Implementation of an Innovative Technology Called the OR Black Box: A Feasibility Study

Introduction. The operating room (OR) Black Box is an innovative technology that captures and compiles extensive real-time data from the OR, allowing identification and analysis of factors that influence intraoperative procedures and performances - ultimately improving patient safety. Implementation of this kind of technology is still an emerging research area and prone to face challenges. Methods. Observational study running from May 2017 to May 2021 conducted at Copenhagen University Hospital - Rigshospitalet, Denmark, involving 152 OR staff and 306 patients. Feasibility of the OR Black Box was assessed in accordance with Bowen's framework with 8 focus areas. Results. The OR Black Box had a high level of acceptability among stakeholders with 100% participation from management, 93% from OR staff, and 98% from patients. The implementation process improved over time, and an average of 80% of the surgeries conducted were captured. The practical aspects such as numerous formal and informal meetings, ethical and legal approval, recruitment of patients were acceptable, albeit time-consuming. The OR Black Box was adopted without any changes in scheduled surgery program, but capturing hours were adjusted to match the surgery program and relocation of OR staff declining to provide consent was possible. Conclusions. Implementation of the OR Black Box was feasible yet challenging. Management, nearly all staff, and patients embraced the initiative; however, ongoing evaluation, information meetings, and commitment from stakeholders are required and crucial to sustain momentum, continue implementation and expansion. Ideas from this study can be useful in the implementation of similar initiatives.

Reproductive and Endocrine Outcomes in a Cohort of Danish Women following Auto-Transplantation of Frozen/Thawed Ovarian Tissue from a Single Center

Ovarian tissue cryopreservation (OTC) is a method of fertility preservation in girls and young women prior to gonadotoxic treatment. It is a safe and promising method to restore fertility. The initial recovery of endocrine function is high, but the longevity of the grafted tissue varies. In this single-center, combined retro- and prospective cohort study, we report the reproductive outcome and hormonal recovery following ovarian tissue transplantation (OTT) and evaluate possible predictors of the chance of pregnancy. The study includes 40 women from eastern Denmark undergoing 53 OTTs between 2003 and 2021. Permission to obtain retrospective data was given by the Danish Patient Safety Authorities and prospective data-collection by informed consent. Initial recovery of endocrine function was seen in 18/19 women with POI, and ongoing function of the grafted tissue in 7/14 two years from OTT. Live birth rate (LBR) was 41%, with 20 children to 39 women trying to conceive. Women who conceived had higher AFC at the time of OTC than women who did not (p ± 0.04). Repeated transplantations were not successful in terms of delivery. Half of all pregnancies were achieved by ART, but PRs were lower after ART than by spontaneous conception. LBRs after OTT are encouraging. Chance of pregnancy after OTT is correlated to ovarian reserve at OTC. Repeated transplantations were not successful in terms of unfulfilled pregnancy wish.

P-462 Reproductive outcomes in a cohort of Danish women following auto-transplantation of frozen/thawed ovarian tissue from a single center

Study question

What is the reproductive outcome from ovarian tissue transplantation (OTT) from a single, experienced center.

Summary answer

The overall delivery rate was 41% (16/39) per woman and a total of 20 children to 39 women is expected.

What is known already

Ovarian tissue cryopreservation (OTC) is a well-established procedure for fertility preservation in girls and young women prior to gonadotoxic treatment and has shown to be a safe and promising method to restore fertility, with more than 200 healthy children born worldwide. Initial recovery of endocrine function is very high, although the longevity of the grafted tissue varies. The success of OTT is multifactorial, and important factors such as high age and poor ovarian reserve at OTC, as well as pelvic radiation are known to impair the chances of success.

Study design, size, duration

This is a single center, combined retro- and prospective cohort study including 40 women undergoing a total of 53 OTTs from the Fertility Clinic at Rigshospitalet University Hospital of Copenhagen, Denmark between 2003 and 2021.

Participants/materials, setting, methods

All women, who underwent OTT, were included in the study. End of follow up was December 31st, 2021. Information about diagnoses, gonadotoxic treatment, gynecologic (incl. endocrine parameters) and obstetric history was retrieved from medical records. Permission to obtain retrospective data from 1999 to 2020 was given by the Danish Patient Safety Authorities (jrn 3-3013-2790/1) and prospective data-collection was given by informed consent from the patients from 2020 and onwards.

Main results and the role of chance

Mean age at OTC was 28.5+5.5 years. Indications for OTC were malignant (n = 34) or benign diseases (n = 6). Mean time to first OTT was 4.2 years and mean age 33.0+5.4 years. At OTT, 19 women had POI (FSH>25 IU/L and amenorrhea), 10 were perimenopausal (intermittent FSH >25 IU/L) and 11 were low responders (AMH<5pmol/L), with normal endocrine parameters but signs of infertility. Minimal follow up was 11 months and maximum 17 years from OTT.

From 39 women with a pregnancy wish, 11 (28%) gave birth to a total of 15 children. In addition, 5 pregnancies are currently ongoing in the last trimester. The overall delivery rate was 51% (20/39) (including 5 ongoing) and 41% (16/39) per woman. Of 20 deliveries, 60% were conceived naturally and 40% from ART. Nineteen children were delivered following the first OTT. Four women had 2 children, of whom one had her second child following the second OTT.

Initial activation of the grafted tissue, defined by a drop of FSH to < 25 IU/L within 6 months, was seen in 18/19 (95%) women with POI prior to OTT. One woman experienced total graft failure.

Data on endocrine function of the grafted tissue will be presented at the meeting.

Limitations, reasons for caution

This study is based on information from medical records in public Danish hospitals, where information of all deliveries in Denmark is available. Pregnancies and deliveries outside Denmark might therefore not be included, why the total number could be slightly underestimated.

Wider implications of the findings

OTC with OTT is an efficient and encouraging way to restore fertility in a selected group of young women with a high risk of infertility following gonadotoxic treatment. Further, our data, from a specialized and experienced center, shows a good chance of livebirth and initial recovery of endocrine function.

Trial registration number

3-3013-2790/1

Use of cryopreserved ovarian tissue in the Danish fertility preservation cohort

OBJECTIVE

To evaluate the use of cryopreserved ovarian tissue in the Danish fertility preservation cohort.

DESIGN

Retrospective cohort study.

SETTING

University hospitals and fertility clinics.

PATIENT(S)

Ovarian tissue cryopreservation (OTC) was performed for 1,186 Danish girls and women from 1999-2020, of whom 117 subsequently underwent ovarian tissue transplantation (OTT). Subgroup 1 included 759 patients with a follow-up period of >5 years. Out of these, OTT rates were further analyzed for those patients who were alive and aged >24 years in July 2020 (subgroup 2; n = 554).

INTERVENTION(S)

OTC and OTT.

MAIN OUTCOME MEASURE(S)

OTT, death, donation of tissue.

RESULT(S)

In subgroup 1, 14% of the patients had undergone OTT, 18% had died, 9% had donated their tissue for research, and 59% still had their tissue stored. In subgroup 2, 19% had undergone OTT and for most diagnoses the OTT rates ranged from 15% to 22% with benign hematologic diseases having the highest OTT rate (35%). On the basis of the entire cohort, stratified age analysis indicated that women aged ≥30 years at OTC were more likely to return for OTT than women aged 18-29 years at OTC; mean storage times were 3.7 and 3.6 years, respectively. Only 4% of the girls aged <18 years at OTC had undergone OTT.

CONCLUSION(S)

The OTT rates depended on the diagnosis, age at OTC, and follow-up time. Specific criteria are needed for reporting and comparing OTT rates. Six out of 10 patients still had their cryopreserved tissue stored and longer follow-up is needed, especially for younger girls.

[Treatment of primary and recurrent ovarian cancer]

With 550 new cases/year ovarian cancer constitutes 3% of all cancers among women. The unspecific symptoms cause delayed diagnosis and hence poor survival rates. Screening initiatives have been disappointing. In order to accelerate diagnosis and correct surgical management, patients are referred to centralized, specialized units. The primary treatment comprises surgical total cytoreduction followed by platinum-based chemotherapy. Newer biological agents are added when randomized trials have shown a benefit. Recurrence is managed by chemotherapy alone or repeated radical surgery followed by chemotherapy.

Pretreatment anti-Müllerian hormone predicts for loss of ovarian function after chemotherapy for early breast cancer

AIM

Improving survival for women with early breast cancer (eBC) requires greater attention to the consequences of treatment, including risk to ovarian function. We have assessed whether biochemical markers of the ovarian reserve might improve prediction of chemotherapy related amenorrhoea.

METHODS

Women (n=59, mean age 42.6 years [(range 23.3-52.5]) with eBC were recruited before any treatment. Pretreatment ovarian reserve markers (anti-Müllerian hormone [AMH], follicle-stimulating hormone [FSH], inhibin B) were analysed in relation to ovarian status at 2 years.

RESULTS

Pretreatment AMH was significantly lower in women with amenorrhoea at 2 years (4.0 ± 0.9 pmol/L versus 17.2 ± 2.5, P<0.0001), but FSH and inhibin B did not differ between groups. By logistic regression, pretreatment AMH, but not age, FSH or inhibin B, was an independent predictor of ovarian status at 2 years (P=0.005; odds ratio 0.013). We combined these data with a similar cohort (combined n=75); receiver-operator characteristic analysis for AMH gave area under curve (AUC) of 0.90 (95% confidence interval (CI) 0.82-0.97)). A cross-validated classification tree analysis resulted in a binary classification schema with sensitivity 98.2% and specificity 80.0% for correct classification of amenorrhoea.

CONCLUSION

Pretreatment AMH is a useful predictor of long term post chemotherapy loss of ovarian function in women with eBC, adding significantly to the only previously established individualising predictor, i.e. age. AMH measurement may assist decision-making regarding treatment options and fertility preservation procedures.

The safety of transplanting cryopreserved ovarian tissue in cancer patients: a review of the literature

BACKGROUND

Transplantation of frozen/thawed ovarian tissue from patients with a malignant condition is associated with a risk of re-introduction of the disease as the tissue usually is removed before anti-cancer therapy and may thus contain malignant cells. We review studies investigating the presence of malignant cells in cryopreserved ovarian tissue from patients with malignant disease and based on the strength of the evidence, recommendations for transplantations are proposed.

MATERIALS AND METHODS

A systematic review of the literature. All peer reviewed studies evaluating the presence of malignant cells in cryopreserved human ovarian tissue were included. Data were searched in Pubmed and Embase with no language restrictions.

RESULTS

The majority of the reviewed papers were casuistic reports and few of the included papers were specifically designed to search for malignant cells. Ovarian tissue from 422 patients has been subject to testing for malignant cells by imaging, histology, immunohistochemistry, molecular biology, animal- or clinical transplantation. In 31 (7 %) of the cases the applied test raised suspicion of malignant cell infiltration. No transplantation-related relapse of cancer has been reported after 33 transplantations of frozen/thawed ovarian cortex.

CONCLUSION

The quality and strength of the evidence is generally low and prospective studies are needed. The risk of re-introducing a malignant condition when transplanting ovarian tissue depends on the particular disease. Based on the available data, the risk was estimated: Leukaemia: HIGH. Gastrointestinal cancers: MODERATE. Breast cancer, sarcomas of the bone and connective tissue, gynaecological cancers, Hodgkin's and Non-Hodgkin's Lymphoma: LOW.

Age determination enhanced by embryonic foot bud and foot plate measurements in relation to Carnegie stages, and the influence of maternal cigarette smoking

BACKGROUND

Reliable age determination of first-trimester human embryos and fetuses is an important parameter for clinical use and basic science. Age determination by ultrasound or morphometric parameters of embryos 4-6 weeks post conception (p.c.) have been questioned, and more accurate methods are required. Data on whether and how maternal smoking and alcohol consumption influence embryonic and fetal foot growth is also lacking.

METHODS

Embryonic tissue from 102 first-trimester legal abortions (aged 35-69 days p.c.) were collected. All women answered a questionnaire concerning smoking and drinking habits, and delivered a urine sample for cotinine analysis. Embryonic age was evaluated by vaginal ultrasound measurements and by post-termination foot length and compared with the Carnegie stages.

RESULTS

Foot bud and foot plate were defined and measured as foot length in embryos aged 35-47 days p.c. (range 0.8-2.1 mm). In embryos and fetuses aged 41-69 days p.c., heel-toe length was measured (range 2.5-7.5 mm). We found a significant linear correlation between foot length and age. Morphology of the feet was compared visually with the Carnegie collection, and we found that the mean ages of the two collections correlated well. Foot length was independent of gender, Environmental Tobacco Smoke, maternal smoking and alcohol consumption.

CONCLUSION

Foot length correlated linearly to embryonic and foetal age, and was unaffected by gender, ETS, maternal smoking and alcohol consumption.

Dynamics and mechanisms of chemotherapy-induced ovarian follicular depletion in women of fertile age

OBJECTIVE

To study ovarian follicular dynamics during chemotherapy to understand the mechanisms behind chemotherapy-induced ovarian follicular depletion and to evaluate whether pretreatment levels of ovarian reserve markers were predictive of the posttreatment levels.

DESIGN

Prospective clinical study.

SETTING

University hospital fertility center.

PATIENT(S)

Seventeen women (median age 30 years; range 19-35 years) undergoing chemotherapy.

INTERVENTION(S)

Patients were seen before, frequently during, and after chemotherapy, until 1 year after the end of treatment. Antral follicle count and levels of FSH, LH, E(2), anti-Müllerian hormone (AMH), and inhibin A and B were monitored at each visit.

MAIN OUTCOME MEASURE(S)

The dynamics of the ovarian reserve markers during chemotherapy and factors predictive of posttreatment ovarian function.

RESULT(S)

Anti-Müllerian hormone level (mean +/- 2 SEM) dropped from 2.7 +/- 1.0 to 1.1 +/- 0.6 and to 0.4 +/- 0.4 ng/mL immediately after one and two series of chemotherapy, respectively. Inhibin B and antral follicle count decreased after three series whereas FSH reached menopausal levels after four series. High pretreatment AMH levels predicted higher posttreatment AMH levels.

CONCLUSION(S)

Anti-Müllerian hormone and inhibin B levels immediately declined in response to chemotherapy, and the follicular target of chemotherapy appeared to be growing follicles. High pretreatment AMH levels were predictive of a higher posttreatment AMH level.

Concentration of anti-Müllerian hormone and inhibin-B in relation to steroids and age in follicular fluid from small antral human follicles

CONTEXT

Ovaries surgically removed for fertility preservation served as a source of follicle fluid from human small antral follicles.

OBJECTIVE

The objective of the study was to measure intrafollicular concentrations of anti-Müllerian Hormone (AMH), inhibin-B, progesterone, androstenedione, testosterone, estradiol, and IGF binding protein-4.

SETTING

The study was conducted at a university hospital.

PATIENTS

Patients included 43 women having one ovary removed prior to receiving gonadotoxic treatment due to malignant disease.

INTERVENTIONS

Fluid from 100 follicles (diameter of 3-9 mm) were included.

MAIN OUTCOME MEASURES

Intrafollicular concentrations of the measured hormones, their possible intercorrelation, and correlation with age were measured.

RESULTS

Concentrations of AMH were unrelated to follicular fluid concentrations of androstenedione and testosterone. There was a significant negative correlation between estradiol, inhibin-B, progesterone, and AMH. In four age groups spanning 11-37 yr, levels of AMH, estradiol, androstenedione, testosterone and inhibin-B remained constant, whereas progesterone showed significant variations. IGF binding protein-4 was unrelated to any other measured hormone.

CONCLUSIONS

This study was unable to confirm a stimulatory effect of androgens on AMH secretion but did enforce a close intimate correlation between AMH and estradiol expressions in the developing human follicle. The insignificant variation of the AMH concentration with age, even in prepubertal girls, suggests that AMH expression is unrelated to menstrual cycle FSH cyclicity.

Coccidioidomycosis with cerebral and cerebellar granulomas

We discuss the diagnosis, treatment and prognosis of a Danish male with disseminated coccidioidomycosis. He presented with headaches and slight fever. Examination showed pulmonary, cutaneous and cerebral and cerebellar granulomas, a rare complication. He was treated with intravenously and subsequently orally administered fluconazole. Symptoms and clinical findings regressed during treatment.

Biochemical pregnancy after fertilization of an oocyte aspirated from a heterotopic autotransplant of cryopreserved ovarian tissue: Case Report

Autotransplantation of frozen/thawed ovarian tissue in women undergoing cancer therapy has so far led to the birth of two healthy babies. In both cases, it can be discussed whether the fertilized oocyte originated from the transplant or from the native ovary. We now present a biochemical pregnancy achieved after heterotopical autotransplantation of cryopreserved ovarian cortical tissue and hence the unquestionable proof that pregnancy can occur after transplantation of cryopreserved ovarian tissue. A woman diagnosed with Hodgkin's lymphoma had ovarian tissue cryopreserved at the age of 28, before receiving chemotherapy and radiation therapy that rendered her amenorrhoeic. After complete remission, she had autotransplantation of ovarian tissue to the remaining ovary, to the right pelvic wall and to a midline subperitoneal pocket on the lower abdominal wall. The transplanted tissue resumed hormone secretion and follicles developed in all three locations. Three times during 8 months, when follicles could not be visualized in other locations, oocytes were aspirated from the subperitoneal autotransplanted tissue on the lower abdominal wall. Twice, an oocyte was retrieved, fertilized by intracytoplasmatic sperm injection (ICSI) and transferred to the woman's uterus. One of the treatments resulted in a positive pregnancy test 14 days after transfer. Clinical pregnancy, however, was not achieved. In conclusion, heterotopic autotransplantation of cryopreserved ovarian tissue can sustain follicle development. The oocytes of aspirated mature follicles are capable of fertilization after ICSI, and the resulting embryo is competent of producing hCG at detectable levels.

Prevention of injuries in young female players in European team handball. A prospective intervention study

Young female players in European handball have a very high injury incidence, up to 50 injuries per 1000 hours of game. More than half of these injuries happen without any external cause. The aim of the study was to investigate the effect of an intervention programme designed to reduce the number of injuries in young female players in European handball, with special emphasis on injuries in the lower extremities. The programme was created using elite athlete training programmes and those designed for rehabilitation of injured athletes with functional instability of their ankles and rupture of the anterior cruciate ligament. It included the use of an ankle disk for 10-15 min at all practice sessions, for one 10-month season (August 1995-May 1996). Twenty-two teams participated in the study, and were randomly assigned to the intervention or control group. Eleven teams with 111 players were randomised to the intervention group and 11 teams with 126 players to the control group. Data were analysed using a t-test for continuous variables, chi2-analysis and Fisher's exact test for dichotomous variables and multivariate methods to determine odds-ratios. The results indicated that using the intervention programme decreased the numbers of both traumatic and overuse injuries significantly. The differences in injuries between the groups were 80% during games and 71% during practice. In addition, the players in the control group had a 5.9 times higher risk of acquiring an injury than the players in the intervention group.

Injuries in young female players in European team handball

The purpose of this study was to examine the nature, extent and severity of sports injuries in young female players in European team handball and to identify the etiological factors involved in the injuries. Twenty-two teams with 217 players, aged 16-18 years, participated in the study. A very high injury incidence during games was observed, with 40.7 injuries/1000 hours of game. Backplayers had the highest incidence (54.8/1000 hours), which is five times higher than any previously recorded injury incidence in players in European team handball. We found that 92.9% of injuries were traumatic and 7.1% were from overuse. One-hundred and twenty-four of the 211 injuries were traumatic injuries of the lower extremities. Of these 63 (51%) were without contact with an opponent. The study confirmed that European team handball is a sport that has a very high injury rate, especially regarding young female players. Field position and earlier injuries are major risk factors, with an earlier injury being the single highest risk factor and with backplayers having a significantly higher number of injuries than players in other field positions.

Inhibition of human immunodeficiency virus type 1 infectivity by secretory leukocyte protease inhibitor occurs prior to viral reverse transcription

Infection of monocytes with human immunodeficiency virus type 1(Ba-L) (HIV-1(Ba-L)) is significantly inhibited by treatment with the serine protease inhibitor, secretory leukocyte protease inhibitor (SLPI). SLPI does not appear to act on virus directly, but rather the inhibitory activity is most likely due to interaction with the host cell. The current study was initiated to investigate how SLPI interacts with monocytes to inhibit infection. SLPI was found to bind to monocytes with high affinity to a single class of receptor sites (approximately 7,000 receptors per monocyte, K(D) = 3.6 nmol/L). The putative SLPI receptor was identified as a surface protein with a molecular weight of 55 +/- 5 kD. A well-characterized function of SLPI is inhibition of neutrophil elastase and cathepsin G. However, two SLPI mutants (or muteins) that contain single amino acid substitutions and exhibit greatly reduced protease inhibitory activity still bound to monocytes and retained anti-HIV-1 activity. SLPI consists of two domains, of which the C-terminal domain contains the protease inhibiting region. However, when tested independently, neither domain had potent anti-HIV-1 activity. SLPI binding neither prevented virus binding to monocytes nor attenuated the infectivity of any virus progeny that escaped inhibition by SLPI. A polymerase chain reaction (PCR)-based assay for newly generated viral DNA demonstrated that SLPI blocks at or before viral DNA synthesis. Therefore, it most likely inhibits a step of viral infection that occurs after virus binding but before reverse transcription. Taken together, the unique antiviral activity of SLPI, which may be independent of its previously characterized antiprotease activity, appears to reside in disruption of the viral infection process soon after virus binding.

Solution conformation of the extracellular domain of the human tumor necrosis factor receptor probed by Raman and UV-resonance Raman spectroscopy: structural effects of an engineered PEG linker

The solution structure of the Escherichia coli-expressed extracellular domain, residues 12-172, of the human 55 kDa type I tumor necrosis factor receptor (TNFR) has been probed by Raman (514.5 nm) and ultraviolet-resonance Raman (244 nm) excitations. The Raman spectra have been collected from both the free TNFR domain and an engineered "dumbbell-like" derivative, consisting of two mutant receptor moieties linked by a 20 kDa polyethylene glycol (PEG) tether. The results demonstrate a TNFR secondary structure which is rich in beta-sheet and deficient in alpha-helix, consistent with the reported X-ray crystal structure of baculovirus expressed receptor complexed with factor beta [Banner, D. W., D'Arcy, A., Janes, W., Gentz, R., Schoenfeld, H.-J., Broger, C., Loetscher, H., & Lesslauer, W. (1993) Cell 73, 431-445]. Conversely, the solution structure of TNFR differs from the crystal structure in its distribution of disulfide rotamers and in the orientation of its unique indole side chain (tryptophan-107). These differences are attributed, respectively, to N-terminal truncation and factor binding in the TNFR crystal structure. The tryptophan configuration, which is easily monitored in both Raman and UVRR spectra, is proposed as a potential signal of receptor/factor recognition and binding. Application of the Raman probes to the engineered TNFR dumbbell, which is of interest as a potential therapeutic, shows that TNFR moieties of the dumbbell exhibit secondary structures and side chain environments which are indistinguishable from those of the native, wild-type moiety. The results suggest that the PEGylated dumbbell may function as an effective TNFR drug delivery system without the consequence of a deleterious antigenic response.

Potent inhibitory effects of glial derived neurotrophic factor against kainic acid mediated seizures in the rat

Recently messenger RNA (mRNA) for glial derived neurotrophic factor (GDNF), a recently discovered member of the TGF-beta superfamily, was shown to increase in the hippocampus after kainic acid-induced seizures. The possibility that exogenous recombinant human (rh) GDNF may have anticonvulsant properties was investigated using a model of temporal lobe epilepsy in the rat. rhGDNF, vehicle or inactive rhGDNF were injected intracerebroventricularly 1 h before peripheral administration of kainic acid. rhGDNF suppressed kainic acid-induced tonic-clonic convulsions when compared to animals treated with vehicle or inactive rhGDNF. The inhibition of kainic acid-induced seizure activity by rhGDNF also prevented the associated neuronal cell loss in hippocampal, thalamic and amygdaloid regions. These results suggest that rhGDNF should be evaluated in other seizure and acute neural disorders that are associated with excitotoxic processes.