GB. Although the reasons for this disparity remain poorly understood, differences in sex steroids have emerged as a leading explanation. Studies indicate that GB-derived cells express androgen receptors (ARs) and synthesize androgens, suggesting that androgens may have a role in the tumor pathogenesis. Thus, our objective was to investigate the effects of the 5α-reductase enzyme inhibitor dutasteride, the AR antagonists cyproterone and flutamide, and combinations of these drugs on the metabolism, proliferation, and invasion capacity of GB-derived U87 cells. We also examined the effects of three natural androgens testosterone, androstenedione and dihydrotestosterone (T, A₄, and DHT) on these cells. Cell metabolism was investigated by MTT assay, proliferation was assessed by the bromodeoxyuridine (BrdU) incorporation assay, and invasion was assessed by Boyden chamber assay. The results revealed that T and especially DHT, but not A₄, increased U87 cell metabolism and proliferation. Following these findings, we examined the effect of adding dutasteride, cyproterone, or flutamide to the culture media and found that they all significantly decreased cell metabolism and proliferation. Dutasteride also significantly reduced cell invasion. Moreover, any combination of these drugs enhanced their inhibitory effects; the combination of dutasteride to flutamide was most effective at decreasing GB cell proliferation. Our results suggest that administering a combination of AR antagonists and enzyme blockers may be a more effective alternative treatment for GB.

Molecular genetic analysis of AKR1C2-4 and HSD17B6 genes in subjects 46,XY with hypospadias

BACKGROUND

The formation of the male urethra depends to enzyme-mediated testosterone (T) conversion into 5α-dihydrotestosterone (DHT). Two metabolic pathways could be operating in the fetal testis to synthesize androgens: 1) the "classic" route (T→DHT) mediated by SRD5A2 and 2) a "backdoor" pathway in which DHT is synthesized by aldo-keto reductase family 1, member C2 (AKR1C2), AKR1C3, and AKR1C4 enzymes without formation of a T intermediate.

OBJECTIVE

We studied four genes of the "backdoor" pathway in karyotypic males with hypospadias to ascertain whether gene defects in AKRs impair urethral DHT formation that result in hypospadias.

DESIGN AND PATIENTS

The coding regions of the AKR1C2-4 and HSD17B6 genes were analyzed by PCR-SSCP and sequencing in a cohort of 25 Mexican patients (0.3-9 year-old-children) with 46,XY-hypospadias. Chi-squared tests was performed to evaluate the distribution of genotypes, alleles, and the Hardy-Weinberg (H-W) equilibrium. The effect of the genetic variants was investigated by in silico studies.

RESULTS

Screening studies revealed distinct genotypic patterns at different exons of AKR1C2-4 whereas HSD17B6 presented a wild-type sequence. The DNA analyses detected two synonymous variants (c.327C>T, c.666T>C/unreported) in AKR1C2. The AKR1C3 had two variants (c.15C>G, c.230A>G), two unreported variants (c.538T>C, c.596G>A), and one silent variant (c.312G>A). Two variants (c.434C>G, c.931C>G) were identified in AKR1C4. All variants were in H-W equilibrium without structural changes.

DISCUSSION

Hypospadias have been associated with defects that alter androgen biosynthesis in the human fetal testis, specifically 5α-DHT. We selected four candidate genes involved in the "backdoor" pathway for the formation of 5α-DHT. Molecular assays of the AKR1C2, AKR1C3, and AKR1C4 genes revealed a total of nine genetic single nucleotide variants. Several variants in the AKR1C genes have been associated with a variety of human pathologies. However, our studies suggest that active steroid biosynthesis via AKR1C might not be involved in hypospadias. Additionally, genetic research suggests a low involvement in the "backdoor" 5α-DHT pathway during human sexual development, specifically, the differentiation of male external genitalia.

CONCLUSION

These results indicate that substitutions in AKR1C2-4 are polymorphisms and all genetic variants lacks deleterious significant association with hypospadias. The data suggest that inactivating mutations in the AKR1C2-4 and HSD17B6 genes are an infrequent cause of hypospadias, which might weaken the contribution of the "backdoor" pathway to embryonic urethral masculinization.

Fertility preservation in boys: recent developments and new insights †

BACKGROUND

Infertility is an important side effect of treatments used for cancer and other non-malignant conditions in males. This may be due to the loss of spermatogonial stem cells (SSCs) and/or altered functionality of testicular somatic cells (e.g. Sertoli cells, Leydig cells). Whereas sperm cryopreservation is the first-line procedure to preserve fertility in post-pubertal males, this option does not exist for prepubertal boys. For patients unable to produce sperm and at high risk of losing their fertility, testicular tissue freezing is now proposed as an alternative experimental option to safeguard their fertility.

OBJECTIVE AND RATIONALE

With this review, we aim to provide an update on clinical practices and experimental methods, as well as to describe patient management inclusion strategies used to preserve and restore the fertility of prepubertal boys at high risk of fertility loss.

SEARCH METHODS

Based on the expertise of the participating centres and a literature search of the progress in clinical practices, patient management strategies and experimental methods used to preserve and restore the fertility of prepubertal boys at high risk of fertility loss were identified. In addition, a survey was conducted amongst European and North American centres/networks that have published papers on their testicular tissue banking activity.

OUTCOMES

Since the first publication on murine SSC transplantation in 1994, remarkable progress has been made towards clinical application: cryopreservation protocols for testicular tissue have been developed in animal models and are now offered to patients in clinics as a still experimental procedure. Transplantation methods have been adapted for human testis, and the efficiency and safety of the technique are being evaluated in mouse and primate models. However, important practical, medical and ethical issues must be resolved before fertility restoration can be applied in the clinic.Since the previous survey conducted in 2012, the implementation of testicular tissue cryopreservation as a means to preserve the fertility of prepubertal boys has increased. Data have been collected from 24 co-ordinating centres worldwide, which are actively offering testis tissue cryobanking to safeguard the future fertility of boys. More than 1033 young patients (age range 3 months to 18 years) have already undergone testicular tissue retrieval and storage for fertility preservation.

LIMITATIONS REASONS FOR CAUTION

The review does not include the data of all reproductive centres worldwide. Other centres might be offering testicular tissue cryopreservation. Therefore, the numbers might be not representative for the entire field in reproductive medicine and biology worldwide. The key ethical issue regarding fertility preservation in prepubertal boys remains the experimental nature of the intervention.

WIDER IMPLICATIONS

The revised procedures can be implemented by the multi-disciplinary teams offering and/or developing treatment strategies to preserve the fertility of prepubertal boys who have a high risk of fertility loss.

STUDY FUNDING/COMPETING INTERESTS

The work was funded by ESHRE. None of the authors has a conflict of interest.

Mutational analysis of SRD5A2: From gene to functional kinetics in individuals with steroid 5α-reductase 2 deficiency

Human steroid 5α-reductase 2 (SRD5A2) plays a determinative role in the masculinization of external genitalia. To date, approximately 114 different mutations of the SRD5A2 gene have been reported; however, little information is available about their impact on catalytic function or their three-dimensional (3D) structures. We determined the effect of point mutations on the testosterone-depend kinetic constants (K_m,app and V_max,app) and structural characteristics of SRD5A2 from Mexican patients with 46,XY-steroid 5α-reductase 2 deficiency. PCR-SSCP assays identified ten distinct gene variants and sequencing analysis identified missense mutations [p.V3I, p.S14R, p.A52T, p.F118L, p.R145W, p.R171S, p.L226P, p.F229S, p.S245Y, and p.A248V]. Mutations were re-created by site-directed mutagenesis and expressed in HEK293 cells. Functional studies demonstrated that 8 variants led to partial (K_m,app = 0.16-2.6 μM; V_max,app = 224-2640 pmol/mg P/min) or complete losses of activity compared to the wild-type enzyme (K_m,app = 0.7 μM; V_max,app = 4044 pmol/mg P/min). All the mutations were assessed using multiple software tools and the results predicted that all of the mutations were associated with disease or damage. Mapping mutations on the model of a 3D structure of SRD5A2 demonstrated alterations in contact sites with their proximal amino acids. Our data show that mutations affect the catalytic efficiency (V_max/K_m) or result in residual enzymatic activity, which could be due to erroneous interactions between amino acid residues, the substrate testosterone, or NADPH.

Potential of topological descriptors to model the retention of polychlorinated biphenyls in different gas chromatography stationary phases, including ionic liquid-based columns

The aim of this study was to develop a statistical model based on a set of intuitive topological descriptors that will help to determine the influence of the polychlorinated biphenyls (PCBs) structural features on the chromatographic behavior of these analytes in a variety of gas chromatographic stationary phases, including the highly polar ionic liquid (IL)-based SLB-IL76 and SLB-IL60 columns. The model was developed using the stepwise multiple linear regression method, and constructed through several levels of increasing complexity to make evident the relative influence of the selected descriptors. The proposed model was easy to implement and provided similar satisfactory results irrespective of the dependent variables used (i.e., retention index or retention time) or the chromatographic conditions applied (i.e., pseudo-isotherm and programmed temperature) for IL-based phases. The model also allowed the correct prediction of the elution order of selected PCBs in these and other less polar phases evaluated (i.e., SW-10, DB-17, ZB-5 and HT-8). To our knowledge, this is the first models based on topological descriptors described in the literature that provided a satisfactory fitting of the PCB behavior in IL-based phases. Our results indicated that the mechanism governing the chromatographic separation of PCBs in these highly polar columns showed significant differences compared with those observed in other less polar stationary phases.

Serum caspase-3 levels during the first week of traumatic brain injury

OBJECTIVE

Confluence between the intrinsic and extrinsic apoptosis pathways is reached at the point of caspase-3 activation, which induces death cell. Higher serum caspase-3 levels have been recorded on day 1 of traumatic brain injury (TBI) in 30-day non-survivors compared to survivors. The objectives of this study therefore were to determine whether serum caspase-3 levels are persistently higher in non-survivors than in survivors, and whether these levels may be used to predict 30-day mortality.

DESIGN

A prospective observational study was carried out.

SETTING

Six Spanish Intensive Care Units.

PATIENTS

Patients with severe isolated TBI (defined as Glasgow Coma Scale <9 points and non-cranial Injury Severity Score <10 points).

INTERVENTIONS

Serum caspase-3 concentrations were measured on days 1, 4 and 8 of TBI.

MAIN VARIABLES OF INTEREST

Thirty-day mortality was considered as the study endpoint.

RESULTS

In comparison with non-survivors (n=34), 30-day survivors (n=90) showed lower serum caspase-3 levels on days 1 (p=0.001), 4 (p<0.001) and 8 (p<0.001) of TBI. Analysis of the ROC curves showed serum caspase-3 concentrations on days 1, 4 and 8 of TBI to have an AUC (95% CI) in predicting 30-day mortality of 0.70 (0.61-0.78; p=0.001), 0.83 (0.74-0.89; p<0.001) and 0.87 (0.79-0.93; p<0.001), respectively.

CONCLUSIONS

The novel findings of our study were that serum caspase-3 levels during the first week of TBI were lower in survivors and could predict 30-day mortality.

DNA and RNA oxidative damage are associated to mortality in patients with cerebral infarction

OBJECTIVE

Secondary injury due to oxidation may occur during ischemic stroke, possibly leading to oxidative damage to deoxyribonucleic acid (DNA) and ribonucleic acid (RNA). Higher blood concentrations of 8-hydroxy-2'-deoxyguanosine (8-OHdG) (through the oxidation of guanosine from DNA) have been found in ischemic stroke patients than in healthy subjects, and in patients with versus without post-ischemic stroke depression. The present study was carried out to explore the possible association between serum DNA and RNA oxidative damage and mortality in patients with cerebral infarction.

METHODS

A prospective, multicenter observational study was carried out in the Intensive Care Units of 6 Spanish hospitals. We included patients with severe malignant middle cerebral artery infarction (MMCAI) defined as ischemic changes evidenced by computed tomography in more than 50% of the middle cerebral artery territory and a Glasgow Coma Score (GCS)<9. Serum concentrations of the three oxidized guanine species (OGS) (8-hydroxyguanine from DNA or RNA, 8-hydroxyguanosine from RNA, and 8-OHdG from DNA) on the day of MMCAI diagnosis were determined. The study endpoint was 30-day mortality.

RESULTS

We found higher serum OGS levels (p<0.001) in non-surviving (n=34) than in surviving patients (n=34). Logistic regression analyses showed serum OGS levels to be associated to 30-day mortality controlling for lactic acid, GCS and platelet count (OR=1.568; 95%CI=1.131-2.174; p=0.01).

CONCLUSIONS

The novel observation in this study is the association between global serum OGS concentration and mortality in ischemic stroke patients.

Isolation and sex steroid effects on the expression of the ATP-binding cassette transporter ABCB6 in Harderian glands of hamster (Mesocricetus auratus)

ATP-Binding Cassette, subfamily B, member 6 (ABCB6) is a transporter that is upregulated by elevated intracellular porphyrin concentrations. In the Harderian gland (HG), the synthesis of porphyrins appears to be under the influence of gonadal steroids and to exhibit a dimorphic pattern. To explore whether ABCB6 is also influenced by sex steroids, we isolated its specific cDNA sequence and investigated its mRNA levels in the HGs of hamsters. ABCB6's cDNA sequence presents an open reading frame (ORF) of 2529 bp that encodes a predicted 842-amino acid (aa) protein with a molecular weight of 93 kDa. Multiple sequence alignments showed that ABCB6's aa sequence is highly conserved and shares the highest homology (93%) with mouse ABCB6. RT-qPCR analysis indicated that ABCB6 is expressed in all the tissues examined, exhibiting high expression levels in the liver, adrenal glands, and testis. The mRNA concentrations of ABCB6 in HGs were very similar between males and in females; similarly, gonadectomy and treatment with sex steroids appear to scarcely affect ABCB6 mRNA levels. The intraglandular content of ABCB6 mRNA showed discrete, though non-significant, variations through the estrous cycle. The results provide evidence that gonadal steroids have a minimal physiological role on the regulation of ABCB6 expression and might indicate that this transporter has a small effect on porphyrin trafficking in the HGs of hamsters.

Impact of De-escalation on Prognosis of Patients With Bacteremia due to Enterobacteriaceae: A Post Hoc Analysis From a Multicenter Prospective Cohort

Background

More data are needed about the safety of antibiotic de-escalation in specific clinical situations as a strategy to reduce exposure to broad-spectrum antibiotics. The aims of this study were to investigate predictors of de-escalation and its impact on the outcome of patients with bloodstream infection due to Enterobacteriaceae (BSI-E).

Methods

A post hoc analysis was performed on a prospective, multicenter cohort of patients with BSI-E initially treated with ertapenem or antipseudomonal β-lactams. Logistic regression was used to analyze factors associated with early de-escalation (EDE) and Cox regression for the impact of EDE and late de-escalation (LDE) on 30-day all-cause mortality. A propensity score (PS) for EDE vs no de-escalation (NDE) was calculated. Failure at end of treatment and length of hospital stay were also analyzed.

Results

Overall, 516 patients were included. EDE was performed in 241 patients (46%), LDE in 95 (18%), and NDE in 180 (35%). Variables independently associated with a lower probability of EDE were multidrug-resistant isolates (odds ratio [OR], 0.50 [95% confidence interval {CI}, .30–.83]) and nosocomial infection empirically treated with imipenem or meropenem (OR, 0.35 [95% CI, .14–.87]). After controlling for confounders, EDE was not associated with increased risk of mortality; hazard ratios (HR) (95% CIs) were as follows: general model, 0.58 (.25–1.31); model with PS, 0.69 (.29–1.65); and PS-based matched pairs, 0.98 (.76–1.26). LDE was not associated with mortality. De-escalation was not associated with clinical failure or length of hospital stay.

Conclusions

De-escalation in patients with monomicrobial bacteremia due to Enterobacteriaceae was not associated with a detrimental impact on clinical outcome.

Retinal vascular tortuosity assessment: inter-intra expert analysis and correlation with computational measurements

Background

The retinal vascular tortuosity can be a potential indicator of relevant vascular and non-vascular diseases. However, the lack of a precise and standard guide for the tortuosity evaluation hinders its use for diagnostic and treatment purposes. This work aims to advance in the standardization of the retinal vascular tortuosity as a clinical biomarker with diagnostic potential, allowing, thereby, the validation of objective computational measurements on the basis of the entire spectrum of the expert knowledge.

Methods

This paper describes a multi-expert validation process of the computational vascular tortuosity measurements of reference. A group of five experts, covering the different clinical profiles of an ophthalmological service, and a four-grade scale from non-tortuous to severe tortuosity as well as non-tortuous / tortuous and asymptomatic / symptomatic binary classifications are considered for the analysis of the the multi-expert validation procedure. The specialists rating process comprises two rounds involving all the experts and a joint round to establish consensual rates. The expert agreement is analyzed throughout the rating procedure and, then, the consensual rates are set as the reference to validate the prognostic performance of four computational tortuosity metrics of reference.

Results

The Kappa indexes for the intra-rater agreement analysis were obtained between 0.35 and 0.83 whereas for the inter-rater agreement in the asymptomatic / symptomatic classification were between 0.22 and 0.76. The Area Under the Curve (AUC) for each expert against the consensual rates were placed between 0.61 and 0.83 whereas the prognostic performance of the best objective tortuosity metric was 0.80.

Conclusions

There is a high inter and intra-rater variability, especially for the case of the four grade scale. The prognostic performance of the tortuosity measurements is close to the experts’ performance, especially for Grisan measurement. However, there is a gap between the automatic effectiveness and the expert perception given the lack of clinical criteria in the computational measurements.