Automated data analysis of unstructured grey literature in health research: A mapping review

The amount of grey literature and 'softer' intelligence from social media or websites is vast. Given the long lead-times of producing high-quality peer-reviewed health information, this is causing a demand for new ways to provide prompt input for secondary research. To our knowledge, this is the first review of automated data extraction methods or tools for health-related grey literature and soft data, with a focus on (semi)automating horizon scans, health technology assessments (HTA), evidence maps, or other literature reviews. We searched six databases to cover both health- and computer-science literature. After deduplication, 10% of the search results were screened by two reviewers, the remainder was single-screened up to an estimated 95% sensitivity; screening was stopped early after screening an additional 1000 results with no new includes. All full texts were retrieved, screened, and extracted by a single reviewer and 10% were checked in duplicate. We included 84 papers covering automation for health-related social media, internet fora, news, patents, government agencies and charities, or trial registers. From each paper, we extracted data about important functionalities for users of the tool or method; information about the level of support and reliability; and about practical challenges and research gaps. Poor availability of code, data, and usable tools leads to low transparency regarding performance and duplication of work. Financial implications, scalability, integration into downstream workflows, and meaningful evaluations should be carefully planned before starting to develop a tool, given the vast amounts of data and opportunities those tools offer to expedite research.

A narrative review of recent tools and innovations toward automating living systematic reviews and evidence syntheses

Living reviews are an increasingly popular research paradigm. The purpose of a 'living' approach is to allow rapid collation, appraisal and synthesis of evolving evidence on an important research topic, enabling timely influence on patient care and public health policy. However, living reviews are time- and resource-intensive. The accumulation of new evidence and the possibility of developments within the review's research topic can introduce unique challenges into the living review workflow. To investigate the potential of software tools to support living systematic or rapid reviews, we present a narrative review informed by an examination of tools contained on the Systematic Review Toolbox website. We identified 11 tools with relevant functionalities and discuss the important features of these tools with respect to different steps of the living review workflow. Four tools (NestedKnowledge, SWIFT-ActiveScreener, DistillerSR, EPPI-Reviewer) covered multiple, successive steps of the review process, and the remaining tools addressed specific components of the workflow, including scoping and protocol formulation, reference retrieval, automated data extraction, write-up and dissemination of data. We identify several ways in which living reviews can be made more efficient and practical. Most of these focus on general workflow management, or automation through artificial intelligence and machine-learning, in the screening process. More sophisticated uses of automation mostly target living rapid reviews to increase the speed of production or evidence maps to broaden the scope of the map. We use a case study to highlight some of the barriers and challenges to incorporating tools into the living review workflow and processes. These include increased workload, the need for organisation, ensuring timely dissemination and challenges related to the development of bespoke automation tools to facilitate the review process. We describe how current end-user tools address these challenges, and which knowledge gaps remain that could be addressed by future tool development. Dedicated web presences for automatic dissemination of in-progress evidence updates, rather than solely relying on peer-reviewed journal publications, help to make the effort of a living evidence synthesis worthwhile. Despite offering basic living review functionalities, existing end-user tools could be further developed to be interoperable with other tools to support multiple workflow steps seamlessly, to address broader automatic evidence retrieval from a larger variety of sources, and to improve dissemination of evidence between review updates.

'You're never pregnant in the same way again': prior early pregnancy loss influences need for health care and support in subsequent pregnancy

STUDY QUESTION

What are couples' needs for health care and support in a subsequent pregnancy after prior early pregnancy loss (PL) and how do needs change across the pregnancy?

SUMMARY ANSWER

Couples described unmet needs for pregnancy care in the first 20 weeks of pregnancy and were more satisfied with the care provided during the remainder of the pregnancy.

WHAT IS KNOWN ALREADY

Despite early PL being common (∼25% of pregnancies), there is a paucity of research to guide practice to optimize treatment and support future pregnancies. There has been low priority for the issue in research and a pervasive acceptance that couples should 'just try again' after experiencing PL. Women with prior PL report increased anxiety during the first trimester of pregnancy compared to those without previous PL. No longitudinal studies explore what couples' needs are throughout the pregnancy and how these needs shift across time.

STUDY DESIGN SIZE DURATION

This was a qualitative longitudinal dyadic (joint) interview study. In total, 15 couples who were pregnant after a prior PL were interviewed four times over their pregnancy. Couples were recruited from the Copenhagen Pregnancy Loss Cohort Research Programme. Interviews were held in person at the hospital or university, or online. Interviews ranged from 20 to 91 min (mean = 54 min).

PARTICIPANTS/MATERIALS SETTING METHODS

Inclusion criteria included couples with one to two prior early PL(s) who self-reported a new pregnancy and were willing to be interviewed together and in English. Couples were interviewed four times: after a positive pregnancy test and once in each trimester. Interviews were transcribed and data were analysed using thematic analysis to compare and contrast needs of the couples at each of the four time periods in the pregnancy and across the entire pregnancy. One same-sex couple and 14 heterosexual couples participated.

MAIN RESULTS AND THE ROLE OF CHANCE

Couples' needs were categorized into two main longitudinal themes across the pregnancy, divided by the 20-week scan. Within each longitudinal theme, there were two themes to represent each time period. In the longitudinal theme 'The first 20 weeks: a 'scary' gap in care' there were two themes: Positive pregnancy test: 'Tell them it's not the same pregnancy' and First trimester: 'We craved that someone was taking care of us'. The standard pregnancy care offered in the public healthcare system in Denmark includes a scan at 12 and 20 weeks. While all couples wished for additional access to scans and monitoring of the foetus in early pregnancy to provide reassurance and detect problems early, they described considerable variation in the referrals and care they were offered. Both partners expressed a high degree of worry and anxiety about the pregnancy, with pregnant women in particular describing 'surviv[ing] from scan to scan' in the early weeks. Couples took scans wherever offered or paid for comfort scans, but this resulted in fragmented care. Instead, they wished for continuity in care, and acknowledgement and sensitivity that a pregnancy after PL is not the same as a first pregnancy. In the longitudinal theme 'The second 20 weeks: Safety in the care system' there were two themes: Second trimester: 'I think we are in good hands' and Third trimester: 'It's more of a 'nice to know' everything is OK than a 'need to know'. Couples reported their distress was lower and overall needs for care were met during this time. They expressed general satisfaction with regular or extended antenatal support although, as in the first 20 weeks, additional acknowledgement and sensitivity regarding their history of PL was desired. Couples said they felt more secure given that they had access to a 24-hour telephone support by midwife/nurse if they had any concerns or questions.

LIMITATIONS REASONS FOR CAUTION

Participants were self-selected from an ongoing cohort study of patients presenting at hospital with PL. Single women were not included in the study. This study was limited to data collection in Denmark; however, other countries with public healthcare systems may have similar offerings with regard to their provision of antenatal care, care provided in recurrent pregnancy loss (RPL) clinics and the availability of private scans.

WIDER IMPLICATIONS OF THE FINDINGS

The findings underscore that an early PL creates an increased need for monitoring and care in a subsequent pregnancy. This study highlights a gap in pregnancy care for those with a history of PL given that their need for monitoring and support is high in the early weeks of a new pregnancy before they have access to antenatal care, and before they have had multiple PLs and can be referred to the RPL unit.

STUDY FUNDING/COMPETING INTERESTS

This project has received funding from the European Union's Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement No 101028172 for E.K. The Copenhagen Pregnancy Loss Cohort is funded by a grant from the BioInnovation Institute Foundation. H.S.N. has received scientific grants from Freya Biosciences, Ferring Pharmaceuticals, BioInnovation Institute, Ministry of Education, Novo Nordisk Foundation, Augustinus Fonden, Oda og Hans Svenningsens Fond, Demant Fonden, Ole Kirks Fond, and Independent Research Fund Denmark. H.S.N. received personal payment or honoraria for lectures and presentations from Ferring Pharmaceuticals, Merck, Astra Zeneca, Cook Medical, Gedeon Richter, and Ibsa Nordic. All other authors declare no competing interests.

Anti-inflammatory IL-8 Regulation via an Advanced Drug Delivery System at the Oral Mucosa

Oral inflammatory diseases are highly prevalent in the worldwide population. Topical treatment of inflammation is challenging due to dilution effects of saliva and crevicular fluid. Thus, there is a great medical need to develop smart anti-inflammatory drug delivery systems for mucosa treatment. We compared two promising anti-inflammatory dendritic poly(glycerol-caprolactone) sulfate (dPGS-PCL) polymers for their applicability to the oral mucosa. Using an ex vivo porcine tissue model, cell monolayers, and full-thickness 3D oral mucosal organoids, the polymers were evaluated for muco-adhesion, penetration, and anti-inflammatory properties. The biodegradable dPGS-PCL₉₇ polymers adhered to and penetrated the masticatory mucosa within seconds. No effects on metabolic activity and cell proliferation were found. dPGS-PCL₉₇ revealed a significant downregulation of pro-inflammatory cytokines with a clear preference for IL-8 in cell monolayers and mucosal organoids. Thus, dPGS-PCL₉₇ exhibits excellent properties for topical anti-inflammatory therapy, suggesting new therapeutic avenues in the treatment of oral inflammatory diseases.

SARS-CoV-2 Infection and the Risk of Suicidal and Self-Harm Thoughts and Behaviour: A Systematic Review

OBJECTIVE

The COVID-19 pandemic has had a complex impact on risks of suicide and non-fatal self-harm worldwide with some evidence of increased risk in specific populations including women, young people, and people from ethnic minority backgrounds. This review aims to systematically address whether SARS-CoV-2 infection and/or COVID-19 disease confer elevated risk directly.

METHOD

As part of a larger Living Systematic Review examining self-harm and suicide during the pandemic, automated daily searches using a broad list of keywords were performed on a comprehensive set of databases with data from relevant articles published between January 1, 2020 and July 18, 2021. Eligibility criteria for our present review included studies investigating suicide and/or self-harm in people infected with SARS-CoV-2 with or without manifestations of COVID-19 disease with a comparator group who did not have infection or disease. Suicidal and self-harm thoughts and behaviour (STBs) were outcomes of interest. Studies were excluded if they reported data for people who only had potential infection/disease without a confirmed exposure, clinical/molecular diagnosis or self-report of a positive SARS-CoV-2 test result. Studies of news reports, treatment studies, and ecological studies examining rates of both SARS-CoV-2 infections and suicide/self-harm rates across a region were also excluded.

RESULTS

We identified 12 studies examining STBs in nine distinct samples of people with SARS-CoV-2. These studies, which investigated STBs in the general population and in subpopulations, including healthcare workers, generally found positive associations between SARS-CoV-2 infection and/or COVID-19 disease and subsequent suicidal/self-harm thoughts and suicidal/self-harm behaviour.

CONCLUSIONS

This review identified some evidence that infection with SARS-CoV-2 and/or COVID-19 disease may be associated with increased risks for suicidal and self-harm thoughts and behaviours but a causal link cannot be inferred. Further research with longer follow-up periods is required to confirm these findings and to establish whether these associations are causal.

Online information seeking and attitudes towards COVID-19 vaccination in Germany

Background

A large proportion of the European population seeks information about the COVID-19 vaccination on the internet. The population seems to split into those with positive stance on the vaccination and those with negative stance, but there are still individuals who do not have a final position yet. By now, there is a lack of understanding about the online information seeking behavior in these three groups. The current analysis sheds light on differences in internet usage and requested qualities of online information regarding the COVID-19 vaccination.

Methods

An online survey with N = 1,000 people (18-74 years) living in Germany was conducted between November 26 and December 8, 2021. The questionnaire included closed questions about frequency, information channels, formats and reasons of online information seeking, as well as one open question about requested qualities of online content. We conducted bivariate analysis for differences in information seeking behavior and content analysis for the requests.

Results

Information seeking behavior differed significantly by attitude towards the vaccination regarding frequency, almost all types of formats, three of ten listed information channels, and three of six reasons for online information seeking. Undecided participants and those who support COVID-19 vaccination used the internet more often than participants who are against the vaccination. Individuals supporting vaccination preferred reading text contributions (e.g. online articles). Informative videos were more often consumed by those who are undecided or against vaccination. Those who have not decided yet preferred online resources providing full information about side-effects and showing reliable facts by credible sources.

Conclusions

Our findings support an online vaccination communication that is tailored to target groups with different attitudes towards the vaccination. Overall, online campaigns should focus on transparent, reliable and complete information.

Key messages

• Online information seeking behavior regarding COVID-19 vaccination varies between individuals with different attitudes towards the vaccination.

• Online information about the COVID-19 vaccination should focus on transparency and reliable information.

The impact of the COVID-19 pandemic on presentations to health services following self-harm: systematic review

BACKGROUND

Evidence on the impact of the pandemic on healthcare presentations for self-harm has accumulated rapidly. However, existing reviews do not include studies published beyond 2020.

AIMS

To systematically review evidence on presentations to health services following self-harm during the COVID-19 pandemic.

METHOD

A comprehensive search of databases (WHO COVID-19 database; Medline; medRxiv; Scopus; PsyRxiv; SocArXiv; bioRxiv; COVID-19 Open Research Dataset, PubMed) was conducted. Studies published from 1 January 2020 to 7 September 2021 were included. Study quality was assessed with a critical appraisal tool.

RESULTS

Fifty-one studies were included: 57% (29/51) were rated as 'low' quality, 31% (16/51) as 'moderate' and 12% (6/51) as 'high-moderate'. Most evidence (84%, 43/51) was from high-income countries. A total of 47% (24/51) of studies reported reductions in presentation frequency, including all six rated as high-moderate quality, which reported reductions of 17-56%. Settings treating higher lethality self-harm were overrepresented among studies reporting increased demand. Two of the three higher-quality studies including study observation months from 2021 reported reductions in self-harm presentations. Evidence from 2021 suggests increased numbers of presentations among adolescents, particularly girls.

CONCLUSIONS

Sustained reductions in numbers of self-harm presentations were seen into the first half of 2021, although this evidence is based on a relatively small number of higher-quality studies. Evidence from low- and middle-income countries is lacking. Increased numbers of presentations among adolescents, particularly girls, into 2021 is concerning. Findings may reflect changes in thresholds for help-seeking, use of alternative sources of support and variable effects of the pandemic across groups.

P03.09.A Proton beam therapy for adults medullobastoma

Background

Although Medulloblastoma (MB) is the most common primary malignant intracranial tumor in childhood, in adults it is extremely rare. Therefore, available data is scarce and experience with radiation and proton beam therapy (PBT) is very limited. The treatment typically includes tumour resection, irradiation of the craniospinal axis (CSI) followed by a boost, +/- concomitant chemotherapy, and maintenance therapy. Herein, we present our preliminary analysis of outcome and toxicity after PBT.

Material and Methods

Patients ≥ 18 years with primary MB treated with PBT between January 2017 and March 2020 enrolled in the prospective registry study (DRKS00004384) were evaluated in this analysis. Within the registry, adverse events were documented according to CTCAE v4.0 before, during, and after PT. The overall survival (OS), local control (LC) and higher-grade toxicity (≥ grade 3) were analyzed.

Results

A total of 19 patients (13 males, 6 females) with a median age of 23 years (range, 18.5- 39 years) were included in this study. Histopathology type were classic, desmoplastic /extensive nodularity or anaplastic MB in 52.6%, 26.3% and 21.1 % of patients, respectively. Complete tumor resection was performed in 57.8 % of patients. 68.4 % of patients had local disease without any metastases. Median total CSI dose was 35.2 Gy(RBE) (range, 23.4-40 Gy) with a median single dose of 1.6 Gy(RBE) (range, 1-1.8 Gy). All patients received either boost to the posterior fossa (57.9%) or to the tumor bed only (42.1%). The median total tumor dose was 18.8 Gy(RBE) (range, 54-68 Gy). Concomitant chemotherapy was given to 63.1% of patients. The median follow-up time after first diagnosis was 28.2 months (range, 8-56 months). No higher-grade acute or late adverse event was documented so far. One patient developed local disease progression. Another patient deceased due to an acute pulmonary embolism during maintenance chemotherapy without evidence of disease. The 3-year LC and OS rate were 89 % and 94 %, respectively.

Conclusion

Early results display good feasibility and high tumor control of PT in adult patient with MB. Results will need to be confirmed in larger cohort with longer follow-up time.<Bookmark(28)>

Counting the cost of public and philanthropic R&D funding: the case of olaparib

Background

Lack of transparency around manufacturing costs, who bears the bulk of research and development costs and how total costs relate to the pricing of products, continue to fuel debates. This paper considers the case of olaparib (Lynparza®), recently indicated for use among BRCA-mutant breast cancer patients, and estimates the extent of public and philanthropic R&D funding.

Methods

We know from previous work that attempting to ascertain the amount of public and philanthropic funding using purely bibliographic sources (i.e., authors’ declarations of funding sources and amounts traced through funders) is limited. Since we knew that a publically funded research unit was pivotal in developing olaparib, we decided to supplement bibliographic data with a Freedom of Information request for administrative records on research funding data from this research centre.

Research

In terms of stages of product development, work conducted in the pre-clinical research stage was the most likely to report non-industry funding (> 90% of pre-clinical projects received public or philanthropic funding). Clinical trials were least likely to be funded through non-industry sources—although even here, contrary to the popular assertion that this is wholly industry-financed, we found public or philanthropic funding declared by 23% of clinical trials. Using information reported in the publications, we identified approximately £128 million of public and philanthropic funding that may have contributed to the development of olaparib. However, this amount was less than one-third of the total amount received by one research institute playing a pivotal role in product discovery. The Institute of Cancer Research reported receiving 38 funding awards to support olaparib work for BRCA-mutant breast cancer totalling over £400 million.

Conclusions

Government or charitable funding of pharmaceutical product development is difficult to trace using publicly available sources, due to incomplete information provided by authors and/or a lack of consistency in funding information made available by funders. This study has shown that a Freedom of Information request, in countries where such requests are supported, can provide information to help build the picture of financial support. In the example of olaparib, the funding amounts directly reported considerably exceeded amounts that could be ascertained using publically available bibliographic sources.

P-497 Men’s attitude towards two fertility education interventions and preferences for future fertility awareness initiatives

Study question

What are men's preferences for communication of fertility information and how to target prevention efforts to promote men to make informed decisions regarding family formation?

Summary answer

Men preferred fertility education interventions to use positive language to create new knowledge, include personal stories as conversation starters, and be provided in different formats.

What is known already

The far majority of men in Denmark wants to become fathers; however, 20% of 50-year-old men are childless compared to 12% among women. Around 40% of men in Denmark have reduced semen quality. Previous studies have found that men have insufficient knowledge about fertility, infertility and associated risk factors, and that men want to receive more information about fertility when they are young. Only few intervention studies have been performed about how to increase men’s and women’s fertility knowledge, and even fewer studies have focused only on men.

Study design, size, duration

Qualitative focus group discussions with 13 men assigned into five focus groups were carried out. Two interventions were introduced; an episode from the podcast “Actually you don’t have to wait that long” about two couples who have become parents in their mid-twenties, and an informational poster developed by The International Fertility Education Initiative was shown during the group discussions. The interviews took place online over Zoom in January 2021. Interviews ranged in average 91 minutes.

Participants/materials, setting, methods

All participants were recruited through Facebook and social networks. The interviewed men were young, childless aged 25-32 in a committed relationship and all residents in Copenhagen, Denmark. Focus group questions were semi-structured and examined the men’s reactions to the podcast and poster and preferences for communication of fertility information. The focus group discussions were recorded, anonymized and transcribed. Data were analyzed using Graneheim and Lundman's method of qualitative content analysis.

Main results and the role of chance

The overall themes were: “Poster: source of information”, “Podcast: report from the lived life” and “Information targeting men”. The men’s reactions to the poster and podcast were categorized into the sub-themes benefits and critiques and suggestions. Benefits of the poster was that it included important knowledge and was relevant to a large target group. Critiques were that it had too much information and lacked the emotional aspect of family formation. They wished for more positive languaging and communication about the fertility information on the poster. The benefit of the podcast was the use of personal stories to highlight the emotional aspect of family formation which was a conversation starter for partners. Critiques were that some men found the personal stories unrelatable and believed it didn’t contribute new knowledge. They suggested to include couples with fertility problems with an expert. According to men, future interventions should focus on how information is communicated. It should be factual, include humor and not be negative or shameful. Different formats to provide fertility information including TV-programs, podcasts, and social media interventions should be used to reach the most men in different ways. They also suggested fertility information should be included in sexual education in school.

Limitations, reasons for caution

All men were residents of the capital city Copenhagen, and men with a short education were underrepresented. Therefore, our results may not represent the opinions of all men aged 25-32 years in Denmark.

Wider implications of the findings

In the future fertility awareness campaigns should be developed in cooperation with the target group together with clinicians, and concurrent intervention studies on the developed methods should be performed. In all probability, a mix of different interventions will be necessary to attain the desired effect to ensure long-lasting fertility awareness.

Trial registration number

Not applicable

O-143 “You’re never pregnant in the same way again”: Prior early pregnancy loss influences needs for health care and support in subsequent pregnancy

Study question

What are couples’ needs for health care and support in subsequent pregnancy after prior early pregnancy loss and do these needs change across the pregnancy?

Summary answer

Couples described unmet needs for pregnancy care in the first 20 weeks of pregnancy and were satisfied with care provided the remainder of the pregnancy. 

What is known already

Despite early pregnancy loss (PL) being common (∼25% of pregnancies), there is a paucity of research to guide practice to optimize treatment and support future pregnancies. There has been low priority in research and pervasive acceptance that couples should “just try again” after experiencing PL.  However, the notion that PL is a single event without wider implications has been challenged. Women with prior PL report increased anxiety during the first trimester of pregnancy compared to those without previous PL. No longitudinal studies explore whether anxiety persists across trimesters, how partners are impacted, and what couples' needs are throughout the pregnancy.

Study design, size, duration

This was a qualitative longitudinal study. During first year of data collection, 13 couples who were pregnant after a prior pregnancy loss were interviewed four times over their pregnancy. Couples were recruited from the Copenhagen Pregnancy Loss Research Programme at Hvidovre Hospital, Denmark. Interviews were held in person at the hospital or university or online. Interviews ranged from 20 to 90 minutes (average= 52 min). Data collection is ongoing and full data will be presented.

Participants/materials, setting, methods

Couples with at least one prior pregnancy loss who self-reported a new pregnancy and were willing to be interviewed together and in English were eligible to participate. Couples were interviewed together after a positive pregnancy test and once in each trimester. Interviews were transcribed and data was analyzed using thematic analysis to compare and contrast needs and experiences within and across the four time-periods. One same-sex couple and 12 heterosexual couples participated.

Main results and the role of chance

Couples’ needs were categorized into two themes:

The first 20 weeks: high needs for pregnancy care with low/varied access: Couples wished for access to regular scans and close monitoring of the fetus to provide reassurance and detect problems early, but described considerable variation in the early pregnancy care offered, with many expressing unmet needs. Their need was more acute during the first 12 weeks, but persisted until the 20-week scan. Women described “surviving from scan to scan” with anxiety and fear about the safety of the fetus.  Some paid for private comfort scans if they did not have access. Both partners continued to process the grief and self-described “trauma” of the prior pregnancy loss and wished for psychological support during this period.

The second 20 weeks: met needs for pregnancy care with high access: Couples expressed satisfaction with care including access to regular or extended antenatal support, access to 24 hour telephone support by midwife/nurse, and confirmation of good health at 20 week scan. They felt reassured there was some plan for their care. They felt more hopeful and shifted their focus to the current pregnancy and future birth, especially given increasing “signs of life” whilst the baby started to kick.

Limitations, reasons for caution

Participants were self-selected thus findings cannot be generalized to all pregnant couples after early pregnancy loss. Single women were not included in the study.

Wider implications of the findings

The findings underscore that an early pregnancy loss is not a single event without wider implications, but rather creates vulnerability and increased need for monitoring and care in a subsequent pregnancy, which in many cases is not met by existing early pregnancy care.

Trial registration number

No

P-500 How do we talk to teenagers and young adults about fertility? A qualitative study on young peoples’ thoughts about fertility

Study question

What are teenagers and young adults’ attitudes towards learning about fertility, and how do they want to receive fertility information?

Summary answer

Young people find it important to learn about fertility from professionals when they are young, and want to hear about fertility in a multifaceted way.

What is known already

During the past 30 years women and men in many high-income countries increasingly postpone family formation. It is estimated that 16-26% of the Danish population who want children will experience infertility at some point during their reproductive years. Several studies have shown that women and men tend to underestimate the decline in fecundity with increasing age and overestimate the success rate of medically assisted reproductive technologies. A growing body of research suggests that young people want to know more about fertility, preferably as part of their education.

Study design, size, duration

Semi-structured qualitative focus group interviews were conducted with teenagers (age 18-19) and young adults (age 20-26). Data collection is still ongoing.

Participants/materials, setting, methods

The study participants (N = 40) were single or cohabiting men and women throughout Denmark. They were between 18 to 26 years old and recruited from both vocational schools and high schools. The interviews were audiotaped, anonymized and transcribed in full. Data were analyzed using qualitative content analysis following the method by Graneheim and Lundman.

Main results and the role of chance

Overall the participants found it very important to learn about fertility as a mandatory part of the curriculum at their educations and they wanted to hear about it in a multifaceted way (e.g., social media, podcasts, theatre and personal stories). The participants want to learn about fertility at an early age, so they have the information they need prior to starting their family in the future. They want to feel involved and heard and have the possibility to ask questions. Knowledge should be provided by a professional other than their teacher. They prefer explanations, rather than listing facts. The participants stressed that personal stories and humor are also important when talking with young people about fertility. They feel a conflict between having a healthy lifestyle to take care of their fertility and the behaviour that they believe is a part of being young.

Limitations, reasons for caution

The study participants had all chosen to be a part of this study. Hence, the results may not be directly transferred to all young people in regard to attitudes towards how to talk to teenagers and young adults about fertility.

Wider implications of the findings

This study contributes to the understanding and implementation of future fertility awareness educational interventions and campaigns targeted to and effective among young people. These findings can be useful in the process of increasing the fertility awareness in this population.

Trial registration number

N/A

Multiplexed apolipoprotein profiling advances the assessment of residual lipid-related cardiovascular risk

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation

Background and Purpose

Low-density lipoprotein cholesterol (LDL-C) is among the conventional lipid parameters used to predict risk of cardiovascular disease (CVD). Statins lower blood levels of pro-atherogenic LDL-C, but a residual cardiovascular risk remains in some individuals with therapeutically optimised LDL-C levels. Although the metabolism of LDL-C and other lipoprotein particles is governed by a range of different apolipoproteins, only apolipoproteins A-I and B are measured in clinical assays. Using a more comprehensive apolipoprotein panel in a large epidemiological cohort, this study aimed to determine the association of individual apolipoprotein levels with risk of coronary heart disease (CHD).

Methods

Bottom-up multiple reaction monitoring–mass spectrometry (MRM–MS) was used in conjunction with stable isotope-labelled peptide standards to quantify plasma levels of 13 apolipoproteins in participants of the Precocious Coronary Artery Disease (PROCARDIS) study (N = 1916; 941 cases of CHD, 975 controls). The relationship between apolipoprotein levels and CHD was assessed after adjusting for established risk factors for CVD and correcting for statin use.

Results

The strongest positive associations with CHD in the PROCARDIS study were seen for triglyceride-related apolipoproteins C-I (odds ratio [OR] 2.38, 95% confidence interval [CI] 1.63–3.46), C-III (OR 2.95, 95% CI 1.85–4.71) and E (OR 2.35, 95% CI 1.54–3.58), as well as for apolipoprotein (a) (kringle IV type 2 repeat, OR 2.84, 95% CI 2.04–3.95). Comparing these with associations of apolipoproteins with CVD in the Bruneck study (N = 688) revealed consistency across the two cohorts. Robust inverse associations with CHD were observed for apolipoproteins A-IV (OR 0.45, 95% CI 0.31–0.65) and M (OR 0.29, 95% CI 0.19–0.44).

Conclusion

Analysing two large epidemiological cohorts, Bruneck and PROCARDIS, demonstrated that multiplexed apolipoprotein profiling improves the understanding of cardiovascular risk independent of conventional lipid parameters. Most prominently, triglyceride-related apolipoproteins were shown to positively associate with residual cardiovascular risk. The findings of this study support the need for development and implementation of standardised, MRM–MS-based apolipoprotein profiling assays to guide novel lipid-modifying therapies beyond statins.

A proteomic atlas of atherosclerosis: regional proteomic signatures for plaque inflammation and calcification

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): This study was mainly supported from the British Heart Foundation (BHF) supporting Prof. Manuel Mayr as a Chair Holder (CH/16/3/32406) with BHF programme grant support (RG/16/14/32397) and Dr. Theofilatos with BHF programm grant support (G/20/10387).

Background

Using proteomics, we strove to reveal novel molecular subtypes of human atherosclerotic lesions, study their associations with histology and imaging and relate them to long-term cardiovascular outcomes.

Methods

219 samples were obtained from 120 patients undergoing carotid endarterectomy. Sequential protein extraction was combined with multiplexed, discovery proteomics. Parallel reaction monitoring for 135 proteins was deployed for targeted validation. A combination of statistical, bioinformatics and machine learning methods was used to perform differential expression, network, pathway enrichment analysis and train and evaluate prognostic models.

Results

Our extensive proteomics analysis from the core and periphery of plaques doubled the coverage of the plaque proteome compared to the largest proteomics study on atherosclerosis thus far. Plaque inflammation and calcification signatures were inversely correlated and validated with targeted proteomics. The inflammation signature was enriched with neutrophil-derived proteins, including calprotectin (S100A8/9) and myeloperoxidase. The calcification signature contained fetuin-A, osteopontin, and gamma-carboxylated proteins. Sex differences in the proteome of atherosclerosis were explained by a higher proportion of calcified plaques in women. Single-cell RNA sequencing data attributed the inflammation signature predominantly to neutrophils and macrophages and the calcification signature to smooth muscle cells, except for certain plasma proteins that were not expressed but retained in the plaque, i.e., fetuin-A. Echogenic lesions reflect the collagen content and calcification of plaque but carotid Duplex ultrasound fails to capture the extent of inflammatory protein changes in symptomatic plaques. Applying dimensionality reduction and machine learning on the proteomics data defined 4 distinct plaque phenotypes and revealed key protein signatures linked to smooth muscle cell content, plaque calcification and structural extracellular matrix, which improved the 9-year prognostic AUC by 25% compared to ultrasound and histology. A biosignature of four proteins (CNN1, PROC, SERPH, and CSPG2) independently predicted the progression of atherosclerosis and cardiovascular mortality with an AUC of 75%

Conclusion

We combined discovery and targeted proteomics with network reconstruction and clustering techniques to provide molecular insights into protein changes in atherosclerotic plaques. The application of proteomics and machine learning techniques revealed distinct clusters of plaques that inform on disease progression and future adverse cardiovascular events.

Proteomics to assess myocardial remodelling in human heart failure and explore the effect of medications and comorbidities

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation

Background

Myocardial remodelling is a hallmark of heart failure (HF). Our previous proteomics analyses demonstrated a profound effect of beta blockers on cardiac extracellular matrix composition in ischaemic HF patients (1). No comprehensive proteomics characterizations has been performed in non-ischaemic HF patients.

Methods

Mass spectrometry was used to analyze intracellular and extracellular protein extracts from left ventricular samples obtained from patients with ischemic (n=65) and non-ischaemic (n=114) HF after heart transplantation, as well as non-failing controls (n=19). All HF patients had ventricular dilatation and reduced ejection fraction (EF%).

Results

The proteomics comparison across 198 cardiac samples with two tissue extracts revealed hallmarks of HF in both groups of patients compared to controls, including elevated levels of atrial natriuretric peptides and the fibroblast marker vimentin, as well as decreases in creatine kinase M/B, troponin C, and myosin light chain 2 (Figure 1). In comparison to ischaemic HF patients, non-ischaemic HF patients showed elevated levels of proteins involved in proteasome activation, consistent with the notion of increased protein degradation in cardiomyocytes even at the end stage of the disease (2). Despite similar clinical characteristics, myocardial remodelling in response to HF medications and the presence of comorbidities was different between the two HF groups. In ischaemic HF patients the use of β-blockers resulted in reduced proteoglycan deposition. In non-ischaemic patients, few protein changes were associated with medication. Instead, comorbidities such as atrial fibrillation and hypertension were critical determinants of myocardial protein remodelling in these HF patients (Figure 2). Notably, hypertensive HF patients showed a marked reduction in angiotensin converting enzyme 2 (ACE2) compared to normotensive patients, and this was accompanied by a reduction in Cysteine And Glycine Rich Protein 3 (CSRP3), a key player in the organization of cytosolic structures in cardiomyocytes, and the nuclear lamina proteins lamin A/C and B. The inflammation-related galectin 3-binding protein was reduced in hypertensive patients as were the extracellular proteases matrix metalloprotease 2, cathepsin G and chymase 1.

Conclusion

Our study constitutes the largest proteomics analysis of HF to date. We observed distinct protein remodelling processes in ischaemic and non-ischaemic HF patients and discerned the myocardial effects of medications and comorbidities such as hypertension.

Comparative secretome analysis of obese perivascular adipose tissue reveals impaired adipose-neuronal crosstalk

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): BHF Programme Grant (RG/16/14/32397)

VASCage-Research Center on Vascular Ageing and Stroke (No. 868624)

Background

While canonical adipose tissue (AT) depots have been extensively characterised in health and disease, comparatively little is known about the pathological changes affecting the perivascular AT’s (PVAT) physiology during obesity.

Purpose

The aim of this study was to study the impact of obesity on the secretory activity of the murine PVAT.

Methods

We exploited proteomics to profile the secretome of peri-aortic and canonical AT depots in wild-type (wt) and obese (ob/ob) mice. In parallel, fat tissues were processed for biochemical and histological analysis and mechanistical experiments were performed in vitro on primary neuronal cultures.

Results

Proteomics on ATs conditioned media from wt mice revealed that each fat depot displays a unique secretory profile. The enrichment of neuronal cell-adhesion molecules detected in PVAT secretomes reflected a higher content of intra-parenchymal sympathetic projections compared to non-perivascular ATs. A significant decrease of the same neuronal proteins in PVAT conditioned media from ob/ob mice was found to be associated with a substantial reduction of the perivascular sympathetic innervation. Intriguingly, a similar decrease of sympathetic markers was detected in the epicardial AT from obese patients. Mechanistically, the conditioned media from ob/ob AT explants was found to exert a deleterious effect on the axons of primary sympathetic neurons in vitro, indicating that this neuropathy is due to local alterations of the PVAT secretome that detrimentally impact on the embedded sympathetic neurites. Among proteins significantly down-regulated in the secretomes of ob/ob PVAT samples, neuronal growth regulator 1 (Negr1) was found to promote axonal elongation and branching on sympathetic neurons in vitro. Administration of recombinant Negr1 also partially restored the neurotrophic effect of ob/ob AT secretomes on sympathetic axons both in vitro and in vivo.

Conclusions

Obesity-related alterations in the secretome of PVAT severely affect the homeostasis of the perivascular environment, leading to a loss of perivascular sympathetic innervation. A novel neurotrophic role is unveiled for Negr1, whose locus has been associated with human obesity.

Suicide and self-harm in low- and middle- income countries during the COVID-19 pandemic: A systematic review

There is widespread concern over the potential impact of the COVID-19 pandemic on suicide and self-harm globally, particularly in low- and middle-income countries (LMIC) where the burden of these behaviours is greatest. We synthesised the evidence from the published literature on the impact of the pandemic on suicide and self-harm in LMIC. This review is nested within a living systematic review (PROSPERO ID CRD42020183326) that continuously identifies published evidence (all languages) through a comprehensive automated search of multiple databases (PubMed; Scopus; medRxiv, PsyArXiv; SocArXiv; bioRxiv; the WHO COVID-19 database; and the COVID-19 Open Research Dataset by Semantic Scholar (up to 11/2020), including data from Microsoft Academic, Elsevier, arXiv and PubMed Central.) All articles identified by the 4th August 2021 were screened. Papers reporting on data from a LMIC and presenting evidence on the impact of the pandemic on suicide or self-harm were included. Methodological quality was assessed using an appropriate tool, and a narrative synthesis presented. A total of 22 studies from LMIC were identified representing data from 12 countries. There was an absence of data from Africa, the Pacific, and the Caribbean. The reviewed studies mostly report on the early months of COVID-19 and were generally methodologically poor. Few studies directly assessed the impact of the pandemic. The most robust evidence, from time-series studies, indicate either a reduction or no change in suicide and self-harm behaviour. As LMIC continue to experience repeated waves of the virus and increased associated mortality, against a backdrop of vaccine inaccessibility and limited welfare support, continued efforts are needed to track the indirect impact of the pandemic on suicide and self-harm in these countries.

Diagnostic accuracy of 1p/19q codeletion tests in oligodendroglioma: A comprehensive meta-analysis based on a Cochrane systematic review

Codeletion of chromosomal arms 1p and 19q, in conjunction with a mutation in the isocitrate dehydrogenase 1 or 2 gene, is the molecular diagnostic criterion for oligodendroglioma, IDH mutant and 1p/19q codeleted. 1p/19q codeletion is a diagnostic marker and allows prognostication and prediction of the best drug response within IDH-mutant tumours. We performed a Cochrane review and simple economic analysis to establish the most sensitive, specific and cost-effective techniques for determining 1p/19q codeletion status. Fluorescent in situ hybridisation (FISH) and polymerase chain reaction (PCR)-based loss of heterozygosity (LOH) test methods were considered as reference standard. Most techniques (FISH, chromogenic in situ hybridisation [CISH], PCR, real-time PCR, multiplex ligation-dependent probe amplification [MLPA], single nucleotide polymorphism [SNP] array, comparative genomic hybridisation [CGH], array CGH, next-generation sequencing [NGS], mass spectrometry and NanoString) showed good sensitivity (few false negatives) for detection of 1p/19q codeletions in glioma, irrespective of whether FISH or PCR-based LOH was used as the reference standard. Both NGS and SNP array had a high specificity (fewer false positives) for 1p/19q codeletion when considered against FISH as the reference standard. Our findings suggest that G banding is not a suitable test for 1p/19q analysis. Within these limits, considering cost per diagnosis and using FISH as a reference, MLPA was marginally more cost-effective than other tests, although these economic analyses were limited by the range of available parameters, time horizon and data from multiple healthcare organisations.

Challenging T > MIC Using Meropenem vs. Escherichia coli and Pseudomonas aeruginosa

Objective: For meropenem 40%T > MIC is associated with optimal killing of P. aeruginosa and E. coli. However, it is unknown how the distribution of %T > MIC through a treatment day impacts the antimicrobial effect in vitro. Therefore, we investigated the in vitro antibiotic activity of meropenem, precisely if 40%T > MIC is achieved in one single long period (single dose), 2 × 20% periods (dosing-bid), or 3 × 13.3% (dosing t.i.d.) thereby keeping the overall period of T > MIC constant.

Material/Methods: Time kill curves (TKC) with P. aeruginosa-ATCC-27853 and E. coli-ATCC-25922 and five clinical isolates each were implemented over 24 h in CAMHB with concentrations from 0.25×MIC-32×MIC. Periods over and under MIC were simulated by centrifugation steps (discarding supernatant and refilling with fresh CAMHB). Double and triple dosing involved further addition and removal of antibiotic. Complementary growth controls (GC) with and without centrifugation steps were done and the emergence of phenotypical resistance was evaluated (repeated MIC-testing after antibiotic administration).

Results: No impact of centrifugation on bacterial growth was seen. TKC with P. aeruginosa showed the best killing in the triple dosage, followed by the double and single dose. In multiple regimens at least a concentration of 4×MIC was needed to achieve a recommended 2-3 log10 killing. Likewise, a reduction of E. coli was best within the three short periods. Contrary to the TKCs with P. aeruginosa we could observe that after the inoculum reached a certain CFU/mL (≥10^8), no further addition of antibiotic could achieve bacterial killing (identified as the inoculum effect). For P. aeruginosa isolates resistance appeared within all regimens, the most pronounced was found in the 40%T > MIC experiments indicating that a single long period might accelerate the emergence of resistance. Contrary, for E. coli no emergence of resistance was found.

Conclusion/Outlook: We could show that not solely the %T > MIC is decisive for an efficient bacterial eradication in vitro, but also the distribution of the selected %T > MIC. Thus, dividing the 40%T > MIC in three short periods requested lowers antibiotic concentrations to achieve efficient bacterial killing and reduces the emergence of resistance in P. aeruginosa isolates. The distribution of the %T > MIC did impact the bacterial eradication of susceptible pathogens in vitro and might play an even bigger role in infections with intermediate or resistant pathogens.

Diagnostic test accuracy and cost-effectiveness of tests for codeletion of chromosomal arms 1p and 19q in people with glioma

BACKGROUND

Complete deletion of both the short arm of chromosome 1 (1p) and the long arm of chromosome 19 (19q), known as 1p/19q codeletion, is a mutation that can occur in gliomas. It occurs in a type of glioma known as oligodendroglioma and its higher grade counterpart known as anaplastic oligodendroglioma. Detection of 1p/19q codeletion in gliomas is important because, together with another mutation in an enzyme known as isocitrate dehydrogenase, it is needed to make the diagnosis of an oligodendroglioma. Presence of 1p/19q codeletion also informs patient prognosis and prediction of the best drug treatment. The main two tests in use are fluorescent in situ hybridisation (FISH) and polymerase chain reaction (PCR)-based loss of heterozygosity (LOH) assays (also known as PCR-based short tandem repeat or microsatellite analysis). Many other tests are available. None of the tests is perfect, although PCR-based LOH is expected to have very high sensitivity.

OBJECTIVES

To estimate the sensitivity and specificity and cost-effectiveness of different deoxyribonucleic acid (DNA)-based techniques for determining 1p/19q codeletion status in glioma.

SEARCH METHODS

We searched MEDLINE, Embase and BIOSIS up to July 2019. There were no restrictions based on language or date of publication. We sought economic evaluation studies from the results of this search and using the National Health Service Economic Evaluation Database.

SELECTION CRITERIA

We included cross-sectional studies in adults with glioma or any subtype of glioma, presenting raw data or cross-tabulations of two or more DNA-based tests for 1p/19q codeletion. We also sought economic evaluations of these tests.

DATA COLLECTION AND ANALYSIS

We followed procedures outlined in the Cochrane Handbook for Diagnostic Test Accuracy Reviews. Two review authors independently screened titles/abstracts/full texts, performed data extraction, and undertook applicability and risk of bias assessments using QUADAS-2. Meta-analyses used the hierarchical summary ROC model to estimate and compare test accuracy. We used FISH and PCR-based LOH as alternate reference standards to examine how tests compared with those in common use, and conducted a latent class analysis comparing FISH and PCR-based LOH. We constructed an economic model to evaluate cost-effectiveness.

MAIN RESULTS

We included 53 studies examining: PCR-based LOH, FISH, single nucleotide polymorphism (SNP) array, next-generation sequencing (NGS), comparative genomic hybridisation (CGH), array comparative genomic hybridisation (aCGH), multiplex-ligation-dependent probe amplification (MLPA), real-time PCR, chromogenic in situ hybridisation (CISH), mass spectrometry (MS), restriction fragment length polymorphism (RFLP) analysis, G-banding, methylation array and NanoString. Risk of bias was low for only one study; most gave us concerns about how patients were selected or about missing data. We had applicability concerns about many of the studies because only patients with specific subtypes of glioma were included. 1520 participants contributed to analyses using FISH as the reference, 1304 participants to analyses involving PCR-based LOH as the reference and 262 participants to analyses of comparisons between methods from studies not including FISH or PCR-based LOH. Most evidence was available for comparison of FISH with PCR-based LOH (15 studies, 915 participants): PCR-based LOH detected 94% of FISH-determined codeletions (95% credible interval (CrI) 83% to 98%) and FISH detected 91% of codeletions determined by PCR-based LOH (CrI 78% to 97%). Of tumours determined not to have a deletion by FISH, 94% (CrI 87% to 98%) had a deletion detected by PCR-based LOH, and of those determined not to have a deletion by PCR-based LOH, 96% (CrI 90% to 99%) had a deletion detected by FISH. The latent class analysis suggested that PCR-based LOH may be slightly more accurate than FISH. Most other techniques appeared to have high sensitivity (i.e. produced few false-negative results) for detection of 1p/19q codeletion when either FISH or PCR-based LOH was considered as the reference standard, although there was limited evidence. There was some indication of differences in specificity (false-positive rate) with some techniques. Both NGS and SNP array had high specificity when considered against FISH as the reference standard (NGS: 6 studies, 243 participants; SNP: 6 studies, 111 participants), although we rated certainty in the evidence as low or very low. NGS and SNP array also had high specificity when PCR-based LOH was considered the reference standard, although with much more uncertainty as these results were based on fewer studies (just one study with 49 participants for NGS and two studies with 33 participants for SNP array). G-banding had low sensitivity and specificity when PCR-based LOH was the reference standard. Although MS had very high sensitivity and specificity when both FISH and PCR-based LOH were considered the reference standard, these results were based on only one study with a small number of participants. Real-time PCR also showed high specificity with FISH as a reference standard, although there were only two studies including 40 participants. We found no relevant economic evaluations. Our economic model using FISH as the reference standard suggested that the resource-optimising test depends on which measure of diagnostic accuracy is most important. With FISH as the reference standard, MLPA is likely to be cost-effective if society was willing to pay GBP 1000 or less for a true positive detected. However, as the value placed on a true positive increased, CISH was most cost-effective. Findings differed when the outcome measure changed to either true negative detected or correct diagnosis. When PCR-based LOH was used as the reference standard, MLPA was likely to be cost-effective for all measures of diagnostic accuracy at lower threshold values for willingness to pay. However, as the threshold values increased, none of the tests were clearly more likely to be considered cost-effective.

AUTHORS' CONCLUSIONS

In our review, most techniques (except G-banding) appeared to have good sensitivity (few false negatives) for detection of 1p/19q codeletions in glioma against both FISH and PCR-based LOH as a reference standard. However, we judged the certainty of the evidence low or very low for all the tests. There are possible differences in specificity, with both NGS and SNP array having high specificity (fewer false positives) for 1p/19q codeletion when considered against FISH as the reference standard. The economic analysis should be interpreted with caution due to the small number of studies.

Evaluation of dose, volume and outcome in children with localized, intracranial ependymoma treated with proton therapy within the prospective KiProReg Study

Background

Radiotherapy (RT) of ependymoma in children is an important part of the interdisciplinary treatment concept. However, feasibility and dose concepts are still under investigation, particularly in very young children. The aim of this study was to evaluate the standard dose and volume of proton therapy (PT) in children with ependymoma.

Methods

In this analysis, 105 patients with localized, intracranial ependymoma under the age of 18 years treated with PT between 2013 and 2018 were included. Patient characteristics, treatment, outcome, and follow-up data were analyzed using descriptive statistics, Kaplan-Meier, and Cox regression analysis.

Results

The median age of patients at PT was 2.8 years (0.9-17.0 years). The molecular subgroup analysis was performed in a subset of 50 patients (37 EP-PFA, 2 EP-PFB, 7 EP-RELA, 2 EP-YAP, 2 NEC [not elsewhere classified]). The median total dose was 59.4 Gy (54.0-62.0 Gy). The median follow-up time was 1.9 years. The estimated 3-year overall survival (OS), local control (LC), and progression-free survival (PFS) rates were 93.7%, 74.1%, and 55.6%, respectively. Within univariable analysis, female gender and lower dose had a positive impact on OS, whereas age ≥4 years had a negative impact on OS and PT given after progression had a negative impact on PFS. In the multivariable analysis, multiple tumor surgeries were associated with lower PFS. New ≥3° late toxicities occurred in 11 patients.

Conclusion

For children with localized ependymoma, PT was effective and well tolerable. Multiple surgeries showed a negative impact on PFS.

Systematic review of the impact of the COVID-19 pandemic on suicidal behaviour amongst health and social care workers across the world

BACKGROUND

The COVID-19 pandemic has had an impact on the mental health of healthcare and social care workers, and its potential effect on suicidal thoughts and behaviour is of particular concern.

METHODS

This systematic review identified and appraised the published literature that has reported on the impact of COVID-19 on suicidal thoughts and behaviour and self-harm amongst healthcare and social care workers worldwide up to May 31, 2021.

RESULTS

Out of 37 potentially relevant papers identified, ten met our eligibility criteria. Our review has highlighted that the impact of COVID-19 has varied as a function of setting, working relationships, occupational roles, and psychiatric comorbidities.

LIMITATIONS

There have been no completed cohort studies comparing pre- and post-pandemic suicidal thoughts and behaviours. It is possible some papers may have been missed in the search.

CONCLUSIONS

The current quality of evidence pertaining to suicidal behaviour in healthcare workers is poor, and evidence is entirely absent for those working in social care. The clinical relevance of this work is to bring attention to what evidence exists, and to encourage, in practice, proactive approaches to interventions for improving healthcare and social care worker mental health.

Assisted reproductive technology treatment and risk of breast cancer: a population-based cohort study

STUDY QUESTION

Is there an increased risk of breast cancer among women after ART treatment including ovarian hormone stimulation?

SUMMARY ANSWER

The risk of breast cancer was slightly increased among women after ART treatment compared to age-matched, untreated women in the background population, and the risk was further increased among women initiating ART treatment when aged 40+ years.

WHAT IS KNOWN ALREADY

The majority of breast cancer cases are sensitive to oestrogen, and ovarian hormone stimulation has been suggested to increase the risk of breast cancer by influencing endogenous oestrogen levels. Previous studies on ART treatment and breast cancer have varied in their findings, but several studies have small sample sizes or lack follow-up time and/or confounder adjustment. Recent childbirth, nulliparity and higher socio-economic status are breast cancer risk factors and the latter two are also associated with initiating ART treatment.

STUDY DESIGN, SIZE, DURATION

The Danish National ART-Couple II (DANAC II) cohort includes women treated with ART at public and private fertility clinics in 1994-2016.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women with no cancer prior to ART treatment were included (n = 61 579). Women from the background population with similar age and no prior history of ART treatment were randomly selected as comparisons (n = 579 760). The baseline mean age was 33.1 years (range 18-46 years). Results are presented as hazard ratios (HRs) with corresponding CIs.

MAIN RESULTS AND THE ROLE OF CHANCE

During follow-up (median 9.69 years among ART-treated and 9.28 years among untreated), 5861 women were diagnosed with breast cancer, 695 among ART-treated and 5166 among untreated women (1.1% versus 0.9%, P < 0.0001). Using Cox regression analyses adjusted for nulliparity, educational level, partnership status, year, maternal breast cancer and age, the risk of breast cancer was slightly increased among women treated with ART (HR 1.14, 95% CI 1.12-1.16). All causes of infertility were slightly associated with breast cancer risk after ART treatment. The risk of breast cancer increased with higher age at ART treatment initiation and was highest among women initiating treatment at age 40+ years (HR 1.37, 95% CI 1.29-1.45). When comparing women with a first birth at age 40+ years with or without ART treatment, the increased risk among women treated with ART persisted (HR 1.51, 95% CI 1.09-2.08).

LIMITATIONS, REASONS FOR CAUTION

Although this study is based on a large, national cohort of women, more research with sufficient power and confounder adjustment is needed, particularly in cohorts with a broad age representation.

WIDER IMPLICATIONS OF THE FINDINGS

An increased risk of breast cancer associated with a higher age at ART treatment initiation has been shown. Ovarian stimulation may increase the risk of breast cancer among women initiating ART treatment when aged 40+ years. Age-related vulnerability to hormone exposure or higher hormone doses during ART treatment may explain the increased risk.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by a PhD grant to D.V. from the Faculty of Health and Medical Sciences, University of Copenhagen, Denmark. Funding for establishing the DANAC II cohort was received from the Ebba Rosa Hansen Foundation. The authors report no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Subjectively perceived healthcare provision during the first wave of the COVID-19 pandemic

Background

An OECD benchmark (2020) shows that Germany has, in effect, an above-average healthcare infrastructure to face COVID-19. Nevertheless, at the beginning of the pandemic, there were restrictions and uncertainties in the use of health-related services. The following analysis examines the subjective perception of respondents with their healthcare provision whether there were sociodemographic differences.

Methods

Data from an online cross-sectional survey conducted between 29 April and 8 May 2020 were used (N = 1,570; 18-74 years). Bivariate test methods were used for analysis, stratified by age group, subjective social status (SSS) and chronic illness. The subjective perception was assessed via subjects' subjectively perceived worries, fears and difficulties of not receiving an adequate healthcare provision during the COVID-19 pandemic. Thus, an index was constructed with a range of values from 3 to 12 (Cronbach's α = 0.886). A higher index implies a poorer perception of the healthcare provision.

Results

Compared to the groups 50-59-year-olds and 60 years and older the 18-29-year-olds (MRank 431.1) had a significantly (p < 0.05) poorer perception of their healthcare provision during COVID-19. In addition, probands with low SSS were found to have a significantly (p < 0.05) worse perception (MRank 423.0) than subjects with medium SSS (MRank 374.1). Chronically ill subjects suffered significantly poorer perception (MRank 406.1; p < 0.05) compared to healthy subjects (MRank 366.0).

Conclusions

Vulnerable groups with poorer perceptions of their health care provision during COVID-19 can be identified. More investigation is needed to identify subjective or COVID-19 related predictors that cause this subjective perception.

Reference

OECD (2020). Beyond Containment: Health systems responses to COVID-19 in the OECD.

Available: https://read.oecd-ilibrary.org/view/?ref=119_119689-ud5comtf84&title=Beyond_Containment:Health_systems_responses_to_COVID-19_in_the_OECD (Accessed: 14.04.2021)

Key messages

It was found that respondents perceived their subjective healthcare provision during COVID-19 differently, according to sociodemographic stratification.

Especially younger, chronically ill, and socioeconomically deprived respondents experienced a poorer perception of their healthcare provision during the first wave of the COVID-19 pandemic.

Web-based planning tool for obesity prevention in childhood and youth – first trial period

Background

The systematic and theory-based development of interventions is complex and requires time and personnel resources. WEPI is a web-based planning tool for municipalities and schools, that follows the evidence-based intervention mapping approach (IMA) but also supports the planning process of obesity prevention user oriented. The project is supported by the Federal Ministry of Health, Germany.

Methods

Data of a systematic literature review (SLR), expert interviews and focus group discussions served as the foundation for the first version of WEPI. Two further SLR were conducted in the databases Pubmed, LIVIVO and Cochrane on evidence-based determinants of obesity development and on proven obesity intervention methods, to meet the requirements of the IMA. In October 2020 the second version of WEPI was tested with selected municipalities and schools. The prototype as a third version was tested by three municipalities and two schools in February 2021. Feedback was collected through questionnaires and interviews.

Results

In a total of 806 hits of the first SLR, determinants for the development of obesity were identified in 8 guidelines and 37 reviews. They were adopted in form of 15 problem areas which support the WEPI user to conduct an evidence-based problem analysis. Result of the second SLR are 25 obesity prevention interventions which were developed using the IMA. Based on this, 192 evaluated methods were identified and integrated as good practice examples into WEPI. In the first trial the expert feedback revealed aspects of content and user-friendliness as well as technical aspects that should be optimized. The feedback of the municipalities and schools underlines, that scientific findings need to be translated into practical logic.

Conclusions

WEPI provides a comprehensive roadmap to the planning process, guiding the user step by step. Acceptance and usability of the planning tool will be evaluated with municipalities and schools from April to November 2021.

Key messages

WEPI enables user oriented, structured and evidence-based planning of prevention interventions. Requirements resulting from practice were considered in the development of the planning tool.

MGMT promoter methylation testing to predict overall survival in people with glioblastoma treated with temozolomide: a comprehensive meta-analysis based on a Cochrane Systematic Review

BACKGROUND

The DNA repair protein O6-methylguanine-DNA methyltransferase (MGMT) causes resistance of tumor cells to alkylating agents. It is a predictive biomarker in high-grade gliomas treated with temozolomide, however, there is no consensus on which test method, methylation sites, and cutoff values to use.

METHODS

We performed a Cochrane Review to examine studies using different techniques to measure MGMT and predict survival in glioblastoma patients treated with temozolomide. Eligible longitudinal studies included (i) adults with glioblastoma treated with temozolomide with or without radiotherapy, or surgery; (ii) where MGMT status was determined in tumor tissue, and assessed by 1 or more technique; and (iii) where overall survival was an outcome parameter, with sufficient information to estimate hazard ratios (HRs). Two or more methods were compared in 32 independent cohorts with 3474 patients.

RESULTS

Methylation-specific PCR (MSP) and pyrosequencing (PSQ) techniques were more prognostic than immunohistochemistry for MGMT protein, and PSQ is a slightly better predictor than MSP.

CONCLUSIONS

We cannot draw strong conclusions about use of frozen tissue vs formalin-fixed paraffin-embedded in MSP and PSQ. Also, our meta-analysis does not provide strong evidence about the best CpG sites or threshold. MSP has been studied mainly for CpG sites 76-80 and 84-87 and PSQ at CpG sites ranging from 72 to 95. A cutoff threshold of 9% for CpG sites 74-78 performed better than higher thresholds of 28% or 29% in 2 of the 3 good-quality studies. About 190 studies were identified presenting HRs from survival analysis in patients in which MGMT methylation was measured by 1 technique only.

P–734 Parenthood among men diagnosed with cancer in childhood and early adulthood – trends over time in a Danish national cohort

Study question

Is the rate of fatherhood among men diagnosed with cancer in childhood and early adulthood different from men without cancer – have differences changed over time?

Summary answer

Men diagnosed with cancer had significantly reduced rates of fatherhood compared with undiagnosed men. Rates of fatherhood among the cancer survivors increased markedly over time.

What is known already

The number of children and young adolescents who survive cancer has steadily increased over the past decades, with a current 5-year survival rate of approximately 80%. Consequently, life circumstances after cancer have gained increasing importance, including the desire among survivors to have children and a family. MAR technologies to aid reproduction among cancer survivors have been developed, and fertility preservation is increasingly a topic being discussed before undergoing cancer treatment. But the potential for fertility preservation differs depending on age at diagnosis and type of cancer. Earlier studies have shown decreased fertility rates among survivors of childhood and adolescent cancer.

Study design, size, duration

This study is a national, register-based cohort study. Men diagnosed with cancer in childhood and early adulthood (&lt;30 years of age) were registered in the Danish Cancer Register in 1978–2016 (n = 15,600). At time of diagnosis, each cancer-diagnosed man was randomly age-matched with 150 undiagnosed men from the background population within the same birth year. The men were followed in medical registers and socio-demographic population registers until death, migration or end of study December 31st, 2017.

Participants/materials, setting, methods

Fatherhood among the boys and young men diagnosed with cancer was compared with the age-matched comparison group in all statistical analyses. Cancer diagnoses were categorized as central nervous system (CNS), haematological cancers or solid cancers. Also, analyses were stratified by age at diagnosis (0–9, 10–19, 20–29 years) and year of diagnosis (1978–89, 1990–99, 2000–16). Death was incorporated as a competing risk in all analyses.

Main results and the role of chance

The study population consisted of 15,600 boys and young men diagnosed with cancer between 1978 and 2016 and 1,386,493 men in the age-matched comparison group. Men surviving CNS cancer had the lowest hazard ratio of fatherhood compared with the age-matched comparison group (HR = 0.64, 95% CI 0.57–0.73), followed by survivors of haematological cancers (HR = 0.90, 95% CI 0.82–0.98) while the highest chance of fatherhood was slightly increased among survivors of solid cancers (HR = 1.13, 95% CI 1.10–1.16). The hazard ratio of becoming a father increased over time. From the first decade to the last decade 30 years later, the hazard ratio of becoming a father increased for solid tumours (HR 0.76, 95% CI 0.72–0.80 to HR 1.07, 95% CI 0.96–1.19), haematological tumours (HR 0.60, 95% CI 0.51–0.71 to HR 0.97, 95% CI 0.76–1.23) and CNS tumours (HR 0.47, 95% CI 0.39–0.58 to HR 1.04, 95% CI 0.56–1.93) compared to the age-matched comparison group. Also, men diagnosed with cancer when aged 20–29 years more likely became fathers over time (HR 0.79, 95% CI 0.74–0.84 to HR 1.09, 95% CI 0.98–1.22).

Limitations, reasons for caution

The study was based on register data, and information was not available about the men’s fertility potential, whether they had a desire to have children and whether it was possible for them to find a partner. Also, information about fertility preservation, e. g. sperm freezing, could have provided additional insights.

Wider implications of the findings: Information and education of male patients diagnosed with cancer about fertility preservation options, and chances to create their own family is crucial. Reassuringly, time trends showed more men with a previous cancer diagnosis becoming fathers in recent years than earlier, reflecting that survival and fertility preservation have improved over time.

Trial registration number

N/A

O-188 Participation in a video-based fertility awareness program advances the desire to have children sooner

Study question

Participating in a fertility awareness program accelerates the intention to have children 6 to 12 months after video- fertility awareness?

Summary answer

In combination with positive childbearing motivation, those in the video condition anticipated their intentions to have children at 6-12 months follow-up

What is known already

Fertility awareness education and initiatives have been focused on increasing fertility awareness and knowledge. However, the role of fertility awareness on reproductive decisions is less explored in literature. There are few studies showing that participating in fertility awareness education is related to higher intentions to have children or decreased time until trying to conceive regarding beforehand planned. Since intentions seem to be a good predictor of behaviour, we were interested in exploring the variables which might predict higher intentions to have children after participating in a fertility awareness education study based on a video intervention

Study design, size, duration

This study is part of a randomised controlled trial initiated in October 2016. Participants were randomly allocated into the intervention (IG) and control group (CG) at baseline (TO). The follow-up was evaluated 6 to 12 months later. IG participants were exposed to a 5-min video delivering information on age-related fertility decline, infertility risk factors, and pregnancy chances after having filled-in the T0 questionnaire: Participants in CG received no stimulus.

Participants/materials, setting, methods

Three hundred sixty-five individuals (65% women) were recruited through social media, gynaecology clinics, and religious pre-marital courses. From those, 128 responded to follow-up (between 6 and 12 months). Childbearing Motivation Scale (positive and negative) and a question about childbearing timing intentions were used. Regression analysis was conducted to explore the role of video intervention and childbearing motivation on childbearing timing intention.

Main results and the role of chance

Participants were, on average, 29.5 years old (SD = 5.13). From baseline to 6-12 months later, participants significantly anticipated their desire to have children (p&lt;.005). Correlations showed that childbearing timing intention was positively and significantly associated with the following subscales of the positive motivations: personal fulfilment, continuity, and couple relationship; negative motivations were not associated with the childbearing timing intention. The regression analysis revealed that only the childbearing motivation regarding couple relationship (having a child would strengthening partnership ties, fulfilling partner’s project, growing as a couple, fulfilling a shared project) and the visualization of the educational video significantly contributed to predicting at follow-up the increased desire to have children sooner at follow-up.

Limitations, reasons for caution

Other factors, not considered, might contribute to the prediction of childbearing motivation timing. Although we had randomly allocated people to CG and IG, the high attrition rate may limit the generalization of our results.

Wider implications of the findings

This study seems to indicate that watching an educational video about fertility awareness might contribute to a significant change in childbearing timing. In addition, the importance of the couple relationship is highlighted. These findings reinforce the importance to assist people with informed reproductive decisions in social and healthcare settings. 

Trial registration number

NCT02813993

P-472 Single mothers by choice - experiences of single women seeking treatment at a public fertility clinic in Denmark: A pilot study

Study question

Are single women in fertility treatment stigmatised and what do they experience?

Summary answer

The women did not feel stigmatised. They experienced self-blame and negative thoughts about themselves, despite experiencing empowerment and receiving positive reactions from families and friends.

What is known already

Since 2007, medical doctors in Denmark have been permitted to offer medically assisted reproduction (MAR) also to single women. Denmark is a welfare state with a public health care sector providing MAR free of charge, 240 days of paid parental leave, and public full-time day-care. There has been an increase in the number of single women deciding to have children through the use of MAR. These women are referred to as ‘single mothers by choice’ (SMC), and they have been criticised for being selfish when raising a child without a father. Previous studies have shown how SMC can feel stigmatised. 

Study design, size, duration

Semi-structured qualitative interviews at a public fertility clinic in Copenhagen, Denmark. Data collection took place between September and October 2020.

Participants/materials, setting, methods

The participants were single and childless women (N = 6) undergoing MAR at the Fertility Clinic, Rigshospitalet in Copenhagen, Denmark. Five women received IVF and one received IUI. The women were between 30 and 40 years old and were all residents in the Capital Region of Denmark. The interviews were audiotaped, anonymised, and transcribed in full. Data were analysed using qualitative content analysis.

Main results and the role of chance

Single women did not differ from cohabiting women seeking MAR in relation to their experiences and attitudes towards motherhood. Four main themes were identified; (1) Experiences of single women seeking fertility treatment, (2) Emotions associated with becoming a single mother by choice, (3) The decision of becoming a single mother by choice, and (4) Family formation – a social interaction. The women would have preferred to have a child in a relationship with a partner and the shattered dream about the nuclear family has caused a wide range of experiences and emotions. The women did not feel stigmatised but they all had an awareness of the prejudices other people might have towards single mothers by choice. Hence, they were ready to defend their choice if necessary. On the other hand, they had received positive reactions and the process of becoming a single mother by choice was influenced by their social relations with family and friends. Despite their dream of the nuclear family the women choose to become SMC because motherhood was of such importance and they feared they would otherwise become too old to have children – the biological clock was ticking. 

Limitations, reasons for caution

The participants were recruited from a public fertility clinic in the Capital Region of Denmark and may not be representative of all single women seeking MAR. Results might not be transferable to other countries with a different cultural context regarding the societal acceptance of different ways to establish a family. 

Wider implications of the findings

This study contributes to the understanding of the experiences of single women seeking fertility treatment in a welfare state where there are no differences in the possibilities for different social classes to seek MAR in the public health care sector. 

Trial registration number

N/A

P–493 Couples joint narratives of coping with and making sense of recurrent pregnancy loss: a dyadic interview study

Study question

What are couples’ joint narratives of coping with, and making sense of recurrent pregnancy loss?

Summary answer

Couples can become stuck in patterns of communication and coping roles that may be dissatisfying and not reflect the complexity of their experience of RPL.

What is known already

Fertility problems such as recurrent pregnancy loss (RPL) are unique health issues because they are a couple problem, in that they involve a blocked parenthood goal for both members of the couple regardless of the cause or source of the fertility issue.

Previous research has focused on the psychosocial impact on the individual or examined gender differences in men and women’s response to RPL. Research suggests that couples’ relationships are impacted, but few examine this issue in interviews with couples as participants. We need appropriate study designs to examine and understand the couple’s experience and process on a dyadic level.

Study design, size, duration

This was a qualitative study using dyadic interviews and analysis. This method facilitates a co-construction of meaning and joint narrative between couples through sharing and comparing their experience in a conjoint dyadic interview.

Thirteen couples who were referred to the RPL program, in Rigshospitalet, Copenhagen, Denmark were interviewed over a two-month period in 2017–2018. Interviews were held at Rigshospitalet and ranged between 81 and 109 minutes (average 91 minutes). Participants/materials, setting, methods: Inclusion criteria included: heterosexual couples with at least three pregnancy losses (PL) under 12 weeks gestation with no children/one child and willing to be interviewed in English. Thirty invitations were sent to couples who met the inclusion criteria and 15 couples contacted the interviewer to schedule an interview. Semi-structured dyadic interviews were conducted in person with 13 couples. Data was analyzed using dyadic analysis with a focus on common themes in co-constructed meaning across couples.

Main results and the role of chance

On average, participants had been in their relationship for 8.4 years, experienced three PLs (range three–six), with most recent PL occurring 4.3 months before the interview.

Couples described becoming stuck in patterns of communication and in rigid roles of coping and relating (e.g., the optimist, the emotional one) that could be dissatisfying and not meet their needs and not reflect the nuances and complexity of their experience of RPL. Common roles included the “optimist” versus the “pessimist”, the “talker” versus the “listener” and the “emotional” versus the “rational / problem solver”. While these roles were rooted in some truth of their experience, the rigidity of these roles did not create space and flexibility for the full spectrum of their reactions and experience. For example, a woman said, “I hope for him to be the pessimist so I get to be the optimist sometimes” and several men shared the depth of their grief for the first time.

The interviews were a way to highlight and create a new dynamic by allowing couples to respond to and correct their partner’s assumptions about their experience or role (e.g., “that’s not how I feel all the time”) and try new ways of communicating.

Limitations, reasons for caution

The findings cannot be generalized to all couples who have experienced RPL given the study design. Whilst dyadic interviews allow for a fuller, more nuanced narrative account, couples may omit some of their experience in the interview due to social desirability.

Wider implications of the findings: This study provides a better understanding of the complexity of communication patterns and roles in couples with RPL that can improve provision of support and counselling.

Dyadic interviews can provide opportunities for couples to communicate differently and break out of dissatisfying patterns while creating common ground and generating shared meaning.

Trial registration number

N/A

P–472 Single mothers by choice - experiences of single women seeking treatment at a public fertility clinic in Denmark: A pilot study

Study question

Are single women in fertility treatment stigmatised and what do they experience?

Summary answer

The women did not feel stigmatised. They experienced self-blame and negative thoughts about themselves, despite experiencing empowerment and receiving positive reactions from families and friends.

What is known already

Since 2007, medical doctors in Denmark have been permitted to offer medically assisted reproduction (MAR) also to single women. Denmark is a welfare state with a public health care sector providing MAR free of charge, 240 days of paid parental leave, and public full-time day-care. There has been an increase in the number of single women deciding to have children through the use of MAR. These women are referred to as ‘single mothers by choice’ (SMC), and they have been criticised for being selfish when raising a child without a father. Previous studies have shown how SMC can feel stigmatised. Study design, size, duration: Semi-structured qualitative interviews at a public fertility clinic in Copenhagen, Denmark. Data collection took place between September and October 2020.

Participants/materials, setting, methods

The participants were single and childless women (N = 6) undergoing MAR at the Fertility Clinic, Rigshospitalet in Copenhagen, Denmark. Five women received IVF and one received IUI. The women were between 30 and 40 years old and were all residents in the Capital Region of Denmark. The interviews were audiotaped, anonymised, and transcribed in full. Data were analysed using qualitative content analysis.

Main results and the role of chance

Single women did not differ from cohabiting women seeking MAR in relation to their experiences and attitudes towards motherhood. Four main themes were identified; (1) Experiences of single women seeking fertility treatment, (2) Emotions associated with becoming a single mother by choice, (3) The decision of becoming a single mother by choice, and (4) Family formation – a social interaction. The women would have preferred to have a child in a relationship with a partner and the shattered dream about the nuclear family has caused a wide range of experiences and emotions. The women did not feel stigmatised but they all had an awareness of the prejudices other people might have towards single mothers by choice. Hence, they were ready to defend their choice if necessary. On the other hand, they had received positive reactions and the process of becoming a single mother by choice was influenced by their social relations with family and friends. Despite their dream of the nuclear family the women choose to become SMC because motherhood was of such importance and they feared they would otherwise become too old to have children – the biological clock was ticking.

Limitations, reasons for caution

The participants were recruited from a public fertility clinic in the Capital Region of Denmark and may not be representative of all single women seeking MAR. Results might not be transferable to other countries with a different cultural context regarding the societal acceptance of different ways to establish a family.

Wider implications of the findings: This study contributes to the understanding of the experiences of single women seeking fertility treatment in a welfare state where there are no differences in the possibilities for different social classes to seek MAR in the public health care sector.

Trial registration number

N/A

P–484 Progesterone supplementation in modified natural frozen embryo transfer (mNC-FET) does not cause mental health adverse effects - A sub-study of a multicenter RCT

Study question

Do women undergoing mNC-FET with progesterone supplementation experience mental health adverse effects at a greater rate compared to a control group.

Summary answer

Progesterone supplementation does not affect mental wellbeing in women undergoing mNC-FET.

What is known already

Women and men undergoing assisted reproductive treatment more likely to experience stress and other adverse psychological effects than the background population. Various factors such as parental age, cause of infertility and treatment method have been shown to affect patient well-being. Progesterone supplementation is known to cause various physical adverse effects, yet few studies have investigated the potential mental health adverse effects of progesterone supplementation in FET.

Study design, size, duration

This is a sub-study of an ongoing RCT investigating the effect of luteal phase progesterone supplementation in mNC-FET. The aim is to investigate possible mental health adverse effects of progesterone. From 2019–2021 a total of 164 women were included (n = 84 and n = 82 in the progesterone and control group, respectively). The health and wellbeing self-reporting survey was fulfilled after randomization on hCG trigger + 11 days.

Participants/materials, setting, methods

A validated, electronic questionnaire in Danish was used to measure mental wellbeing in women aged 18–41 years undergoing mNC-FET with and without use of progesterone supplementation in the luteal phase at seven Danish public hospitals. Women were randomized to either progesterone treatment or no progesterone by a computerized randomization algorithm with minimization for female age &gt; =37 years, previous oocyte retrievals and previous FET. Comparisons of survey responses were performed by chi-square tests.

Main results and the role of chance

The survey response rate was 68%. We observed no significant differences in any of the three items between the progesterone group and the control group. On the first item “to which degree have you felt sensitive due to treatment”, 56% and 52% responded “to a large degree” or “to some degree” sensitive in the progesterone vs. control group, while 25% and 34% vs. 19% and 13% responded “to a lesser extent” or “not at all” sensitive in progesterone vs. controls (P = 0.35).

On the second item, “to which degree have you felt aggressive due to treatment”, 10% and 9% responded “to a large degree” or “to some degree”, 29% and 22% answered “to a lesser degree” and 62% and 70% responded “not at all” in the progesterone vs control group (P = 0.57).

On the third item “to which degree have you cried unexpectedly due to treatment” 25% and 18% responded “to a large degree” or “to some degree” in the progesterone vs control group, 20% and 27% answered “to a lesser extent”, while 55% in both groups answered “not at all” (P = 0.44).

Limitations, reasons for caution

In a self-reported survey selection bias, due to a less than 100% response rate, and reporting bias cannot be excluded. However with the possibility to answer the survey online at leisure, the risk of reporting bias is minimized.

Wider implications of the findings: A large concern for clinicians working with ART is patient wellbeing. Our study suggests that luteal phase support does not cause extra emotional distress, though further research is needed.

Trial registration number

NCT03795220

How do young men want to receive information about fertility? Young men's attitudes towards a fertility campaign targeting men in Copenhagen, Denmark

STUDY QUESTION

What are young men’s attitudes towards the Danish fertility campaign ‘How’s your sperm?’ and how do they want to receive fertility information in the future?

SUMMARY ANSWER

The young men found that the campaign had limited impact because it was not relevant to their current life situation and they believed general fertility awareness should be a mandatory part of education, while more targeted information would be helpful through web-based venues when it was more relevant to their lives (e.g. when ready to have children).

WHAT IS KNOWN ALREADY

It is estimated that 16–26% of the Danish population who want children will experience infertility at some point in their lives. In Denmark, 25% of young healthy men have decreased sperm quality, and 20% of 50-year-old men are childless. Men play an important role in the fertility decision-making of couples, thus, it is important to target men and ensure that they have sufficient fertility knowledge. However, fertility awareness is limited among men and there have been few fertility awareness initiatives targeting men. In October 2018, the Municipality of Copenhagen launched the campaign ‘How’s your sperm?’ as a tool to increase fertility knowledge among men. To identify potential barriers for the effect of fertility campaigns targeting men, evaluations of such campaigns are needed.

STUDY DESIGN, SIZE, DURATION

This study was a cross-sectional, qualitative study of six focus groups including a total of 27 currently childless young men from the Capital Region of Copenhagen, Denmark. Data collection took place between April and October 2019.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The interviewed young men were currently childless and were all residents in the Capital Region of Copenhagen. They were between 23 and 32 years old with an average age of 26 years, and almost all were university students or had a university degree. The focus group discussions were audiotaped, anonymized and transcribed in full. Data were analyzed using qualitative content analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

Overall, the campaign had limited influence on the young men because they believed the campaign was not relevant to their current life situation. Furthermore, the young men were confused about the aim and message of the campaign, as they thought it encouraged them to have their sperm quality tested. The young men also criticized the campaign for making a link between sperm quality and masculinity. They recognized the importance of knowledge about reproductive health but they wanted access to accurate information about fertility and risk factors for infertility. According to the young men, future initiatives should prioritize clear communication of accurate, reliable and understandable fertility information in web-based venues. In addition, the young men suggested that general fertility information should be a mandatory part of the (sexual) education curriculum in primary and secondary schools.

LIMITATIONS, REASONS FOR CAUTIONS

Participants were young and highly educated; thus the findings cannot be generalized to all men of a similar age group or to men at older ages.

WIDER IMPLICATIONS OF THE FINDINGS

Different strategies that are relevant to the lifespan are needed to increase fertility awareness in the male population. The young men’s responses underscored that any fertility awareness strategy or campaign must convey respect for the individual’s autonomy. The findings highlight that how information is communicated and the quality or type of information that is disseminated are both important in acceptability by target users.

STUDY FUNDING/COMPETING INTEREST(S)

No funding was received for this study. No conflicts were declared for all authors.

TRIAL REGISTRATION NUMBER

N/A.

Parenthood among men diagnosed with cancer in childhood and early adulthood: trends over time in a Danish national cohort

STUDY QUESTION

Is the rate of fatherhood among men diagnosed with cancer in childhood and early adulthood different from men without cancer, and, if so, have the differences changed over time?

SUMMARY ANSWER

Men diagnosed with cancer have had significantly reduced rates of fatherhood compared with undiagnosed men; however, the rates of fatherhood among the cancer survivors have increased markedly over time.

WHAT IS KNOWN ALREADY

The number of children and young adolescents who survive cancer has steadily increased over recent decades, with a current 5-year survival rate of approximately 80%. Consequently, life circumstances after cancer have gained increasing importance, including the desire among survivors to have children and a family. ARTs to aid reproduction among cancer survivors have been developed, and fertility preservation is increasingly a topic being discussed before undergoing cancer treatment. But the potential for fertility preservation differs dependent on age at diagnosis and type of cancer. Earlier studies have shown a decreased fertility rate among survivors of child and adolescent cancer compared to those diagnosed in early adulthood.

STUDY DESIGN, SIZE, DURATION

This study is a national, register-based cohort study. Men diagnosed with cancer in childhood and early adulthood (<30 years of age) were registered in the Danish Cancer Register in 1978-2016 (n = 9353). According to the time of diagnosis, each cancer-diagnosed man was randomly matched with 150 undiagnosed men from the background population within the same birth year. The men were followed until having their first child, death, migration or the end of the study (31 December 2017) in medical registers and socio-demographic population registers.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Fatherhood among the boys and young men diagnosed with cancer were compared with the age-matched comparison group in all statistical analyses. Cancer diagnoses were categorised as central nervous system (CNS) cancers, haematological cancers or solid cancers. Analyses were stratified by age at diagnosis (0-9, 10-19, 20-29 years) and time of diagnosis (1978-1989, 1990-1999, 2000-2009, 2010-2016). Death was incorporated as a competing risk in all analyses.

MAIN RESULTS AND THE ROLE OF CHANCE

The study population consisted of 9353 boys and young men diagnosed with cancer between 1978 and 2016 and 1 386 493 men in the age-matched comparison group. Those surviving CNS cancer as young men had the lowest hazard ratio (HR) of fatherhood compared with the age-matched comparison group (HR 0.67, 95% CI 0.57-0.79), followed by survivors of haematological cancers (HR 0.90, 95% CI 0.81-1.01), while the highest chance of fatherhood was among survivors of solid cancers (HR 1.16, 95% CI 1.12-1.20) with a slightly increased HR compared with undiagnosed males. The HR of becoming a father increased over time. From the first decade to the last decade 30 years later, the HR of becoming a father increased for solid tumours (HR 0.78, 95% CI 0.73-0.83 to HR 1.08, 95% CI 0.95-1.22), haematological cancers (HR 0.64, 95% CI 0.53-0.79 to HR 0.97, 95% CI 0.73-1.30) and CNS cancers (HR 0.44, 95% CI 0.34-0.57 to HR 0.98, 95% CI 0.49-1.95) compared to the age-matched comparison group. Also, when compared with the age-matched comparison group, men diagnosed with cancer when aged 20-29 years were more likely became fathers over the time of the study (HR 0.80, 95% CI 0.74-0.86 to HR 1.08, 95% CI 0.96-1.22).

LIMITATIONS, REASONS FOR CAUTION

The study was based on register data, and information was not available about the men's fertility potential, whether they had a desire to have children and whether it was possible for them to find a partner. Information about fertility preservation, e.g. sperm freezing, could also have provided additional insights. Furthermore, information about diagnosis and ART treatment would have been beneficial.

WIDER IMPLICATIONS OF THE FINDINGS

Information and education of male patients diagnosed with cancer about fertility preservation options and their chances to create their own family is crucial. Reassuringly, time trends showed more men with a previous cancer diagnosis becoming fathers in recent years than in earlier years, reflecting that survival and fertility preservation have improved over time.

STUDY FUNDING/COMPETING INTEREST(S)

R.S. received a PhD grant from the Rosa Ebba Hansen Foundation and from the Health Foundation (J.nr. 15-B-0095). The funding for the establishment of the DANAC II Cohort was obtained from the Rosa Ebba Hansen Foundation. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Data extraction methods for systematic review (semi)automation: Update of a living systematic review

Background: The reliable and usable (semi)automation of data extraction can support the field of systematic review by reducing the workload required to gather information about the conduct and results of the included studies. This living systematic review examines published approaches for data extraction from reports of clinical studies. Methods: We systematically and continually search PubMed, ACL Anthology, arXiv, OpenAlex via EPPI-Reviewer, and the  dblp computer science bibliography. Full text screening and data extraction are conducted within an open-source living systematic review application created for the purpose of this review. This living review update includes publications up to December 2022 and OpenAlex content up to March 2023. Results: 76 publications are included in this review. Of these, 64 (84%) of the publications addressed extraction of data from abstracts, while 19 (25%) used full texts. A total of 71 (93%) publications developed classifiers for randomised controlled trials. Over 30 entities were extracted, with PICOs (population, intervention, comparator, outcome) being the most frequently extracted. Data are available from 25 (33%), and code from 30 (39%) publications. Six (8%) implemented publicly available tools Conclusions: This living systematic review presents an overview of (semi)automated data-extraction literature of interest to different types of literature review. We identified a broad evidence base of publications describing data extraction for interventional reviews and a small number of publications extracting epidemiological or diagnostic accuracy data. Between review updates, trends for sharing data and code increased strongly: in the base-review, data and code were available for 13 and 19% respectively, these numbers increased to 78 and 87% within the 23 new publications. Compared with the base-review, we observed another research trend, away from straightforward data extraction and towards additionally extracting relations between entities or automatic text summarisation. With this living review we aim to review the literature continually.

Data extraction methods for systematic review (semi)automation: A living systematic review

Background: The reliable and usable (semi)automation of data extraction can support the field of systematic review by reducing the workload required to gather information about the conduct and results of the included studies. This living systematic review examines published approaches for data extraction from reports of clinical studies. Methods: We systematically and continually search MEDLINE, Institute of Electrical and Electronics Engineers (IEEE), arXiv, and the dblp computer science bibliography databases. Full text screening and data extraction are conducted within an open-source living systematic review application created for the purpose of this review. This iteration of the living review includes publications up to a cut-off date of 22 April 2020. Results: In total, 53 publications are included in this version of our review. Of these, 41 (77%) of the publications addressed extraction of data from abstracts, while 14 (26%) used full texts. A total of 48 (90%) publications developed and evaluated classifiers that used randomised controlled trials as the main target texts. Over 30 entities were extracted, with PICOs (population, intervention, comparator, outcome) being the most frequently extracted. A description of their datasets was provided by 49 publications (94%), but only seven (13%) made the data publicly available. Code was made available by 10 (19%) publications, and five (9%) implemented publicly available tools. Conclusions: This living systematic review presents an overview of (semi)automated data-extraction literature of interest to different types of systematic review. We identified a broad evidence base of publications describing data extraction for interventional reviews and a small number of publications extracting epidemiological or diagnostic accuracy data. The lack of publicly available gold-standard data for evaluation, and lack of application thereof, makes it difficult to draw conclusions on which is the best-performing system for each data extraction target. With this living review we aim to review the literature continually.

EU FP7 research funding for an orphan drug (Orfadin®) and vaccine (Hep C) development: a success and a failure?

BACKGROUND

We considered the extent of the contribution of publicly funded research to the late-stage clinical development of pharmaceuticals and medicinal products, based on the European Commission (EC) FP7 research funding programme. Using two EC FP7-HEALTH case study examples-representing two types of outcomes-we then estimated wider public and charitable research funding contributions.

METHODS

Using the publicly available database of FP7-HEALTH funded projects, we identified awards relating to late-stage clinical development according to the systematic application of inclusion and exclusion criteria, classified them according to product type and clinical indication, and calculated total EC funding amounts. We then identified two case studies representing extreme outcomes: failure to proceed with the product (hepatitis C vaccine) and successful market authorisation (Orfadin® for alkaptonuria). Total public and philanthropic research funding contributions to these products were then estimated using publicly available information on funding.

RESULTS

12.3% (120/977) of all EC FP7-HEALTH awards related to the funding of late-stage clinical research, totalling € 686,871,399. Pharmaceutical products and vaccines together accounted for 84% of these late-stage clinical development research awards and 70% of its funding. The hepatitis C vaccine received total European Community (FP7 and its predecessor, EC Framework VI) funding of €13,183,813; total public and charitable research funding for this product development was estimated at € 77,060,102. The industry sponsor does not consider further development of this product viable; this now represents public risk investment. FP7 funding for the late-stage development of Orfadin® for alkaptonuria was so important that the trials it funded formed the basis for market authorisation, but it is not clear whether the price of the treatment (over €20,000 per patient per year) adequately reflects the substantial public funding contribution.

CONCLUSIONS

Public and charitable research funding plays an essential role, not just in early stage basic research, but also in the late-stage clinical development of products prior to market authorisation. In addition, it provides risk capital for failed products. Within this context, we consider further discussions about a public return on investment and its reflection in pricing policies and decisions justified.

Prognostic value of test(s) for O6-methylguanine-DNA methyltransferase (MGMT) promoter methylation for predicting overall survival in people with glioblastoma treated with temozolomide

BACKGROUND

Glioblastoma is an aggressive form of brain cancer. Approximately five in 100 people with glioblastoma survive for five years past diagnosis. Glioblastomas that have a particular modification to their DNA (called methylation) in a particular region (the O6-methylguanine-DNA methyltransferase (MGMT) promoter) respond better to treatment with chemotherapy using a drug called temozolomide.

OBJECTIVES

To determine which method for assessing MGMT methylation status best predicts overall survival in people diagnosed with glioblastoma who are treated with temozolomide.

SEARCH METHODS

We searched MEDLINE, Embase, BIOSIS, Web of Science Conference Proceedings Citation Index to December 2018, and examined reference lists. For economic evaluation studies, we additionally searched NHS Economic Evaluation Database (EED) up to December 2014.

SELECTION CRITERIA

Eligible studies were longitudinal (cohort) studies of adults with diagnosed glioblastoma treated with temozolomide with/without radiotherapy/surgery. Studies had to have related MGMT status in tumour tissue (assessed by one or more method) with overall survival and presented results as hazard ratios or with sufficient information (e.g. Kaplan-Meier curves) for us to estimate hazard ratios. We focused mainly on studies comparing two or more methods, and listed brief details of articles that examined a single method of measuring MGMT promoter methylation. We also sought economic evaluations conducted alongside trials, modelling studies and cost analysis.

DATA COLLECTION AND ANALYSIS

Two review authors independently undertook all steps of the identification and data extraction process for multiple-method studies. We assessed risk of bias and applicability using our own modified and extended version of the QUality In Prognosis Studies (QUIPS) tool. We compared different techniques, exact promoter regions (5'-cytosine-phosphate-guanine-3' (CpG) sites) and thresholds for interpretation within studies by examining hazard ratios. We performed meta-analyses for comparisons of the three most commonly examined methods (immunohistochemistry (IHC), methylation-specific polymerase chain reaction (MSP) and pyrosequencing (PSQ)), with ratios of hazard ratios (RHR), using an imputed value of the correlation between results based on the same individuals.

MAIN RESULTS

We included 32 independent cohorts involving 3474 people that compared two or more methods. We found evidence that MSP (CpG sites 76 to 80 and 84 to 87) is more prognostic than IHC for MGMT protein at varying thresholds (RHR 1.31, 95% confidence interval (CI) 1.01 to 1.71). We also found evidence that PSQ is more prognostic than IHC for MGMT protein at various thresholds (RHR 1.36, 95% CI 1.01 to 1.84). The data suggest that PSQ (mainly at CpG sites 74 to 78, using various thresholds) is slightly more prognostic than MSP at sites 76 to 80 and 84 to 87 (RHR 1.14, 95% CI 0.87 to 1.48). Many variants of PSQ have been compared, although we did not see any strong and consistent messages from the results. Targeting multiple CpG sites is likely to be more prognostic than targeting just one. In addition, we identified and summarised 190 articles describing a single method for measuring MGMT promoter methylation status.

AUTHORS' CONCLUSIONS

PSQ and MSP appear more prognostic for overall survival than IHC. Strong evidence is not available to draw conclusions with confidence about the best CpG sites or thresholds for quantitative methods. MSP has been studied mainly for CpG sites 76 to 80 and 84 to 87 and PSQ at CpG sites ranging from 72 to 95. A threshold of 9% for CpG sites 74 to 78 performed better than higher thresholds of 28% or 29% in two of three good-quality studies making such comparisons.

The association between antidepressant use and assisted reproductive technology (ART) treatment in Danish women: A national registry-based cohort study

OBJECTIVE

To investigate (1) if antidepressant use among women in assisted reproductive technology (ART) treatment and among women without ART treatment influences cumulative live birth rates (CLBR) and number of initiated treatment cycles per woman, (2) whether women undergoing ART treatment are at higher risk of initiating use of antidepressants compared to women not having undergone ART, (3) if mothers after ART treatment have higher risk for postpartum use of antidepressants after ART treatment compared to mothers not having used ART treatment.

STUDY DESIGN

A Danish nation-wide register-based cohort study including all women in ART treatment between 1995 through 2009 and an age-matched comparison group of women not having initiated ART treatment. In both groups, women had no previous children before study entry. The women were followed from time of initiating first ART treatment until time of permanent emigration (> 6 months), date of death, or end of follow-up by 31st of December 2009. Chi-square test was used to assess whether observed differences in CLBR between groups were significant. Adjusted incidence rates (IR) and incidence rate ratio (IRR) with 95 % confidence interval (CI) were calculated using Poisson regression analysis. The main outcome measures were: CLBR, number of initiated ART treatment cycles and IRR of initiating antidepressant use.

RESULTS

Women using antidepressants before, during or after ART treatment were significantly older, had a lower CLBR and a lower mean number of initiated ART treatment cycles compared to women in ART treatment with no use of antidepressants. No significant difference was found in the incidence of initiating antidepressant use between women in ART treatment and the comparison group. However, when comparing only women with a live birth, significantly more women in ART treatment initiated antidepressant use in the postpartum period (adjusted incidence rate ratio (IRR) = 2.56 (95 % CI 1.98-3.30; p < 0.001)).

CONCLUSION

Generally, women undergoing ART treatment are not at higher risk of initiating use of antidepressants compared with an age-matched comparison group not treated with ART. However, women with antidepressant medication use prior to ART initiate fewer ART treatments and have lower CLBR. Even though it has not been possible to adjust for all relevant confounders and our follow-up period only runs until the end of 2009, we still believe the results of this study to be highly relevant. According to our study, clinicians should be aware that women conceiving after ART treatment might experience an increased level of psychological strain during the postpartum period compared to mothers who conceived without ART.

Risk and Protective Factors in the COVID-19 Pandemic: A Rapid Evidence Map

Background: Given the worldwide spread of the 2019 Novel Coronavirus (COVID-19), there is an urgent need to identify risk and protective factors and expose areas of insufficient understanding. Emerging tools, such as the Rapid Evidence Map (rEM), are being developed to systematically characterize large collections of scientific literature. We sought to generate an rEM of risk and protective factors to comprehensively inform areas that impact COVID-19 outcomes for different sub-populations in order to better protect the public. Methods: We developed a protocol that includes a study goal, study questions, a PECO statement, and a process for screening literature by combining semi-automated machine learning with the expertise of our review team. We applied this protocol to reports within the COVID-19 Open Research Dataset (CORD-19) that were published in early 2020. SWIFT-Active Screener was used to prioritize records according to pre-defined inclusion criteria. Relevant studies were categorized by risk and protective status; susceptibility category (Behavioral, Physiological, Demographic, and Environmental); and affected sub-populations. Using tagged studies, we created an rEM for COVID-19 susceptibility that reveals: (1) current lines of evidence; (2) knowledge gaps; and (3) areas that may benefit from systematic review. Results: We imported 4,330 titles and abstracts from CORD-19. After screening 3,521 of these to achieve 99% estimated recall, 217 relevant studies were identified. Most included studies concerned the impact of underlying comorbidities (Physiological); age and gender (Demographic); and social factors (Environmental) on COVID-19 outcomes. Among the relevant studies, older males with comorbidities were commonly reported to have the poorest outcomes. We noted a paucity of COVID-19 studies among children and susceptible sub-groups, including pregnant women, racial minorities, refugees/migrants, and healthcare workers, with few studies examining protective factors. Conclusion: Using rEM analysis, we synthesized the recent body of evidence related to COVID-19 risk and protective factors. The results provide a comprehensive tool for rapidly elucidating COVID-19 susceptibility patterns and identifying resource-rich/resource-poor areas of research that may benefit from future investigation as the pandemic evolves.

Women's perceptions of fertility assessment and counselling 6 years after attending a Fertility Assessment and Counselling clinic in Denmark

STUDY QUESTION

What are women's perceptions and experience of fertility assessment and counselling 6 years after attending a Fertility Assessment and Counselling (FAC) clinic in Denmark?

SUMMARY ANSWER

Women viewed the personalized fertility knowledge and advice they received as important aids to decision-making and they felt the benefits outweighed the risks of receiving personalized fertility information.

WHAT IS KNOWN ALREADY

Many young people wish to become parents in the future. However, research demonstrates there is a gap in women's and men's knowledge of fertility and suggests they may be making fertility decisions based on inaccurate information. Experts have called for the development of interventions to increase fertility awareness so that men and women can make informed fertility decisions and achieve their family-building goals. Since 2011, the FAC clinic in Copenhagen, Denmark has provided personalized fertility assessment and guidance based on clinical examination and evaluation of individual risk factors. Available qualitative research showed that attending the FAC clinic increased fertility awareness and knowledge and was experienced as a catalyst for change (e.g. starting to conceive, pursuing fertility treatment, ending a relationship) in women 1-year post-consultation.

STUDY DESIGN SIZE DURATION

The study was a 6-year follow-up qualitative study of 24 women who attended the FAC clinic between January and June 2012. All women were interviewed during a 2-month period from February to March 2018 at Rigshospitalet, their home or office, in Copenhagen, Denmark. Interviews were held in English and ranged between 60 and 94 min (mean 73 min).

PARTICIPANTS/MATERIALS SETTING METHODS

Invitations to participate in an interview-based follow-up study were sent to 141 women who attended the FAC clinic in 2012. In total, 95 women read the invitation, 35 confirmed interest in participating and 16 declined to participate. Twenty-five interviews were booked and 24 interviews held. Interviews followed a semi-structured format regarding reasons for attending the FAC clinic, if/how their needs were met, and perceptions of fertility assessment and counselling. Data were analysed using thematic analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

At the follow-up interview, women were on average 39.5 years old. Ten were currently single or dating and 14 were married/cohabiting. All were childless when they attended the FAC clinic. At the follow-up interview, 21 women were parents (14 women with one child; 6 with two children; 1 with three children) and the remaining three women intended to have children in the future. The most common reason for originally attending the FAC clinic was to determine how long they could delay childbearing. Most of the women now believed their needs for attending had been met. Those who were dissatisfied cited a desire for more exact ('concrete') information as to their remaining years of fertility, although acknowledged that this was likely not realistic. Women stated that they had felt reassured as to their fertility status after attending the FAC clinic whilst receiving the message that they could not delay childbearing 'too long'. Women viewed personalized fertility knowledge as an important aid to decision-making but cautioned about developing a false sense of security about their fertility and chance of conceiving in the future based on the results. Although women were generally satisfied with their experience, they wished for more time to discuss options and to receive additional guidance after their initial meeting at the FAC clinic.

LIMITATIONS REASONS FOR CAUTION

Participants were from a group of Danish women attending the FAC clinic and interviews were conducted in English, which means they are not representative of all reproductive-aged women. Nevertheless, the study group included a broad spectrum of women who achieved parenthood through different means (heterosexual/lesbian relationship, single parent with donor, co-parent) with various family sizes, and women who were currently childless.

WIDER IMPLICATIONS OF THE FINDINGS

Our study provides support for an individualized approach to fertility education, assessment and counselling provided at a time when the information is relevant to the individual and their current fertility decision-making. The findings suggest that although satisfied with their visit to the FAC clinic, the women wished for more information and guidance after this visit, suggesting that the current intervention may need to be expanded or new interventions developed to meet these additional needs.

STUDY FUNDING/COMPETING INTERESTS

E.K. was funded by an ESHRE Travel/Training grant by ReproUnion, co-financed by the European Union, Interreg V OKS. J.B. reports that the risk evaluation form used at the Fertility Assessment Clinic was inspired by the Fertility Status Awareness Tool FertiSTAT that was developed at Cardiff University for self-assessment of reproductive risk. J.B. also reports personal fees from Merck KGaA, Merck AB, Theramex, Ferring Pharmaceuticals A/S and a research grant from Merck Serono Ltd outside the submitted work. A.N.A. has received personal fees from both Merck Pharmaceuticals and Ferring and grants from Roche Diagnostics outside the submitted work. The other authors report no conflicts of interest.

The impact of the COVID-19 pandemic on self-harm and suicidal behaviour: a living systematic review

Background: The COVID-19 pandemic has caused morbidity and mortality, as well as, widespread disruption to people's lives and livelihoods around the world. Given the health and economic threats posed by the pandemic to the global community, there are concerns that rates of suicide and suicidal behaviour may rise during and in its aftermath. Our living systematic review (LSR) focuses on suicide prevention in relation to COVID-19, with this iteration synthesising relevant evidence up to June 7 th 2020. Method:  Automated daily searches feed into a web-based database with screening and data extraction functionalities. Eligibility criteria include incidence/prevalence of suicidal behaviour, exposure-outcome relationships and effects of interventions in relation to the COVID-19 pandemic. Outcomes of interest are suicide, self-harm or attempted suicide and suicidal thoughts. No restrictions are placed on language or study type, except for single-person case reports. Results: Searches identified 2070 articles, 29 (28 studies) met our inclusion criteria, of which 14 articles were research letters or pre-prints awaiting peer review. All articles reported observational data: 12 cross-sectional; eight case series; five modelling; and three service utilisation studies. No studies reported on changes in rates of suicidal behaviour. Case series were largely drawn from news reporting in low/middle income countries and factors associated with suicide included fear of infection, social isolation and economic concerns.   Conclusions:  A marked improvement in the quality of design, methods, and reporting in future studies is needed. There is thus far no clear evidence of an increase in suicide, self-harm, suicidal behaviour, or suicidal thoughts associated with the pandemic. However, suicide data are challenging to collect in real time and economic effects are evolving. Our LSR will provide a regular synthesis of the most up-to-date research evidence to guide public health and clinical policy to mitigate the impact of COVID-19 on suicide. PROSPERO registration: CRD42020183326 01/05/2020.

The impact of the COVID-19 pandemic on self-harm and suicidal behaviour: update of living systematic review

Background: The COVID-19 pandemic has caused considerable morbidity, mortality and disruption to people's lives around the world. There are concerns that rates of suicide and suicidal behaviour may rise during and in its aftermath. Our living systematic review synthesises findings from emerging literature on incidence and prevalence of suicidal behaviour as well as suicide prevention efforts in relation to COVID-19, with this iteration synthesising relevant evidence up to 19 th October 2020. Method:  Automated daily searches feed into a web-based database with screening and data extraction functionalities. Eligibility criteria include incidence/prevalence of suicidal behaviour, exposure-outcome relationships and effects of interventions in relation to the COVID-19 pandemic. Outcomes of interest are suicide, self-harm or attempted suicide and suicidal thoughts. No restrictions are placed on language or study type, except for single-person case reports. We exclude one-off cross-sectional studies without either pre-pandemic measures or comparisons of COVID-19 positive vs. unaffected individuals. Results: Searches identified 6,226 articles. Seventy-eight articles met our inclusion criteria. We identified a further 64 relevant cross-sectional studies that did not meet our revised inclusion criteria. Thirty-four articles were not peer-reviewed (e.g. research letters, pre-prints). All articles were based on observational studies. There was no consistent evidence of a rise in suicide but many studies noted adverse economic effects were evolving. There was evidence of a rise in community distress, fall in hospital presentation for suicidal behaviour and early evidence of an increased frequency of suicidal thoughts in those who had become infected with COVID-19. Conclusions:  Research evidence of the impact of COVID-19 on suicidal behaviour is accumulating rapidly. This living review provides a regular synthesis of the most up-to-date research evidence to guide public health and clinical policy to mitigate the impact of COVID-19 on suicide risk as the longer term impacts of the pandemic on suicide risk are researched.

Age-related natural fertility outcomes in women over 35 years: a systematic review and individual participant data meta-analysis

STUDY QUESTION

What is the rate of natural conception leading to ongoing pregnancy or livebirth over 6–12 months for infertile women of age ≥35 years?

SUMMARY ANSWER

Natural conception rates were still clinically relevant in women aged 35 years and above and were significantly higher in women with unexplained infertility compared to those with other diagnoses.

WHAT IS KNOWN ALREADY

In recent years, increasing numbers of women have attempted to conceive at a later age, resulting in a commensurate increase in the need for ART. However, there is a lack of data on natural fertility outcomes (i.e. no interventions) in women with increasing age.

STUDY DESIGN, SIZE, DURATION

A systematic review with individual participant data (IPD) meta-analysis was carried out. PubMed, MEDLINE, EMBASE, the Cochrane Library, clinicaltrials.gov were searched until 1 July 2018 including search terms ‘fertility service’, ‘waiting list’, ‘treatment-independent’ and ‘spontaneous conception’. Language restrictions were not imposed.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Inclusion criteria were studies (at least partly) reporting on infertile couples with female partner of age ≥35 years who attended fertility services, underwent fertility workup (e.g. history, semen analysis, tubal status and ovulation status) and were exposed to natural conception (e.g. independent of treatment such as IVF, ovulation induction and tubal surgery). Studies that exclusively studied only one infertility diagnosis, without including other women presenting to infertility services for other causes of infertility, were excluded. For studies that met the inclusion criteria, study authors were contacted to provide IPD, after which fertility outcomes for women of age ≥35 years were retrieved. Time to pregnancy or livebirth and the effect of increasing age on fertility outcomes after adjustment for other prognostic factors were analysed. Quality of studies was graded with the Newcastle–Ottawa Scale (non-randomised controlled trials (RCTs)) or the Cochrane Risk of Bias tool (for RCTs).

MAIN RESULTS AND THE ROLE OF CHANCE

We included nine studies (seven cohort studies and two RCTs) (n = 4379 women of at least age 35 years), with the observed composite primary outcome of ongoing pregnancy or livebirth occurring in 429 women (9.8%) over a median follow-up of 5 months (25th to 75th percentile: 2.5–8.5 months). Studies were of moderate to high quality. The probability of natural conception significantly decreased with any diagnosis of infertility, when compared with unexplained infertility. We found non-linear effects of female age and duration of infertility on ongoing pregnancy and tabulated the predicted probabilities for unexplained infertile women aged 35–42 years with either primary or secondary infertility and with a duration of infertility from 1 to 6 years. For a 35-year-old woman with 2 years of primary unexplained infertility, the predicted probability of natural conception leading to ongoing pregnancy or livebirth was 0.15 (95% CI 0.11–0.19) after 6 months and 0.24 (95% CI 0.17–0.30) after 12 months. For a 42-year-old woman, this decreased to 0.08 (95% CI 0.04–0.11) after 6 months and 0.13 (95% CI 0.07–0.18) after 12 months.

LIMITATIONS, REASONS FOR CAUTION

In the studies selected, there were different study designs, recruitment strategies in different centres, protocols and countries and different methods of assessment of infertility. Data were limited for women above the age of 40 years.

WIDER IMPLICATIONS OF THE FINDINGS

Women attending fertility services should be encouraged to pursue natural conception while waiting for treatment to commence and after treatment if it is unsuccessful. Our results may aid in counselling women, and, in particular, for those with unexplained infertility.

STUDY FUNDING/COMPETING INTEREST(S)

S.J.C. received funding from the University of Adelaide Summer Research Scholarship. B.W.M. is supported by a NHMRC Investigator grant (GNT1176437), B.W.M. reports consultancy for ObsEva, Merck, Merck KGaA, iGenomix and Guerbet. B.W.M. reports research support by Merck and Guerbet.

PROSPERO REGISTRATION NUMBER

CRD42018096552.

Patients' attitudes and preferences towards a freeze-all strategy in ART treatment

STUDY QUESTION

What are the attitudes towards different aspects of a freeze-all strategy and elective frozen embryo transfer (eFET) in comparison with fresh embryo transfer in assisted reproductive technology treatment among female and male patients before and after their first ART treatment cycle in a public health care setting?

SUMMARY ANSWER

Despite concerns about the delay in embryo transfer associated with eFET, nearly 60% of the participants were in favor of eFET compared with fresh embryo transfer assuming that the clinical pregnancy rate was equivalent.

WHAT IS KNOWN ALREADY

Vitrification and blastocyst transfer have considerably improved success rates after FET with ongoing pregnancy rates in frozen cycles approaching those seen in fresh treatment cycles. Furthermore, the risk of ovarian hyperstimulation syndrome (OHSS) is essentially eliminated in FET cycles, and FET may be beneficial to the endometrial and fetal development because a hormonal environment mirroring the natural cycle is enabled. However, the freeze-all strategy is not yet implemented as standard care. One reason is the presumption of negative patient attitudes towards a freeze-all embryo strategy. So far, no data regarding patients' attitudes on a freeze-all strategy have been published.

STUDY DESIGN, SIZE, DURATION

This study was designed as a descriptive cross-sectional study including 165 fertility patients referred for their first ART treatment from December 2014 to June 2016.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All newly referred patients participating in a mandatory meeting before initiating ART treatment at the Fertility Clinic, Hvidovre Hospital, Copenhagen, Denmark were requested to fill in an online web-based questionnaire separately for men and women covering attitudes towards a freeze-all strategy, socio-demographic data and reproductive history. The patients were informed about both conventional fresh embryo transfer strategy and the freeze-all strategy prior to answering the questionnaire.

MAIN RESULTS AND THE ROLE OF CHANCE

The total response rate was 77.1% (n = 165), and for women and men respectively 85.8 versus 66.0%. The female respondents were significantly more likely to consider the postponement of embryo transfer difficult compared to the male population (78.6 versus 35.5%; P < 0.001) and they were significantly more willing to accept a risk in treatment on own health to achieve a pregnancy than were the male respondents on their partners health (82.5 versus 96.8%; P = 0.025). However, 59.2% of the women and 59.7% of the men agreed that they would choose eFET over fresh embryo transfer if the chance of pregnancy were the same. Most of the patients furthermore agreed that the health of the mother and their baby was of highest importance. In the adjusted analyses we found no significant predictive factors for preferences towards a freeze-all strategy apart from a negative attitude towards delay of transfer in case of previous unsuccessful ART attempts.

LIMITATIONS, REASONS FOR CAUTION

Selection bias cannot be excluded, as the total response rate was 77.1%. The hypothetical nature of the items may furthermore limit the validity of the results. In addition, the participants were from a single Fertility Clinic in the Capital Region of Denmark and may therefore not be representative for all fertility patients.

WIDER IMPLICATIONS OF THE FINDINGS

In a clinical setting with similar pregnancy rates for eFET and fresh embryo transfer, these results indicate that patients, when given access to information on advantages and disadvantages of both fresh embryo transfer and eFET, are less prone to opt for fresh embryo transfer. This may be ground breaking for a patient-centered paradigm shift in routine ART treatment with a wider implementation of a freeze-all and eFET-strategy eliminating the risk of OHSS.

STUDY FUNDING/COMPETING INTEREST(S)

The Danish Council for Independent Research and Merck Serono supported the study. The study is part of the Reprounion Collaborative study, co-financed by the European Union, Interreg V ÖKS. No competing interests exist.

Recurrent pregnancy loss: couples' perspectives on their need for treatment, support and follow up

STUDY QUESTION

What do couples referred to or attending a recurrent pregnancy loss (RPL) clinic believe they need in terms of treatment, support and follow up?

SUMMARY ANSWER

Men and women wish for more information, earlier access to treatment, support and follow up that is sensitive to their history of pregnancy loss (PL), includes both members of the couple, and acknowledges the psychological impact of RPL.

WHAT IS KNOWN ALREADY

Previous research has highlighted women's dissatisfaction with medical care provided post-PL and their desire for medical professionals to have increased awareness about PL and recognition of the psychological impact of PL. Less is known about the needs of the male partner, the needs of those experiencing RPL and whether the needs differ during different reproductive stages.

STUDY DESIGN, SIZE, DURATION

Over a 2-month period in 2017-2018, 13 couples who were referred to the national RPL program in Copenhagen, Denmark were qualitatively interviewed.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Inclusion criteria were heterosexual couples with at least three consecutive PLs before 12 weeks' gestation with no children or one child prior to the PLs, not currently pregnant, and willing to be interviewed in English. Couples were interviewed together in a semi-structured format. Data were analyzed using thematic analysis. Invitations (n = 30) were sent to couples recently referred to the RPL program who indicated an interest in participating and 17 couples contacted the interviewer to schedule an interview. Due to cancellations, 15 interviews were held. Data from 13 interviews that met the study criteria were used for the current analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

The participants had experienced a median of three PLs (range 3-6). Both men and women described the cumulative effect of RPL with an increase in pressure and exhaustion by the third and subsequent losses. Inclusion of the male partner in consultations and treatment was seen as important. Men felt pressured to remain positive and support their partners despite their own feelings of loss. The findings showed that couples desired reliable and accurate information about RPL. They wished for recognition from the medical community that RPL has a significant psychological impact, and stressed that effective treatment should include both members of the couple, with attention to both physical and psychological aspects of the RPL and should be tailored to their current reproductive stage, in order to help them cope with the negative impact of RPL and the anxiety associated with conception and another pregnancy.

LIMITATIONS, REASONS FOR CAUTION

Participants were self-selected thus findings cannot be generalized to all couples with RPL.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first study addressing the needs of the female and male partners in couples suffering from RPL. The findings highlight a disconnect between couples' perceived needs and their experience of medical care after RPL. This may be partly due to a discrepancy in couples' and medical professionals' perceptions of the PLs. The findings highlight that medical professionals need to take a holistic and couple-focused approach in their treatment of RPL and include attention to the psychological impact and cumulative effect of the multiple PLs on the couple. The results underscore the need for informational resources and psychological support for couples experiencing RPL, tailored to their reproductive stage.

STUDY FUNDING/COMPETING INTEREST(S)

EK was funded by a Travel/Training Fellowship from ReproUnion, co-financed by the European Union, Interreg V ÖKS. No other competing interests were declared.

TRIAL REGISTRATION NUMBER

N/A.

Depression among men in ART treatment: a register-based national cohort study

STUDY QUESTION

Are male factor infertility or remaining childless risk factors for unipolar depression among men in assisted reproductive technology (ART) treatment?

SUMMARY ANSWER

Male factor infertility was not associated with a significantly increased risk of unipolar depression and men remaining childless did not have a significantly increased risk of developing unipolar depression compared to men in ART treatment who became fathers.

WHAT IS KNOWN ALREADY

Men in medically assisted reproduction due to male factor infertility are more distressed and have more negative emotions such as feelings of loss, stigma and low self-esteem compared to men in fertility treatment due to other infertility diagnosis. Stress is in general a risk factor for depression. However, previous studies show conflicting results whether male factor infertility is a risk factor for depression.

STUDY DESIGN, SIZE, DURATION

This national, register-based cohort study consisted of 37 913 cohabitant male partners of women in ART treatment recorded in the Danish IVF register (1994–2009). Via a national register, the men’s personal identification number data were linked to the Danish Psychiatric Central Research Register (PCRR) (1969–2009) which records psychiatric diagnoses including unipolar depression, based on the ICD-8 and ICD-10 classification system.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The full cohort of male partners (n = 37 913) was included in the initial analysis on prevalence of unipolar depression before or after ART treatment initiation. The association between male factor infertility and unipolar depression diagnosis after initiating ART treatment was analysed with Cox regression analysis in a sub-study population of men with the exclusion of men having a depression prior to ART treatment or not having full data on educational level and infertility diagnosis (n = 34 817).

MAIN RESULTS AND THE ROLE OF CHANCE

Overall, 1.2% (n = 446) of the men were diagnosed with unipolar depression either before initiating ART treatment (n = 146) or during follow-up (n = 300). In all, 76.0% of men with depression prior to or after ART treatment achieved fatherhood compared to 82.3% of men without depression (P < 0.001). In the sub-study population (n = 34 817, which included 266 men with a unipolar depression diagnosis), male factor infertility was not associated a significantly increased risk of depression (adjusted hazard ratio (aHR) = 1.04, 95% CI: 0.79–1.36, P = 0.804), and ART-treated men who remained childless did not have a significantly increased risk of developing depression compared to ART treated men who became fathers (aHR = 1.13, 95% CI: 0.87–1.48, P = 0.355).

LIMITATIONS, REASONS FOR CAUTIONS

Only severe cases of depression are recorded and included in this national register-based study given that only men with clinically diagnosed unipolar depression recorded in a psychiatric hospital (in-patient and out-patient) are included in the Danish PCRR. It is difficult to completely rule out an association between the exposures and depression as this outcome is so rare, and therefore the results are still statistically uncertain despite a large cohort. Furthermore, only men in ART treatment were included in this study, and caution should be taken in generalising findings to the total population of men in all areas of medically assisted reproduction or infertile men who have not sought treatment.

WIDER IMPLICATIONS OT THE FINDINGS

This large national cohort study suggests that despite evidence showing that male factor infertility is a potential severe stressor for men, which can increase psychological distress and negative emotions, infertile men in ART treatment and men remaining childless after ART are not at a significantly increased risk of developing clinically diagnosed unipolar depression.

STUDY FUNDING/COMPETING INTERESTS

C.S.S. was funded by unrestricted research grants received by Lone Schmidt from The Danish Health Insurance Foundation (J.nr. 2008B105) and Merck Sharp & Dohme (MSD). The sponsors had no influence on how data were retrieved and analysed or on the conclusions of the study. C.S.S. and L.S. have declared conflicts of interests; the remaining co-authors have no conflicts of interests to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

[Coronavirus: Predictive brain and terror management]

Emerging infectious diseases like Covid-19 cause a major threat to global health. When confronted with new pathogens, individuals generate several beliefs about the epidemic phenomenon. Many studies have shown that individual protective behaviors largely depend on these beliefs. Due to the absence of treatment and vaccine against these emerging pathogens, the relation between these beliefs and these behaviors represents a crucial issue for public health policies. In the premises of the Covid-19 pandemic, several preliminary studies have highlighted a delay in the perception of risk by individuals, which potentially holds back the implementing of the necessary precautionary measures: people underestimated the risks associated with the virus, and therefore also the importance of complying with sanitary guidelines. During the peak of the pandemic, the salience of the threat and of the risk of mortality could then have transformed the way people generate their beliefs. This potentially leads to upheavals in the way they understand the world. Here, we propose to explore the evolution of beliefs and behaviors during the Covid-19 crisis, using the theory of predictive coding and the theory of terror management, two influential frameworks in cognitive science and in social psychology.