Embryo blastulation and quality between days 5 and 6 of extended embryo culture.

PURPOSE: This study aims to know what proportion of culture day 5 pre-blastocyst-stage embryos develop into blastocysts by culture day 6 and what patient and cycle characteristics are associated with delayed blastocyst formation. METHODS: A retrospective observational cohort analysis was performed including a total of 9886 embryos from 1008 IVF cycles in 835 patients, who underwent treatment between January 1, 2016, and December 31, 2018. Autologous fresh in vitro fertilization (IVF) cycles at a single academic center were included in the analysis. Embryos were group-cultured using single-step culture media. Blastulation was defined as the presence of a new blastocyst. Usable blastulation was defined as the presence of a new good or excellent quality, expanded, hatching, or hatched blastocysts. RESULTS: The mean blastulation rate between days 5 and 6 of extended embryo culture was 30.9%. The mean percentage of embryos developing into usable blastocyst-stage embryos was 19.8%. The factors associated with blastulation on day 6 included the total number of embryos and the number of pre-blastocysts on day 5, as well as the use of ICSI. Age, the number of total embryos, those remained in culture and pre-blastocysts, as well as the blastulation rate on day 5 were associated with usable blastulation. CONCLUSION: It is important to know the usable blastocyst development rate between culture days 5 and 6 in order to adequately counsel patients debating whether to proceed with fresh ET on day 5 or forego ET with the expectation that embryos will be biopsied for PGT and/or cryopreserved on culture day 6. Our findings provide evidence to help guide patients in this difficult decision.

Neural correlates of social influence on risk perception during development.

Studies have shown that adolescents are more likely than adults to take risks in the presence of peers than when alone, and that young adolescents' risk perception is more influenced by other teenagers than by adults. The current fMRI study investigated the effect of social influence on risk perception in female adolescents (aged 12-14) and adults (aged 23-29). Participants rated the riskiness of everyday situations and were then informed about the (alleged) risk ratings of a social influence group (teenagers or adults), before rating each situation again. The results showed that adolescents adjusted their ratings to conform with others more than adults did, and both age groups were influenced more by adults than by teenagers. When there was a conflict between the participants' own risk ratings and the ratings of the social influence group, activation was increased in the posterior medial frontal cortex, dorsal cingulate cortex and inferior frontal gyrus in both age groups. In addition, there was greater activation during no-conflict situations in the right middle frontal gyrus and bilateral parietal cortex in adults compared with adolescents. These results suggest that there are behavioral and neural differences between adolescents and adults in conflict and no-conflict social situations.

Addressing Cultural Determinants of Health for Latino and Hmong Patients with Limited English Proficiency: Practical Strategies to Reduce Health Disparities.

We explored how addressing culture may improve patient-provider relationships and reduce health disparities for racial and ethnic individuals with limited English proficiency (LEP). We analyzed qualitative data collected to explore health disparities in preventive cancer screenings for Hmong and Spanish-speaking LEP patients in a large Midwest healthcare system. We interviewed 20 participants (10 from each group) and the audiotaped interviews were transcribed verbatim, then back translated focusing on meaning. Data was analyzed using content analysis. Two themes are: conversation is relational and quality time is valued. Good communication skills involve the amount of conversation, clear explanations, and engaging with the patient. Quality of time meant physical time spent with patient and the task-oriented nature of the encounter. Cultural literacy in healthcare practice helps to understand the whole patient rather than focusing on the symptoms of illness. Patients should not be treated in isolation of their culture. A patient-centered approach to care means physicians should not remain culturally neutral but be more culturally sensitive. We propose steps to reduce disparities by increasing the awareness of cultural literacy for physicians to improve patient-provider relationship.

Impact of interpreter services on delivery of health care to limited-English-proficient patients.

OBJECTIVE: To determine whether professional interpreter services increase the delivery of health care to limited-English-proficient patients. DESIGN: Two-year retrospective cohort study during which professional interpreter services for Portuguese and Spanish-speaking patients were instituted between years one and two. Preventive and clinical service information was extracted from computerized medical records. SETTING: A large HMO in New England. PARTICIPANTS: A total of 4,380 adults continuously enrolled in a staff model health maintenance organization for the two years of the study, who either used the comprehensive interpreter services (interpreter service group [ISG]; N = 327) or were randomly selected into a 10% comparison group of all other eligible adults (comparison group [CG]; N = 4,053). MEASUREMENTS AND MAIN RESULTS: The measures were change in receipt of clinical services and preventive service use. Clinical service use and receipt of preventive services increased in both groups from year one to year two. Clinical service use increased significantly in the ISG compared to the CG for office visits (1.80 vs. 0.70; P <.01), prescriptions written (1.76 vs 0.53; P <.01), and prescriptions filled (2.33 vs. 0.86; P<.01). Rectal examinations increased significantly more in the ISG compared to the CG (0.26 vs. 0.02; P =.05) and disparities in rates of fecal occult blood testing, rectal exams, and flu immunization between Portuguese and Spanish-speaking patients and a comparison group were significantly reduced after the implementation of professional interpreter services. CONCLUSION: Professional interpreter services can increase delivery of health care to limited-English-speaking patients.

Limits to buprenorphine dosing: a comparison between quintuple and sextuple the maintenance dose every 5 days.

The relative efficacy of quintuple and sextuple buprenorphine dosing in abating withdrawal symptoms for 120 h was compared in opioid-dependent outpatients. Fourteen subjects received buprenorphine in a double-blind, placebo-controlled, cross-over design. Daily sublingual maintenance doses were 4 mg/70 kg (n=4) and 8 mg/70 kg (n=10). After a stabilization period of daily maintenance administration, subjects received quintuple (5x daily maintenance dose) and sextuple (6x daily maintenance dose) doses every 120 h. Measures of opioid agonist and withdrawal effects were assessed daily. Subjective ratings of withdrawal were significantly greater than baseline ratings beyond 96-h post dosing under both regimens. There was no evidence, however, that those subjective ratings of withdrawal differed between the two regimens. Thus, these data suggest that sextuple buprenorphine dosing, administered every 5 days, does not abate opioid-withdrawal beyond 96 hours.

Receipt of cancer screening procedures among Hispanic and non-Hispanic health maintenance organization members.

BACKGROUND: Hispanic Americans have been shown to receive fewer cancer screening procedures than nonminority populations. Although lack of insurance or a regular source of care appear to be important determinants, cultural factors also have been suggested. This study examines whether Hispanic patients receive cancer screening at the same rate as the non-Hispanic population when both groups have equivalent insurance and a regular source of care. METHODS: Receipt of five cancer screening procedures (mammography, Pap test, fecal occult blood testing, breast examination, and rectal examination) was determined for adult health maintenance organization (HMO) members who met appropriate age and gender criteria. Rates of receipt were compared for 2 cohorts over a 2-year period: Hispanic members identified by surname and a comparison group, a 10% random sample of the non-Spanish surnamed members. Only members with at least one HMO contact over the study period were included. Logistic regression was used to test whether being in the Hispanic group was associated with decreased likelihood of receiving the procedure at least once over the 2 years, adjusting for potential confounders. RESULTS: Among the comparison group, a high proportion received each recommended procedure at least once (0.70-0.86). The proportions were very similar for the Hispanic group (0.67-0.84). None of the rates differed statistically for the two groups. CONCLUSIONS: Hispanic HMO members received cancer screening at the same high rate as non-Hispanics, suggesting that insurance coverage and continuity of care are more important than cultural factors in determining rates of cancer screening receipt.

Language barriers to informed consent and confidentiality: the impact on women's health.

Obtaining informed consent and maintaining confidentiality are critical to the way we practice medicine and remain a crucial part of our medicolegal responsibility to the patient and to society. Nevertheless, little attention has been paid to these topics in populations who may have limited English proficiency. Despite research suggesting that language barriers have direct effects on health and health care delivery, many health care settings do not provide professionally trained interpreters to patients who need them. This is clearly a challenge that will only grow as our nation becomes more diverse. Perhaps nowhere is this issue more significant than in women's health, given the very personal and sensitive nature of the medical exams and interventions. As health care providers, we must conduct and facilitate research on how language barriers compromise quality of care, and we must advocate for systems and policy change.

Human performance on negative slope schedules of points exchangeable for money: a failure of molar maximization.

Panel pressing was generated and maintained in 5 adult humans by schedules of points exchangeable for money. Following exposure to a variable-interval 30-s schedule and to a linear variable-interval 30-s schedule (which permitted points to accumulate in an unseen "store" in the absence of responding), subjects were exposed to a series of conditions with a point-subtraction contingency arranged conjointly with the linear variable-interval schedule. Specifically, points were added to the store according to the linear-variable interval 30-s schedule and were subtracted from the store according to a ratio schedule. Ratio value varied across conditions and was determined individually for each subject such that the subtraction contingency would result in an approximately 50% reduction in the rate of point delivery. Conditions that included the subtraction contingency were termed negative slope schedules because the feedback functions were negatively sloped across all response rates greater than the inverse of the variable-interval schedule, in this case, two per minute. Overall response rates varied inversely with the subtraction ratio, indicating sensitivity to the negative slope conditions, but were in excess of that required by accounts based on strict maximization of overall reinforcement rate. Performance was also not well described by a matching-based account. Detailed analyses of response patterning revealed a consistent two-state pattern in which bursts of high-rate responding alternated with periods of prolonged pausing, perhaps reflecting the joint influence of local and overall reinforcement rates.

Three predictions of the economic concept of unit price in a choice context.

Economic theory makes three predictions about consumption and response output in a choice situation: (a) When plotted on logarithmic coordinates, total consumption (i.e., summed across concurrent sources of reinforcement) should be a positively decelerating function, and total response output should be a bitonic function of unit price increases; (b) total consumption and response output should be determined by the value of the unit price ratio, independent of its cost and benefit components; and (c) when a reinforcer is available at the same unit price across all sources of reinforcement, consumption should be equal between these sources. These predictions were assessed in human cigarette smokers who earned cigarette puffs in a two-choice situation at a range of unit prices. In some sessions, smokers chose between different amounts of puffs, both available at identical unit prices. Individual subjects' data supported the first two predictions but failed to support the third. Instead, at low unit prices, the relatively larger reinforcer (and larger response requirement) was preferred, whereas at high unit prices, the smaller reinforcer (and smaller response requirement) was preferred. An expansion of unit price is proposed in which handling costs and the discounted value of reinforcers available according to ratio schedules are incorporated.

Modeling drug consumption in the clinic using simulation procedures: demand for heroin and cigarettes in opioid-dependent outpatients.

Use of a time- and cost-efficient simulation procedure to assess reinforcement efficacy in humans was explored in the present study. Opioid-dependent outpatients completed questionnaires asking how many cigarettes or bags of heroin they would purchase across a range of prices. Reported consumption patterns conformed to a quantitative model that has been successful in accounting for data obtained in studies using real rather than hypothetical consequences, suggesting the self-report data may have been a valid proxy for observations of actual consumption patterns. Simulation procedures may thus be a useful supplement to traditional operant methods for the assessment of reinforcement efficacy in humans, particularly in situations where the use of operant methods is logistically difficult or ethically questionable. The relationship between behavioral-economic and traditional measures of reinforcement efficacy is also discussed.

Discounting of delayed rewards in opioid-dependent outpatients: exponential or hyperbolic discounting functions?

Recent theories of substance abuse have used value discounting of delayed rewards to partly explain the decision to take drugs. Normative-economic theory holds that an exponential function describes the effects of delay on discounting, whereas the matching law posits a hyperbolic discounting function. The ability of these functions to describe 18 human heroin-dependent individuals' monetary- and heroin-reward delay-discounting functions was assessed. In the 1st condition, participants chose between immediate and delayed hypothetical monetary rewards. Delayed rewards were $1,000, and the immediate reward amount was adjusted until choices reflected indifference. In the 2nd condition, participants chose between immediate and delayed heroin (the delayed amount was that which each participant reported he or she could purchase with $1,000). The hyperbolic function produced significantly higher R2 values and significantly lower sums of squared error values. Consistent with previous findings, delayed heroin rewards were discounted at a significantly higher rate than were delayed monetary rewards.

Signs of emotional disturbance three years after early hospitalization.

Tested by a retrospective study the hypothesis that children in the 6-36 months age range in case of lengthy (> 3 days) or repeated (more than once) hospitalization are susceptible to persistent emotional disturbances. Families of children with such a "risky" hospitalization history were approached by mail, several years (M = 36 months, SD = 10) after the latest discharge. The parents of these children (N = 40; mean age 59 months) and of a control group without a risky hospitalization history (N = 73; mean age 58 months) reported about current problem behavior of their child. Scores on the Behaviour Checklist (Richman et al., 1982) were significantly (p < .05) elevated in the sample. Specific signs were poor concentration, immoderate attention seeking, deficits of bowel control, and fearfulness. Cases of surgery significantly exceeded others in signs of disturbance. Although the protective value of parental attendance could not be demonstrated in this study, on the basis of prior research, rooming-in is recommended as a necessary precaution in the 6-36 months age range.

Effects of culture on back pain in Australian aboriginals.

STUDY DESIGN: A cross-sectional survey was conducted. OBJECTIVES: To describe the occurrence of back pain and associated behaviors and disabilities in a semitraditional Australian aboriginal community. SUMMARY OF BACKGROUND DATA: There are few studies of back pain in isolated and nonindustrial societies. METHODS: The authors lived with, observed, and interviewed most adult members of a small aboriginal community and placed information about spinal pain in context of aboriginal beliefs and practices. RESULTS: Nearly half the adults in this community experienced long-term private spinal pain, but because of their cultural beliefs, did not commonly make this pain public. CONCLUSIONS: Cultural beliefs and practices influence how people respond to back pain in themselves and in others, including how and whether they present to health professionals or seek involvement of others.

Humans' choices in situations of time-based diminishing returns: effects of fixed-interval duration and progressive-interval step size.

Four adult humans made repeated choices between two time-based schedules of points exchangeable for money: a fixed-interval schedule and a progressive-interval schedule that began at 0 s and increased in fixed increments following each point delivered by that schedule. Under reset conditions, selection of the fixed schedule not only produced a point but also reset the progressive interval to 0 s. Reset conditions alternated with no-reset conditions, in which the progressive-interval duration was independent of fixed-interval choices. Fixed-interval duration and progressive-interval step size were varied independently across conditions. Subjects were exposed to all step sizes in ascending order at a given fixed-interval value before the value was changed. Switching from the progressive-interval schedule to the fixed-interval schedule was systematically related to fixed-interval duration, particularly under no-reset conditions. Switching occurred more frequently and earlier in the progressive-schedule sequence under reset conditions than under no-reset conditions. Overall, the switching patterns conformed closely to predictions of an optimization account based upon maximization of overall reinforcement density, and did not appear to depend on schedule-controlled response patterns or on verbal descriptions of the contingencies.

Suppression of human granulocyte-macrophage colony formation in vitro by natural killer cells.

This study has demonstrated the ability of human bone marrow natural killer (NK) cells to inhibit the formation of granulocyte-macrophage colonies from autologous bone marrow derived committed progenitors in vitro. NK cell activity was demonstrated in all marrow samples and could be significantly increased by pretreatment of the bone marrow mononuclear cells with IFN-alpha. Bone marrow preincubated with IFN-alpha produced significantly fewer colonies in both Day 7 and Day 14 colony assays compared with untreated marrow. Removal of active NK cells by Leu 11b and complement significantly increased the number of colonies observed in both Day 7 and Day 14 assays, but this was not the case when NK cell-depleted marrow was treated with IFN-alpha prior to the GM assays. These results have further shown that NK cells and IFN-alpha are involved in regulating granulopoiesis by demonstrating that IFN-alpha can inhibit granulocyte/macrophage colonies in the presence or absence of NK cells in the bone marrow.

The role of polysomnography in the differential diagnosis of chronic insomnia.

The authors examined the accuracy of the differential diagnosis of chronic insomnia with and without sleep laboratory studies in a consecutive series of 123 patients. All patients were evaluated by means of a sleep/wake log, a sleep habits questionnaire, structured psychiatric and clinical interviews, and a minimum of two consecutive nights of polysomnography. Notwithstanding a high rate of Research Diagnostic Criteria (RDC)-diagnosed psychopathology (63%) in this sample, the major finding was that in 49% of the patients laboratory results added to, refuted, and/or failed to support the clinical impression. This resulted in substantial modification of the initial diagnostic formulation and therefore in increased specificity of diagnosis.

Recognizing the adolescent drug abuser.

Adolescents are at high risk for using and abusing illicit drugs. Guidelines for recognizing drug abusers are presented as well as a staging process for progression of drug use. The family physician is in an ideal position to identify young users/abusers and to assist them and their families in obtaining much needed assistance.