Online physical exercise intervention in older adults during lockdown: Can we improve the recipe?

BACKGROUND

Recorded and live online physical exercise (PE) interventions are known to provide health benefits. However, the effects of prioritizing the number of live or recorded sessions remain unclear.

AIMS

To explore which recorded-live sessions ratio leads to the best implementation and benefits in older adults.

METHODS

Forty-six community-dwelling adults (> 60y.o.) were randomized into two groups completing a 12-week online PE intervention. Each group had a different ratio of live-recorded online sessions as follows: Live-Recorded-Live sessions (LRL; n = 22) vs. Recorded-Live-Recorded sessions (RLR; n = 24).

RESULTS

Drop-out rates did not reach significance (LRL:14% vs. RLR: 29%, p = 0.20), and adherence was similar (> 85%) between groups. Both groups reported similar levels of satisfaction (> 70%), enjoyment (> 75%), and perceived exertion (> 60%). Both groups increased physical health and functional capacities, with greater improvements in muscle power (LRL: LRL: + 35 ± 16.1% vs. RLR: + 7 ± 13.9%; p = 0.010) and endurance (LRL: + 34.7 ± 15.4 vs. RLR: + 27.0 ± 26.5, p < 0.001) in the LRL group.

DISCUSSION

Both online PE intervention modalities were adapted to the participants' capacities and led to a high level of enjoyment and retention. The greater physical improvements observed in the LRL group are likely due to the higher presence of the instructor compared to the RLR group. Indeed, participants received likely more feedback to appropriately adjust postures and movements, increasing the quality of the exercises.

CONCLUSION

When creating online PE interventions containing both recorded and live sessions, priority should be given to maximizing the number of live sessions and not the number of recorded sessions.

Clinical and laboratory parameters associated with pregnancy outcomes in patients undergoing frozen euploid blastocyst transfer

RESEARCH QUESTION

Which factors impact on clinical pregnancy rate (CPR) and live birth rates (LBR) in euploid frozen embryo transfer (eFET) cycles?

DESIGN

Retrospective observational study including 1660 eFET cycles with 2439 euploid blastocysts, from November 2016 to December 2020. The impact of clinical and laboratory parameters on CPR, biochemical miscarriage rate (BMR), clinical miscarriage rate (CMR) and LBR was evaluated.

RESULTS

CPR per transfer was 63.4%, LBR per transfer 51.6%. CPR and LBR were significantly higher when double embryo transfer (DET) was performed (71.6% versus 57.7%, P < 0.001; 55.2% versus 49.1%, P = 0.016, respectively). However, pregnancy loss was significantly higher in the DET group (28.8% versus 22.8%, P = 0.02). When patients were classified by body mass index (BMI), no differences were observed for CPR, but CMR was lower (P < 0.001) and LBR higher (p = 0.031) for the normal BMI group. The natural cycle protocol revealed lower CMR (P < 0.001) and lower pregnancy loss (P < 0.001); subsequently, higher LBR (57.6%, 48.8%, 45.0%, P = 0.001) compared with hormonal replacement protocol and stimulated cycle. Day of trophectoderm biopsy affected CPR (P < 0.001) and LBR (P < 0.001), yet no differences were observed for BMR, CMR or pregnancy loss. The multivariate analysis showed that day 6/7 embryos had lower probabilities for pregnancy; overweight and obesity had a negative impact on LBR, and natural cycle improved LBR (adjusted odds ratio 1.445, 95% confidence interval 0.519-0.806).

CONCLUSIONS

Day of biopsy affected CPR, while BMI and endometrial preparation protocol were associated with LBR in eFET. DET should be discouraged as it will increase the risk of pregnancy loss. Women with higher BMI should be aware of the higher risk of pregnancy loss and lower LBR even though a euploid blastocyst is transferred.

P-589 Natural endometrial preparation for single euploid frozen embryo transfer increases the likelihood of live birth in obese patients

Study question

Does a natural endometrial preparation for single euploid frozen embryo transfer increase the odds of live birth (LB) in obese patients?

Summary answer

Compared to an artificial approach, a natural endometrial preparation for single euploid frozen embryo transfer improves the odds of LB in obese patients.

What is known already

Several protocols to prepare the endometrium for frozen embryo transfer have been described with comparable clinical outcomes, and no individual protocol has been demonstrated to be superior. Likewise, no specific patient group has been defined that can substantially benefit from a natural endometrial preparation. Despite obesity being linked to adverse clinical outcomes, observational studies and clinical trials have traditionally included participants with normal weight when comparing protocols, resulting in obese patients being underrepresented in clinical research. Therefore, studies focusing on endometrial preparation protocols for frozen embryo transfer that include obese patients are required.

Study design, size, duration

This study involved the analysis of a retrospective dataset including 975 single euploid frozen embryo transfer cycles performed at two tertiary referral centers between March 2017 and November 2019. The primary outcome was LB after natural and artificial endometrial preparation. Participants were stratified according to the World Health Organization Body mass index (BMI) classification into three groups (G): G1: Normal-weight ≤24.9 (n = 390), G2: Overweight 25 to 29.9 (n = 332), and G3: Obese ≥30 (n = 253).

Participants/materials, setting, methods

Cycles included infertility patients attempting a single euploid frozen blastocyst transfer under natural (n = 324) or artificial (n = 651) endometrial preparation. PGT-A was performed after trophectoderm biopsy using Next-Generation Sequencing. Spontaneous LH rise confirmed ovulation for natural endometrial preparation, and embryo transfer occurred five days after initial progesterone elevation. Hormones were measured from blood samples. For artificial preparation, embryo transfer was performed after oral estradiol and 120-hour vaginal progesterone exposure. All participants received luteal phase support.

Main results and the role of chance

Within each BMI group, no statistically significant differences in age were observed in patients between a natural and artificial endometrial preparation: G1 (33.5±5.1 vs. 32.7±5.2 years; p = 0.13), G2 (34.5±4.9 vs. 33.9±5.8 years; p = 0.39), and G3 (35.6±4.9 vs. 34.3±5.6 years; p = 0.1). Similarly, no statistically significant differences were observed regarding implantation rates: G1 (60% vs 57.1%; p = 0.57), G2 (54.8% vs 55.7%; p = 0.88), and G3 (64.3% vs 51.4%; p = 0.07). LB rates remained constant across all BMI groups when a natural preparation was conducted: G1 [56.66% (n = 85/150)], G2 [49.03% (n = 51/104)], and G3 [58.57% (n = 41/70)]. We observed a decrease in LB rates in G3 when an artificial endometrial preparation was performed: G1 [47.5% (n = 114/240)], G2 [44.73% (n = 102/228)], and G3 [34.42% (n = 63/183)]. The positive impact of a natural preparation on LB rates was more significant in G3, showing a 24% difference of effect between the natural and artificial endometrial preparations. Univariate logistic regression analysis showed a statistically significant difference in the primary outcome (LB) when a natural endometrial preparation was conducted in G3 (OR 2.69, 95% CI 1.53-4.74; p = 0.001), with no differences found in G1 (OR 1.45, 95% CI 0.96-2.18; p = 0.08) and G2 (OR 1.19, 95% CI 0.75-1.89; p = 0.73).

Limitations, reasons for caution

This study could be subject to bias due to its retrospective nature. Sperm quality was not considered for the present study.

Wider implications of the findings

Obese women appear to be the patient group that can obtain benefit from a natural endometrial preparation for frozen embryo transfer by increasing the odds of LB. Future prospective studies should confirm this hypothesis. A natural approach might be unfeasible in a subgroup of obese patients due to anovulatory cycles.

Trial registration number

not applicable

P-358 Effect of endometrial thickness on biochemical pregnancy rate: an analysis of 1534 frozen euploid embryo transfers

Study question

Can a thick endometrial lining measured prior to embryo transfer be considered a protective factor against Biochemical Pregnancy (BP)?

Summary answer

The risk of BP is independent of Endometrial Thickness (EMT), but rather dependent of the type of endometrial preparation and parity.

What is known already

Higher EMT prior to embryo transfer is associated with better clinical outcomes in general, like higher implantation and livebirth, and lower miscarriage rates. But up to our knowledge, no studies evaluated the effect of EMT on BP per say.

Study design, size, duration

This is a two-center retrospective observational study including a total of 1534 euploid Frozen Embryo Transfer (FET) cycles between March 2017 and March 2020 at ART Fertility Clinics Muscat, Oman and Abu Dhabi, UAE. BP is defined as blood beta-hCG &gt;15 mIU/ml on day 12 post FET, that is progressively decreasing, with no evidence of gestational sac on ultrasound.

Participants/materials, setting, methods

The study group consisted of 112 cases of BP, while the control group consisted of the remaining 1422 FET’s that led to different clinical outcomes. EMT was measured by transvaginal ultrasound on the day of progesterone rise (±1 day); that rise was either spontaneous in Natural Cycles (NC), or iatrogenic in Hormone Replacement Therapy (HRT) cycles. Euploidy status of the embryos was assessed by NGS analysis of trophectoderm biopsies. Bivariate and multivariate analyses were conducted.

Main results and the role of chance

There was no difference in mean EMT between the study and the control groups (7.55 vs. 7.68 mm, p = 0.154).

Looking at the association of different variables with the rate of BP, there was no effect of age, BMI, AMH, number of embryos transferred, degree of blastocyst expansion, inner cell mass or trophectoderm grade, day of biopsy, nor presence of blood or mucus on the transfer catheter. However, patients on HRT cycles had significantly higher rates of BP compared to NC (8.42% vs. 4.99%, p = 0.015). Also, those with a previous livebirth had higher rates of BP compared to nulliparous women (8.7% vs. 5.39%, p = 0.014).

The distribution of BP showed that 54.5% occurred with EMT &lt;7.5 mm, 34.8% with EMT 7.5-9 mm, and 10.7% with EMT &gt;9 mm. These represents respectively 8.16%, 6.68%, and 5.94% of the total sample. This decreasing trend of BP with increasing EMT didn’t reach statistical significance (p = 0.429). Univariate analysis comparing the risk of BP in FET’s done with lower and higher EMT to those performed at 7.5-9 mm yielded similar conclusion: OR = 1.24 [0.82-1.88] for &lt;7.5 mm, and OR = 0.88 [0.45-1.72] for &gt;9 mm.

Controlling for different confounders, HRT cycles and multiparity remained as independent risk factors for BP.

Limitations, reasons for caution

Inter-observer variability in EMT measurement and the transfer technique, the retrospective nature of the study, and the lack of data on the mode of delivery of parous women could all have interfered with the conclusion.

Wider implications of the findings

The reduced adverse clinical outcomes with NC shed light on the role of the corpus luteum in the early phases of implantation, and some potential secreted mediators other than progesterone. Besides, the effect of previous deliveries on the endometrium and its receptivity needs further investigation.

Trial registration number

not applicable

P-628 Do ovarian reserve markers and female age predict the rate of euploid blastocysts in IVF/ICSI cycles?

Study question

Are female age and ovarian reserve markers (anti-Mullerian hormone (AMH) and Antral Follicle Count (AFC)), able to predict euploid blastocyst rate in IVF/ICSI cycles?

Summary answer

Female age, serum AMH, AFC and the number of mature oocytes collected during IVF/ICSI cycles significantly affect the rate of euploid blastocysts

What is known already

The age-associated decline in female reproduction has been clearly demonstrated, due to the reduction of the ovarian reserve and the increased risk of chromosomal abnormality occurring in the oocyte. Lately, it has been debated whether a reduced ovarian reserve, independently of age, could be associated with higher aneuploidy rate in embryos. Ovarian reserve can now be accurately measured by serum AMH levels and AFC, both markers with similar high reliability.

Study design, size, duration

This analysis includes data from 10556 blastocysts after preimplantation genetic testing for aneuploidy (PGT-A) with Next Generation Sequencing (NGS). Embryos were obtained from 2564 IVF/ICSI cycles of infertile couples, at ART Fertility Clinics UAE, from November 2016 to December 2020.

Participants/materials, setting, methods

10556 blastocysts with chromosomal information for ploidy were included, mosaic and non-informative embryos were excluded. Trophectoderm biopsy was performed on day 5, 6 or 7 blastocysts. Serum AMH concentrations were measured by Elecsys® AMH automated assay (Cobas 601 platform, Roche®) for all patients in a single laboratory. AFC (sum of small antral follicles in both ovaries) was evaluated with transvaginal 2D-sonography (Voluson E8, GE Healthcare). Ethical approval was obtained from the Research Ethics Committee (REFA023b).

Main results and the role of chance

Patients’ characteristics are described as mean ± SD (min-max): age: 34.72±6.13(18-50), years of infertility: 3.43±3.43(0-25), AMH: 2.52±2.70ng/mL(0.01-23.00), AFC: 11.57±7.86(0-61), body mass index (BMI): 28.57±4.83Kg/m2(14.34-44.96), Metaphase II (MII) inseminated oocytes: 10.11±6.53(1-50), 2PN embryos 7.32±5.12(1-42), blastocysts 4.12±3.21(1-26). Fertilization rate was 73.31%(±19.30), blastulation rate 61.05%(±25.69) and euploidy rate 39.42%(±35.24).

A significant negative Pearson correlation coefficient was found between age and euploidy rate (ρ=-0.5398, p &lt; 0.001). AMH, AFC and total of MII inseminated oocytes showed a significant positive Pearson correlation coefficient with euploid rate (AMH:ρ=0.2076, p &lt; 0.001; AFC: ρ = 0.2578, p &lt; 0.001; MII:ρ=0.2036, p &lt; 0.001). Linear regression analysis was conducted to evaluate the predictability of the variables on euploid rate. As expected, age clearly had a negative impact (Coef=-3.10, Std. Err=0.10, p &lt; 0.0001). A positive effect was observed for AMH (Coef=2.75, Std. Err=0.31, p &lt; 0.0001), AFC (Coef=1.16, Std. Err=0.09, p &lt; 0.0001), number of MII inseminated oocytes (Coef=1.10, Std. Err=0.10, p &lt; 0.0001) and 2PN embryos (Coef=1.43, Std. Err=0.13, p &lt; 0.0001). For patients &gt;35 years old and AMH lower than 1.3 ng/mL, euploid rate was significantly lower compared with the patients &gt;35 years old and AMH equal or higher than 1.3 ng/mL (21.2% vs 25.5%, p = 0.0192).

Limitations, reasons for caution

Despite the large number of cycles and embryos included, the retrospective study design is a limitation.

Wider implications of the findings

Ovarian reserve is not only a quantitative, but also a qualitative biomarker of oocyte-embryo competence. Cumulative success rates for IVF/ICSI cycles are dependent on the availability of euploid blastocysts. Age and ovarian reserve markers should be combined for adequate counselling.

Trial registration number

Not applicable

O-255 Clinical and laboratory factors associated with pregnancy outcomes in patients undergoing frozen euploid blastocyst transfer

Study question

Which variables do have an impact on the pregnancy and live birth rates (LBR) when euploid frozen embryo transfers (FET) are performed?

Summary answer

Day of trophectoderm biopsy, Body Mass Index (BMI) and endometrial preparation protocol have an impact on pregnancy rate (PR) and LBR in FET cycles.

What is known already

Preimplantation genetic testing for aneuploidy (PGT-A) and morphological grading of embryos are the two main criteria to select a blastocyst from a pool of embryos, having the highest implantation potential. However, other clinical and laboratory variables might play a crucial role for a successful outcome when top quality euploid embryos are transferred in a FET cycle. It has been described that higher BMI increases the odds for miscarriage when compared with non-obese women.

Study design, size, duration

This analysis includes 1660 FET cycles with data from of pregnancy rates, miscarriage rate and LBR. Embryos were obtained from 2564 IVF/ICSI cycles of couples with primary or secondary infertility at ART Fertility Clinics UAE, from November 2016 to December 2020.

Participants/materials, setting, methods

A total of 1660 FET cycles with 2439 euploid blastocysts were included. FET cycles with mosaic or segmental aneuploid embryos were excluded. PGT-A was performed on trophectoderm cells, using Next Generation Sequencing (NGS). Biopsy was performed on day 5, 6 or 7 blastocysts. Endometrial preparation included ovulatory natural cycles (NC) and hormone replacement therapy (HRT) cycles, chosen according to physician’s discretion. Ethical approval was obtained from the Research Ethics Committee (REFA023b).

Main results and the role of chance

Patients’ characteristics are described as mean±SD (min-max): age: 33.5±5.43(19-47), AMH: 3.30±3.05ng/mL(0.01-23.00), BMI: 27.1±4.87Kg/m2(13.1-43.90), mean number of blastocysts transferred: 1.4±0.49(1-3). Patients were categorized according to age (years) in 4 categories (&lt;30,n=404; 30-34,n=487; 35-40,n=595; &gt;40,n=174) and no association with pregnancy rate (PR, p = 0.856), biochemical miscarriage rate (BMR, p = 0.940), clinical miscarriage rate (CMR, p = 0.06) nor LBR (p = 0.154) was found. BMI (kg/m2) was divided into four groups according to World Health Organization: underweight (&lt;18.5;n=32), normal weight (18.5–24.9;n=555), overweight (25–29.9;n=622), and obese (≥30;n=426). Although no differences were seen for PR or BMR between groups (p = 0.507 and p = 0.343, respectively), CMR was significantly lower for normal BMI group (p &lt; 0.001) and LBR significantly higher when compared to the overweight and obese group (&lt;18.5kg/m2=68.42%; 18.5–24.9kg/m2=68.35%; 25–29.9kg/m2=60.14%; ≥30kg/m2=53.29%; p &lt; 0.001). No differences were observed on the outcomes when AMH was sub-divided as per Bologna Criteria (&lt;1.3ng/mL,n=327; ≥1.3ng/mL,n=1090). Regarding endometrial preparation, NC protocol showed significantly lower BMR and CMR (7.93% vs 12.27%,p=0.026; 8.44% vs 17.97%,p&lt;0.001), and higher LBR (70.33% vs 55.06%,p&lt;0.001) compared to HRT. Day of trophectoderm biopsy had a significant higher PR for day 5 (day 5=75.58% vs day 6=61.1% and day 7=23.81%, p &lt; 0.0001), yet no differences were observed for BMR, CMR nor LBR.

Limitations, reasons for caution

Although the large number of FET included, performed in the same centre with same methodology, the retrospective study design is a limitation. We could not discard other hypothetical variables contributing to miscarriage such as KIR-HLA discrepancies, or other obstetric factors affecting late miscarriage and live birth.

Wider implications of the findings

Evaluating the factors associated with pregnancy outcomes should be considered prior to euploid frozen embryo transfer for personalized treatment approach and adequate blastocyst selection. Women with higher BMI should be aware of higher risk of miscarriage and lower LBR although an euploid blastocyst is transferred.

Trial registration number

not applicable

P-137 ICM and TE quality significantly impact the live birth in euploid frozen blastocyst transfer cycles

Study question

Is the live birth rate (LBR) in euploid frozen blastocyst transfer (FET) affected by the quality of ICM (Inner cell mass) and TE (Trophectoderm)?

Summary answer

ICM and TE significantly impacts the LBR with a decline of LB from 57.3% (ICM-A) to 48.5% (ICM-B) to 22.1% (ICM-C) (p &lt; 0.001)

What is known already

The morphological blastocyst grading system proposed by Gardner-Schoolcraft remains the most accepted system to identify blastocysts with higher implantation potential. It relies on morphological features within the blastocyst, including ICM and TE. Several studies tried to identify the individual contribution of each. However, the conclusions remain contradictory and no clear consensus has yet been achieved. Due to heterogeneity of parameters evaluated between different publications, where embryos with unknown ploidy status were transferred in conjunction with a variability of stimulation protocols and in the number of transferred embryos, the real effect of the ICM and TE is difficult to infer.

Study design, size, duration

This two-center retrospective observational study includes a total of 977 euploid single FET cycles between March 2017 and March 2020 at ART Fertility Clinics Muscat, Oman and Abu Dhabi, UAE.

Participants/materials, setting, methods

Trophectoderm biopsies were analyzed with Next Generation Sequencing (NGS). All blastocysts available on D5 or D6 with a quality ≥ BL3CC were subjected to TE biopsy for PGT-A analysis and LBR was recorded. Vitrification/warming of blastocysts was performed using Cryotop method (Kitazato). Bivariate and multivariate analysis were performed between LB outcomes and ICM and TE grade while controlling for confounding factors.

Main results and the role of chance

A total of 977 single FET cycles were analyzed: 651 in hormone replacement therapy (HRT) and 326 in natural cycle regimen (NC) resulting in a 46.88% LBR. The mean patients’ age was 33.80 years with a mean Body Mass Index (BMI) of 26.80 kg/m2. Though all qualities of ICM and TE were associated with LB, blastocyst ICM-A LBR was statistically significantly higher (57.3%) than ICM-B (48.4%) and ICM-C (22.1%) (p &lt; 0.001). Similarly, blastocyst TE-A LBR was statistically significantly higher (59.2%) than TE- B (48.6%) and TE- C (30.3%) (p &lt; 0.001). Miscarriage rate was similar in all groups.

The grade of ICM and TE were significantly associated with Anti-Mullerian-Hormone (AMH) and day of blastocyst biopsy. Mean AMH (ng/ml) was higher in ICM groups (A: 3.78, B: 3.24, p &lt; 0.001) and TE group (A: 3.63, B: 3.38, p &lt; 0.05) compared to lower grade (ICM-C: 2.86, TE-C: 2.82).

In multivariate analysis, endometrial preparation for FET, BMI and AMH were the parameters influencing LBR: OR:1.45, [CI:1.07-1.96], p &lt; 0.015) for NC; OR 0.96 [CI:0.93-0.99], p = 0.004 for BMI; OR 0.95 [CI:0.90-1.00], p = 0.033 for AMH; Both, ICM-C and TE-C, resulted in a significantly lower chance of LB [ICM: OR 0.32, CI:0.17-0.61, p &lt; 0.001; TE: OR 0.44, CI:0.27-0.73, p = 0.002), compared to grade A.

Limitations, reasons for caution

The retrospective nature of the study and inter-observer variability in blastocyst scoring is a limitation. The physician/embryologist performing the embryo transfer could not been standardized due to the multicenter design. Randomized controlled studies are needed to determine whether ICM or TE should be prioritized in the selection of the blastocyst.

Wider implications of the findings

The ICM and TE scoring in FET may influence the LBR and should be considered as an important factor for the success of embryo transfer cycles. Whether these results can be extrapolated to fresh embryo transfer and to blastocysts with unknown ploidy status, needs further investigation.

Trial registration number

not applicable

A retrospective validation of CanAssist Breast in European early-stage breast cancer patient cohort

CanAssist Breast (CAB), a prognostic test uses immunohistochemistry (IHC) approach coupled with artificial intelligence-based machine learning algorithm for prognosis of early-stage hormone-receptor positive, HER2/neu negative breast cancer patients. It was developed and validated in an Indian cohort. Here we report the first blinded validation of CAB in a multi-country European patient cohort. FFPE tumor samples from 864 patients were obtained from-Spain, Italy, Austria, and Germany. IHC was performed on these samples, followed by recurrence risk score prediction. The outcomes were obtained from medical records. The performance of CAB was analyzed by hazard ratios (HR) and Kaplan Meier curves. CAB stratified European cohort (n = 864) into distinct low- and high-risk groups for recurrence (P < 0.0001) with HR of 3.32 (1.85–5.93) like that of mixed (India, USA, and Europe) (n = 1974), 3.43 (2.34–4.93) and Indian cohort (n = 925), 3.09 (1.83–5.21). CAB provided significant prognostic information (P < 0.0001) in women aged ≤ 50 (HR: 4.42 (1.58–12.3), P < 0.0001) and >50 years (HR: 2.93 (1.44–5.96), P = 0.0002). CAB had an HR of 2.57 (1.26–5.26), P = 0.01) in women with N1 disease. CAB stratified significantly higher proportions (77%) as low-risk over IHC4 (55%) (P < 0.0001). Additionally, 82% of IHC4 intermediate-risk patients were stratified as low-risk by CAB. Accurate risk stratification of European patients by CAB coupled with its similar performance inIndian patients shows that CAB is robust and functions independent of ethnic differences. CAB can potentially prevent overtreatment in a greater number of patients compared to IHC4 demonstrating its usefulness for adjuvant systemic therapy planning in European breast cancer patients.

•

CanAssist Breast risk (CAB) risk stratification is accurate in European breast cancer patients.

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CAB performance in European cohort was like that of Indian as assessed by low-risk group DMFS, HR and C-index.

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CAB identified significantly higher proportions as low risk compared to IHC4.

•

Greater number of IHC4 intermediate risk patients were identified as low risk by CAB.

Assessing Progress Towards SDGs Implementation Using Multiple Reference Point Based Multicriteria Methods: The Case Study of the European Countries

To achieve the UN 2030 Agenda Goals, and considering their complexity and multidisciplinary, Multi-criteria analysis appears to be a suitable approach to give a true support to public decision makers in defining policy lines. This study focuses on the application of the Multiple Reference Point Weak-Strong Composite Indicators (MRP-WSCI) and its partially compensatory version (MRP-PCI), to assess, in the framework of the UN 2030 Agenda, the sustainability of the 28 members of the European Union (pre-Brexit). Countries were analyzed and compared according to their conditions and progress against the 17 Sustainable Development Goals, considering three reference years: 2007, 2012 and 2017. The analysis shows that Nordic countries reach a good level of global sustainability, with values of the indicators, W-W-W and S-W-W, between 2 and 3; while the States of east Europe, in particular Romania, Bulgaria and Greece, stay at the worst levels, having overall indicators values less than 1.5. Furthermore, the results highlight how countries in the lower group have difficulties especially in social and economic sustainability. On the other hand, states with a good overall condition record the worst results in the environmental dimension, such as the Netherlands, which shows, for the year 2017, a value for this sphere less than 2, while in the other two show a good value (over 2.5).

Administration and monitoring of clofazimine for NTM infections in children with and without cystic fibrosis

Few studies have evaluated clofazimine (CLOF) drug monitoring and safety in children. We treated 10 children, 8 with CF, for NTM infection with multiple antimicrobials, including CLOF. All had serial blood CLOF concentrations measured and were followed for adverse events. Despite CLOF dose escalation, most children with CF did not reach a target CLOF concentration. Our data suggest that children with CF may require earlier initiation of CLOF at higher doses than is currently recommended.

P–677 Endometrial thickness, endometrial preparation protocol and number of euploid embryos transferred, significantly impact the live birth in frozen embryo transfer cycles

Study question

Is the live birth rate (LBR) in euploid frozen embryo transfer (FET) cycles affected by the endometrial thickness (EMT)?

Summary answer

A significantly higher LBR was observed in patients with an endometrial thickness of at least 7.5mm (46.24% vs. 54.63%)

What is known already

Parameters assessing the endometrium prior planning a FET include endometrial thickness, pattern and blood flow. The impact of the endometrial thickness on ART outcomes is controversial, with conflicting results published. A recent meta-analysis evaluated whether EMT could predict pregnancy outcomes and suggested that lower EMT was associated with lower incidence of clinical pregnancy rate (CPR), implantation rate (IR) and LBR. Due to heterogeneity of parameters evaluated between different publications, where embryos with unknown ploidy status were transferred, in conjunction with variability of stimulation protocols and the number of embryos transferred, the real effect of the EMT was difficult to infer.

Study design, size, duration

This was a two-center retrospective observational study including a total of 1522 euploid FET cycles between March 2017 and March 2020 at ART Fertility Clinics Muscat, Oman and Abu Dhabi, UAE.

Participants/materials, setting, methods

Trophectoderm biopsies were analyzed with Next Generation Sequencing (NGS). Vitrification/warming of blastocysts was performed using Cryotop method (Kitazato). EMT was measured by vaginal ultrasound prior initiating the progesterone administration (± 1 day) and LBR was recorded. Multivariate analysis was performed between LB outcomes and median EMT while controlling for confounding factors.

Main results and the role of chance

A total of 1522 FET cycles were analyzed: 975 single embryo transfer (SET) and 547 double embryo transfer (DET). The mean age of the patients was 33.38 years with a mean BMI of 27.1 kg/m2. FET were performed in EMT ranging from 3 to 15 mm and 50.52% resulted in a live birth. Though potentially all ranges of EMT were associated with LB, the median EMT in patients with LB was significantly higher than the median EMT of patients without LB (7.6mm vs. 7.4mm; p &lt; 0.001).

The dataset was stratified into two groups based on the median EMT (7.5mm): &lt; 7.5mm (n = 744 cycles) and ≥ 7.5mm (n = 778 cycles). A significantly higher live birth rate was observed in ≥ 7.5mm group (46.24% vs. 54.63%. p = 0.0012).

In multivariate analysis, EMT, FET endometrial preparation protocol, and number of embryos transferred were the main parameters influencing the chance to achieve LB: OR 1.10 [1.01–1.19], p &lt; 0.015 for the EMT; OR 1.84 [1.47–2.30], p &lt; 0.0001 for Natural Cycle protocol and OR 1.55 [1.25–1.93], p &lt; 0.0001 for DET. Intercept 0.18 [0.07–0.44] p &lt; 0.0002. Female age did not reach significance: OR 1.02 [1.00–1.04], p = 0.056.

Limitations, reasons for caution

Besides the retrospective nature of the study, the inter-observer variability in EMT assessment between different physicians is a limitation. The physician and embryologist performing the embryo transfer could not been standardized due to the multicenter design of the study.

Wider implications of the findings: The EMT in FET may influence the LBR and should be considered as an important factor for the success of embryo transfer cycles. Whether these results can be extrapolated to fresh embryo transfer and to blastocysts with unknown ploidy status, needs further investigation.

Trial registration number

Not applicable

External cranial expansion as treatment of intracranial hypertension. Technical note

Intracranial hypertension may be idiopathic or due to multiple etiologies. Some bone dysplasias and chronic shunt overdrainage syndrome may sometimes lead to intracranial hypertension associated with craniocerebral disproportion due to thickening of cranial diploe. The internal cranial expansion procedure has been used for patients with intracranial hypertension, whether or not associated with craniocerebral disproportion. Its purpose is to increase the intracranial volume by drilling down the inner table. This technique enables the craniocerebral disproportion to be improved and intracranial hypertension reduced. In other etiologies of intracranial hypertension with non-thickened diploe, internal cranial expansion may not be enough to resolve the hypertension. For these cases we propose a modification of the technique by expanding the cranial vault outwards; external cranial expansion. We describe this technique as used in a pediatric patient who presented with chronic headache, tonsillar ectopia, and sleep apnea syndrome. This patient also had a multisuture craniosynostosis, a non-thickened diploe, and intracranial hypertension.

The CONSTANCES Cohort Biobank: An Open Tool for Research in Epidemiology and Prevention of Diseases

“General-purpose cohorts” in epidemiology and public health are designed to cover a broad scope of determinants and outcomes, in order to answer several research questions, including those not defined at study inception. In this context, the general objective of the CONSTANCES project is to set up a large population-based cohort that will contribute to the development of epidemiological research by hosting ancillary projects on a wide range of scientific domains, and to provide public health information. CONSTANCES was designed as a randomly selected sample of French adults aged 18–69 years at study inception; 202,045 subjects were included over an 8-year period. At inclusion, the selected participants are invited to attend one of the 24 participating Health Prevention Centers (HPCs) for a comprehensive health examination. The follow-up includes a yearly self-administered questionnaire, and a periodic visit to an HPC. Procedures have been developed to use the national healthcare databases to allow identification and validation of diseases over the follow-up. The biological collection (serum, lithium heparinized plasma, EDTA plasma, urine and buffy coat) began gradually in June 2018. At the end of the inclusions, specimens from 83,000 donors will have been collected. Specimens are collected according to a standardized protocol, identical in all recruitment centers. All operations relating to bio-banking have been entrusted by Inserm to the Integrated Biobank of Luxembourg (IBBL). A quality management system has been put in place. Particular attention has been paid to the traceability of all operations. The nature of the biological samples stored has been deliberately limited due to the economic and organizational constraints of the inclusion centers. Some research works may require specific collection conditions, and can be developed on request for a limited number of subjects and in specially trained centers. The biological specimens that are collected will allow for a large spectrum of biomarkers studies and genetic and epigenetic markers through candidate or agnostic approaches. By linking the extensive data on personal, lifestyle, environmental, occupational and social factors with the biomarker data, the CONSTANCES cohort offers the opportunity to study the interplays between these factors using an integrative approach and state-of-the-art methods.

Squamous cell carcinoma related with dental implants. A clinical cases report

One third of all cases of head and neck carcinoma (CA) concern the oral mucosa. The use of dental implants (DI) for dental rehabilitation is widely extended. However, a few studies have reported some cases with neoplasic alterations, among the tissue surrounding implants. Our aim was to analyze possible alterations at the bone-implant interface in patients with oral squamous cell carcinoma (SCC), providing new evidence that could relate or discard a possible link between these factors. We used, for the first time, different techniques, including electron microscopy and histology, to analyze the implant ´s surface and the surrounding tissue from four clinical cases with neoplasic alterations surrounding DI. Histologically, ample inflammatory tissue was found in direct contact with the implant surface. Surface analysis of this tissue, revealed titanium percentages. According to our study, no oncological relation with deterioration of the implant surface was found, although DI were constantly related with peri-implantitis, a chronic trauma of the oral mucosa that could involve a neoplastic factor.

Key words:Dental implants, carcinoma, peri-implantitis.

Resolution of inflammation during multiple sclerosis

Multiple sclerosis (MS) is a frequent autoimmune demyelinating disease of the central nervous system (CNS). There are three clinical forms described: relapsing-remitting multiple sclerosis (RRMS), the most common initial presentation (85%) among which, if not treated, about half will transform, into the secondary progressive multiple sclerosis (SPMS) and the primary progressive MS (PPMS) (15%) that is directly progressive without superimposed clinical relapses. Inflammation is present in all subsets of MS. The relapsing/remitting form could represent itself a particular interest for the study of inflammation resolution even though it remains incomplete in MS. Successful resolution of acute inflammation is a highly regulated process and dependent on mechanisms engaged early in the inflammatory response that are scarcely studied in MS. Moreover, recent classes of disease-modifying treatment (DMTs) that are effective against RRMS act by re-establishing the inflammatory imbalance, taking advantage of the pre-existing endogenous suppressor. In this review, we will discuss the active role of regulatory immune cells in inflammation resolution as well as the role of tissue and non-hematopoietic cells as contributors to inflammation resolution. Finally, we will explore how DMTs, more specifically induction therapies, impact the resolution of inflammation during MS.

The potential of a Technosol and tropical native trees for reclamation of copper-polluted soils

Technosols created to reclaim degraded soils is a promising solution that needs further research. The objectives of the study were: i) to create a Technosol with a very high capacity to immobilize copper from mining, ii) to assess the capacity of the Technosol to immobilize copper after planting two tropical native tree species, and iii) to analyse the capacity of the native trees for extracting copper from polluted soils. Myracrodruon urundeuva (aroeira) and Cedrela fissilis (pink cedar) were planted in pots with Technosol spiked with copper at concentrations of 125, 1525 and 3050 mg Cu kg^-1. Height and stem diameter were measured over 90 days. Biomass and Cu concentration in leaves, stem and roots were determined. Copper was analysed in soils by sequential extraction, as well as in leached water. The Technosol showed a very high capacity to immobilize copper, since 60-80% of the added copper was strongly retained in the soil, mainly by bentonite and carbonates. The Technosol with trees showed the same capacity to immobilize copper as the control, since concentration in shoots was higher than 300 mg Cu kg^-1 and concentration in roots was even higher. These results show that Technosol and both species are useful tools to immobilize copper in polluted soils. Further studies are necessary to determine the total capacity of these trees to immobilize and/or extract copper in the long term and under field conditions.

Screening of native tropical trees for phytoremediation in copper-polluted soils

Due to the limited number of studies on phytoremediation using native tree species in tropical soils, the aim was to identify new phytoremediator species from tropical climate with the purpose of promoting an increase in the diversity of tropical native trees used in phytoremediation projects. Seven native tree species from Brazil were selected: Cedrela fissilis, Handroanthus serratifolius, Copaifera langsdorffii, Hymenaea courbaril, Mimosa caesalpiniifolia, Cecropia sp. and Myracrodruon urundeuva. Seedlings of these species were planted in pots with an unpolluted Arenosol, and then spiked with 60, 100 and 500 mg kg^-1 Cu. Height and stem diameters were measured over 60 days. Biomass and total Cu concentration were determined in leaves, stem and roots. Copper in bulk soils and rhizospheres was analyzed by a sequential extraction method. All species accumulated high concentration of Cu in roots (>300 mg kg^-1), so they could be used as phytostabilizators for this metal. Copper mobilization increased in the rhizospheres, but it was mostly absorbed by roots. Cecropia sp., M. urundeuva and C. langsdorffii are hyperaccumulators of Cu (>300 mg kg^-1 in shoots), so they are potential phytoextractor species. This study evidence the potential of seven tree species native from tropical regions for phytostabilizing copper-polluted soils.

Luteal phase serum progesterone levels after GnRH-agonist trigger - how low is still high enough for an ongoing pregnancy?

In the past years, individualization of assisted reproductive technique (ART)-treatment is increasingly common to customize the treatment protocol to the patient's specific conditions. The use of GnRH-agonist for final oocyte maturation in a gonadotropin-releasing hormone (GnRH)-antagonist protocol is the best approach to reduce the risk for ovarian hyperstimulation in high responder patients. However, due to severe luteolysis, the reproductive outcome with this approach in combination with the use of vaginal progesterone as luteal phase support, was poor. Cycle segmentation as alternative to a fresh transfer requires embryo freezing which might not be applicable to all patients due to various reasons. The concept of luteal coasting monitors the progesterone-level closely and human chorionic gonadotropin (hCG) for rescue of the corpora lutea is administered when the progesterone-level drops below a certain threshold. However, the lower range of progesterone levels in the early luteal phase after GnRH-agonist trigger, which is compatible with achieving and maintaining a pregnancy, is unknown. This case-series demonstrates, that ongoing pregnancies can be achieved even with a progesterone-level below 15 ng/ml in the early luteal phase with the timely administration of an hCG-rescue bolus. With the concept of luteal coasting, individualization of the luteal phase support according to the patient's specific luteolysis pattern is possible.

Individual luteolysis post GnRH-agonist-trigger in GnRH-antagonist protocols

Over the past few years, the use of Gonadotropin-releasing-hormone (GnRH)-agonist for final oocyte maturation in GnRH-antagonist-protocols in stimulated IVF/ICSI cycles has gained worldwide acceptance, as this approach reduces significantly the risk for development of ovarian hyperstimulation syndrome (OHSS). Final oocyte maturation with GnRH-agonist leads to sever luteolysis, which cannot be counterbalanced using standard luteal phase support with purely progesterone (P4) application and therefore administration of hCG or high doses of P4 is considered to be essential to prevent/counteract luteolysis. However, lately publications indicate, that luteolysis is not always complete after GnRH-agonist for trigger. This case-series evaluates the degree of luteolysis in high-responder-patients, who received GnRH-agonist for final oocyte maturation. Assessment of estradiol (E2)- and P4-levels 48 h after oocyte-pick-up (OPU) procedure demonstrate clearly, that luteolysis after GnRH-agonist trigger is individual-specific, even in high-responder patients with the same number of oocytes. Hence, individualization of luteal phase support with the focus on avoiding unnecessary administration of hCG, bearing the risk for development of OHSS, a new concept of luteal coasting needs to be developed, based on severity of luteolysis following luteal coasting.

Building Bridges for Innovation in Ageing: Synergies between Action Groups of the EIP on AHA

The Strategic Implementation Plan of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) proposed six Action Groups. After almost three years of activity, many achievements have been obtained through commitments or collaborative work of the Action Groups. However, they have often worked in silos and, consequently, synergies between Action Groups have been proposed to strengthen the triple win of the EIP on AHA. The paper presents the methodology and current status of the Task Force on EIP on AHA synergies. Synergies are in line with the Action Groups' new Renovated Action Plan (2016-2018) to ensure that their future objectives are coherent and fully connected. The outcomes and impact of synergies are using the Monitoring and Assessment Framework for the EIP on AHA (MAFEIP). Eight proposals for synergies have been approved by the Task Force: Five cross-cutting synergies which can be used for all current and future synergies as they consider overarching domains (appropriate polypharmacy, citizen empowerment, teaching and coaching on AHA, deployment of synergies to EU regions, Responsible Research and Innovation), and three cross-cutting synergies focussing on current Action Group activities (falls, frailty, integrated care and chronic respiratory diseases).

Longitudinal study: lifestyle and cardiovascular health in health science students

BACKGROUND

Changing lifestyle habits is considered the principal measure for the control of blood pressure and obesity. The aim of this study was to characterize the eating habits, anthropometric characteristics, physical fitness and blood pressure of students of health science degrees during the first three academic years and to explore the relation between the aforementioned parameters.

METHODS

This was a longitudinal study conducted over three years on the eating habits and physical fitness of health science students (n=366) and the influence of these factors on blood pressure and obesity.

RESULTS

The mean food group intakes of both female and male participants corresponded to a high consumption of lean and fatty meat, sweets and pastries and a low consumption of cereals, fruits, vegetables, olive oil, fish, nuts and vegetables. Blood pressure and obesity-related parameters were within normal ranges and did not change over the study period. Aerobic capacity values increased in men from the beginning to the end of the study, while V02max decreased in women between the first and second years.

CONCLUSION

We note that, in both women and men, blood pressure values were lower when diet was high in vegetables, legumes, nuts, fish and olive oil. In both sexes, we found a negative correlation between aerobic capacity and systolic and diastolic blood pressure and a positive correlation between obesity and blood pressure. The pattern of the eating habits and changes therein were different in young women and men, the former being focused on improving their diet and the latter on improving their physical fitness.

Economic modelling of diagnostic and treatment pathways in National Institute for Health and Care Excellence clinical guidelines: the Modelling Algorithm Pathways in Guidelines (MAPGuide) project

BACKGROUND

National Institute for Health and Care Excellence (NICE) clinical guidelines (CGs) make recommendations across large, complex care pathways for broad groups of patients. They rely on cost-effectiveness evidence from the literature and from new analyses for selected high-priority topics. An alternative approach would be to build a model of the full care pathway and to use this as a platform to evaluate the cost-effectiveness of multiple topics across the guideline recommendations.

OBJECTIVES

In this project we aimed to test the feasibility of building full guideline models for NICE guidelines and to assess if, and how, such models can be used as a basis for cost-effectiveness analysis (CEA).

DATA SOURCES

A 'best evidence' approach was used to inform the model parameters. Data were drawn from the guideline documentation, advice from clinical experts and rapid literature reviews on selected topics. Where possible we relied on good-quality, recent UK systematic reviews and meta-analyses.

REVIEW METHODS

Two published NICE guidelines were used as case studies: prostate cancer and atrial fibrillation (AF). Discrete event simulation (DES) was used to model the recommended care pathways and to estimate consequent costs and outcomes. For each guideline, researchers not involved in model development collated a shortlist of topics suggested for updating. The modelling teams then attempted to evaluate options related to these topics. Cost-effectiveness results were compared with opinions about the importance of the topics elicited in a survey of stakeholders.

RESULTS

The modelling teams developed simulations of the guideline pathways and disease processes. Development took longer and required more analytical time than anticipated. Estimates of cost-effectiveness were produced for six of the nine prostate cancer topics considered, and for five of eight AF topics. The other topics were not evaluated owing to lack of data or time constraints. The modelled results suggested 'economic priorities' for an update that differed from priorities expressed in the stakeholder survey.

LIMITATIONS

We did not conduct systematic reviews to inform the model parameters, and so the results might not reflect all current evidence. Data limitations and time constraints restricted the number of analyses that we could conduct. We were also unable to obtain feedback from guideline stakeholders about the usefulness of the models within project time scales.

CONCLUSIONS

Discrete event simulation can be used to model full guideline pathways for CEA, although this requires a substantial investment of clinical and analytic time and expertise. For some topics lack of data may limit the potential for modelling. There are also uncertainties over the accessibility and adaptability of full guideline models. However, full guideline modelling offers the potential to strengthen and extend the analytical basis of NICE's CGs. Further work is needed to extend the analysis of our case study models to estimate population-level budget and health impacts. The practical usefulness of our models to guideline developers and users should also be investigated, as should the feasibility and usefulness of whole guideline modelling alongside development of a new CG.

FUNDING

This project was funded by the Medical Research Council and the National Institute for Health Research through the Methodology Research Programme [grant number G0901504] and will be published in full in Health Technology Assessment; Vol. 17, No. 58. See the NIHR Journals Library website for further project information.

Study of coercive measures in prisons and secure psychiatric hospitals: the views of inmates and caregivers

AIM

The aim of the study was to ascertain the opinions of both inmates and staff of prison establishments about the use of coercive measures justified for clinical reasons for people with mental health problems and about the need to create protocols to regulate the application of these measures.

METHOD

These opinions were gathered in a Qualitative Study with Focus Groups (prison inmates and prison staff) from the Granada Penitentiary Centre and the Alicante Penitentiary Psychiatric Hospital, both in Spain.

RESULTS

The results showed that forced medication is the most commonly used coercive measure in these institutions. The inmates did not understand and rejected the use of this measure, above all because they were poorly informed about their illness and the medication required to treat it. The staff however defended the benefits of psychiatric medicine, even when administered without the patient's consent.

CONCLUSIONS

Both inmates and staff agreed that it would be useful to have a protocol regulating the use of coercive measures. The study has also identified a number of important factors that could help to reduce the need for coercive measures or make their use unnecessary.