Behavioural, developmental and psychological characteristics in children with germline PTEN mutations: a carer report study

BACKGROUND

PTEN is primarily known as a tumour suppressor gene. However, research describes higher rates of difficulties including intellectual disability and difficulties relating to autism spectrum conditions (ASCs) in people with germline PTEN mutations. Other psychological characteristics/experiences are less often reported and are explored in this study.

METHODS

The parents of 20 children with PTEN mutations completed an online survey exploring adaptive behaviour, ASC-associated behaviours, anxiety, mood, hypermobility, behaviours that challenge, sensory experiences, quality of life and parental wellbeing. Published normative data and data from groups of individuals with other genetic neurodevelopmental conditions were used to contextualise findings.

RESULTS

Overall levels of adaptive behaviour were below the 'typical' range, and no marked relative differences were noted between domains. Higher levels of ASC-related difficulties, including sensory experiences, were found in comparison with 'typically developing' children, with a possible peak in restrictive/repetitive behaviour; ASC and sensory processing atypicality also strongly correlated with reported joint hypermobility. A relative preservation of social motivation was noted. Anxiety levels were found to be elevated overall (and to relate to sensory processing and joint hypermobility), with the exception of social anxiety, which was comparable with normative data. Self-injurious behaviour was common.

CONCLUSIONS

Results suggest a wide range of possible difficulties in children with PTEN mutations, including elevated anxiety. Despite elevated ASC phenomenology, social motivation may remain relatively strong. Firm conclusions are restricted by a small sample size and potential recruitment bias, and future research is required to further explore the relationships between such characteristics.

Medicine in the marketplace: clinician and patient views on commercial influences on assisted reproductive technology

RESEARCH QUESTION

What are the views and experiences of patient and expert stakeholders on the positive and negative impacts of commercial influences on the provision of assisted reproductive technology (ART) services, and what are their suggestions for governance reforms?

DESIGN

Semi-structured interviews were conducted with 31 ART industry experts from across Australia and New Zealand and 25 patients undergoing ART from metropolitan and regional Australia, between September 2020 and September 2021. Data were analysed using thematic analysis.

RESULTS

Expert and patient participants considered that commercial forces influence the provision of ART in a number of positive ways - increasing sustainability, ensuring consistency in standards and providing patients with greater choice. Participants also considered commercial forces to have a number of negative impacts, including increased costs to government and patients; the excessive use of interventions that lack sufficient evidence to be considered part of standard care; inadequately informed consent (particularly with regard to financial information); and threats to patient-provider relationships and patient-centred care. Participants varied in whether they believed that professional self-regulation is sufficient. While recognizing the benefits of commercial investment in healthcare, many considered that regulatory reforms, as well as organizational cultural initiatives, are needed as means to ensure the primacy of patient well-being.

CONCLUSIONS

The views expressed in this study should be systematically and critically examined to derive insights into how best to govern ART. These insights may also inform the design and delivery of other types of healthcare that are provided in the private sector.

Mineral Indicators of Geologically Recent Past Habitability on Mars

We provide new support for habitable microenvironments in the near-subsurface of Mars, hosted in Fe- and Mg-rich rock units, and present a list of minerals that can serve as indicators of specific water-rock reactions in recent geologic paleohabitats for follow-on study. We modeled, using a thermodynamic basis without selective phase suppression, the reactions of published Martian meteorites and Jezero Crater igneous rock compositions and reasonable planetary waters (saline, alkaline waters) using Geochemist's Workbench Ver. 12.0. Solid-phase inputs were meteorite compositions for ALH 77005, Nakhla, and Chassigny, and two rock units from the Mars 2020 Perseverance rover sites, Máaz and Séítah. Six plausible Martian groundwater types [NaClO4, Mg(ClO4)2, Ca(ClO4)2, Mg-Na2(ClO4)2, Ca-Na2(ClO4)2, Mg-Ca(ClO4)2] and a unique Mars soil-water analog solution (dilute saline solution) named "Rosy Red", related to the Phoenix Lander mission, were the aqueous-phase inputs. Geophysical conditions were tuned to near-subsurface Mars (100 °C or 373.15 K, associated with residual heat from a magmatic system, impact event, or a concentration of radionuclides, and 101.3 kPa, similar to <10 m depth). Mineral products were dominated by phyllosilicates such as serpentine-group minerals in most reaction paths, but differed in some important indicator minerals. Modeled products varied in physicochemical properties (pH, Eh, conductivity), major ion activities, and related gas fugacities, with different ecological implications. The microbial habitability of pore spaces in subsurface groundwater percolation systems was interrogated at equilibrium in a thermodynamic framework, based on Gibbs Free Energy Minimization. Models run with the Chassigny meteorite produced the overall highest H2 fugacity. Models reliant on the Rosy Red soil-water analog produced the highest sustained CH4 fugacity (maximum values observed for reactant ALH 77005). In general, Chassigny meteorite protoliths produced the best yield regarding Gibbs Free Energy, from an astrobiological perspective. Occurrences of serpentine and saponite across models are key: these minerals have been observed using CRISM spectral data, and their formation via serpentinization would be consistent with geologically recent-past H2 and CH4 production and sustained energy sources for microbial life. We list index minerals to be used as diagnostic for paleo water-rock models that could have supported geologically recent-past microbial activity, and suggest their application as criteria for future astrobiology study-site selections.

Real-world practices of hormone monitoring during ovarian stimulation in assisted reproductive technology: a global online survey

Objective

The aim of this study is to understand the global practice of routine hormonal monitoring (HM) during ovarian stimulation (OS) in the context of assisted reproductive technique (ART) treatment.

Methods

An open-access questionnaire was available to 3,845 members of IVF-Worldwide.com from September 8 to October 13, 2021. The survey comprised 25 multiple-choice questions on when and how ultrasound (US) and hormone tests were conducted during ovarian stimulation OS. For most questions, respondents were required to select a single option. Some questions allowed the selection of multiple options.

Results

In all, 528 (13.7%) members from 88 countries responded to the questionnaire. Most respondents (98.9%) reported using US to monitor OS cycles. HM was used by 79.5% of respondents during any of the cycle monitoring visits and was most commonly performed on the day of, or a day prior to final oocyte maturation. Overall, 87% of respondents claimed adjusting the dose of gonadotropin during OS, with 61.7% adjusting the dose based on hormonal levels. Oestradiol (E2) was the most frequently monitored hormone during all visits and was used by 74% of respondents for the prediction of ovarian hyperstimulation syndrome (OHSS). On or a day prior to ovulation triggering (OT), the number of respondents who measured progesterone increased from 34.3% in the second/third visit to 67.7%. Approximately one-third of respondents measured luteinizing hormone during all visits.

Conclusion

Globally, most ART specialists (~80%) use HM, along with US, for monitoring OS, especially for the prevention of OHSS.

Current challenges and recent advances on the path towards continuous biomanufacturing

Continuous biopharmaceutical manufacturing is currently a field of intense research due to its potential to make the entire production process more optimal for the modern, ever-evolving biopharmaceutical market. Compared to traditional batch manufacturing, continuous bioprocessing is more efficient, adjustable, and sustainable and has reduced capital costs. However, despite its clear advantages, continuous bioprocessing is yet to be widely adopted in commercial manufacturing. This article provides an overview of the technological roadblocks for extensive adoptions and points out the recent advances that could help overcome them. In total, three key areas for improvement are identified: Quality by Design (QbD) implementation, integration of upstream and downstream technologies, and data and knowledge management. First, the challenges to QbD implementation are explored. Specifically, process control, process analytical technology (PAT), critical process parameter (CPP) identification, and mathematical models for bioprocess control and design are recognized as crucial for successful QbD realizations. Next, the difficulties of end-to-end process integration are examined, with a particular emphasis on downstream processing. Finally, the problem of data and knowledge management and its potential solutions are outlined where ontologies and data standards are pointed out as key drivers of progress.

Driving adoption of new technologies in biopharmaceutical manufacturing

The challenge of introducing new technologies into established industries is not a problem unique to the biopharmaceutical industry. However, it may be critical to the long-term competitiveness of individual manufacturers and, more importantly, the ability to deliver therapies to patients. This is especially true for new treatment modalities including cell and gene therapies. We review several barriers to technology adoption which have been identified in various public forums including business, regulatory, technology, and people-driven concerns. We also summarize suitable enablers addressing one or more of these barriers along with suggestions for developing synergies or connections between innovation in product discovery and manufacturing or across the supplier, discovery, manufacturing, and regulatory arms of the holistic innovation engine.

Normative cut-offs for polycystic ovary syndrome (PCOS) diagnostic features in adolescents using cluster analysis

OBJECTIVE

The diagnosis of polycystic ovary syndrome (PCOS) remains challenging with International guidelines prioritising accurate cut-offs for individual diagnostic features. These diagnostic cut-offs are currently based on arbitrary percentiles, often from poorly characterised cohorts, and are dependent on variable laboratory ranges defined by assay manufacturers, limiting diagnostic accuracy. Cluster analysis is the recommended approach for defining normative cut-offs within populations for clinical syndromes. Few PCOS adult studies have applied cluster analysis, with no studies in adolescents. We aimed to define normative cut-offs for individual PCOS diagnostic features in a community-based population of adolescents using cluster analysis.

DESIGN

This analysis utilised data from the Menstruation in Teenagers Study, a sub-group of the Raine Study, which is a population based prospective cohort of 244 adolescents whose mean age at PCOS assessment was 15.2 years.

METHODS

K-means cluster analysis and receiver operating characteristics curves were used to define normative cut-offs for Ferriman Gallwey score (mFG), free testosterone (free T), free androgen index (FAI) and menstrual cycle length.

RESULTS

Normative cut-offs for mFG, free T, FAI and menstrual cycle lengths were 1.0, 23.4 pmol/l, 3.6 and 29 days respectively. These corresponded to the 65th, 71st, 70th and 59th population percentiles respectively.

CONCLUSION

In this novel study we define the normative diagnostic criteria cut-offs in this unselected adolescent population and show that these cut-offs correspond to lower percentiles than conventional cut-offs. These findings highlight the pertinent need to re-define PCOS diagnostic cut-offs in adolescents. Validation is required in larger, multi-ethnic and well characterised adolescent cohorts.

Randomized control trial of a decision aid for women considering elective egg freezing: The Eggsurance study protocol

BACKGROUND

Uptake of elective egg freezing has increased globally. The decision to freeze eggs is complex, and detailed, unbiased information is needed. To address this, we developed an online Decision Aid for women considering elective egg freezing. Decision Aids are the standard of care to support complex health decisions.

OBJECTIVES

This study will measure the impact of the Decision Aid on decision-making (e.g. decisional conflict, engagement in decision-making, distress, and decision delay) and decision quality (e.g. knowledge, level of informed choice, and regret).

METHODS AND ANALYSIS

A single-blinded two-arm parallel-group randomized controlled trial. Women considering elective egg freezing will be recruited using social media, newsletters, and fertility clinics. Data will be collected at baseline (recruitment), 6-month, and 12-month post-randomization. The primary hypothesis is that the intervention (Decision Aid plus Victorian Assisted Reproductive Technology Authority website) will reduce decisional conflict (measured using the Decisional Conflict Scale) at 12 months more than control (Victorian Assisted Reproductive Technology Authority website only). Secondary outcomes include engagement in decision-making (Perceived Involvement in Care Scale), distress (Depression, Anxiety, and Stress Scale), decision delay, knowledge, informed choice (Multi-dimensional Measure of Informed Choice), and decisional regret (Decisional Regret Scale).

ETHICS

The study was approved by the University of Melbourne Human Research Ethics Committee (Ethics ID: 2056457). Informed consent will be obtained from all participants prior to enrolment.

DISCUSSION

This is the first international randomized controlled trial that aims to investigate the effect of an elective egg freezing Decision Aid on decision-related outcomes (e.g. decisional conflict, informed choice, and regret). It is anticipated that participants who receive the Decision Aid will have better decision and health outcomes.

REGISTRATION DETAILS

ACTRN12620001032943: Comparing different information resources on the process and quality of decision-making in women considering elective egg freezing.

P-641 Physicians’ practices towards hormone monitoring during ovarian stimulation in context of treatment with Assisted Reproductive Technology (ART). A global Survey conducted through IVFworldwide.com

Study question

What is the practice of routine hormone monitoring (HM) during ovarian stimulation (OS) in the context of ART treatment?

Summary answer

The majority of ART specialists (∼80%) use HM, along with ultrasound, for monitoring OS, especially for the prevention of ovarian hyperstimulation syndrome (OHSS).

What is known already

Ovarian stimulation (OS) is an essential part of ART and optimal monitoring is essential in order to optimize final outcome and ensure safety. Monitoring of OS can be either done with ultrasound (US) and/or hormonal monitoring in order to adjust gonadotropin dose, to trigger ovulation and to maximize success while avoiding the risk of OHSS. Clinical practice guidelines typically propose US monitoring as the cornerstone of OS monitoring during ART treatment. Although HM is practiced widely, the current attitude and practice of clinicians regarding HM has not been evaluated on a global scale.

Study design, size, duration

In a cross-sectional study carried out using a survey on current practice of blood HM, we evaluated physicians’ attitudes towards blood HM during OS in context of ART treatment. An open-access questionnaire was accessible to the members of IVF-Worldwide.com, from September 8 to October 13,2021 on IVF-Worldwide.com and was completed by 528 participants. Data analysis was performed using Excel (Microsoft Inc., USA), statistics were calculated once giving all survey entries an equal representation.

Participants/materials, setting, methods

An initial invitation and one reminder were sent to all 3845 registered members of IVF-Worldwide.com by email. In total, 528 participants answered the survey (13.7%). The survey was composed of 25 multiple-choice questions with mainly single answers. These questions asked about tests performed during any cycle monitoring visits during OS for ART treatment (blood hormone monitoring, ultrasound, timing, and frequency of prescribed tests), about monitoring to prevent OHSS as well as to adjust gonadotropin dose.

Main results and the role of chance

A total of 528 members from 88 countries responded to this web-based survey.

Most participants (87.9%) were clinicians and practiced reproductive medicine for more than 15 years (56.7%). Nearly half (46.2%) performed more than 500 oocyte aspiration cycles in their clinic annually.

Of the 528 respondents, the vast majority (98.9%) used US to monitor OS cycles during ART treatment. Hormone monitoring (HM) was widely accepted and performed by 420 (79.5%) of participants during any of the cycle monitoring visits for OS (from stimulation day 1 until the day before ovulation triggering (OT)).

Among different visits, participants most frequently monitored hormones on the day on or before the final oocyte maturation (71%) as compared with 57% on the first visit and 61% on the second and third visit during OS. The most frequent reason for HM was for prediction of OHSS (74%) and for adjusting gonadotropin dose (50%), whereas 45% of physicians considered HM for timing of OT.

Most respondents (60.7%) considered that hormones play an important role in monitoring ovarian response during OS and a 58% considered that blood hormone tests are important to guiding decision-making in preventing OHSS.

Limitations, reasons for caution

The survey was designed to represent self-reported statistics and opinions from experts in the field. It did not capture actual clinician performance or patient data.

Wider implications of the findings

Although several guidelines consider US monitoring as the cornerstone for monitoring ovarian response during OS for ART, the majority of ART specialists consider HM as essential. Good quality studies are needed to document the value of HM during OS, with respect to dose adjustment, ovulation triggering and prevention of OHSS.

Trial registration number

not applicable

Bernard Hart (1879-1966) and his influence on British psychiatry

Bernard Hart was among the most eminent 20th-century British psychiatrists. Following medical qualification at University College Hospital, London, he trained in psychiatry, which included two years studying in Paris and Zurich. He was appointed as the first psychiatric consultant at University College Hospital, then spent some time in Liverpool, where he specialized in treating war neurosis. Early in his career, Hart was one of the first to introduce the ideas of Freud and Janet, and the importance of unconscious processes, to the British public. After the First World War, Hart returned to University College Hospital, where he remained until 1947, building up a flourishing department. Hart was appointed to numerous senior offices and directed the psychiatric section of the British Emergency Medical Services in the Second World War. Hart is believed to be the last psychiatrist to certify someone (John Amery) as being of sufficiently sound mind to die for treason.

Higher Doses of FSH Used for Superovulation Do Not Adversely Affect Embryonic Ploidy: A Randomized Controlled Trial (STimulation Resulting in Embryonic Aneuploidy using Menopur (STREAM) Trial)

Research Question: Does the dose of gonadotropin used for superovulation in IVF affect the proportion of euploid blastocysts obtained after fertilization?

Study Design: Multicentre randomized controlled trial recruiting 57 women who were treated with ovarian stimulation using either 150 or 300 IU Menopur per day. Both groups received GnRH antagonist from day 5 of ovarian stimulation and final oocyte maturation was induced using a leuprolide GnRH (gonadotropin releasing hormone) agonist trigger when three or more follicles reached 17 mm diameter. Oocyte collection was scheduled 36–38 hours post trigger. In vitro fertilization (IVF) or Intracytoplasmic Sperm Injection (ICSI) were performed according to individual unit protocol and embryos were cultured to blastocyst stage. A trophectoderm biopsy was performed on day 5 of embryo culture and used for preimplantation genetic testing for aneuploidy. Euploid embryos were transferred in subsequent frozen embryo transfer cycles with appropriate endometrial preparation.

Results: The number of oocytes obtained from women randomized to 150 IU Menopur was between 3 and 17 (mean = 9), whereas the number of oocytes obtained from women randomized to 300 IU Menopur was between 3 and 24 (mean = 11). There was a positive linear relationship between serum AMH concentration and oocyte yield in both the 150 and 300 IU Menopur groups ([Formula: see text] = 0.3359, [Formula: see text] = 0.1129 and [Formula: see text] = 0.3741, [Formula: see text] = 0.1399). The percentage of euploid to aneuploid embryos in the 150 IU Menopur group was 63% and in the 300 IU Menopur group, the proportion was 75%, which was not significantly different ([Formula: see text] = 0.17).

Conclusion: The higher dose ovarian stimulation protocol did not significantly increase the number of oocytes retrieved, nor did the higher dose protocol reduce the proportion of euploid embryos created. This study does not support the hypothesis that use of higher doses of gonadotropin for ovarian stimulation results in a reduction in the proportion of euploid embryos obtained after IVF.

O-072 Markers of cardiometabolic health of adolescents conceived through assisted reproductive technologies (ART) appear reassuring

Study question

Is the cardiometabolic health of adolescents conceived through ART worse than that of their spontaneously-conceived counterparts?

Summary answer

The majority of cardiometabolic and vascular health parameters of ART-conceived adolescents are more favourable than those of their spontaneously-conceived counterparts of similar age.

What is known already

It has been proposed that ART induces epigenetic alterations during embryonic development which could lead to cardiometabolic disease later in life. However, individuals requiring ART may themselves be metabolically less healthy than the general population, which could lead to a genetically increased risk of cardiometabolic disorders in the offspring, rather than the ART procedure. The literature pertaining to cardiometabolic health of ART-conceived offspring is contradictory, but generally suggests unfavourable cardiometabolic health parameters. With over 8 million children and adults born through ART worldwide, it is imperative to investigate whether early signs of adverse cardiometabolic differences persist into adolescence and beyond.

Study design, size, duration

The Growing Up Healthy Study (GUHS) is a prospective study that recruited 303 ART-conceived adolescents, born 1991-2001 in Western Australia. Their health parameters, including cardiometabolic factors, were assessed and compared with spontaneously conceived counterparts of similar socioeconomic background and age from the Raine Study Generation 2 (Gen2). The 2868 Gen2 participants were born 1989-1992 and are representative of the Western Australian adolescent population. At age 16-17 (2013-2017), GUHS participants replicated assessments previously completed by Gen2.

Participants/materials, setting, methods

Cardiometabolic parameters were compared between 165 GUHS (male = 50.9%) and 1690 Gen2 (male = 49.8%) adolescents. Assessments consisted of a detailed questionnaire; health and demographic parameters, anthropometric assessments; height, weight, body-mass index (BMI), waist circumference and skinfold thickness, fasting serum biochemistry, arterial stiffness and blood pressure assessment using applanation tonometry, assessment of non-alcoholic fatty liver (NAFLD) and thickness of abdominal fat compartments using ultrasonography. Chi2, Fisher’s Exact and Mann-Whitney U tests, performed in SPSS V25, examined cohort differences.

Main results and the role of chance

GUHS adolescents appeared to be healthier from a cardiometabolic perspective than their Gen2 counterparts. They were leaner, with lower BMI (median: 21.23 vs. 22.06, P = 0.004), lower waist circumference (median: 74.10 vs. 76.75 cm, P = 0.031), and thinner skinfolds (triceps median: 12.1 vs. 14.0 mm, P = 0.019, subscapular median: 10.6 vs. 11.9 mm, P &lt; .001, mid-abdominal median: 16.0 vs. 19.9 mm, P &lt; 0.001, supraspinal median: 10.7 vs. 13.5 mm, P &lt; 0.001). No significant differences were detected in the following serum fasting parameters: glucose, insulin, HOMA-IR, LDL cholesterol, total cholesterol, cholesterol/HDL-ratio, triglycerides, CRP and ALT. HDL cholesterol levels were more favourable in GUHS (P &lt; 0.001). NAFLD was present in 10.9% of GUHS vs. 15.2% of Gen2 adolescents (P = 0.174), with no difference in steatosis severity score (P = 0.309). ART offspring had less subcutaneous adipose tissue (median: 8.0 vs. 14.0 mm, P &lt; .001), more visceral adipose tissue (median: 40.0 vs. 32.0 mm, P &lt; 0.001), with no difference in pre-peritoneal adipose tissue (P = 0.087). Measures of arterial stiffness were lower in GUHS. Pulse wave velocity: median 6.1 vs. 6.4 m/s, P &lt; 0.001 and heart rate corrected augmentation index: median -10.25 vs. -8.00, P = 0.006. No significant differences in blood pressure or heart rate were detected. Stratification by sex did not greatly alter the results.

Limitations, reasons for caution

Despite the substantial study size and the unique study design, we were unable to differentiate between different types of ART (e.g. IVF vs. ICSI), draw definite conclusions or relate outcomes to cause of infertility. Given the observational character of this study, causation cannot be proven.

Wider implications of the findings

In this study we did not detect any adverse effect of ART on cardiometabolic health at adolescence, in contrast to some studies. Given the lack of consensus, future well-designed and appropriately-powered studies are necessary to investigate cardiometabolic health in ART adults.

Trial registration number

not applicable

O-053 Early life factors that may influence adult male reproductive

This presentation will provide a brief overview of testicular development and will describe a critical period of development at approximately 8-14 weeks of gestation, when the testicle may be vulnerable to external influences, potentially having a negative effect on subsequent development. The talk with then describe the testicular dysgenesis syndrome hypothesis, proposed by Niels Skakkebæk, and using the presenters work within the Western Australian (Raine) Cohort will go onto demonstrate how early life exposures may influence mature testicular function. Worryingly, the presentation will describe how adolescent features of early metabolic disturbance within the Raine Cohort are already having a determinantal effect on the reproductive function of these men in late adolescence, many years before the majority are seeking paternity. 

P–593 Self-monitoring of hormones via a urine-based hormonal assay — a topical endeavour into telemedicine in medically-assisted reproduction (MAR)

Study question

How can cycle monitoring using a urine-based hormonal assay device improve current clinical practice in medically assisted reproduction (MAR)?

Summary answer

A urine-based hormonal assay has the potential to overcome the inconvenience of blood tests and reduce the frequency of appointments, waiting times and patient burden.

What is known already

Cycle monitoring via ultrasound and serum-based hormonal assays during MAR can provide information on the ovarian response and assist in optimising treatment strategies and reducing complications, such as ovarian hyperstimulation syndrome (OHSS). However, blood tests may cause inconvenience to patients due to repeated venepuncture and the need for frequent clinic appointments. Urine-based assays have been historically used by fertility specialists in clinics, but since got replaced by more practical and automated serum-based assays. Novel technology utilising rapid chromatographic immunoassay to test urinary reproductive hormones in a home setting could provide an alternative to current serum-based testing at clinics.

Study design, size, duration

A questionnaire was disseminated among 24 fertility specialists (2019–2020) on the use of ultrasound and serum-based hormone monitoring in clinical practice. In addition, the literature on the reliability of urine-based hormonal assays compared to serum-based hormonal assays during MAR was reviewed in order to examine if urine-based hormonal monitoring could be re-introduced in clinical practice using novel state-of-the-art technology.

Participants/materials, setting, methods

All 24 surveyed fertility specialists responded, representing 10 countries from across Europe, Asia and Latin America. Questions assessed the frequency and role of hormonal monitoring, the hormones tested and the drawbacks of blood tests. The PubMed search engine was used to search the Medline database for publications between 1960–2020 with (MeSH-) search terms related to cycle monitoring (e.g. fertility monitoring, controlled ovarian stimulation, ovulation confirmation) and hormonal assays (e.g. estrone–3-glucuronide or E1–3G).

Main results and the role of chance

The survey confirmed that many fertility practitioners (n = 22/24) routinely conducted hormone monitoring during MAR, primarily for guiding dose adjustments (n = 20/24) and indicating risk of OHSS (n = 20/24). The reported drawbacks of blood tests included validity of results from different service providers, long waiting times and discomfort to patients due to travelling to clinics for tests and repeated venepunctures. The hormones routinely checked were E2 (n = 22/22), P4 (n = 18/22) and LH (n = 15/22). The literature review revealed a relatively high correlation (correlation coefficients 0.85–0.95) between serum E2 and urinary E1–3G in gonadotrophin stimulated cycles (Lessing 1987, Catalan 1989, Rapi 1992 and Alper 1994). No studies assessed the correlation between serum P4 and urinary PdG or between serum LH and urinary LH in stimulated cycles. In natural cycles, the correlation coefficients between serum P4 and urinary PdG seemed to be slightly higher than those between serum E2 and urinary E1–3G (0.73–0.94 vs. 0.54–0.88) (Denari 1981, Munro 1991, Roos 2015, Stanczyk 1980). One study reported a moderate correlation coefficient (0.72) between serum and urinary LH in natural cycles (Roos 2015).

Limitations, reasons for caution

There is risk of selection-bias for fertility specialists included in survey, however, the 100% response rate is reassuring. The correlation coefficients between serum- and urine-based hormonal assay and the cost-effectiveness and time-efficiency of urinary assay should be confirmed in further clinical studies using a novel state-of-the-art remote urinary monitoring device.

Wider implications of the findings: Remote hormonal monitoring can be part of a novel digital health solution that includes remote ultrasound and tele-counselling to link clinics and patients at home. Especially during the unprecedented times of the COVID–19 pandemic, the prospect of remote monitoring system has the potential to improve patient experience during fertility treatment.

Trial registration number

Not applicable

Prenatal exposure to maternal stressful life events and earlier age at menarche: the Raine Study

STUDY QUESTION

Is there an association between prenatal exposure to stressful life events and age at menarche, and does childhood BMI mediate this association?

SUMMARY ANSWER

Girls exposed to prenatal stress had a slightly earlier age at menarche, but this association did not show a dose-response effect and was not mediated by childhood offspring BMI.

WHAT IS ALREADY KNOWN

Prenatal stress may impact on reproductive function in females including age at menarche, but human data are very limited. High childhood BMI is known to be associated with earlier age at menarche. Only one small study has measured the association between maternal stress and age at menarche and reported that childhood BMI mediated the association between maternal stress and earlier age at menarche. However, neither maternal stress nor age at menarche was prospectively recorded and the study was limited to 31 mother-daughter pairs.

STUDY DESIGN, SIZE, DURATION

The Raine Study is a large prospective population-based pregnancy cohort study (n = 1414 mother-daughter pairs) continuously followed from prenatal life through to adolescence. In the present study, we examined the association between exposure to maternal stressful life events during early, late and total gestation and age at menarche in offspring using 753 mother-daughter pairs with complete case information.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Mothers prospectively reported stressful life events during pregnancy at 18 and 34 weeks using a standardized 10-point questionnaire. Exact date of menarche was assessed using a purpose-designed questionnaire at 8, 10, 14 and 17 years of age. Complete information on exposure, outcome and confounding variables was obtained from 753 mothers-daughter pairs. Multivariate linear regression complete case analysis was used to examine associations between maternal stressful life event exposure and age at menarche. Potential selection bias was evaluated using multiple imputations (50 datasets). The mediating effects of offspring childhood BMI (ages 5, 8, or 10 years) on these associations were measured in separate sub-analyses.

MAIN RESULTS AND ROLE OF CHANCE

Most (580/753, 77%) daughters were exposed to at least one prenatal stressful life event. Exposure to maternal stressful life events during the entire pregnancy was associated with a non-linear earlier age at menarche. Exposure to one event and two or more psychological stressful events was associated with a 3.5 and 1.7-month earlier onset of puberty, respectively when compared to the reference group with no exposure maternal stressful life events. The estimates from multiple imputation with 50 datasets were comparable with complete case analysis confirming the existence of an underlying effect. No separate significant effects were observed for exposure during early or late gestation. The association between prenatal stressful events and age at menarche was not mediated by childhood BMI in the offspring.

LIMITATIONS, REASONS FOR CAUTION

Stressful life events may have affected pregnant women in different ways and self-perceived maternal stress severity may have provided a more precise estimate of gestational psychological stress. The observed non-linear U-shape of the association between maternal psychological stress and age at menarche did not reflect a dose-response. This suggests that the first exposure to prenatal stress exerts a greater effect on fetal reproductive development. A potential mechanism is via dramatic initial activation of the hypothalamic-pituitary-adrenal (HPA) axis following the first stressful life event which is greater than that observed following subsequent exposure to two or more maternal stressful life events. Whilst we adjusted for a priori chosen confounders, we cannot exclude residual confounding or confounding by factors we did not include. Maternal age at menarche was not available so the effects of familial history/genetics could not be assessed. There was a large loss due to the number of girls with no information on date of menarche and missing confounder information implying risk of selection bias and multiple imputation analyses did not fully exclude this risk (similar direction but slightly weaker estimate magnitude).

WIDER IMPLICATIONS OF THE FINDINGS

Menarche is a sentinel reproductive event and earlier age at menarche carries implications for psychological, social and reproductive health and for long-term risk of common non-communicable diseases. Understanding the factors regulating age at menarche has extensive health implications. This is the first population-based cohort study in humans to demonstrate that prenatal psychological stress might directly modify age at menarche.

STUDY FUNDING/COMPETING INTEREST(S)

Dr. Bräuner and Trine Koch's salaries were supported by Doctor Sofus Carl Emil Friis and spouse Olga Doris Friis foundation, The Danish Cancer Society (Kræftens Bekæmpelse, RP15468, R204-A12636, Denmark) and The Danish Health Foundation (Helsefonden, F-22181-23, Denmark). Martha Hickey was funded by NHMRC Practitioner Fellowships. The funding bodies played no role in the design, collection, analysis, or interpretation of data; in the writing of the manuscript; or in the decision to submit the manuscript for publication. Dr. Hart has received personal fees in his function as the Medical Director of Fertility Specialists of Western Australia and received educational sponsorship grants from MSD, Merck-Serono and from Ferring Pharmaceuticals. Dr Hart has also received personal fees from Shareholders in Western IVF outside the submitted work.

TRIAL REGISTRATION NUMBER

NA.

Specimen oriented intraoperative margin assessment in oral cavity and oropharyngeal squamous cell carcinoma

OBJECTIVE

Evaluate the oncologic outcomes and cost analysis of transitioning to a specimen oriented intraoperative margin assessment protocol from a tumour bed sampling protocol in oral cavity (OCSCC) and oropharyngeal squamous cell carcinoma (OPSCC).

STUDY DESIGN

Retrospective case series and subsequent prospective cohort study SETTING: Tertiary care academic teaching hospital SUBJECTS AND METHODS: Retrospective case series of all institutional T1-T2 OCSCC or OPSCC treated with primary surgery between January 1st 2009 - December 31st 2014. Kaplan-Meier survival estimates with log rank tests were used to compare patients based on final margin status. Cost analysis was performed for escalation of therapy due to positive final margins. Following introduction of a specimen derived margin protocol, successive prospective cohort study of T1-T4 OCSCC or OPSCC treated with primary surgery from January 1st 2017 - December 31st 2018. Analysis and comparison of both protocols included review of intraoperative margins, final pathology and treatment cost.

RESULTS

Analysis of our intra-operative tumour bed frozen section protocol revealed 15 of 116 (12.9%) patients had positive final pathology margins, resulting in post-operative escalation of therapy for 14/15 patients in the form of re-resection (7/14), radiation therapy (6/14) and chemoradiotherapy (1/14). One other patient with positive final margins received escalated therapy for additional negative prognostic factors. Recurrence free survival at 3 years was 88.4 and 50.7% for negative and positive final margins respectively (p = 0.048). Implementation of a specimen oriented frozen section protocol resulted in 1 of 111 patients (0.9%) having positive final pathology margins, a statistically significant decrease (p < 0.001). Utilizing our specimen oriented protocol, there was an absolute risk reduction for having a final positive margin of 12.0% and relative risk reduction of 93.0%. Estimated cost avoidance applying the specimen oriented protocol to our previous cohort was $412,052.812017 CAD.

CONCLUSION

Implementation of a specimen oriented intraoperative margin protocol provides a statistically significant decrease in final positive margins. This change in protocol leads to decreased patient morbidity by avoiding therapy escalation attributable only to positive margins, and avoids the economic costs of these treatments.

In utero exposure to maternal stressful life events and risk of polycystic ovary syndrome in the offspring: The Raine Study

BACKGROUND

PCOS is the most common endocrine disorder in reproductive age women. The origins of PCOS are unknown but experimental and limited human evidence suggests that greater prenatal exposure to androgens may predispose to PCOS. Experimental evidence suggests that maternal stressors may affect reproductive function in the offspring via changes in prenatal androgen exposure. In this present study, we aim to investigate whether maternal stressful life events during pregnancy are associated with polycystic ovary morphology (PCOM) or polycystic ovary syndrome (PCOS) in adolescent offspring.

METHOD

In a large population-based pregnancy cohort study (The Raine Study) continuously followed from prenatal life through to adolescence we examined the association between maternal stressful life events during pregnancy in both early and late gestation, and subsequent circulating concentrations of ovarian and adrenal androgens, PCOM and PCOS in the normal menstrual cycle of offspring age 14-16 years. Maternal stressful life events were prospectively recorded during pregnancy at 18 and 34 weeks using a 10-point questionnaire. Female offspring (n = 223) completed a questionnaire about their menstrual cycles, underwent a clinical examination for hirsutism (Ferriman-Gallwey score) and transabdominal pelvic ultrasound examination to determine ovarian morphology according to standardized criteria for classification of PCOM. Plasma samples were obtained at day 2-6 of the normal menstrual cycle for measurement of androgens. PCOM was defined according to the international consensus definition, 2003 and the evidence-based guideline for the assessment and management of PCOS, 2018. PCOS was diagnosed according to Rotterdam criteria and National Institute of Health (NIH) criteria. Multivariate linear and logistic regression analyses were used to examine the associations between maternal stressful life event exposure and ovarian morphology (PCOM), circulating ovarian and adrenal androgens (clinical and biochemical hyperandrogenism (hirsutism)) and presence of PCOS.

RESULTS

Of 223 recruited adolescent girls, 78 (35.9%) and 68 (31.3%) had PCOM by the 2003 and 2018 criteria respectively, while 66 (29.6%) and 37 (16.6%) had PCOS, using Rotterdam and NIH criteria, respectively. Most girls (141/223, 63.2%) were exposed to at least one stressful life event in early gestation and around half (121/223, 54.3%) were exposed to at least one stressful life event in late gestation. Maternal stressful life events in early gestation were associated with a statistically significant lower prevalence of PCOM when applying the 2003 criteria [adjusted odds ratio [aOR] and 95% confidence intervals (CI): 0.74 (95% CI: 0.55; 0.99)], and a similar association was detected when applying the 2018 PCOM criteria (aOR, 0.69, 95% CI: 0.50; 0.95)]. Maternal stressful life events in early gestation were also associated with lower circulating concentrations of testosterone (β = -0.05, 95% CI: -0.09; -0.004) and androstenedione (β = -0.05, 95% CI: -0.10; -0.002) in the offspring. No similar effects for PCOM or circulating androgens were detected in late gestation. No statistically significant associations between maternal stressful life events in early or late gestation with PCOS (neither Rotterdam nor NIH criteria) in adolescence were detected. The prospective collection of maternal stressful life events during both early and late gestation and direct measurement of PCOM, PCOS and circulating androgens in adolescence and key co-variates implies minimal possibility of recall, information bias and selection bias.

CONCLUSION

Maternal exposure to stressful life events in early gestation is associated with significantly reduced circulating ovarian and adrenal androgen concentrations in adolescence (testosterone and androstenedione), and an indication of fewer cases of polycystic ovary morphology (PCOM) defined by the 2003 international consensus definition and by the 2018 international evidence-based guideline, but has no effect on polycystic ovary syndrome (PCOS), diagnosed using either Rotterdam or NIH criteria.

End-to-end collaboration to transform biopharmaceutical development and manufacturing

An ambitious 10‐year collaborative program is described to invent, design, demonstrate, and support commercialization of integrated biopharmaceutical manufacturing technology intended to transform the industry. Our goal is to enable improved control, robustness, and security of supply, dramatically reduced capital and operating cost, flexibility to supply an extremely diverse and changing portfolio of products in the face of uncertainty and changing demand, and faster product development and supply chain velocity, with sustainable raw materials, components, and energy use. The program is organized into workstreams focused on end‐to‐end control strategy, equipment flexibility, next generation technology, sustainability, and a physical test bed to evaluate and demonstrate the technologies that are developed. The elements of the program are synergistic. For example, process intensification results in cost reduction as well as increased sustainability. Improved robustness leads to less inventory, which improves costs and supply chain velocity. Flexibility allows more products to be consolidated into fewer factories, reduces the need for new facilities, simplifies the acquisition of additional capacity if needed, and reduces changeover time, which improves cost and velocity. The program incorporates both drug substance and drug product manufacturing, but this paper will focus on the drug substance elements of the program.

The association between in utero exposure to maternal psychological stress and female reproductive function in adolescence: A prospective cohort study

Background

Method

Results

Conclusion

•

Animal studies suggest reproductive function is influenced by maternal stress.

•

Human evidence is sparse and inconsistent.

•

We used a population-based pregnancy cohort of 228 mother female offspring.

•

Exposure to maternal psychological stress in late gestation affects uterine volume and ovarian AFC.

[Rotational Stability of the Knee Joint 2 Years after the Anterolateral Ligament and ACL Reconstruction: Biomechanical Study]

PURPOSE OF THE STUDY Knee injuries accompanied by anterior cruciate ligament (ACL) tears can also result in rotational instability of the joint. Subsequent insufficient rotational stability after the ACL reconstruction can be a direct consequence also of injuries to lateral knee structures, specifically the anterolateral ligament (ALL). This residual postoperative rotational instability may be prevented by multiple surgical techniques. The purpose of this study was (1) to evaluate the knee stability in internal rotation after the "anatomical" single-bundle (SB) anterior cruciate ligament reconstruction together with ALL reconstruction compared to the double-bundle (DB) ACL reconstruction two years after surgery; (2) to compare the knee joint stability after the ACL and ALL reconstruction with the healthy contralateral knee joint. MATERIAL AND METHODS All the measurements were conducted by the computer navigation system. The study included 20 patients after the single-bundle ACL and ALL reconstruction and 20 patients after the double-bundle ACL reconstruction. The follow-up examination was carried out at 25 months after surgery on average (24 months at least). All measurements were performed in both the healthy and operated knee. Once the data necessary for navigation were determined, the patient remained in standing position with both feet firmly placed on the mat with intermalleolar distance of 20 cm. Then, at 30-degree flexion of the knee joints, the patient first performed the joint internal rotation by trunk torsion, followed by external rotation. Each measurement was repeated 3 times. A non-parametric t-test was used for statistical processing. RESULTS The mean internal rotation in the injured knee joint was 19.1 degrees preoperatively and 8.1 degrees postoperatively, while in the healthy knee it was 8.4 degrees. External rotation was not assessed. The reported internal rotation in the knees after DB ACL reconstruction was 9.2 degrees (p ≥ 0.05). DISCUSSION The double-bundle ACL reconstruction is a complex technique that can lead to many intraoperative and postoperative complications. Grafts harvested from both hamstrings can have an effect on the rotational stability of the joint. In order to restore the knee rotational stability with fewer potential complications, the method of choice can be the ACL reconstruction using the quadriceps femoris muscle graft and the ALL reconstruction using the gracilis muscle graft, leaving the semitendinosus tendon intact. CONCLUSIONS The obtained values reveal that the single-bundle ACL reconstruction in combination with ALL reconstruction results in the same internal rotational stability in the knee joint as the double-bundle ACL reconstruction. Similar joint rotational stability is observed in all the knee joints reconstructed with the use of these techniques and in the contralateral healthy knee joint. Key words: anterolateral ligament, anterior cruciate ligament, internal rotational stability, objective measurement.

Constraints on the K_{S}^{0}→μ^{+}μ^{-} Branching Fraction

A search for the decay K_{S}^{0}→μ^{+}μ^{-} is performed using proton-proton collision data, corresponding to an integrated luminosity of 5.6  fb^{-1} and collected with the LHCb experiment during 2016, 2017, and 2018 at a center-of-mass energy of 13 TeV. The observed signal yield is consistent with zero, yielding an upper limit of B(K_{S}^{0}→μ^{+}μ^{-})<2.2×10^{-10} at 90% C.L.. The limit reduces to B(K_{S}^{0}→μ^{+}μ^{-})<2.1×10^{-10} at 90% C.L. once combined with the result from data taken in 2011 and 2012.

Observation of Enhanced Double Parton Scattering in Proton-Lead Collisions at sqrt[s_{NN}]=8.16 TeV

A study of prompt charm-hadron pair production in proton-lead collisions at sqrt[s_{NN}]=8.16  TeV is performed using data corresponding to an integrated luminosity of about 30  nb^{-1}, collected with the LHCb experiment. Production cross sections for different pairs of charm hadrons are measured and kinematic correlations between the two charm hadrons are investigated. This is the first measurement of associated production of two charm hadrons in proton-lead collisions. The results confirm the predicted enhancement of double parton scattering production in proton-lead collisions compared to the single parton scattering production.

Clinical summary guide: reproduction in women with previous abdominopelvic radiotherapy or total body irradiation

STUDY QUESTION

What is the evidence to guide the management of women who wish to conceive following abdominopelvic radiotherapy (AP RT) or total body irradiation (TBI)?

SUMMARY ANSWER

Pregnancy is possible, even following higher doses of post-pubertal uterine radiation exposure; however, it is associated with adverse reproductive sequelae and pregnancies must be managed in a high-risk obstetric unit.

WHAT IS KNOWN ALREADY

In addition to primary ovarian insufficiency, female survivors who are treated with AP RT and TBI are at risk of damage to the uterus. This may impact on its function and manifest as adverse reproductive sequelae.

STUDY DESIGN SIZE DURATION

A review of the literature was carried out and a multidisciplinary working group provided expert opinion regarding assessment of the uterus and obstetric management.

PARTICIPANTS/MATERIALS SETTING METHODS

Reproductive outcomes for postpubertal women with uterine radiation exposure in the form of AP RT or TBI were reviewed. This included Pubmed listed peer-reviewed publications from 1990 to 2019, and limited to English language..

MAIN RESULTS AND THE ROLE OF CHANCE

The prepubertal uterus is much more vulnerable to the effects of radiation than after puberty. Almost all available information about the impact of radiation on the uterus comes from studies of radiation exposure during childhood or adolescence.An uncomplicated pregnancy is possible, even with doses as high as 54 Gy. Therefore, tumour treatment doses alone cannot at present be used to accurately predict uterine damage.

LIMITATIONS REASONS FOR CAUTION

Much of the data cannot be readily extrapolated to adult women who have had uterine radiation and the publications concerning adult women treated with AP RT are largely limited to case reports.

WIDER IMPLICATIONS OF THE FINDINGS

This analysis offers clinical guidance and assists with patient counselling. It is important to include patients who have undergone AP RT or TBI in prospective studies to provide further evidence regarding uterine function, pregnancy outcomes and correlation of imaging with clinical outcomes.

STUDY FUNDING/COMPETING INTERESTS

This study received no funding and there are no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

ApoB48-Lipoproteins Are Associated with Cardiometabolic Risk in Adolescents with and without Polycystic Ovary Syndrome

CONTEXT

Adolescents with polycystic ovary syndrome (PCOS) have increased incidence of cardiometabolic risk factors including dyslipidemia. Atherogenic apolipoprotein (apo) B-lipoprotein remnants are associated with increased cardiovascular disease (CVD) risk.

OBJECTIVE

The aim of this study was to determine the concentrations of fasting plasma apoB-lipoprotein remnants, apoB48 and apoB100, and their association with cardiometabolic risk factors and androgen indices in adolescent girls with and without PCOS.

DESIGN SETTING AND PARTICIPANTS

Participants (n = 184) aged 17 years were recruited in the Menstruation in Teenagers Study from the Western Australian Pregnancy Cohort (Raine) Study.

THE MAIN OUTCOME MEASURES

Fasting plasma apo-B48 and -B100 lipoprotein remnant concentrations in adolescent girls with and without PCOS.

RESULTS

Fasting plasma apoB48-lipoprotein remnants but not apoB100-lipoprotein remnants were elevated in adolescent girls with increased cardiometabolic risk compared with those with lower cardiometabolic risk (13.91 ± 5.06 vs 12.09 ± 4.47 µg/mL, P < .01). ApoB48-lipoprotein remnants were positively correlated with fasting plasma triglycerides (b = .43, P < .0001). The prevalence of increased cardiometabolic risk factors was 2-fold higher in those diagnosed with PCOS (35.3%) than in those without PCOS (16.3%).Conclusion: Adolescents with PCOS have a 2-fold higher incidence of cardiometabolic risk factors than those without PCOS. Fasting apoB48-lipoprotein remnants are elevated in adolescent girls with a high prevalence of cardiometabolic risk factors.

The association between in-utero exposure to stressful life events during pregnancy and male reproductive function in a cohort of 20-year-old offspring: The Raine Study

STUDY QUESTION

Is exposure to gestational stress in the critical time window for the normal differentiation and growth of male reproductive tissue associated with male reproductive function in offspring in later life?

SUMMARY ANSWER

Exposure to stressful life events (SLEs) in early, but not late gestation, are associated with reduced adult male reproductive function, consistent with the hypothesis that events during early prenatal life programme adult male reproductive function.

WHAT IS ALREADY KNOWN

Animal studies suggest that gestational stress may impact on the reproductive function of male offspring, but human evidence is sparse.

STUDY DESIGN, SIZE, DURATION

Using a prospective longitudinal cohort, we examined the association between number and type of maternal stressors during pregnancy in both early and late gestation and reproductive function in 643 male Generation 2 (offspring) at age 20 years. Mothers and their male Generation 2 (offspring) from The Raine Study participated. Mothers prospectively reported SLEs during pregnancy recorded at gestational weeks 18 and 34 using a standardized 10-point questionnaire.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The 643 male Generation 2 (offspring) underwent testicular ultrasound examination and semen analysis and provided serum for reproductive hormone analysis. Multivariate linear regression analysis was used to examine associations.

MAIN RESULTS AND ROLE OF CHANCE

Of 643 recruited males, 407 (63%) were exposed to at least one SLE in early gestation. Fewer SLEs were reported in late gestation (n = 343, 53%). Maternal SLE exposure in early gestation was negatively associated with total sperm count (β = -0.31, 95% CI -0.58; -0.03), number of progressive motile sperm (β = -0.15, 95% CI -0.31; 0.00) and morning serum testosterone concentration (β = -0.04, 95% CI -0.09; -0.00). No similar effects of maternal SLE exposure in late pregnancy were detected. The large sample size and an objective detailed direct assessment of adult male reproductive function with strict external quality control for sperm quality, as well as detailed prospectively collected information on prenatal SLEs in two distinct time windows of pregnancy reported by the women in early and late gestation along with other risk factors, imply minimal possibility of recall, information bias and selection bias. When assessing our results, we adjusted for a priori chosen confounders, but residual confounding or confounding by factors unbeknown to us cannot be ruled out.

LIMITATIONS, REASONS FOR CAUTION

It is not possible to measure how SLEs impacted differently on the mother's experience or perception of stress. Resilience (coping) gradients may alter cortisol levels and thus modify the associations we observed and the mothers' own perception of stress severity may have provided a more precise estimate of her exposure.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings suggest that exposure to SLEs in early, but not late gestation, are associated with reduced adult male reproductive function. Improved support for women with exposure to SLEs during pregnancy, particularly during the first trimester, may improve the reproductive health of their male offspring in later life. Intervention studies of improved pregnancy support could provide more insight into this association and more information is needed about the potential specific epigenetic mechanisms underlying this association.

STUDY FUNDING/COMPETING INTEREST(S)

The male fertility sub-study was funded by NHMRC Grant 634 457. The core management of the Raine Study is funded by University of Western Australia, Curtin University, Telethon Kids Institute, Women and Infants Research Foundation, Edith Cowan University, Murdoch University, The University of Notre Dame Australia and Raine Medical Research foundation. Dr Bräuner's salary was supported by Læge Sofus Carl Emil Friis og Hustru Olga Doris Friis foundation in Denmark. All authors declare no competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Measurement of CP-Averaged Observables in the B^{0}→K^{*0}μ^{+}μ^{-} Decay

An angular analysis of the B^{0}→K^{*0}(→K^{+}π^{-})μ^{+}μ^{-} decay is presented using a dataset corresponding to an integrated luminosity of 4.7  fb^{-1} of pp collision data collected with the LHCb experiment. The full set of CP-averaged observables are determined in bins of the invariant mass squared of the dimuon system. Contamination from decays with the K^{+}π^{-} system in an S-wave configuration is taken into account. The tension seen between the previous LHCb results and the standard model predictions persists with the new data. The precise value of the significance of this tension depends on the choice of theory nuisance parameters.

Observation of New Ξ_{c}^{0} Baryons Decaying to Λ_{c}^{+}K^{-}

The Λ_{c}^{+}K^{-} mass spectrum is studied with a data sample of pp collisions at a center-of-mass energy of 13 TeV corresponding to an integrated luminosity of 5.6  fb^{-1} collected by the LHCb experiment. Three Ξ_{c}^{0} states are observed with a large significance and their masses and natural widths are measured to be m[Ξ_{c}(2923)^{0}]=2923.04±0.25±0.20±0.14  MeV, Γ[Ξ_{c}(2923)^{0}]=7.1±0.8±1.8  MeV, m[Ξ_{c}(2939)^{0}]=2938.55±0.21±0.17±0.14  MeV, Γ[Ξ_{c}(2939)^{0}]=10.2±0.8±1.1  MeV, m[Ξ_{c}(2965)^{0}]=2964.88±0.26±0.14±0.14  MeV, Γ[Ξ_{c}(2965)^{0}]=14.1±0.9±1.3  MeV, where the uncertainties are statistical, systematic, and due to the limited knowledge of the Λ_{c}^{+} mass. The Ξ_{c}(2923)^{0} and Ξ_{c}(2939)^{0} baryons are new states. The Ξ_{c}(2965)^{0} state is in the vicinity of the known Ξ_{c}(2970)^{0} baryon; however, their masses and natural widths differ significantly.

Search for the Rare Decays B_{s}^{0}→e^{+}e^{-} and B^{0}→e^{+}e^{-}

A search for the decays B_{s}^{0}→e^{+}e^{-} and B^{0}→e^{+}e^{-} is performed using data collected with the LHCb experiment in proton-proton collisions at center-of-mass energies of 7, 8, and 13 TeV, corresponding to integrated luminosities of 1, 2, and 2  fb^{-1}, respectively. No signal is observed. Assuming no contribution from B^{0}→e^{+}e^{-} decays, an upper limit on the branching fraction B(B_{s}^{0}→e^{+}e^{-})<9.4(11.2)×10^{-9} is obtained at 90(95)% confidence level. If no B_{s}^{0}→e^{+}e^{-} contribution is assumed, a limit of B(B^{0}→e^{+}e^{-})<2.5(3.0)×10^{-9} is determined at 90(95)% confidence level. These upper limits are more than one order of magnitude lower than the previous values.

OR31-02 Diagnostic Criteria for Polycystic Ovary Syndrome in Adolescents: Impact on Prevalence and Longitudinal Body Mass Index Trajectories

Background: Polycystic ovary syndrome (PCOS) is characterised by oligo-anovulation (OA), hyperandrogenism (HA) and polycystic ovary morphology (PCO). While the Rotterdam criteria (defined as 2 out of 3 features) are the most widely used criteria in adults, controversy remains for the diagnostic criteria in adolescents as many PCOS features overlap with normal pubertal physiological changes. The 2018 international evidence-based PCOS guideline recommends modified Rotterdam criteria (OA and HA) in adolescents based on expert consensus. We aimed to 1) compare the prevalence of PCOS using original and modified Rotterdam criteria in an unselected adolescent cohort and 2) explore the association between diagnostic phenotypes and long-term body mass index (BMI) trajectories. Methods: 227 adolescent females of the Western Australian Pregnancy Cohort (Raine) Study undertook detailed PCOS assessment at the mean age of 15.3 years (mean age of menarche 12.4 years). Detailed anthropometric measurements were collected from birth until age 22 years. T-test was used for group BMI comparisons and longitudinal BMI was analysed using Generalised Estimating Equations with PCOS by time and PCOS phenotypes by time as interaction terms. Results: PCOS was diagnosed in 66 (29.1%) participants using original Rotterdam criteria versus 37 (16.3%) participants using modified Rotterdam criteria. Using modified Rotterdam criteria, participants with PCOS had higher mean group BMI than participants without PCOS from age 5 years onwards. Significant interaction was detected between PCOS and time (p<0.001) on longitudinal BMI gain where higher BMI gain was observed in participants with PCOS from age 14 years onwards. Only the modified criteria phenotype was significantly associated wth long-term BMI gain whereas other PCOS phenotypes had similar BMI trajectories as participants without PCOS (p<0.001). Conclusions: Our findings validate the PCOS guideline recommendation as modified Rotterdam criteria reduce over-diagnosis of PCOS in adolescents and accurately identify the phenotype at risk of long-term weight gain. The BMI trajectories of females with and without PCOS diverge from early childhood suggesting that metabolic dysfunction in PCOS commences early in the pre-pubertal period. Disclosures: Nothing to disclose. Funding: PCOS CRE scholarship and Research Training Program Scholarship awarded to CT; NHMRC Medical Research Future fund awarded to HT; National Heart Foundation Future Leader Fellowship awarded to LM; NHMRC early career fellowship awarded to AJ.

Isospin Amplitudes in Λ_{b}^{0}→J/ψΛ(Σ^{0}) and Ξ_{b}^{0}→J/ψΞ^{0}(Λ) Decays

Ratios of isospin amplitudes in hadron decays are a useful probe of the interplay between weak and strong interactions and allow searches for physics beyond the standard model. We present the first results on isospin amplitudes in b-baryon decays, using data corresponding to an integrated luminosity of 8.5  fb^{-1}, collected with the LHCb detector in pp collisions at center of mass energies of 7, 8, and 13 TeV. The isospin amplitude ratio |A_{1}(Λ_{b}^{0}→J/ψΣ^{0})/A_{0}(Λ_{b}^{0}→J/ψΛ)|, where the subscript on A indicates the final-state isospin, is measured to be less than 1/21.8 at 95% confidence level. The Cabibbo suppressed Ξ_{b}^{0}→J/ψΛ decay is observed for the first time, allowing for the measurement |A_{0}(Ξ_{b}^{0}→J/ψΛ)/A_{1/2}(Ξ_{b}^{0}→J/ψΞ^{0})|=0.37±0.06±0.02, where the uncertainties are statistical and systematic, respectively.

First Observation of Excited Ω_{b}^{-} States

We report four narrow peaks in the Ξ_{b}^{0}K^{-} mass spectrum obtained using pp collisions at center-of-mass energies of 7, 8, and 13 TeV, corresponding to a total integrated luminosity of 9  fb^{-1} recorded by the LHCb experiment. Referring to these states by their mass, the mass values are m[Ω_{b}(6316)^{-}]=6315.64±0.31±0.07±0.50  MeV, m[Ω_{b}(6330)^{-}]=6330.30±0.28±0.07±0.50  MeV, m[Ω_{b}(6340)^{-}]=6339.71±0.26±0.05±0.50  MeV, m[Ω_{b}(6350)^{-}]=6349.88±0.35±0.05±0.50  MeV, where the uncertainties are statistical, systematic, and the last is due to the knowledge of the Ξ_{b}^{0} mass. The natural widths of the three lower mass states are consistent with zero, and the 90% confidence-level upper limits are determined to be Γ[Ω_{b}(6316)^{-}]<2.8  MeV, Γ[Ω_{b}(6330)^{-}]<3.1  MeV and Γ[Ω_{b}(6340)^{-}]<1.5  MeV. The natural width of the Ω_{b}(6350)^{-} peak is 1.4_{-0.8}^{+1.0}±0.1  MeV, which is 2.5σ from zero and corresponds to an upper limit of 2.8 MeV. The peaks have local significances ranging from 3.6σ to 7.2σ. After accounting for the look-elsewhere effect, the significances of the Ω_{b}(6316)^{-} and Ω_{b}(6330)^{-} peaks are reduced to 2.1σ and 2.6σ, respectively, while the two higher mass peaks exceed 5σ. The observed peaks are consistent with expectations for excited Ω_{b}^{-} resonances.

Search for A^{'}→μ^{+}μ^{-} Decays

Searches are performed for both promptlike and long-lived dark photons, A^{'}, produced in proton-proton collisions at a center-of-mass energy of 13 TeV. These searches look for A^{'}→μ^{+}μ^{-} decays using a data sample corresponding to an integrated luminosity of 5.5  fb^{-1} collected with the LHCb detector. Neither search finds evidence for a signal, and 90% confidence-level exclusion limits are placed on the γ-A^{'} kinetic mixing strength. The promptlike A^{'} search explores the mass region from near the dimuon threshold up to 70 GeV and places the most stringent constraints to date on dark photons with 214<m(A^{'})≲740  MeV and 10.6<m(A^{'})≲30  GeV. The search for long-lived A^{'}→μ^{+}μ^{-} decays places world-leading constraints on low-mass dark photons with lifetimes O(1)  ps.

The cumulative success of ovulation induction therapy with gonadotrophins in therapy-naïve anovulatory women: An observational study

BACKGROUND

The use of gonadotrophins as a first-line treatment for anovulatory infertility has been limited by a perception of a risk of multi-fetal gestation and ovarian hyperstimulation syndrome (OHSS). However, it has recently been recognised as an acceptable first-line treatment if appropriate monitoring is performed.

AIMS

To determine the cumulative live birth rate, incidence of multiple gestation, cycle cancellation rate and incidence of OHSS for therapy-naïve anovulatory women undergoing ovulation induction with gonadotrophins.

MATERIALS AND METHODS

A prospective observational study of 258 patients undergoing ovulation induction with a 'low-dose step-up' protocol was performed over a three-year period across two fertility centres (40% of patients were currently or recently prescribed metformin).

RESULTS

Twenty-six percent of patients required concurrent use of luteinising hormone. The cumulative pregnancy and live birth rates were 22.5% and 18.2%, 40.3% and 34.5%, 47.7% and 41.1% after completion of the first, second and third cycles of stimulation, respectively, with a median duration of stimulation of 15 days. No patients developed OHSS and 10.5% of cycles were cancelled due to an excessive or no follicular response. The multiple pregnancy rate was 2%. The cumulative pregnancy rate was reduced for women over 35 years of age (23.8 vs 55.3%, P = 0.006) and for women with a body mass index greater than 25 kg/m² (40.6 vs 56.7%, P = 0.027)_. CONCLUSIONS: This study demonstrated that ovulation induction with gonadotrophin therapy, in the context of appropriate monitoring, is a safe and effective treatment for young therapy-naïve patients with anovulatory infertility.

[Derotational Intertrochanteric Osteotomy in Habitual Dislocation of the Patella]

PURPOSE OF THE STUDY The preoperative planning in habitual dislocation of the patella should take into account all pathologies and the procedure should address all abnormalities. One of them might be also the rotational deformity of the femur. The purpose of this prospective study was to confirm the hypothesis that the only correction of pathological femoral anteversion by derotational intertrochanteric osteotomy (in the absence of another pathology) or the correction of femoral anteversion with simultaneous reconstruction of the patellofemoral joint provide adequate stability for the patellofemoral joint, with respect to the elimination of the risk of recurrent dislocation of the patella. MATERIAL AND METHODS In the course of 15 years, 17 patients (20 knee joints) with habitual dislocation of the patella were included in the study, in whom the CT scan also confirmed the femoral anteversion of 35° and greater. The group was female-dominant, often with BMI > 30. The mean age was 26 years. In 4 cases only derotational intertrochanteric osteotomy was performed, in 16 patients the osteotomy was followed by the stabilization of the patella in the knee region (always individually in dependence on the diagnosed pathology), of whom in 2 cases as the second step procedure because of thrombophilic disorders detected earlier. Immediately after the surgery, or at 6 weeks postoperatively (depending on the knee procedure done), individual rehabilitation was commenced. Partial weight bearing was recommended for the period of 3 months after the surgery. The mean follow-up period was 39 months (minimum of 36 months). RESULTS In one case a failure of osteosynthesis was observed and revision osteosynthesis with an intramedullary nail was performed. In all the other cases, primary healing of the osteotomy was achieved. The other complications were less significant (1 case of asymptomatic deep vein thrombosis of the lower limb, evacuation of subcutaneous haematoma in 1 case, 3 cases of the knee stiffness solved by manipulation under general anaesthesia at 6 weeks after surgery). Recurrent patellar dislocation was not observed in any of the patients. No pain in the upper thigh was reported by patients during the last follow-up control (at least 3 years postoperatively). Three female patients reported an isolated feeling of patellar instability. DISCUSSION There are very few studies focusing on the femoral derotational osteotomy for habitual dislocation of the patella in world literature. If any at all, they concern supracondylar and not intertrochanteric femoral osteotomy and the groups of patients were smaller than the group evaluated by us. CONCLUSIONS Preoperative planning for habitual dislocation of the patella should definitely reflect all pathologies. Therefore, the femoral derotational osteotomy should certainly be mastered by the orthopaedic surgeon, though it is a larger and more exacting procedure than patellar stabilizations in the knee region. Indications for this type of osteotomy should include anteversion greater than 30°, or 35°. The derotational intertrochanteric osteotomy alone or its combination with the stabilization of the patella in the knee region brings reliable results with no risk of recurrent dislocation. Key words: patella, habitual dislocation, femur, anteversion, derotational osteotomy.

[Occult Injuries to Posterior Pelvic Segment in Elderly Patients with Pubic Rami Fractures]

PURPOSE OF THE STUDY The incidence of pelvic fractures in geriatric population has been increasing. The diagnostic method of first choice is plain pelvic anteroposterior X-ray which, however, mostly reveals merely the pubic rami fractures. The pain caused by undiagnosed lesion of the posterior pelvic segment may substantially reduce the patient s mobility, thus also their self-sufficiency which is crucial in elderly patients. The purpose of this prospective study was to evaluate the incidence of an occult injury to the posterior pelvic ring in patients with an X-ray finding of pubic rami fractures only. MATERIAL AND METHODS Throughout a three-year period (2017-2019), the incidence of an occult injury to the posterior pelvic ring was evaluated by means of a CT scan in 50 patients aged 65 years and over, in whom the plain anteroposterior pelvic radiograph initially revealed only the pubic rami fractures. The mean age of 35 women and 15 men was 76 years (the range of 65-94 years). RESULTS In 15 patients (30%) only, the CT scan confirmed the isolated pubic rami fracture. In the remaining 35 cases (70%), the CT scan revealed an injury to the posterior pelvic segment, namely in 32 cases ipsilaterally, in one case contralaterally and in two patients bilaterally. In 4 patients (8%) only, signs of the injury to the posterior pelvic segment were subsequently found on the plain X-ray of the pelvis. DISCUSSION Diagnosis of a pubic rami fracture in geriatric patients solely based on the performed X-ray can be misleading. It has been proven in our prospective study that majority of injuries to posterior pelvic ring is not detected on the plain X-ray, which is also the conclusion arrived at by foreign authors. The CT scan alone can safely determine the actual extent of the pelvic injury. While the isolated injuries to the anterior pelvic ring show biomechanical stability, and thus are less painful and can be successfully treated non-operatively, the associated injuries to the posterior pelvic ring can cause a certain degree of instability, which has to be reflected in treatment strategy. CONCLUSIONS Injuries to the posterior pelvic segment in geriatric population are much more frequent than expected. They are, however, rarely distinguishable on a plain radiograph. Often times, only the pubic rami fractures are clearly visible. The fractures of posterior segment tend to be accompanied by a higher number of complications and a worse prognosis. A reliable method to detect these injuries is the unenhanced CT scan of the pelvis that should be performed routinely in all the patients with pubic rami fractures identified on a radiograph. In cases when pain substantially limits the mobilisation of the patients, minimally invasive surgical treatment should be considered. Key words: pelvic ring injury, pubic rami, geriatric population.

Observation of New Resonances in the Λ_{b}^{0}π^{+}π^{-} System

We report the observation of a new structure in the Λ_{b}^{0}π^{+}π^{-} spectrum using the full LHCb data set of pp collisions, corresponding to an integrated luminosity of 9  fb^{-1}, collected at sqrt[s]=7, 8, and 13 TeV. A study of the structure suggests its interpretation as a superposition of two almost degenerate narrow states. The masses and widths of these states are measured to be m_{Λ_{b}(6146)^{0}}=6146.17±0.33±0.22±0.16  MeV,m_{Λ_{b}(6152)^{0}}=6152.51±0.26±0.22±0.16  MeV,Γ_{Λ_{b}(6146)^{0}}=2.9±1.3±0.3  MeV,Γ_{Λ_{b}(6152)^{0}}=2.1±0.8±0.3  MeV,with a mass splitting of Δm=6.34±0.32±0.02  MeV, where the first uncertainty is statistical, the second systematic. The third uncertainty for the mass measurements derives from the knowledge of the mass of the Λ_{b}^{0} baryon. The measured masses and widths of these new excited states suggest their possible interpretation as a doublet of Λ_{b}(1D)^{0} states.

A Review of First Line Infertility Treatments and Supporting Evidence in Women with Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is the most common cause of anovulatory infertility in women of reproductive age. Lifestyle change is considered the first line treatment for the management of infertile anovulatory women with PCOS, and weight loss for those who are overweight or obese. First line medical ovulation induction therapy to improve fertility outcomes is letrozole, whilst other less efficacious ovulation induction agents, such as clomiphene citrate, metformin, and metformin combined with clomiphene citrate, may also be considered. Metformin combined with clomiphene citrate is more effective than clomiphene citrate alone. In obese women with PCOS, clomiphene citrate could be used in preference to metformin alone whilst clomiphene citrate could be added to metformin alone in order to improve reproductive outcome in all women with PCOS. Gonadotrophins, which are more effective than clomiphene citrate in therapy naïve women with PCOS, can be considered a first line therapy in the presence of ultrasound monitoring, following counselling on the cost and the potential risk of multiple pregnancy.

A Review of Second- and Third-line Infertility Treatments and Supporting Evidence in Women with Polycystic Ovary Syndrome

In clomiphene-citrate-resistant anovulatory women with polycystic ovary syndrome (PCOS) and no other infertility factors, either metformin combined with clomiphene citrate or gonadotrophins could be used as a second-line pharmacological therapy, although gonadotrophins are more effective. Gonadotrophins could also be used as a second-line pharmacological therapy in anovulatory women with PCOS and clomiphene-citrate-failure. Laparoscopic ovarian surgery can also be used as a second-line therapy for ovulation induction in anovulatory women with clomiphene-citrate-resistant PCOS and no other infertility factors. The usefulness of letrozole as a second-line pharmacological treatment for ovulation induction in clomiphene-citrate-resistant women with PCOS requires further research. In terms of improving fertility, both pharmacological anti-obesity agents and bariatric surgery should be considered an experimental therapy in anovulatory women with PCOS and no other infertility factors. Where first- or second-line ovulation induction therapies have failed, in vitro fertilization (IVF)/ intracytoplasmic sperm injection (ICSI) could be offered as a third-line therapy in women with PCOS in the absence of an absolute indication for IVF/ICSI. For women with PCOS undergoing IVF/ICSI treatment, the gonadotropin-releasing hormone (GnRH) antagonist protocol is preferred and an elective frozen embryo transfer strategy could be considered. In assisted conception units with sufficient expertise, in-vitro maturation (IVM) of oocytes could be offered to women with PCOS.