VOCs) in exhaled breath. VOCs generated via metabolic processes are candidate biomarkers of (patho)physiological pathways. We explored the feasibility of using an e‐nose to generate human “breathprints” at high altitude. Furthermore, we explored the hypothesis that pathophysiological processes involved in the development of acute mountain sickness (AMS) would manifest as altered VOC profiles. Breath analysis was performed on Sherpa and lowlander trekkers at high altitude (3500 m). The Lake Louise Scoring (LLS) system was used to diagnose AMS. Raw data were reduced by principal component (PC) analysis (PCA). Cross validated linear discriminant analysis (CV‐LDA) and receiver‐operating characteristic area under curve (ROC‐AUC) assessed discriminative function. Breathprints suitable for analysis were obtained from 58% (37/64) of samples. PCA showed significant differences between breathprints from participants with, and without, AMS; CV‐LDA showed correct classification of 83.8%, ROC‐AUC 0.86; PC 1 correlated with AMS severity. There were significant differences between breathprints of participants who remained AMS negative and those whom later developed AMS . PCA demonstrated discrimination between Sherpas and lowlanders . This study demonstrated the feasibility of breath analysis for VOCs using an e‐nose at high altitude. Furthermore, it provided proof‐of‐concept data supporting e‐nose utility as an objective tool in the prediction and diagnosis of AMS. E‐nose technology may have substantial utility both in altitude medicine and under other circumstances where adaptation to hypoxia may be important .Electronic nose (e‐nose) devices may be used to identify volatile organic compounds ( The physiological responses to hypoxemia are diverse and the mechanisms that underpin human hypoxic adaptation remain unclear  is a handheld vapor analyser, known as an electronic nose (e‐nose). Although not designed for clinical use, it can be used to analyze exhaled VOCs. The 32 carbon polymer sensors absorb volatiles causing a change in the sensors’ electrical resistance. The magnitude and distribution of changes of resistance creates a specific pattern or “breathprint” for that sample. Analysis by pattern recognition algorithms can then discriminate between samples, without identifying individual molecular components. E‐noses have been shown to be capable of distinguishing between various respiratory diseases, including lung cancer and asthma  are a diverse group of carbon‐based molecules, generated via various metabolic processes. Endogenous VOCs have a multi‐systemic origin and are transported within the blood before being excreted in exhaled breath. The number of VOCs in exhaled breath exceeds several thousand and the profile varies according to underlying inflammatory states that is feasible to use in an austere high altitude environment. Secondary aims were to investigate if breath analysis during early exposure to high altitude hypobaric hypoxia can be used to: (1) diagnose those suffering from AMS; (2) identify those at risk of developing AMS; and (3) to distinguish Sherpas from lowlanders.Ethical approval was obtained from the Nepal Health Research Council (reference 139/2012) and the University College London Research Ethics Committee (reference 3750/006). Written informed consent was obtained from all participants and the study complied with the standards set by the Declaration of Helsinki.Participants were adult volunteer trekkers (aged over 18 years) recruited from two distinct population groups: lowland residents  and indigenous Sherpas with confirmed Tibetan ancestry. Study eligibility was dependent upon good health .This study formed part of a research programme that made up the “Xtreme Everest 2” expedition to Nepal (2013) , to which an angle piece  was attached to allow subjects to inhale through the filter apparatus and exhale into ambient air. Nose clips were worn to prevent nasal entrainment of nonfiltered ambient air. An expiratory vital capacity breath was then collected into an inert Nalophan bag. This collection system was made by cutting 60 cm sections of double‐layered Nalophan sheet: one end was sealed using a plastic locking system ; the other end was sealed around a 20 cm section of polytetrafluoroethylene tubing using a cable tie. The polytetrafluoroethylene tube then served as a mouthpiece to allow subjects to provide their sample. After collection, the bag was immediately connected to the sample inlet of the e‐nose via the polytetrafluoroethylene tubing. VOC filtered air was used as reference air for the 60 sec baseline draw, followed by a 40‐sec sample draw and completed by 180 sec of purging with VOC filtered air (60 sec via the purge inlet and 120 sec via the sample inlet). The image in Figure A validated method for breath sample collection  was performed and receiver operating characteristic (ROC) area under curve  was calculated to classify cases into categorical divisions. ANOVA and regression analysis were used to ascertain correlation between principal components and LLS for AMS.Offline analysis of raw e‐nose data was performed, using SPSS software (version 20.0). After verifying normal distribution, data were reduced by principal component analysis (PCA). PCA is a statistical procedure for reducing high‐dimensional datasets into smaller sets of linearly uncorrelated variables, called principal components, that retain the trends and patterns of the original data . It was not possible to exclude AMS for one lowlander at Everest Base Camp because of missing diary data.The 37 subjects were divided into 18 Sherpas and 19 lowlanders , with similar male: female ratios. Four Sherpas and one lowlander were smokers. Two participants suffered from mild, well‐controlled asthma; there were no other respiratory diseases amongst the trekkers. There was a significantly greater proportion of lowlanders (72%) diagnosed with AMS   suffered from AMS at Namche Bazaar. From the original 37 breathprints produced by the e‐nose, three principal components with an eigenvalue larger than 1 were derived, capturing 83% of the variance within the total dataset. The subsequent bootstrapped independent samples ly) Fig. .P = 0.02). Linear regression analysis indicates a correlation between both variables .Maximum LLS for individuals was used as an indicator of severity of AMS. Missing diary data for one lowlander at Namche, although it did not affect AMS diagnosis, did prevent accurate calculation of total LLS and hence the subject was excluded from this subset analysis. ANOVA showed a significant difference between principal component 1 and maximum LLS at Namche Bazaar (P = 0.009). CV‐LDA showed correct classification of 68.8% of cases, ROC‐AUC 0.76 ± 0.18, with sensitivity of 46% and specificity of 81%.The four participants diagnosed with AMS at Namche Bazaar were excluded. A fifth participant was excluded because of missing diary entries. Eleven out of the remaining 32 participants were diagnosed with AMS at some time in their trek from Namche to Everest Base Camp. Following PCA, pattern‐based breath analysis between participants who remained AMS negative and those that developed AMS showed a significant difference on principal component 1 (P = 0.001)  Fig. . CV‐LDA 01) Fig.  with senThis study demonstrated the first exhaled breath analyses, using the Cyranose 320 e‐nose at high altitude and it is the first to have investigated its role in the diagnosis and prediction of AMS. It is also the first time that an e‐nose has been used to compare breathprints from Sherpas with lowlanders, further developing the concept that different hypoxic response phenotypes may be reflected in the profile of exhaled volatiles.There is currently no objective method to diagnose and/or assess AMS. The results of this study provide a strong signal that breath analysis using an e‐nose can distinguish participants with AMS from those without. Significant differences between both principal components 1 and 2, indicate that VOC patterns within these two groups may be discriminatory. The low number of AMS positive participants, however, produced a skewed data set that makes it difficult to draw definitive conclusions about the diagnostic capability of e‐noses.There are indications that breath analysis may have a role not only in AMS diagnosis but also in assessing severity. When trekkers were grouped according to their maximum LLS at the time of sampling, there was a significant difference between the respective sets of breathprints and linear regression showed a weak correlation between LLS and principal component 1.In light of these results, it is worth considering whether the AMS negative plots that are grouped close to positive plots in Figure There was a significant difference between breathprints from trekkers who remained AMS negative compared to those who developed AMS later in the expedition; the e‐nose was able to identify those at risk of developing AMS with reasonable discrimination. There is currently no reliable method to risk‐stratify people for AMS. The ability to do so would provide a great advantage to medical teams, allowing targeted and timely interventions to prevent progression to AMS.There were provocative results for the ability of the e‐nose to distinguish Sherpas from lowlanders. This is an exciting outcome which supports the use of breath analysis to discriminate between people with different responses to hypoxia. It also suggests that analysis of VOCs in exhaled breath may help us to understand better the physiological mechanisms that result in adaptation to hypoxia. Alternatively, it is worth considering whether the differences observed in exhaled VOCs between Sherpas and lowlanders may be related to behavioral or genetic distinctions that are unrelated to hypoxia.Our design proved durable to the hostile conditions at high altitude, supporting the potential use of breath analysis as an objective assessment tool for AMS. However, the 27 exclusions detailed in the results merit further discussion about the reliability of the method under such conditions. The four failed sample draws may have been secondary to an incorrect pump speed for low ambient barometric pressure, since changing to a high‐speed setting resolved the issue. This is important for those wishing to use similar apparatus at altitude. The remaining 23 exclusions were unexplained anomalies: on four separate days, in which both Sherpas & lowlanders were tested, the raw sensor data was grossly abnormal for all trekkers and across all 32 sensors. The interindividual spread was similar but the absolute values were substantially different from samples analyzed on all other testing days. Including these results for data analysis would make interpretation unreliable. One plausible explanation may relate to variations in the ambient temperature and/or humidity; a problem that has been identified with e‐noses during fieldwork in the environmental sector . This produced a skewed data set which made it difficult to comment with confidence on the e‐nose's diagnostic utility. A second reading at Everest Base Camp, where the proportion of AMS positive subjects was greater, would have helped draw clearer conclusions. Likewise, additional breath analysis at sea level would have helped distinguish if there were differing exhaled VOC profiles between Sherpas and lowlanders independent of the effects of altitude i.e., are the demonstrated differences in VOCs a result of a constitutive or inducible physiological process.The equipment used for breath collection and sampling was not designed for the purpose and substantial efforts were made to minimize contamination from components and ambient air. However, specifically designed equipment which has undergone external validation would help substantiate results for this and future projects. Furthermore, we would welcome studies to clarify the impact of environmental variables  on e‐nose breath analysis and to support the development of standardized methodology for field‐based research.Evidence suggests there is an intimate relationship between hypoxia and inflammation that is primarily mediated by hypoxia inducible factor adaptation.Analysis of exhaled breath VOCs may have potential to be developed into an objective prognostic and diagnostic tool for not only AMS, but also other clinical conditions. If breath analysis can identify the poor responders to hypobaric hypoxia it may also have utility in identifying those maladapted to In this study we have demonstrated the feasibility of a method for exhaled VOC analysis in a remote high altitude environment using an e‐nose (Cyranose 320). Our results provide proof‐of‐concept for its use as an objective tool in the prediction and diagnosis of AMS. The development of such a tool could have major impacts on altitude medicine as well as other clinical areas. The ability to differentiate the breathprints of Sherpas from lowlanders supports the use of breath analysis to discriminate between different (patho)physiological responses to hypoxic conditions. It also suggests that analysis of exhaled breath may provide us with a route to better mechanistic understanding of hypoxic adaptation. Translational research to explore exhaled breath biomarkers in critical illness could help the development of improved, phenotype‐specific management strategies for our sickest patients.JL, CK, JvdK, PB, EG‐K declare that they have no competing interests.MG is Joint Editor‐in‐Chief, Extreme Physiology and Medicine; Associate Editor, Perioperative Medicine; Medical Advisory Board, Sphere Medical Ltd; Board and Research Council, National Institute of Academic Anaesthesia; National Specialty Lead, NIHR Anaesthesia, Perioperative Medicine and Pain Specialty Group; Council, Royal College of Anaesthetists; Board, Faculty of Intensive Care Medicine; Chair, National Adult Critical Care Data Group; International Advisory Board, American Society of Enhanced Recovery; Board, Enhanced Recovery after Surgery UK; Chair, Xtreme Everest Oxygen Research Consortium; Chair, Fit‐4‐Surgery Research Collaboration; recipient of unrestricted grant to institution – Sphere Medical Ltd; honorarium and travel support for lecture – Edwards Lifesciences; funds for travel and accommodation – Smiths Medical Ltd.MM is founding Editor‐in‐Chief of Perioperative Medicine; Editorial Board, British Journal Anaesthesia; Editorial Board, Critical Care; Consultant, Edwards Lifesciences and Deltex Medical; Director, Medinspire Ltd; Director, Clinical Hydration Solutions Ltd; Director, Bloomsbury Innovation Group CiC; Director, Evidence‐based Perioperative Medicine CiC; International Advisory Board, American Society of Enhanced Recovery; Board member, Xtreme Everest Oxygen Research Consortium; Council, Royal College of Anaesthetists; Council Member and Chair, Board of the National Institute of Academic Anaesthesia; Smiths Medical Professor of Anaesthesia and Critical Care at University College London; recipient of funds for travel and accommodation from Edwards Lifesciences and Deltex Medical.DM has received consultancy fees from Siemens Healthcare.


A large‐scale audit and peer review of ultrasound images may improve sonographer performance, but is rarely performed consistently as it is time‐consuming and expensive. The aim of this study was to perform a large‐scale audit of routine fetal anatomy scans to assess if a full clinical audit cycle can improve clinical image‐acquisition standards.A large‐scale, clinical, retrospective audit was conducted of ultrasound images obtained during all routine anomaly scans performed from 18 + 0 to 22 + 6 weeks' gestation at a UK hospital during 2013 (Cycle 1), to build a baseline understanding of the performance of sonographers. Targeted actions were undertaken in response to the findings with the aim of improving departmental performance. A second full‐year audit was then performed of fetal anatomy ultrasound images obtained during the following year (Cycle 2). An independent pool of experienced sonographers used an online tool to assess all scans in terms of two parameters: scan completeness  and image quality using objective scoring . Both were assessed in each audit at the departmental level and at the individual sonographer level. A random sample of 10% of scans was used to assess interobserver reproducibility.P < 0.001); median image‐quality score for all fetal views improved from 0.83 to 0.86 (P < 0.001). The improvement was greatest for those sonographers who performed poorest in the first audit; with regards to scan completeness, the poorest performing 15% of sonographers in Cycle 1 improved by more than 30 percentage points, and with regards to image quality, the poorest performing 11% in Cycle 1 showed a more than 10% improvement. Interobserver repeatability of scan completeness and image‐quality scores across different fetal views were similar to those in the published literature.In Cycle 1 of the audit, 103 501 ultrasound images from 6257 anomaly examinations performed by 22 sonographers were assessed; in Cycle 2, 153 557 images from 6406 scans performed by 25 sonographers were evaluated. The analysis was performed including the images obtained by the 20 sonographers who participated in both cycles. Departmental median scan completeness improved from 72% in the first year to 78% at the second assessment (Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.A clinical audit and a set of targeted actions helped improve sonographer scan‐acquisition completeness and scan quality. Such adherence to recommended clinical acquisition standards may increase the likelihood of correct measurement and thereby fetal growth assessment, and should allow better detection of abnormalities. As such a large‐scale audit is time consuming, further advantages would be achieved if this process could be automated. © 2018 The Authors.  A mid‐trimester fetal anatomy ultrasound scan  is offered to pregnant women in most developed countries. Clinical guidelines, such as those defined by the Fetal Anomaly Screening Programme (FASP)Such protocols aim to guide practice of fetal ultrasonography to provide a ‘checklist’ of what imaging planes to capture. In principle, if all standard imaging planes are examined, detection of anomalies should be maximized. The quality of archived images reflects overall quality of fetal anatomical survey. Whilst this correlation is not absolute, the concern is that failure to archive images or poor image quality could support medicolegal claims.Regular audit, peer review and quality assurance procedures are recognized to improve and sustain good practiceIn theory, an automated software‐based ultrasound image audit could be a solution for full (100%) clinical auditing. Putting aside technical challenges to achieve this, it is important to first ascertain whether a comprehensive image‐quality audit can improve performance.The aim of this study was to determine whether a full clinical audit improves performance in terms of image acquisition/storage and image quality in a large maternity ultrasound department.This quality‐improvement study comprised a retrospective baseline audit (Cycle 1) of anonymized routine fetal anomaly scans performed over a 12‐month period in 2013 at a large teaching hospital with over 6500 births per annum. This was followed by feedback to sonographers of individual and departmental performance scores and implementation of a number of targeted interventions to improve quality of imaging. In the subsequent 12‐month period, a re‐audit (Cycle 2) using the same quality criteria was performed in order to evaluate the impact of the changes.Ultrasound images and meta‐data  were extracted from the hospital database  and anonymized to remove all patient identifiable information.Images were audited by 12 experienced sonographers, currently practicing in different hospitals in the UK, using a standard audit pro forma including a custom‐built easy‐to‐use online interface created by Intelligent Ultrasound Ltd . This facilitated the auditing of scan completeness (assessment of whether a scan had the complete minimum set of required images) and image quality (assessment of recorded images against a scoring system).Before commencing the study, all assessors participated in a training day to ensure familiarity with imaging protocols, quality criteria and software, and had the opportunity to practice quality assessment using a large number of case examples.Scan completeness and image quality were measured at the level of the department and the individual sonographer for all departmental sonographers who undertook at least 30 anomaly scans in each cycle.According to the UK FASP guidelinesThe quality of images of the head TV, head TC, AC, FL, face (lips) and spine views was also audited. The quality of each image was assessed against a number of criteria Table  based onFindings from the first cycle of the audit relating to performance of the department as a whole were fed back to the sonography team. An individualized written report was also generated for each of the sonographers, who were given the opportunity to discuss any concerns or training needs. Following this, a number of actions and interventions were agreed and undertaken, including the production and dissemination of updated and formalized anomaly scan departmental protocol, the production for each scan room of aide memoire posters of the FASP base image menu (six views) required for storage, the introduction of guidance on image storage as well as a cardiac scanning protocol with specific hands‐on training sessions, and providing supported practice for individuals with specific training needs identified in Cycle 1 of the audit.To assess the effect of quality‐improvement interventions on the performance of sonographers in the department, all anomaly scans acquired in 2014 were audited (follow‐up audit) following the same procedures used to analyze the 2013 data.In order to measure agreement, 10% of the audited baseline and follow‐up images were selected by computer randomization and assessed by two independent reviewers. Agreement in scan completeness was measured as the percentage of agreed images for each view (i.e. if Reviewer 1 and Reviewer 2 agreed on the view type) and a kappa statistic was calculated. The ultrasound views for which reviewers had the highest disagreement were investigated. Variability in image‐quality assessment was evaluated by comparing overall image scores. The variability for each criterion in all views was assessed to investigate which criteria contributed most to the overall variability of reviewers.t‐tests are reported and the significance level was set at < 0.05. Analysis was performed using Stata 15 .The chi‐squared test was used to assess whether changes in scan completeness between the two cycles were statistically significant. For image‐quality scoring, paired comparisons of the normalized score (from 0 to 1) were performed using the Wilcoxon matched‐pairs signed‐ranks test, as normality tests suggested evidence of a non‐normal distribution. Two‐sided In Cycle 1, 103 501 images from 6257 anomaly examinations performed by 22 sonographers were assessed. Sonographers had varying working patterns . The median number of scans per sonographer was 237 and the median number of audited images per scan was 16. In Cycle 2, 153 557 images were evaluated from 6406 anomaly examinations performed by 25 sonographers, of whom 20 also performed examinations in Cycle 1. The median number of scans per sonographer in Cycle 2 was 189 and the median number of audited images per scan was 24. All scans were performed between 18 + 0 and 22 + 6 weeks of gestation  with improved completeness for all views. Table n = 20) who acquired at least 30 scans in each year. For example, sonographer 1 undertook 138 scans in Cycle 1, of which 113 were complete. The scan‐completeness audit demonstrated that the improvement was particularly noticeable for those sonographers who had the lowest completeness in the baseline audit. Sonographers whose scan completeness in Cycle 1 was less than 50% had a mean scan completeness improvement from 19.0% to 60.3% in Cycle 2. While this could be purely due to ‘regression to the mean’, this is unlikely given the consistency of improvements seen.Overall scan completeness in the baseline audit was 72%, which improved to 78% in the follow‐up audit  improved from 0.83 (interquartile range (IQR), 0.69–0.89) in 2013 to 0.86  in 2014  and grading of gradable images (6.4 ± 5.5 min). Overall, the assessment of Cycle 1 took approximately 876 h while Cycle 2 took about 897 h.In this study, we assessed the effect of a full audit cycle involving large‐scale fetal anomaly scan audit on the performance of sonographers. In this audit, fetal scans were assessed manually by experts to evaluate scan completeness and image quality. A full‐year baseline audit was performed to establish the sonographers' baseline performance. Actions were implemented in the department in the following year and a second follow‐up audit was performed. We found that both scan completeness and image quality improved significantly between the audit cycles.Although the improvement was by a relatively small margin as a department, Cycle 2 demonstrated large improvements for those sonographers who performed least well in the first audit cycle. Sonographers whose scan completeness in the baseline audit was less than 50% had a mean scan completeness improvement from 19.0% to 62.3% in the follow‐up audit, including two sonographers (sonographers 19 and 20) who had 0% scan completeness in the baseline audit. Similarly, normalized image‐quality score for sonographers whose baseline image‐quality score was less than 0.80 improved from a mean of 0.70 to 0.80 in the follow‐up audit. In contrast, sonographers who had good scan completeness and image quality at baseline performed similarly in the follow‐up audit.Reduction in variation in practice and sustaining good practice are both recognized factors in upholding patient safetyInterobserver agreement was high for the assessment of scan completeness; it was lowest for the head TV view, which may be because the original local protocol was unclear as to whether the head TV or transthalamic (TT) view should be stored, and therefore some recorded head views were in the TT view. Although TV and TT planes are very close to each otherOne of the key strengths of this study is that the entire scan output of a single department was assessed, removing any potential biases in selection of examinations for review and offering the most comprehensive assessment of both departmental and individual performance. A limitation of this approach is that it is very labor intensive. Although it is possible that a retrospective audit of a small number (e.g. 10–20 cases) of consecutive scans would suffice, this would provide only limited understanding of individual and departmental performance. Another option, self‐scoring, in which sonographers appraise their own images, has been shown previously to be feasibleet al.In our study, independent visual assessment was performed by experienced sonographers. This was based on an objective, criteria‐based scoring system that was shown to have a high degree of reproducibility for image scoring. High reproducibility  for image scoring methods shown in a previous studyOne potential limitation of this study was that the two audit cycles were back‐to‐back. This was to allow seamless observation of practice over time. It is highly likely that, had we allowed a period of time to pass before re‐audit to ensure that changes in practice in response to Cycle 1 were more embedded, greater improvements would have been seen. Given the described audit process, it is possible that some of the observed improvements in performance may have related more to sonographer awareness of ongoing audit and knowledge of the specific criteria used to evaluate performance. However, a longer study period could have been subject to confounding due to other unmeasured changes. Another limitation is that we assessed only six views, based on the recommendations for practice in the UK; we, of course, recognize that other scanning protocols suggest a larger number of images to be stored. However, the improvements seen in this smaller number of views should also apply. Although imaging of cardiac views was introduced in 2014, this was on the basis of best practice and they were not included in the analysis as they were not assessed in Cycle 1.In conclusion, we have shown that large‐scale clinical audit, coupled with implementation of targeted changes and feedback to sonographers, can lead to improvements in image quality on the mid‐trimester anomaly scan, in terms of both completeness of scans and image quality. However, while quality improvement is possible, such comprehensive manual audit in a high‐throughput clinical setting is a very labor‐intensive process and this would be a major barrier for implementation in routine practice. Ongoing work on automated image analysis


Small RNAs and their associated RNA interference (RNAi) pathways underpin diverse mechanisms of gene regulation and genome defense across all three kingdoms of life and are integral to virus–host interactions. In plants, fungi and many animals, an ancestral RNAi pathway exists as a host defense mechanism whereby viral double‐stranded RNA is processed to small RNAs that enable recognition and degradation of the virus. While this antiviral RNAi pathway is not generally thought to be present in mammals, other RNAi mechanisms can influence infection through both viral‐ and host‐derived small RNAs. Furthermore, a burgeoning body of data suggests that small RNAs in mammals can function in a non‐cell autonomous manner to play various roles in cell‐to‐cell communication and disease through their transport in extracellular vesicles. While vesicular small RNAs have not been proposed as an antiviral defense pathway per se, there is increasing evidence that the export of host‐ or viral‐derived RNAs from infected cells can influence various aspects of the infection process. This review discusses the current knowledge of extracellular RNA functions in viral infection and the technical challenges surrounding this field of research.Regulatory RNAs/RNAi/Riboswitches > Regulatory RNAsRNA in Disease and Development > RNA in DiseaseRegulatory RNAs/RNAi/Riboswitches > RNAi: Mechanisms of ActionThis article is categorized under: Small RNAs usually operate by guiding an Argonaute (AGO) protein to another nucleic acid target through Watson–Crick base pair complementarity  miRNAs regulate nearly every signaling pathway inside the cells and they work in concert with transcription factors to control initiation, maintenance, and resolution of cell response to injury and stress   polymerase of mammalian poxviruses polyadenylates host miRNAs resulting in their degradation . At the same time, emerging data suggest viral infections also impact the secretion of miRNAs from infected cells, and this can include both viral‐ and host‐derived miRNAs. In this review, we consider the extracellular realm when thinking about the role of miRNAs and other small RNAs in viral infection.3It has long been known that various RNA species exist outside of cells in different body fluids, and can be released from cells and internalized by other cells under physiological conditions  are 100–1,000 nm vesicles released by budding from the plasma membrane, while exosomes are small vesicles (~100 nm) of endosomal origin which are released by fusion of multivesicular endosomes (MVEs) with the plasma membrane  cells and this miRNA trafficking has been proposed to facilitate infection through the regulation of immune responses . The authors showed proof‐of‐concept with reporter assays that EVs transfer viral miRNAs from infected cells to other cells and demonstrated the immune‐stimulatory gene 5.1.2Small RNAs derived from the HIV genome have been reported both in intra‐ and extra‐cellular contexts , which is found in EVs derived from human placental trophoblasts ‐infected patients. Transfer of this miRNA to primary alveolar cells leads to the downregulation of the antiviral factor MX1, thereby potentiating IAV infection  , transfer RNA (tRNA) YRNAs, 7S RNA, and Vault RNAs are generally more abundant in EVs than individual miRNAs and their levels in EVs are enriched compared to intracellularly  are either depleted during library preparation or discarded in small RNA‐seq analysis (Kopylova, Noé, & Touzet, Further work on the functions of rRNA and tRNA fragments inside the cells will help create a framework for why and how specific sequences are exported and whether this could be used by viruses or the host defense system. Assuming the export of certain small RNA species from a cell has an important functional role, it is expected that this process would be controlled, and perhaps targeted, by the virus. There is still little understanding on small RNA export and uptake mechanisms but this is an area of active investigation.8Extracellular RNA is found outside of cells either protected in EVs or bound to proteins including AGO or high density lipoproteins (Fritz et al., 9Just as there is a variety of export vehicles for extracellular RNA that includes EVs, RBPs and lipoproteins, it is expected that there are different routes to cross the plasma membrane Figure . HoweverAfter target cell binding, internalization of EV cargo can be achieved by direct fusion with the plasma membrane (Del Conde, Shrimpton, Thiagarajan, & López, 10To date the above example is one of only a few reports providing information on the subcellular localization of EVs following internalization in recipient cells. Advances in single molecular imaging technologies and EV labeling strategies will continue to be important to advance the field, as well as studies under physiologically relevant conditions. Novel mouse transgenic approaches have recently provided compelling evidence for transfer of RNA between via EVs in vivo. The Cre‐loxP transgenic mouse system was used by Stefan Momma's group to show direct transfer of EVs containing Cre mRNA from the blood to the brain in response to inflammation (Ridder et al., 11A key hurdle in the field is purifying sufficient quantities and homogenous populations of EVs for functional studies. Many strategies are now focused on this aspect, which is reviewed further in Konoshenko et al.  In partiAnother major issue in EV purifications is contaminants from the culture media in the case of in vitro studies (Tosar et al., 12In summary, the field of extracellular RNA offers many new exciting possibilities for how cells communicate with one another, and how viruses have evolved to exploit or modulate these mechanisms during their lifecycles. However, there are many technical challenges and unknowns that come with the youth of this field Box . SequencHowever, many technical challenges exist that need to be addressed to move the field forward. In particular, the ability to study RNA export, including selectivity mechanisms, requires isolation of pure populations of extracellular RNA. We are still learning what those populations are and they include both vesicular and nonvesicular complexes. In the case of vesicular RNAs, we know the EVs themselves are heterogenous: cells produce multiple EV subsets whose cargo and functions can differ (Kowal et al., The authors have declared no conflicts of interest for this article.RNA in extracellular vesicles


The essence of molecular biology education lies in understanding of gene expression, with subtopics including the central dogma processes, such as transcription and translation. While these concepts are core to the discipline, they are also notoriously difficult for students to learn, probably because they cannot be directly observed. While nearly all active learning strategies have been shown to improve learning compared with passive lectures, little has been done to compare different types of active learning. We hypothesized that physical models of central dogma processes would be especially helpful for learning, because they provide a resource that students can see, touch, and manipulate while trying to build their knowledge. For students enrolled in an entirely active‐learning‐based Cell & Molecular Biology course, we examined whether model‐based activities were more effective than non‐model based activities. To test their understanding at the beginning and end of the semester, we employed the multiple‐select Central Dogma Concept Inventory (CDCI). Each student acted as their own control, as all students engaged in all lessons yet some questions related to model‐based activities and some related to clicker questions, group problem‐solving, and other non‐model‐based activities. While all students demonstrated learning gains on both types of question, they showed much higher learning gains on model‐based questions. Examining their selected answers in detail showed that while higher performing students were prompted to refine their already‐good mental models to be even better, lower performing students were able to construct new knowledge that was much more consistent with an expert's understanding. © 2018 The Authors. Biochemistry and Molecular Biology Education published by Wiley Periodicals, Inc. on behalf of International Union of Biochemistry and Molecular Biology., 46(5):435–444, 2018. Vision and ChangeThe “Central Dogma of Molecular Biology” refers to the concept of managing information flow in a cell, from storage in DNA through expression as a protein DNA, RNA and proteins are complex biomolecules that are both incredibly small , yet extraordinarily large (often thousands or millions of subunits). Research has demonstrated that students have particular difficulty bringing in and using the molecular/submicroscopic scale when wrestling with complex ideas about genetic information Just as certain topics may be more or less challenging for undergraduate students to learn, certain pedagogies are more or less effective in promoting learning in the undergraduate science classroom. Although lecture‐only pedagogies have been shown to be relatively ineffective for student learning, many college STEM instructors still use a lecture‐only approach in their teaching et al. also underscored the importance of allowing learners to explore multiple representations and build and manipulate molecular models using a computer‐based visualization tool called eChem findings suggest that models can serve as a vehicle for students to generate mental images…” lending support to the idea that models may provide students with a tool on which to scaffold and build new knowledge.Constructing and using models is a practice used by scientists to ask and answer questions about the natural world. Models facilitate discussion and discovery by providing scientists a shared resource as a baseline or starting point. It is not surprising, then, that recent educational reform initiatives in K‐12 Because we have been using physical model‐based activities and the CDCI assessment in a Cell and Molecular biology course, we decided to undertake a retrospective study using three years’ worth of assessment data. We asked if these model‐based activities were a superior instructional tool compared with other active‐engagement strategies when teaching concepts related to the Central Dogma of Molecular Biology. In this article, we present compelling evidence that physical model‐based activities focusing on biomolecules and information flow produce higher learning gains on Central Dogma related concepts than do other active‐engagement strategies (non‐model‐based activities). Furthermore, we describe how features of model‐based activities may reduce cognitive load to improve learning and discuss how model‐based activities may align with frameworks of cognitive sciences to create optimal learning environments for students.http://www.3dmoleculardesigns.com/3DMD.htm), but they are also available from the Milwaukee School of Engineering Model Lending Library (cbm.msoe.edu/lendingLibrary/). Descriptions of the relevant models are found in the Appendix.Several physical models of biomolecules and processes were used as the foci of activities in a Cell and Molecular Biology course to teach Central Dogma concepts. Except where indicated, each of these models was purchased from 3D Molecular Designs  at the beginning and end of each semester Before any analysis of data, researchers (LKW and DLN) did a preliminary analysis, parsing the CDCI questions into two groups: 1) questions in which the underlying concepts aligned with a model‐based activity used in the class and 2) questions in which the concept did not align with a model‐based activity. The CDCI questions and the list of models used in the course were presented to a group of eight biology faculty who were experienced with most of the model‐based activities but were not directly involved in the study. Feedback from the eight scientists agreed with the authors’ alignment. Approximately half of the questions (12) related to a model‐based activity and half (10) related to non‐model‐based activities; one CDCI question was excluded from the analysis due to ambiguity of its classification.Students who did not complete either the pre or post‐test  were excluded from analysis. Data were analyzed in the following ways: 1) Learning gains of whole question score: questions were only marked as “correct” when they chose the correct combination of correct answers . Normalized learning gains were calculated from the pre and post percentages as (post − pre)/(1 − pre) t‐tests were used to determine the significance of differences observed between questions that related to a model and those that did not.Paired Students enrolled in the Cell & Molecular Biology course were exposed to many different types of active learning strategies as they learned about Central Dogma concepts. Since none of the class meetings was devoted entirely to lecture, we were able to test whether model‐based activities were superior to other active‐learning pedagogies for teaching Central Dogma‐related concepts. Table n =  103) and female (n =  196) students for concepts that were taught with and without models. Although males had higher scores overall, both groups benefited equally from using models .Whole question scores  were used to calculate normalized learning gains for each CDCI question. In order to test our hypothesis that model‐based activities helped students learn more than non‐model based activities, we grouped CDCI questions into those that aligned with model‐based activities and those aligned with non‐model based activities. As illustrated by Fig. We then leveraged the format of the CDCI to do a more thorough analysis on student responses, as we also were interested to learn if students made partial gains on assessment questions. In other words, did students choose more correct choices and fewer incorrect choices pre to post? For this analysis we calculated the change in frequency of correct and incorrect responses for CDCI questions aligned with model‐based activities compared with CDCI questions aligned with non‐model based activities. Figure We were also interested to know if the model‐based activities had positive impacts for all students, or only students in certain ability quartiles. We retroactively sorted students into ability quartiles based on the pre‐course score on the CDCI tool and calculated normalized learning gains for each quartile. Students in the first quartile outperformed students in the other quarters dramatically, on both pre‐ and post‐tests Fig. . HoweverTo explore the hypothesis that lower quartile students made learning gains without getting whole questions correct, we calculated the average changes in frequency of selected responses for model‐aligned CDCI questions for all quartiles of students Fig. . Here ouCompared with lecture‐only pedagogies, active‐engagement strategies yield higher learning gains and can help reduce achievement gaps in STEM courses In this study, we have taken a slightly different approach. Using the validated published Central Dogma Concept Inventory tool The basic tenet of constructivism is that students learn best when they construct their own explanations through guided activities zone of proximal development; a measurement between a student's ability to solve a problem independently compared with instructor/peer guidance In addition to models helping students correct their faulty mental models, psychologists know there is an intrinsic social quality in learning and cognitive development. Vygotsky's theory of cognitive development suggests learning occurs in the The shaky foundational knowledge and incorrect mental models of Central Dogma concepts held by many students prevent them from productively incorporating new material. If a student cannot visualize the process of transcription, for example, how can they conceptualize and understand the more complex idea of gene regulation? Well‐designed models in biology help give students a “starting point” on which to scaffold new information and ideas which also help correct or fill in gaps of faulty incoming mental models. By constructing a model of RNA transcription with peers, for example, students are able to “see” and verbalize the steps of the process, especially at the usually‐hidden molecular scale, and build upon the new (and correct) model of the process as they attempt to learn new things. For instance, the Flow of Genetic Information Kit© (FGIK) transcription activity includes an RNA polymerase structure that facilitates proper construction of the mRNA and prevents RNA from being built backward (in the incorrect 3′–5′ direction). Similarly, in the FGIK Translation activity, as students push the mRNA through the ribosome, foam bumpers cause the incoming amino acid to physically touch the growing polypeptide chain allowing students to properly connect them, representing peptide bond formation. This idea has been articulated by Yelland and Masters Cognitive load theory dictates that the cognitive architecture of humans limits the conditions that will be ideal for learning As students work with the model, they refine and match their mental models to fit the physical model more closely and thus can refer to shared ideas during discussion and problem solving. The adage “a picture is worth a thousand words” reflects of the value of a common mental model between speaker and listener. Physical, interactive models become the embodiment of a shared mental model while also allowing for a dynamic discussion of interactions and processes.Learning, like scientific practice, assimilates observations into a cohesive schema; as additional information is gathered, the schema is modified to result in iterative knowledge refinement. While non‐model active engagement strategies can also align with theories of cognitive science that promote learning, model‐based activities may be superior for helping students learn topics related to molecular biology and genetic information flow. While performance on assessment questions is only a proxy for measuring learning, our data consistently show that students make higher gains on concepts that were taught using a model compared with concepts taught with other active engagement strategies. In contrast to a recent study by Forbes‐Lorman refine their mental models of Central Dogma processes and concepts and made them even more expert‐like. Students in the lowest two quartiles, who entered the class with mostly incorrect ideas (or no knowledge) about Central Dogma processes, constructed correct mental models about these processes. Students in this group may have not had the time to refine their own models all the way to the expert side of the continuum, but still made significant gains in their learning. The model‐based activities described here seemed to benefit all students, regardless of what knowledge they entered the course with. One caveat of this study is that it was retrospective rather than prospective. Thus, we did not create parallel activities to target the same concepts with and without models. In contrast to the traditional case‐control study, which compares the performance of different students on the same concepts, we compared the performance of the same students on different concepts . We used normalized learning gains to negate the effect of differences in question difficulty, so we are still able to conclude that students learned more when models were used. There are many resources that help good students get better or provide remedial help for struggling students, but well‐designed physical models are particularly beneficial because they seem to support learning of all students, regardless of status.While the highest performing students in the class show the greatest normalized gain on the multiple select assessment questions, the lowest performing students make the greatest absolute gains. Viewed through the lens of the expert‐novice continuum


CO2). However, many biotic and abiotic factors influence the outcome of this interaction, resulting in variable efficiency of the remediation process. The difficulty to predict precisely the timeframe associated with rhizoremediation leads to low adoption rates of this green technology. Here, we review recent literature related to rhizoremediation, with a particular focus on soil organisms. We then expand on the potential of rhizoremediation to be a model plant‐microbe interaction system for microbiome manipulation studies.Phytoremediation is a green and sustainable alternative to physico‐chemical methods for contaminated soil remediation. One of the flavours of phytoremediation is rhizoremediation, where plant roots stimulate soil microbes to degrade organic contaminants. This approach is particularly interesting as it takes advantage of naturally evolved interaction mechanisms between plant and microorganisms and often results in a complete mineralization of the contaminants (i.e. transformation to water and  Phytoremediation is the use of plants to remediate contaminated environments . Many processes can be involved in the removal of the pollutants such as phytovolatilization , phytotransformation (the transformation of contaminants from one state to another), phytostabilization (the stabilization of mobile contaminants in the soil), phytoextraction . Although all these processes involve both the plant and its microbiota, rhizoremediation clearly stands out as an integrated plant‐microbes endeavour. Rhizoremediation is the degradation of organic pollutants in the soil zone surrounding the plant roots (the rhizosphere), usually as a result of the stimulation of the catalytic activities of microorganisms by the plant roots . Third, the capacity to degrade hydrocarbons is widespread among bacteria, and major players, such as Pseudomonas and Rhodococcus can be easily cultured. It is thus relatively easy to create consortia of hydrocarbon‐degrading bacteria, follow their fate in the environment using molecular tools and measure their effect on rhizoremediation efficiency. It is also possible to measure the effects of various manipulations on the hydrocarbon‐degrading microbiota abundance and activities in the rhizosphere using relatively inexpensive molecular tools such as qPCR.Rhizoremediation offers a unique system to study plant‐microbe interactions and experiment with microbiome manipulation approaches. First, the response variable of interest is easily measurable: a lowered soil contamination. Second, the hydrocarbon degradation pathways are well known, and the genes are well represented and annotated in databases  or aromatic hydrocarbons. Hydroxylation of an alkyl group catalyzed by oxygenases is usually the first step in the degradation of organic compounds alkanes. There are several categories of alkyl‐group hydroxylases, including cytochrome P450s (CYP) and alkane hydroxylase . These bacteria are ubiquitous even in the most pristine environments  and Oenothera biennis (common evening primrose) root endophytes belonging to the genera Rhizobium, Pseudomonas, Stenotrophomonas and Rhodococcus harbored genes encoding for CYP153 alkane hydroxylases and showed the capacity to grow with n‐hexadecane as sole source of carbon , Soligado canadensis (Canadian goldenrod), Trifolium aureum (hop clover) and Dactylis glomerata (orchard grass), growing in a heavily contaminated site, harbored hydrocarbon‐degrading bacterial endophytes mostly belonging to the Actinobacteria  have shown remarkable , et al. , but it  et al., .et al., et al., et al., However, even if the microbial partners have the genetic capacity to degrade the contaminants, many substances are recalcitrant and elude microbial degradation. For instance, high molecular weight petroleum molecules (HMW) present a low bioavailability  growing in oil‐contaminated soil and inoculated with an Acinetobacter PGPR strain showed an increased dry mass and stem height compared to controls, along with a higher rate of decontamination  growth in PAH contaminated soils than when inoculating with the wild‐type strains  growing in soil contaminated with 100 mg kg−1 phenanthrene resulted in a 25–40% increase in the degradation rate of this PAH compared to uninoculated controls anthracene in AMF‐inoculated pots as compared to non‐inoculated pots  have multiple interesting roles that can improve rhizoremediation. For instance, under contaminated settings AMF can modify the rhizosphere microbial communities  are often more abundant when earthworms are present. For instance, the application of the earthworms to an anthracene contaminated soil resulted in a shift in the soil microbial community with a decrease in the relative abundance of Gemmatimonadetes, Chloroflexi and Acidobacteria and an increase in the Proteobacteria compared to the untreated soil   are often selected for rhizoremediation purposes as they produce a dense secondary root system that can harbor an abundant microbial community , Festuca arundinacea , and Medicago sativa  growing in pots , Albizia lebbeck (lebbeck), Delonix regia (flame tree) and Dalbergia sissoo (North Indian rosewood)] to reduce soil PAH levels was evaluated  was measured in the rhizosphere of et al., et al., Sphaerosporella brunnea, whereas Asian and European genotypes did not associate with this particular fungus  with different concentrations of the alkane degrading Pantoea sp., resulted in maximum plant growth, diesel degradation, bacterial abundance and CYP153 alkane hydroxylase gene expression in the treatment with the densest inoculation (108 cell cm−3 soil)  . Similarly, the growth of willows after 100 days in highly contaminated soil could be predicted by the initial bacterial and fungal community composition and the initial relative abundance of specific taxa (Yergeau et al., et al., Because it is a biological process, the time for soil decontamination by way of phytoremediation is difficult to estimate accurately, which often makes this option less attractive. Recent work has provided interesting evidence that various ecosystem processes could be predicted from microbiological data. For instance, the degradation of diesel in arctic soils could be predicted by the initial bacterial diversity and the abundance of specific assemblages of in situ soil remediation (Mench et al., in situ phytoremediation. Additionally, phytoremediation is rarely suggested as a remediation technique by accredited experts because it is believed to be inefficient and because of the inability to precisely determine the duration of this biological process as it depends on contaminant and soil natures, plant used, environmental conditions and microbial activities (Montpetit and Lachapelle, et al., Despite the remarkable advances detailed above, phytoremediation remains a marginal option for None declared.


Varicose veins impair quality of life and can lead to chronic leg ulcers. National Institute for Health and Care Excellence (NICE) guidelines (CG168) set out evidence‐based standards for patient management. In England, Clinical Commissioning Groups (CCGs) fund NHS care within their locality. The objective of this study was to evaluate CCGs' commissioning policies and compare them with CG168.Searches were made for the published policies of all 206 English CCGs. They were reviewed for compliance with NICE guidelines and the associated quality standard. Areas of disagreement were analysed for themes.Some 203 CCGs (98·5 per cent) had a published policy and 190 (93·6 per cent) of these were published after publication of CG168. Only 73 of the policies (36·0 per cent) were compliant with CG168. Treatment was restricted on the basis of clinical disease severity in 119 CCGs (58·6 per cent); 29 (14·3 per cent) stipulated delay of treatment using a ‘trial’ of conservative treatment; 22 (10·8 per cent) used lifestyle‐related factors such as BMI and smoking status to ration treatment. Treatment was commissioned for uncomplicated symptomatic varicose veins in 87 CCGs (42·9 per cent), but some applied additional rationing mechanisms; 109 CCGs (53·7 per cent) would treat oedema, 183 (90·1 per cent) would treat skin and soft tissue damage, 202 (99·5 per cent) healed ulceration, and all would allow active ulcers to be treated.The majority of CCGs in England have commissioning policies that contradict NICE guidelines. Rationing strategies include disease severity, delay and patient lifestyle‐related factors, creating unwarranted geographical variation for varicose vein treatment, disregarding the NHS Constitution for England, and perhaps leading to an increase in costly treatment of chronic complications in the long term. Varicose veins (VVs) are the most common manifestation of a spectrum of disease caused by superficial venous incompetence (SVI) of the leg. They stem from inflammatory changes in the vein wall and valve structure that remain poorly understood. The resulting venous incompetence leads to venous hypertension, which produces further inflammatory and structural changes within the veins, causing them to develop their classic bulging, tortuous appearance and progressive incompetence. The venous hypertension can also cause oedema and inflammatory changes in the soft tissues of the lower leg, resulting in permanent skin damage, lipodermatosclerosis and ulceration. The factors governing progression through this spectrum are unclear, and the prognosis for the individual patient is unpredictable.VVs are extremely common, affecting 40–50 per cent of the adult populationTreatment of VVs aims to reduce venous pressure back to normal physiological levels. Typically the incompetent veins are either removed  or ablated . Randomized trials comparing the outcomes of the different treatments have shown that they all result in a significant improvement in QoLDespite the evidence of benefit, financial pressures on health services, especially during the last 10 years, have resulted in widespread restrictions in access to treatment in England. Commissioners in different parts of the country have introduced a variety of restrictions to the referral and treatment of patients with VVs. In response to this geographical variation, the National Institute for Health and Care Excellence (NICE) published a Clinical Guideline (CG168) in July 2013The aim of this study was to establish whether the current commissioning policies in England comply with the evidence‐based NICE guidelines.® spreadsheet , which was also used for data analysis. CCGs with no policy available online were contacted by telephone to ascertain whether they had a policy, and to acquire the policy if there was one. If telephone contact failed, a written freedom of information request was submitted. By law, this requires a response within 20 working days.NHS England has a system of local commissioning for the treatment of VVs. Commissioning decisions are made by local Clinical Commissioning Groups (CCGs) regarding the availability and funding of care in their local areas. Each commissioning area was researched separately by two authors. Their websites were searched between 17 and 24 April 2017 for any published policy on referral and treatment of VVs. Both authors independently noted commissioning criteria from the policy. These were compared and, if there was any disagreement about the precise criteria, a final decision was made by another author. The data were recorded and stored in a Microsoft ExcelTable The primary outcome measure was whether the policy was fully compliant with NICE CG168 and allowed the routine commissioning of the treatment of suitable patients as per the stated criteria  group was set up in 2015 using a National Institute for Health Research PPI grant; the group supported the importance of this study and reviewed the final draft of the manuscript.Some 203 of the 206 CCGs in England (98·5 per cent) had a written policy for the commissioning of treatment for VVs. In 198 (97·5 per cent) the policy was available online. The three CCGs with no policy were in the process of drafting one. Some 190 policies (93·6 per cent) were published after the publication of NICE CG168 in July 2013 and therefore should have been written with knowledge of it.Fig. Fig. Only 73 (36·0 per cent) of the policies were fully compliant with NICE CG168 , and patients with oedema in association with their VVs had access in only 109 CCG areas (53·7 per cent). Patients with skin and soft tissue damage had access in 183 CCG areas (90·1 per cent), those with healed ulceration in 202 (99·5 per cent), and those with active ulceration in 203 (100 per cent). These figures apply to clinical severity in isolation; a proportion of policies applied more than one rationing mechanism. For example, 14 of the 87 CCGs treating uncomplicated symptomatic VVs applied additional rationing, by either delay or lifestyle factors, or both (Some of the policies were explicit about their reasons for non‐compliance with NICE CG168. A common reason given was that implementation of the NICE guideline was ‘too costly’ (11 CCGs). Statements were made that VVs were ‘low priority’ (9 CCGs), and 11 CCGs labelled VV treatment as a ‘cosmetic procedure’. Correspondence with some CCGs indicated that they were considering drafting a more restrictive policy in the near future. From 1 December 2017, a group of CCGs in the North of England changed to a combined policy in which commissioning is limited to the treatment of ulcer disease, but only after a delay of 6 months, and one of these CCGs will not commission treatment for smokers or those with a BMI over 35 kg/mNICE guidance is regarded as describing the standard of care for health services in the UK and is it normally expected that its recommendations will be followed by commissioners and providers of healthcare services. NICE guidelines are produced by independent committees including all key stakeholders, using well defined and established processesThere is another important consideration regarding the provision of care, and that is the NHS ConstitutionFigs This study of local commissioning policies across England has identified widespread, conscious non‐compliance with the NICE guidance on which patients may be referred and treated. It has identified three main strategies for limiting access to treatment. The first and most common strategy is to withhold intervention until a later disease stage, for example when skin changes have developed or even when ulceration or bleeding has occurred. This approach is applied variably across the country, as shown in This strategy ignores the evidence showing that QoL improvement is actually higher when the disease is treated before skin damage is done and recurrence rates also appear to be lowerThe second strategy for rationing is by delay, through a period of conservative management before referral or definitive treatment. Evidence suggests that conservative treatment is inferiorThe third strategy is the introduction of lifestyle‐related criteria, restricting referral because of obesity or smoking. Similar rationing strategies have attracted controversy in the commissioning of orthopaedic lower‐limb proceduresIn considering the reasons for the widespread non‐compliance with NICE guidance, cost may be the key factor. Some CCGs were explicit that the reason for their non‐compliance was the cost of implementation. The interventional treatment of VVs has been shown to be highly cost‐effective compared with conventional willingness‐to‐pay thresholdsThe perception of VVs and their implications is an important issue. VVs are widely perceived as primarily a cosmetic problem and they are bundled within cosmetic surgery in commissioning policies. Cosmetic concern is an issue for many people with VVs; however, when they start to give rise to symptoms, these can cause significant impairment in QoL even when relatively modestThe main limitation of this study is that it examined only the published or stated policies of CCGs. In practice, commissioning practices may not concur with published policies; some are more restrictive. One CCG has a policy stating that it will routinely fund the treatment of patients with any skin changes. However, in practice this is not the case and the CCG demands an individual funding request for each patient with a justification required as to their ‘exceptional’ need for treatment. The methodology of this study did not capture this practice.The NHS is currently under great financial strain and it is not surprising that decisions are being made to restrict services. However, these decisions should be based on a good understanding of the issues and on sufficient public debate. It is clear from this study that at an overall national level there has been no improvement in access to care for people with VVs since the publication of NICE CG168 (and QS67), compared with restrictions documented before that time


This simple reagent activates the poorly nucleophilic NH2 group in a sulfonamide, enabling the formation of one of the best electrophiles in organic synthesis: a sulfonyl chloride. Because of the variety of primary sulfonamides in pharmaceutical contexts, special attention has been focused on the direct conversion of densely functionalized primary sulfonamides by a late‐stage formation of the corresponding sulfonyl chloride. A variety of nucleophiles could be engaged in this transformation, thus permitting the synthesis of complex sulfonamides, sulfonates, sulfides, sulfonyl fluorides, and sulfonic acids. The mild reaction conditions and the high selectivity of Pyry‐BF4 towards NH2 groups permit the formation of sulfonyl chlorides in a late‐stage fashion, tolerating a preponderance of sensitive functionalities.Reported here is a simple and practical functionalization of primary sulfonamides, by means of a pyrylium salt (Pyry‐BF It's never too late: The conversion of primary sulfonamides into sulfonyl chlorides has been achieved by capitalizing on the use of Pyry‐BF4 as activating reagent. The mild reaction conditions and high selectivity of the protocol permit the presence of a preponderance of functional groups and the conversion of poorly nucleophilic and unreactive sulfonamides for late‐stage functionalizations. Indeed, the traditional and most common strategy for the formation of complex sulfonamides has been the reaction between a sulfonyl chloride and the corresponding amine.3, SO2Cl2, and derivatives thereof  and its high reactivity towards NH2 groups in heteroaromatic amines, thus priming them for SNAr reaction to forge a plethora of new carbon–heteroatom bonds  was chosen as a model substrate  were obtained . The presence of electron‐deficient groups in the aryl ring of the sulfonamide, afforded lower yields both of sulfonic acid and sulfonyl chloride (5 and 6), suggesting that the lone pair of the NH2 group in these cases is even less nucleophilic and condensation with 1 is slower. We next turned our attention to the use of simple alkyl sulfonamides. In this case, smooth conversion into the corresponding acid or sulfonyl chloride was obtained independent of the sterics and electronics on the alkyl groups (13–18). In an attempt to trap the intermediate of the condensation, tert‐butylsulfonamide was reacted with 1 in the absence of MgCl2 in CD3OD. Indeed, a 65 % of the sulfonate product 19 was obtained after 3 hours of reaction, thus highlighting the ability of mildly nucleophilic oxygenated compounds to outcompete sulfonic acid formation. Although the use of a primary alcohol as solvent affords the corresponding sulfonate, attempts to reduce the amount of ROH in solution resulted in almost exclusive formation of sulfonic acid.To explore the reactivity of 20). A sulfonamide bearing a trifluoromethyl ketone and an amide in their structure smoothly reacted to afford 77 % of sulfonyl chloride (21). Despite the presence of a secondary amine, an ester and furan, furosemide could successfully be modified and high yields of the sulfonyl chloride were obtained (22). The highly chelating precursor to glibenclamide (diabetes type‐II) also afforded good yields (23). A sulfonamido‐urea derivative bearing an aryl bromide smoothly reacted under the optimized conditions . Compounds bearing the medicinally relevant trifluoromethoxy group (OCF3) were also amenable for sulfonyl chloride formation (25). The protocol boded well with the presence of unprotected alcohols as exemplified by the good yields obtained of compound 26 (83 %). Gratifyingly, free carboxylic acids were also compatible with these reaction conditions, affording 69 % of the sulfonyl chloride 27. N‐Boc‐protected anilines also posed no difficulties in forging the sulfonyl chloride . Oryzalin, a microtubule disruptor herbicide bearing a tertiary amine, was smoothly converted from the sulfamino group into the corresponding sulfonyl chloride . Alkyl sulfonamides were also amenable to sulfonyl chloride formation as exemplified by (1S)‐10‐camphor sulfonamide, which could successfully be converted into the corresponding sulfonyl chloride (30). Not surprisingly, when the sulfonamide compound bears an unprotected amine in their structure, competition for condensation with 1 occurs, thus preventing sulfonyl chloride formation (31). This result highlights one of the main limitations of this protocol. It is important to mention that the mild reaction conditions of this method for the synthesis of sulfonyl chlorides from sulfonamides are in stark contrast to the methods reported utilizing POCl3 and sulfonic acids as starting materials. As a result, the reactions are plagued with side reactions resulting in low‐selectivities and limited functional‐group tolerance. For example, the use of POCl3 in the presence of simple amides, lactames or ureas leads to Vilsmeyer acyl chloride derivatives and subsequent side‐reactions occur.The use of simple reagents and mild reaction conditions to form sulfonyl chlorides led us to hypothesize that a wide variety of functional groups could potentially be tolerated. In this sense, we speculated that this protocol could serve as an excellent tool for providing sulfonyl chlorides in late‐stage functionalization contexts were functional‐group compatibility is essential. To this end, we explored a variety of complex druglike derivatives bearing primary sulfonamides in their structures Table . Gratify32–35). To provide medicinally relevant examples, we decided to explore even more complex nucleophiles as potential coupling partners in sulfonamide or sulfonate bond formation. To this end, we turned our attention to biologically active compounds bearing various functional groups embedded in their structure. In this sense, furosemide could be coupled with the polycyclic antidepressant amoxapine in excellent yields (36). Celecoxib was also successfully coupled with a variety of primary and secondary amines, affording excellent yields of the corresponding sulfonamides over two steps (37–42). Pharmacologically relevant and highly functionalized molecules such as paroxetine bearing a benzodioxole  or sitagliptin bearing two Lewis‐basic nitrogen atoms  were both amenable for sulfonamide linkage with celecoxib. When the glibenclamide precursor was subjected to coupling with warfarin, an anticoagulant drug, a 67 % yield of the sulfonate linkage was obtained (45). Similarly, the sulfonamide linkage between the glibenclamide precursor and duloxetine formed in a 75 % yield (46). Other complex primary sulfonamides were also compatible in the sulfonamide bond formation by this simple two‐step process and through the parent sulfonyl chloride as exemplified by 47–49. It is important to mention that the yields reported in Table 1 was carried out in the presence of a primary or secondary alcohol, a sulfonate linkage was obtained. Capitalizing on this reactivity, the complex antipsychotic (±)‐sulpiride, bearing a tertiary amine, reacted similarly and afforded excellent yields of methyl sulfonate . In a similar manner, the diuretic and anti‐edema hydrochlorothiazide bearing a cyclic secondary sulfonamide and a secondary amine in their core posed no difficulties for obtaining the ethyl sulfonate when the reaction was carried in EtOH .Having established a protocol for synthesizing highly versatile and electrophilic sulfonyl chlorides from various complex molecules, selective diversification of these entities is within reach in a facile and straightforward fashion. With the importance of complex sulfonamide linkages in drug discovery,2−NR2 and SO2−OR bonds, we intended to extend the protocol to other desirable linkages derived from complex primary sulfonamides, namely S−P bonds and S−F bonds. In the former, we capitalized on the report by Li and Zhang,52). In a similar way, the conversion of sulfonyl chlorides into more robust sulfonyl fluorides has recently attracted a lot of attention for its tremendous properties as click reagents.53). To further illustrate the robustness of the protocol, we scaled‐up our sulfonyl chloride synthesis using benzyl furosemide as starting material. Without modification of the original protocol, 1 gram of benzyl furosemide could successfully be converted into 22 without noticeable erosion in yield  as an activating agent and MgCl2 as the chloride source. The mild reaction conditions and the tolerance to a wide variety of functional groups permit the derivatization of complex sulfonamides, whose diversification would be troublesome with other methods available. This report also highlights the simplicity of stitching together molecules through the venerable and “old‐school” sulfonamide coupling without requiring complicated setups and tedious work‐arounds. The method reported herein intends to provide a platform for rapid derivatization of libraries of complex primary sulfonamides which are currently conceived as an unreactive end‐point. With this method, those compounds could be revisited and repurposed to implement further complexity. We strongly believe that the combined practicality and robustness of this method will find direct applications in the chemical community.In conclusion, we report a simple, practical, robust, and efficient method for the synthesis of sulfonyl chlorides from primary sulfonamides. The reaction capitalizes on the use of a simple pyryilium reagent  should be addressed to the authors.SupplementaryClick here for additional data file.


Smoking during pregnancy is strongly associated with negative pregnancy and perinatal outcomes. Some guidelines recommend nicotine replacement therapy (NRT) for smoking cessation during pregnancy, but adherence with NRT is generally poor and could be partially explained by nicotine‐related safety concerns. We compared pregnant women's cotinine and nicotine exposures from smoking with those when they were abstinent from smoking and using NRT.Systematic review with meta‐analysis and narrative reporting. Twelve studies were included: in most, only one type of NRT was used. Seven were quality‐assessed and judge of variable quality.Studies from any setting that reported nicotine or cotinine levels when smoking and later when abstinent and using NRT.Pregnant women who smoked and became abstinent but used NRT either in a cessation study or in a study investigating other impacts of NRT.We quality‐assessed longitudinal cohort studies using a modified version of the Newcastle–Ottawa scale. For meta‐analysis, we used mean within‐person differences in cotinine or nicotine levels when smoking and at later follow‐up when abstinent and using NRT. Where such data were not available, we calculated differences in group mean levels and reported these narratively, indicating where data were not completely longitudinal.n = 83) were combined in a random effects meta‐analysis; the pooled estimate for the mean difference  in cotinine levels between when women were smoking and abstinent but using NRT was 75.3 (57.1 to 93.4) ng/ml . Of eight narratively‐described studies, six reported lower cotinine and/or nicotine levels when abstinent and using NRT; two had mixed findings, with higher levels when abstinent but using NRT reported from at least one assay time‐point.Of the 12 included studies, four cotinine‐measuring studies (Pregnant women who use nicotine replacement therapy instead of smoking reduce their nicotine exposure. Smoking in pregnancy causes much morbidity and mortality In the United Kingdom, when other cessation methods have been ineffective, pregnant women who want to stop can be recommended to use nicotine replacement therapy (NRT) Improving pregnant smokers’ adherence to NRT could result in this being more effective at helping them to stop smoking. In non‐pregnant smokers, prescribing higher doses of NRT results in greater use of NRT Pregnant women's reluctance to use NRT seems to be partially explained by their worries about the safety of nicotine This review followed the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) methods https://www.gsk‐clinicalstudyregister.com/); World Health Organization International Clinical Trials Registry Platform ; US National Library of Medicine Clinical Trials database ; and the ISRCTN registry (http://www.isrctn.com/). Finally, we searched the Cochrane Library using the terms ‘smoking’, ‘pregnancy’ and ‘nicotine replacement’. Non‐bibliographic database searches were completed by 7 September 2017. There were no language restrictions and literature was searched from 1980, as the first trials of NRT were reported after that. In tandem with electronic searches, we scanned the references of papers included in reviews identified by the searches, and which covered the topic of interest, but were not eligible for inclusion.We developed a search strategy in MEDLINE using a combination of MESH and plain text terms and adapted it to use in Web of Science and EBSCO see ; the strIdentified citations (titles and abstracts) were manipulated in an EndNote library. One reviewer (C.H.) screened these to assess whether or not articles should be included, and where there was uncertainty or papers were thought likely to be eligible, full texts were assessed by two reviewers with agreement on inclusion or exclusion being reached by consensus.Data were extracted by one researcher (C.H.) and checked by a second (T.C.). The following study details were extracted: objectives, setting, inclusion and exclusion criteria, study design and analysis; and number and characteristics of participants providing data for this review, baseline information on nicotine addiction or heaviness of smoking. The following intervention details were extracted: completeness of follow‐up for women in longitudinal analyses; reasons for dropout; biochemical confirmation of participant's smoking abstinence or not; dose(s) and type(s) of NRT used; instructions given on how regularly and for how long NRT should be used. The following details on measurements were extracted: body fluids sampled; whether nicotine or cotinine was assayed; time‐points at which samples were taken and timings of samples relative to smoking or NRT use; and relevant numerical findings (e.g. mean differences between concentrations of cotinine or nicotine concentrations at baseline and later time‐points). For ongoing studies, we e‐mailed the Principal Investigator enquiring whether data were available and we asked the same of corresponding authors for those papers which reported insufficient data for meta‐analysis . For two studies We quality‐assessed those studies which had been designed as longitudinal cohort studies and which stated, a priori, that a reason for the study was to take measurements when smoking and later abstinent and using NRT. These studies designs were, therefore, directly relevant to this review—any biases in methods used could be adjudged directly from published reports; this was performed using Wells’ modified version of the Newcastle–Ottawa Scale (NCOS) Wells’ modified version of the NCOS allocates stars to reflect study quality on eight items grouped under three domains: selection or comparability of study group and ascertainment of exposure/outcome Longitudinal, within‐person data, from the same women at baseline and at later time‐points, were used to estimate the mean differences between body fluid levels of nicotine or cotinine when smoking and later when abstinent and using NRT. We aimed to provide a pooled estimate of this difference in body fluid levels and to investigate the impacts of the type and dose of NRT and gestational age, but anticipated that the meta‐analysis undertaken would depend upon the available data and that a final decision on which studies (if any) to include in analyses would be taken once available literature were identified. For inclusion in meta‐analyses, study manuscripts had to report such a mean difference and its standard error or to report sufficient other data from which these could be calculated. Where such data were not included in papers, we contacted authors requesting either aggregated data as mean differences and standard errors or as individual participants’ data. A saliva : blood cotinine ratio has been reported as 1.01 (95% CI = 0.99–1.04) I2 statistic Meta‐analysis was conducted in Stata version 15 using the Metan command employing random‐effects models For studies which could not be included in meta‐analysis, we calculated differences in group mean levels (of cotinine or nicotine) and report these narratively, indicating where data were not completely longitudinal. For studies which provided ‘within‐participant’, longitudinal data with no loss to follow‐up, percentage nicotine substitution was calculated by dividing follow‐up mean cotinine (nicotine) levels by baseline ones and multiplying by 100. The percentage nicotine substitution measure indicates how completely NRT substitutes for nicotine from smoked tobacco.After removing duplicates, 3576 potentially relevant citations were found from library databases . Within these studies, percentage nicotine substitution varied between 26.5% (2 mg gum) Data obtained from 83 participants in four saliva cotinine‐measuring studies were included in a meta‐analysis , exposure levels were higher when smoking than when abstinent and using NRT. In the remaining two studies, findings were mixed and details follow; Table The study summarized in row 5 reported higher urinary cotinine levels when smoking In rows 6–9, four longitudinal cohort studies are described Row 10 describes a longitudinal cohort study in which women were followed‐up daily for 4 days when abstinent after starting NRT Rows 11 and 12 describe women in NRT arms of RCTs A meta‐analysis comparing cotinine exposures when pregnant women smoke with those when they use NRT found that levels were, on average, 75.3 ng/ml lower when abstinent and using NRT than when the same women smoked. Similarly, lower exposures after NRT occurred in six of the remaining eight studies.Only 12 empirical studies were included; five had not been designed as longitudinal cohorts and most did not publish sufficient details to be included in a meta‐analysis. Nevertheless, longitudinal, within‐participant data were available from 10 studies and so only two were of limited use for answering review questions We believe this study is original, and the systematic approach used combined with the rigorous contact made with authors should have sourced all available data within identified studies. Despite substantial variation in the types of NRT issued and in how participants were instructed to use this, and also in the timings of sample measurement across studies, the low level of heterogeneity in the pooled mean difference estimate indicates that the data synthesis undertaken was valid and the estimate is robust.It was not possible to combine studies’ findings to investigate the impacts of different NRT doses or regimens on cotinine levels. However, consideration of individual studies’ findings does not suggest that different NRT doses or giving different instructions about using NRT has substantial impact. For example, the mean differences in cotinine levels obtained when smoking and later from women who were abstinent and used NRT, and so were adherent, were similar in two major RCTs investigating NRT in which participants were told to use this treatment in different ways A key reason for this study was to determine whether pregnant smokers who have concerns about the safety of nicotine in pregnancy and which might deter them from using NRT regularly enough and in sufficiently high doses to help them stop smoking could be reassured about its use Among pregnant women who quit smoking, standard‐dose NRT generates lower nicotine exposure than smoking. This lower exposure, combined with the very strong likelihood that nicotine is not responsible for the majority of fetal harms caused by tobacco smoke, makes it very likely that relative to smoking, NRT is safer for the fetus than smoking. Additionally, when NRT promotes maternal smoking cessation this is very likely to improve fetal health by reducing adverse pregnancy outcomes.Prospero protocol registration number: CRD42017081914I.B. has received honoraria from Pfizer Ltd for talks and participation in advisory board. C.O. has received study medication  from Pfizer Ltd for an NIH‐funded study of a nicotine inhaler for smoking cessation during pregnancy. C.H., S.L., K.C., R.C., S.C., T.C/‐H. and T.C.; none to declare.Appendix S1 Example search run in MEDLINE.Appendix S2 Amended Newcastle‐Ottawa Scale for Cohort Studies: item definitions.Click here for additional data file.


IVF), as increasingly large and automatically‐generated data sets have come to play an instrumental role in assisted reproduction. The article addresses this datafication of reproduction by analysing time‐lapse embryo imaging, a key data‐driven technology for embryo selection in IVF cycles. It discusses the new forms of knowledge and value creation enabled by data‐driven embryo selection and positions this technology as a harbinger of a wider datafication of (reproductive) health. By analysing the new ways of seeing embryos with ‘in silico vision,’ the ‘data generativity’ of developing embryos and the patenting of embryo selection algorithms, I argue that this datafied method of embryo selection may not just result in more or less ‘IVF success,’ but also affects the conceptualisation and commercialisation of the assisted reproductive process. In doing so, I highlight how the datafication of reproduction both reflects and reinforces a consolidating trend in the fertility sector—characterised by mergers resulting in larger fertility chains, online platforms organising fertility care and expanded portfolios of companies aiming to cover each step of the IVF cycle.The 21st century has witnessed the emergence of  The emergence of in silico reproduction alongside the familiar in vitro reproduction (e.g. IVF) follows from an understanding that an increasing number of aspects of reproduction can be ‘measured and monitored and treated as technical problems with technical solutions’ . Through a case study approach, which Feagin et al. , p. 1 deet al.  method oThe Baby Business by focusing on a newer, data‐driven technology that allows for a characterisation of more recent changes in the IVF sector, including its ongoing expansion and consolidation, the rise of private equity investments, the significance of patenting and the commercialisation of reproductive data. These focus points align with a surge of scholarship in science and technology studies concerned with the relation between reproduction, cellular life and capital. Notably, the work on ‘biovalue’ and ‘biocapital’ by Sarah Franklin . In this process, a multiplicity of parameters recording specific visual aspects of the cells may be combined to ascribe a unique quantified value to each embryo Merck . In turnin silico vision’ in the embryological work flow. Now touching the screen instead of the petri dish, time‐lapse embryo imaging allows embryologists to observe, record and compare cellular behaviours that occurred in the petri dish in their absence – both in the incubated embryo cohort and those historical populations that preceded them. Tracking algorithms can record key developmental markers and provide suggestions for manual annotation , the company that produced the Reproductive BioMedicine Online, led a scholarly response to the Auxogyn patents and wrote a plea against ‘patenting time and other natural phenomena’ in this journal:in vitro are now owned by a corporation. . In response, Stanford professor and inventor of the patent Renee Reijo Pera claimed that the patents cover the ‘assays intended to distinguish optimal [and suboptimal] embryos for transfer in IVF’ and therefore entail a method rather than a natural phenomenon (2013).in vivo and in vitro cell cycles are fundamentally different processes; in fact it is their close resemblance that has resulted in the birth of over 5 million children from IVF. ‘Arguing that those processes were somehow not natural (and therefore patentable),’ he suggests, ‘may instigate an entirely different discussion, not unlike those that engaged the opponents of IVF in its early days’  in natural conception; and in nature women simply do not conceive outside of the body’ . Cohen responds that no studies have supported the premise that s’ Cohen , p. 115.Bioinformation (2017), Bronwyn Parry and Beth Greenhough describe the difficulties of differentiating between ‘discoveries’ from ‘inventions’ in the context of biotechnologically reworked material, such as isolated DNA or immortalised cell lines. A series of legal rulings have determined that intellectual property rights to human biologicals can be claimed even if they are derived from human bodies, ‘because bringing them into the world was deemed an act of manufacture or invention, not just discovery’ and the patents would recompense corporations for their expended labour ..2013, ppet al. can be measured automatically using the cell tracking algorithms and software previously described. The systems and methods described can be used to diagnose embryo outcome with key imaging predictors and can allow for the transfer of fewer embryos earlier in development. . The patenting of embryo development similarly points to a mode of cellular generativity that coincides with value production. The incubated embryo's data‐generativity propels not only clinical and scientific knowledge production, but also the emergence of future life, as the data flows drawn from time‐lapse embryos can be repurposed as tools for future selections. Once datafied as both tool and object of selection, the incubated developing embryo enters the realm of economic valuation neither, in the first instance, as an exchangeable commodity, nor as the materially and commercially self‐accumulative stem cell line  as the key to IVF success. The datafication of embryo selection thus creates novel algorithmic products, which reflect both the new forms of bioinformatical labour in the fertility clinic and new forms of value production both through the branding of technological innovation and a promise of increased IVF success that comes with an additional price tag.KIDScore tool. Along with Vitrolife's Embryo‐Scope, clinics can purchase this software package, which consists of algorithms that measure the ‘implantation potential’ of the embryos in the incubator and provides a ‘morphokinetic score’ between 1 and 5 to embryologists, who can then ‘select the embryos ranked high with better chances of implanting and becoming a child’ .At the level of the producer, the labour of collecting and instrumentalising embryo data likewise yields software products. Vitrolife's ‘largest database’ of known implantation data (KID) is translated into a valuable asset through its ny Merck . KIDScorKIDScore and Xtend were developed on the basis of data sets sourced from IVF clinics across the world. The (contested) claim that such networked embryo data collection is feasible with these time‐lapse systems is itself a key element in the marketisation of these algorithmic products. After all, their selling point is not simply the promise of improved pregnancy rates, but an improved workflow in the lab. Vitrolife emphasises that KIDScore is easy to use and requires annotation of only a limited number of variables, which its predictive analytics method anticipates. It thereby enables a ‘high level of consistency in embryo scoring in your clinic’  and Fakih IVF Group in the United Arab Emirates ($207 million)  embryo data sharing that emerge with the introduction of time‐lapse embryo imaging enable new forms of connectivity between actors in the fertility industry – whether through the live‐streaming of embryo videos from the incubator to the intended parents’ iPad or through downloads of updated parameters for embryo selection from the manufacturer into the local time‐lapse system. Even if not all pathways for data sharing built‐in to the system are necessarily in use, the introduction of time‐lapse systems facilitates automated embryo data exchanges between the manufacturer, the patient and the incubator in the IVF lab. The resultant key shift is that the direction and scope of embryo data flows are constrained by the clinic's decision‐making rather than primarily logistic in nature.The spatial dispersal of the embryo selection process enabled by time‐lapse systems particularly suits the spatial dispersal of consolidated fertility companies that expand their geographical reach through mergers and acquisitions. The connectivity built‐in to the time‐lapse systems offers a means of bridging the distances between clinics within a single group by streamlining embryo selection protocols and practices and by sharing embryo data to build proprietary data sets. The alignment of in‐house reproductive data infrastructures and the organisational model of consolidated fertility companies may thus widen the gap associated with data and financial asymmetries between smaller and larger organisations. In the case of time‐lapse embryo imaging, consolidation and datafication thus appear to function as mutually reinforcing conditions of co‐emergence. Larger clinics facilitate the introduction of the apparatuses while the connected and automated method materialised in the machine facilitates coordinating clinical processes across different labs and clinics.et al. Eeva test, which was first produced by Auxogyn, a biotechnological company which attained exclusive licensing for the technology through the abovementioned Stanford patent. In 2014, Auxogyn merged with FertilityAuthority, a ‘patient‐matching technology platform’ and self‐reportedly the world's largest fertility web portal with 1 million monthly visitors, which had itself acquired the leading global FertileThoughts.com social network in 2010 , Eggbanxx (egg freezing) and Progyny corporate fertility insurance.The institutional genealogy of time‐lapse embryo imaging highlights a wider trend of ‘platformisation’  that when coupled with the healthiest embryo, result in the fastest track to success’  clinics’  health care is not only the increase or decrease of pregnancy rates, but numerous conceptual, epistemological and institutional shifts that lie at the foundation of both contemporary technologised reproduction and the future reconfigurations of the relation between biomedicine and society. It is, in other words, crucial to understand data‐driven IVF as not a peripheral phenomenon, but as a harbinger of how power relations between networks of social and corporate actors can be built‐in to the institutional infrastructures that deliver digital health.