Do patient factors influence embryologists' decisions to freeze borderline blastocysts?

RESEARCH QUESTION: To investigate whether patient factors influence the decision to freeze a blastocyst with low implantation potential. DESIGN: This experimental study assessed 170 practicing embryologists from a variety of countries who were recruited via an online survey. Participants were currently practicing embryologists, who grade blastocysts as part of this role. The survey presented decision-making 'vignettes' to participants. These included specific patient information, as well as an image of an expanded blastocyst that was of borderline quality for inner cell mass and trophectoderm, for which the embryologist selected whether or not to freeze. High/low maternal age, the presence/absence of other top quality blastocysts, and the presence/absence of previously unsuccessful IVF cycles were systematically varied within the patient information in a 2 × 2 × 2 design. Participants reported how likely they would be to freeze a particular blastocyst on a scale of 1 (Extremely Unlikely) to 7 (Extremely Likely), and whether or not they would ultimately freeze each blastocyst (Yes or No). RESULTS: Lower maternal age, no other high-quality blastocysts within the cohort, and multiple unsuccessful IVF cycles were associated with greater likelihood of recommending to freeze (P < .001). Furthermore, significant interactions among all three patient factors were noted. CONCLUSION: This study provides evidence suggesting that when faced with an uncertain blastocyst, factors pertaining to the patient (maternal age, the presence/absence of other top quality blastocysts, and the presence/absence of previously unsuccessful IVF cycles) influence the decision to freeze.

Emergency department visits for attempted suicide and self harm in the USA: 2006-2013.

AIMS: To characterise and identify nationwide trends in suicide-related emergency department (ED) visits in the USA from 2006 to 2013. METHODS: We used data from the Nationwide Emergency Department Sample (NEDS) from 2006 to 2013. E-codes were used to identify ED visits related to suicide attempts and self-inflicted injury. Visits were characterised by factors such as age, sex, US census region, calendar month, as well as injury severity and mechanism. Injury severity and mechanism were compared between age groups and sex by chi-square tests and Wilcoxon rank-sum tests. Population-based rates were computed using US Census data. RESULTS: Between 2006 and 2013, a total of 3 567 084 suicide attempt-related ED visits were reported. The total number of visits was stable between 2006 and 2013, with a population-based rate ranging from 163.1 to 173.8 per 100 000 annually. The frequency of these visits peaks during ages 15-19 and plateaus during ages 35-45, with a mean age at presentation of 33.2 years. More visits were by females (57.4%) than by males (42.6%); however, the age patterns for males and females were similar. Visits peaked in late spring (8.9% of all visits occurred in May), with a smaller peak in the fall. The most common mechanism of injury was poisoning (66.5%), followed by cutting and piercing (22.1%). Males were 1.6 times more likely than females to use violent methods to attempt suicide (OR = 1.64; 95% CI = 1.60-1.68; p < 0.001). The vast majority of patients (82.7%) had a concurrent mental disorder. Mood disorders were the most common (42.1%), followed by substance-related disorders (12.1%), alcohol-related disorders (8.9%) and anxiety disorders (6.4%). CONCLUSIONS: The annual incidence of ED visits for attempted suicide and self-inflicted injury in the NEDS is comparable with figures previously reported from other national databases. We highlighted the value of the NEDS in allowing us to look in depth at age, sex, seasonal and mechanism patterns. Furthermore, using this large national database, we confirmed results from previous smaller studies, including a higher incidence of suicide attempts among women and individuals aged 15-19 years, a large seasonal peak in suicide attempts in the spring, a predominance of poisoning as the mechanism of injury for suicide attempts and a greater use of violent mechanisms in men, suggesting possible avenues for further research into strategies for prevention.

Fibrocartilaginous embolism: a cause of acute ischemic myelopathy.

STUDY DESIGN: A case report of fibrocartilaginous embolism (FCE) presenting as acute myelopathy. OBJECTIVES: To illustrate the clinical presentation and magnetic resonance imaging features of FCE. SETTING: Johns Hopkins Transverse Myelitis Center. CASE REPORT: A 16-year-old boy was diagnosed with ischemic myelopathy secondary to FCE 2 years after symptom onset. Diagnosis was delayed because the clinical and radiological characteristics were not recognized initially. After rehabilitation, the patient made a modest recovery. CONCLUSIONS: Diagnosis of FCE can be made by recognition of the characteristic clinical and radiological features and a high index of suspicion.

Thalidomide for acute treatment of neurosarcoidosis.

STUDY DESIGN: Case report. CLINICAL SETTING: Johns Hopkins University School of Medicine, Baltimore, MD, USA. CASE REPORT: Sarcoidosis is a multi-system granulomatous disease of unknown etiology with worldwide distribution. The involvement of the nervous system is common-neurosarcoidosis. Immune responses play an important role in the inflammatory process and granuloma formation. We report a case of neurosarcoidosis that was refractory to two courses of intravenous steroids. Upon initiation of oral thalidomide, the patient showed dramatic improvement clinically and on magnetic resonance imaging. CONCLUSION: Thalidomide is an immunomodulatory agent that acts to inhibit production of tumor-necrosis factor-alpha (TNF-alpha), an important mediator in CNS inflammation, by enhancing TNF-alpha mRNA degradation. Corticosteroids have been the mainstay of treatment of neurosarcoidosis with success at halting progression of the immune process in 50% cases. Thalidomide offers unique opportunities at managing CNS inflammation due to neurosarcoidosis. DISCLOSURES: None.

Trypsin enhances sympathetic neuron-dependent plasma extravasation in the rat knee joint.

Perfusion of 6-hydroxydopamine through the rat knee joint causes an increase in plasma extravasation by activation of sympathetic neuron terminals. Similarly, the increase in plasma extravasation in the rat knee joint produced by the inflammatory mediator bradykinin is dependent on the sympathetic post-ganglion neuron. There is evidence that both 6-hydroxydopamine and bradykinin release a number of mediators, some of which appear to enhance plasma extravasation and some which inhibit it. We attempted to determine the nature of inhibitory factor(s) by co-infusing trypsin (which rapidly cleaves peptides) with 6-hydroxydopamine. We observed a marked enhancement of 6-hydroxydopamine-induced plasma extravasation by trypsin. This effect appeared to be specific to neurogenic plasma extravasation since trypsin alone had little effect on plasma extravasation and trypsin did not affect non-neurogenic plasma extravasation (that produced by platelet activating factor). Taken together, the data suggests that 6-hydroxydopamine not only releases mediators from the sympathetic neuron that produce plasma extravasation, but also an inhibitor(s) of plasma extravasation that is peptide in nature.