Electrical stimulation in the bed nucleus of the stria terminalis alleviates severe obsessive-compulsive disorder

In 1998, we proposed deep brain stimulation as a last-resort treatment option for patients suffering from severe, treatment-resistant obsessive-compulsive disorder (OCD). Here, 24 OCD patients were included in a long-term follow-up study to evaluate the effects of electrical stimulation in the anterior limbs of the internal capsule (ALIC) and bed nucleus of the stria terminalis (BST). We find that electrical stimulation in the ALIC/BST area is safe and significantly decreases obsessions, compulsions, and associated anxiety and depressive symptoms, and improves global functioning in a blinded crossover trial (n=17), after 4 years (n=18), and at last follow-up (up to 171 months, n=24). Moreover, our data indicate that BST may be a better stimulation target compared with ALIC to alleviate OCD symptoms. We conclude that electrical stimulation in BST is a promising therapeutic option for otherwise treatment-resistant OCD patients.

Experimental selection of paromomycin and miltefosine resistance in intracellular amastigotes of Leishmania donovani and L. infantum

Although widespread resistance of Leishmania donovani and L. infantum against miltefosine (MIL) and paromomycin (PMM) has not yet been demonstrated, both run the risk of resistance selection. Unraveling the dynamics and mechanisms of resistance development is key to preserve drug efficacy in the field. In this study, resistance against PMM and MIL was experimentally selected in vitro in intracellular amastigotes of several strains of both species with different antimony susceptibility background. To monitor amastigote susceptibility, microscopic determination of IC50-values and promastigote back-transformation assays were performed. Both techniques were also used to evaluate the susceptibility of field isolates from MIL-relapse patients. PMM-resistance could readily be selected in all species/strains, although promastigotes remained fully PMM-susceptible. Successful MIL-resistance selection was demonstrated only by promastigote back-transformation at increasing MIL-concentrations upon successive selection cycles. Important to note is that amastigotes with the MIL-resistant phenotype could not be visualized after Giemsa staining; hence, MIL-IC50-values showed no shift. The same phenomenon was observed in a set of recent clinical isolates from MIL-relapse patients. This study clearly endorses the need to use intracellular amastigotes for PMM- and MIL-susceptibility testing. When monitoring MIL-resistance, promastigote back-transformation should be used instead of the standard Giemsa staining. In-depth exploration of the mechanistic background of this finding is warranted.

154 compared to 54 mmol per liter of sodium in intravenous maintenance fluid therapy for adult patients undergoing major thoracic surgery (TOPMAST): a single-center randomized controlled double-blind trial

PURPOSE

To determine the effects of the sodium content of maintenance fluid therapy on cumulative fluid balance and electrolyte disorders.

METHODS

We performed a randomized controlled trial of adults undergoing major thoracic surgery, randomly assigned (1:1) to receive maintenance fluids containing 154 mmol/L (Na154) or 54 mmol/L (Na54) of sodium from the start of surgery until their discharge from the ICU, the occurrence of a serious adverse event or the third postoperative day at the latest. Investigators, caregivers and patients were blinded to the treatment. Primary outcome was cumulative fluid balance. Electrolyte disturbances were assessed as secondary endpoints, different adverse events and physiological markers as safety and exploratory endpoints.

FINDINGS

We randomly assigned 70 patients; primary outcome data were available for 33 and 34 patients in the Na54 and Na154 treatment arms, respectively. Estimated cumulative fluid balance at 72 h was 1369 mL (95% CI 601-2137) more positive in the Na154 arm (p < 0.001), despite comparable non-study fluid sources. Hyponatremia < 135 mmol/L was encountered in four patients (11.8%) under Na54 compared to none under Na154 (p = 0.04), but there was no significantly more hyponatremia < 130 mmol/L (1 versus 0; p = 0.31). There was more hyperchloremia > 109 mmol/L under Na154 (24/35 patients, 68.6%) than under Na54 (4/34 patients, 11.8%) (p < 0.001). The treating clinicians discontinued the study due to clinical or radiographic fluid overload in six patients receiving Na154 compared to one patient under Na54 (excess risk 14.2%; 95% CI - 0.2-30.4%, p = 0.05).

CONCLUSIONS

In adult surgical patients, sodium-rich maintenance solutions were associated with a more positive cumulative fluid balance and hyperchloremia; hypotonic fluids were associated with mild and asymptomatic hyponatremia.

In vitro and in vivo pharmacodynamics of three novel antileishmanial lead series

Objectives

Three new chemical series (bicyclic nitroimidazoles, aminopyrazoles and oxaboroles) were selected by Drugs for Neglected Diseases initiative as potential new drug leads for leishmaniasis. Pharmacodynamics studies included both in vitro and in vivo efficacy, cross-resistance profiling against the current antileishmanial reference drugs and evaluation of their cidal activity potential.

Methods

Efficacy against the reference laboratory strains of Leishmania infantum (MHOM/MA(BE)/67/ITMAP263) and L. donovani (MHOM/ET/67/L82) was evaluated in vitro on intracellular amastigotes and in vivo in the early curative hamster model. Cidal activity was assessed over a period of 15 days in an in vitro ‘time-to-kill’ assay. Cross-resistance was assessed in vitro on a panel of L. infantum strains with different degrees of resistance to either antimony, miltefosine or paromomycin.

Results

All lead compounds showed potent and selective in vitro activity against the Leishmania strains tested and no cross-resistance could be demonstrated against any of the current antileishmanial drugs. Cidal activity was obtained in vitro for all series within 15 days of exposure with some differences noted between L. donovani and L. infantum. When evaluated in vivo, all lead compounds showed high efficacy and no adverse effects were observed.

Conclusions

The new lead series were shown to have cidal pharmacodynamic activity. The absence of cross-resistance with any of the current antileishmanial drugs opens possibilities for combination treatment to reduce the likelihood of treatment failures and drug resistance.

•

Good efficacy was evaluated for all series in vitro and in vivo.

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No cross-resistance towards current anti-leishmanial drugs was observed.

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Cidal activity was obtained in vitro for all series within 15 days of exposure.

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Some differences were observed between L. infantum and L. donovani.

Evidence of a drug-specific impact of experimentally selected paromomycin and miltefosine resistance on parasite fitness in Leishmania infantum

OBJECTIVES

Although miltefosine and paromomycin were only recently introduced to treat visceral leishmaniasis, increasing numbers of miltefosine treatment failures and occasional primary resistance to both drugs have been reported. Understanding alterations in parasite behaviour linked to drug resistance is essential to assess the propensity for emergence and spread of resistant strains, particularly since a positive effect on fitness has been reported for antimony-resistant parasites. This laboratory study compared the fitness of a drug-susceptible parent WT clinical Leishmania infantum isolate (MHOM/FR/96/LEM3323) and derived miltefosine and paromomycin drug-resistant lines that were experimentally selected at the intracellular amastigote level.

METHODS

Parasite fitness of WT, paromomycin-resistant and miltefosine-resistant strains, in vitro and in vivo parasite growth, metacyclogenesis, infectivity and macrophage stress responses were comparatively evaluated.

RESULTS

No significant differences in promastigote fitness were noted between the WT and paromomycin-resistant strain, while clear benefits could be demonstrated for paromomycin-resistant amastigotes in terms of enhanced in vitro and in vivo growth potential and intracellular stress response. The miltefosine-resistant phenotype showed incomplete promastigote metacyclogenesis, decreased intracellular growth and weakened stress response, revealing a reduced fitness compared with WT parent parasites.

CONCLUSIONS

The rapid selection and fitness advantages of paromomycin-resistant amastigotes endorse the current use of paromomycin in combination therapy. Although a reduced fitness of miltefosine-resistant strains may explain the difficulty of miltefosine resistance selection in vitro, the growing number of miltefosine treatment failures in the field still requires further exploratory research.

"My Death Will Not [Be] in Vain": Testimonials from Last Gift Rapid Research Autopsy Study Participants Living with HIV at the End of Life

End-of-life (EOL) HIV cure-related research provides a novel approach to studying HIV reservoirs. The Last Gift is a rapid autopsy research study at the University of California San Diego that enrolls terminally ill people living with HIV (PLWHIV) with a desire to contribute to HIV cure-related research. We conducted in-depth baseline and follow-up interviews with Last Gift study participants. We analyzed interview data applying conventional content analysis. Since summer 2017, 13 participants have been enrolled (n = 11 males and 2 females; aged 45-89 years) and 8 participants interviewed. Terminal illnesses included cancers, heart diseases, and neurodegenerative illnesses. Our analysis revealed five key themes: (1) The Last Gift study has tremendous meaning for participants at the end of their life. (2) HIV-specific altruism was a primary motivator to join the Last Gift study, nested within the context of community, scientific advancement, and moral obligation. (3) Participants did not expect physical benefits yet they perceived emotional/psychological, financial, and societal/scientific benefits. (4) There were minimal participant-perceived risks and concerns. (5) Last Gift participants expressed immense gratitude toward study staff. The Last Gift study provides a framework for ethical HIV cure-related research at EOL and highlighted participants' perspectives, motivations, and experiences. Knowing how PLWHIV understand and experience such studies will remain critical to designing ethical, fully informed HIV cure research protocols that are acceptable to PLWHIV.

Perceptions of Next-of-Kin/Loved Ones About Last Gift Rapid Research Autopsy Study Enrolling People with HIV/AIDS at the End of Life: A Qualitative Interview Study

A growing number of people living with HIV/AIDS are participating in HIV cure-related research at the end of life (EOL). Due to the novelty of EOL HIV cure-related research, there is a need to understand how their next-of-kin (NOK) perceive such research. We conducted in-depth interviews with NOK of the Last Gift study participants at the University of California, San Diego. The Last Gift study occurs in the context of the EOL and involves a full body donation. NOK completed two interviews: (1) shortly after the participants' enrollment in the study and (2) following death. We applied thematic analysis to analyze qualitative data. NOK included seven individuals (five males and two females), including two spouses, one ex-partner, one sister, a grandmother/grandfather, and a close friend. Thematic analysis revealed five key themes: (1) NOK viewed the Last Gift program in a positive light and had an accurate overall understanding of the study; (2) NOK identified factors that motivated participants to donate their body to science; (3) NOK identified benefits of the Last Gift program for both the donors and themselves; (4) NOK did not perceive any physical risks or decisional regrets of study but wanted to minimize psychosocial impacts and ensure the dignity of participants at all times; and (5) NOK noted elements that remained essential to the successful implementation of EOL HIV cure-related research, such as early involvement and clear communication. Our study uniquely contributes to increased understanding and knowledge of what is important from the point of view of supportive NOK to ensure successful implementation of EOL HIV cure-related research. More research will be needed to understand perspectives of less supportive NOK.

Transmission potential of paromomycin-resistant Leishmania infantum and Leishmania donovani

OBJECTIVES

Former studies demonstrated quick selection of paromomycin resistance for Leishmania infantum and Leishmania donovani accompanied by increased fitness. The present study aimed to interpret these findings in an epidemiological context by comparing infection of WT and experimentally derived paromomycin-resistant strains in the sand fly vector.

METHODS

Depending on the Leishmania species, Lutzomyia longipalpis and Phlebotomus perniciosus or Phlebotomus argentipes sand flies were artificially infected with procyclic promastigotes of WT and paromomycin-resistant L. infantum (MHOM/FR/96/LEM3323-cl4) or L. donovani (MHOM/NP/03/BPK275/0-cl18). The infection rate and gut/stomodeal valve colonization were determined to monitor parasite phenotypic behaviour within the vector. The impact of the previously described gain of fitness in the vertebrate host on infectivity for the vector was assessed by feeding L. longipalpis on Syrian golden hamsters heavily infected with either WT or paromomycin-resistant parasites.

RESULTS

WT and paromomycin-resistant Leishmania of both species behaved similarly in terms of infection and parasite location within the studied sand fly species. Blood feeding on infected hamsters did not reveal differences in acquisition of WT and paromomycin-resistant parasites, despite the higher organ burdens observed for the paromomycin-resistant strain. Strains remained resistant after passage in the vector.

CONCLUSIONS

Although paromomycin-resistant parasites show an increased parasite fitness in vitro and in laboratory rodents, the intrinsic infection potential of paromomycin-resistant parasites remains unaltered in the sand fly. Of importance is the fact that paromomycin-resistant Leishmania are able to complete development in the natural vectors and produce stomodeal infection with metacyclic forms, which clearly suggests their potential to spread and circulate in nature.

Performing rapid autopsy for the interrogation of HIV reservoirs

: Rapid autopsy at the end of life in people with HIV (PWH) permits the preservation of valuable tissue specimens for subsequent study of HIV reservoirs. At our institution, we have developed a cohort of PWH who consent to a rapid autopsy to gather a wide range of fluids and tissues with the goal of advancing HIV cure research. The protocol for successfully performing these autopsies has required careful thought and development over months and years. We have now successfully performed six rapid autopsies and detail here our steps to build the study cohort, train and staff a team of more than a dozen personnel, and process and preserve hundreds of samples from each autopsy.

Validation of the Flemish version of the Quality of Life in Short Stature Youth (QoLISSY) questionnaire

OBJECTIVES

The Quality of Life in Short Stature Youth (QoLISSY) questionnaire was recently developed in five European countries to assess health-related quality of life in children and adolescents with idiopathic short stature or growth hormone deficiency from child and parent perspectives. In addition to the existing French version, a Flemish version is needed for use of QoLISSY in the Flemish speaking part of Belgium.

METHODS

Children (8-18 years) and their parents recruited from two Belgian paediatric endocrinology clinics completed the QoLISSY in a cross-sectional study. Cronbach's Alpha and test-retest reliability was assessed. Validity was examined by correlation with the generic KIDSCREEN questionnaire as well as by group comparisons according to diagnostic and treatment status.

RESULTS

The QoLISSY scales had an acceptable internal consistency with Cronbach's Alpha ranging from 0·80 to 0·94 (child version) and from 0·77 to 0·92 (parent version). Test-retest reliability correlation coefficients ranged from r = 0·75 to 0·89 in the child version and from r = 0·58 to 0·85 in the parent version. Moderate correlations with the generic KIDSCREEN questionnaire suggested construct validity. Differences between child groups according to child age, underlying diagnosis, and degree of height deficit were found. Correlations with the European QoLISSY were significant for all scales.

DISCUSSION

The Flemish QoLISSY instrument is a psychometrically sound, reliable, and valid short stature specific questionnaire measuring health-related quality of life. It is expected to be of great use in upcoming clinical research on growth disorders and growth hormone treatment in Belgium and Europe.

Ethical and practical considerations for interventional HIV cure-related research at the end-of-life: A qualitative study with key stakeholders in the United States

Background

A unique window of opportunity currently exists to generate ethical and practical considerations presented by interventional HIV cure-related research at the end-of-life (EOL). Because participants would enroll in these studies for almost completely altruistic reasons, they are owed the highest ethical standards, safeguards, and protections. This qualitative empirical ethics study sought to identify ethical and practical considerations for interventional HIV cure-related research at the EOL.

Methods and findings

We conducted 20 in-depth interviews and three virtual focus groups (N = 36) with four key stakeholder groups in the United States: 1) bioethicists, 2) people with HIV, 3) HIV care providers, and 4) HIV cure researchers. This study produced six key themes to guide the ethical implementation of interventional HIV cure-related research at the EOL: 1) all stakeholder groups supported this research conditioned upon a clearly delineated respect for participant contribution and autonomy, participant understanding and comprehension of the risks associated with the specific intervention(s) to be tested, and broad community support for testing of the proposed intervention(s); 2) to ensure acceptable benefit-risk profiles, researchers should focus on limiting the risks of unintended effects and minimizing undue pain and suffering at the EOL; 3) only well-vetted interventions that are supported by solid pre-clinical data should be tested in the EOL translational research model; 4) the informed consent process must be robust and include process consent; 5) research protocols should be flexible and adopt a patient/participant centered approach to minimize burdens and ensure their overall comfort and safety; and 6) a participant’s next-of-kin/loved ones should be a major focus of EOL research but only if the participant consents to such involvement.

Conclusions

To our knowledge, this empirical ethics study generated the first ethical and practical considerations for interventional HIV cure-related research at the EOL. The ethical complexities of such research must be considered now. We must navigate this ethical conundrum so that we are good stewards of the participants’ extremely altruistic gifts by maximizing the impact and social value of this research. We hope that this study will serve as the foundation for future research and discussion on this topic.

Partial characterization of matrix components interacting with cartilage proteoglycans

The charge content of aqueous suspensions of milled cartilage samples was determined by a colloid titration technique using a particle charge detector, and the data were compared with estimates from chemical analyses. Results indicated a close correlation between charge content determined by titration and that estimated by chemical analyses for samples of nasal septa only (a nonarticular cartilage). Such correlation did not hold for articular cartilages (metacarpalphalangeal joint and patella); extraction of these tissues with 0.1 or 1.2 M NaCl markedly increased the availability of the negative groups. Protein analysis, by SDS--PAGE, of the 1.2 M extracts indicated the presence of basic proteins, some of collagenous origin, such as chondrocalcin and proline-arginine-rich protein, and some of noncollagenous proteins such as pleiotrophin and histone-H2b. These data thus suggest electrostatic interactions between these basic proteins and the negative groups of proteoglycans. Such interactions would have an important effect on the osmotic properties and in the organization of cartilage.

Introducing TOPMAST, the first double-blind randomized clinical trial specifically dedicated to perioperative maintenance fluid therapy in adults

BACKGROUND

Although prescribed to every patient undergoing surgery, maintenance fluid therapy is a poorly researched part of perioperative fluid therapy. The tonicity of the chosen solutions, could be an important cause of morbidity, with hyponatremia being a potential side effect of hypotonic solutions, where isotonic solution could lead to fluid overload.

METHODS

The TOPMAST-trial is an ongoing prospective single-center double-blind randomized trial comparing an isotonic and a hypotonic maintenance fluid strategy during and after surgery in patients undergoing different types of major thoracic surgery. Patients receive NaCl 0.9% in glucose 5% with an added 40 mmol L-1 of potassium chloride or a premixed solution containing 54 mmol L-1 sodium, 55 mmol L-1 chloride and 26 mmol of potassium at a rate of 27 mL per kg of body weight per day. The primary hypothesis is that isotonic maintenance solutions cause a more positive perioperative fluid balance than hypotonic fluids. Different secondary safety endpoints will be explored, especially the effect of the study treatments on the occurrence electrolyte disturbances (e.g. hyponatremia, hyperchloremia) and a set of clinical endpoints. Efficacy endpoints include the need for resuscitation fluids and assessment of renal and hormonal adaptive mechanisms. An anticipated 68 patients will be included between March 2017 and January 2018.

DISCUSSION

The study will provide the most comprehensive evaluation of clinically important outcomes associated with the choice of perioperative maintenance fluid therapy.

Lessons learned from the Last Gift study: ethical and practical challenges faced while conducting HIV cure-related research at the end of life

The Last Gift is an observational HIV cure-related research study conducted with people with HIV at the end of life (EOL) at the University of California San Diego. Participants agree to voluntarily donate blood and other biospecimens while living and their bodies for a rapid research autopsy postmortem to better understand HIV reservoir dynamics throughout the entire body. The Last Gift study was initiated in 2017. Since then, 30 volunteers were enrolled who are either (1) terminally ill with a concomitant condition and have a prognosis of 6 months or less or (2) chronically ill with multiple comorbidities and nearing the EOL.Multiple ethical and logistical challenges have been revealed during this time; here, we share our lessons learnt and ethical analysis. Issues relevant to healthcare research include surrogate informed consent, personal and professional boundaries, challenges posed conducting research in a pandemic, and clinician burnout and emotional support. Issues more specific to EOL and postmortem research include dual roles of clinical care and research teams, communication between research personnel and clinical teams, legally required versus rapid research autopsy, identification of next of kin/loved ones and issues of inclusion. Issues specific to the Last Gift include logistics of body donation and rapid research autopsy, and disposition of the body as a study benefit.We recommend EOL research teams to have clear provisions around surrogate informed consent, rotate personnel to maintain boundaries, limit direct contact with staff associated with clinical care and have a clear plan for legally required versus research autopsies, among other recommendations.

Ethical and practical considerations for HIV cure-related research at the end-of-life: a qualitative interview and focus group study in the United States

BACKGROUND

One of the next frontiers in HIV research is focused on finding a cure. A new priority includes people with HIV (PWH) with non-AIDS terminal illnesses who are willing to donate their bodies at the end-of-life (EOL) to advance the search towards an HIV cure. We endeavored to understand perceptions of this research and to identify ethical and practical considerations relevant to implementing it.

METHODS

We conducted 20 in-depth interviews and 3 virtual focus groups among four types of key stakeholders in the United States (PWH, biomedical HIV cure researchers, HIV clinicians, and bioethicists) to obtain triangulated viewpoints because little was known about the ethics of this topic. Each group was queried as to ethical considerations, safeguards, and protections for conducting HIV cure-related research at the EOL to ensure this research remains acceptable.

RESULTS

All four key stakeholder groups generally supported HIV cure-related research conducted at the EOL because of the history of altruism within the PWH community and the potential for substantial scientific knowledge to be gained. Our informants expressed that: (1) Strong stakeholder and community involvement are integral to the ethical and effective implementation, as well as the social acceptability of this research; (2) PWH approaching the EOL should not inherently be considered a vulnerable class and their autonomy must be respected when choosing to participate in HIV cure-related research at the EOL; (3) Greater diversity among study participants, as well as multi-disciplinary research teams, is necessitated by HIV cure-related research at the EOL; (4) The sensitive nature of this research warrants robust oversight to ensure a favorable risk/benefit balance and to minimize the possibility of therapeutic misconception or undue influence; and (5) Research protocols should remain flexible to accommodate participants' comfort and needs at the EOL.

CONCLUSION

Because of the ethical issues presented by HIV cure-related research at the EOL, robust ethical safeguards are of utmost importance. The proposed ethical and practical considerations presented herein is a first step in determining the best way to maximize this research's impact and social value. More much inquiry will need to be directed towards understanding context-specific and cultural considerations for implementing EOL HIV cure research in diverse settings.

Dg-mapping as a tool to determine the spatial distribution of the focal sources and the number of reentries during torsade de pointes in the cavb dog model

Funding Acknowledgements

Type of funding sources: None.

Background

Torsade de Pointes (TdP) is a ventricular tachycardia that is still incompletely understood. While the origin of the arrhythmia is generally accepted to be caused by triggered activity, the perpetuation of such an episode is still under debate.

Purpose

We compare the difference in reentrant activity between self- and non-terminating(ST and NT) TdP episodes. In addition, we analyzed the distribution of the triggered activity for preferred locations.

Methods

A total of 5 dogs with Chronic Atrioventricular Block developed 54 episodes of TdP. These episodes were examined for reentry loops and focal sources. First, to detect loops, we used Directed Graph Mapping, a novel mapping technique based on principles from network theory. Subsequently, the number of simultaneous loops and the presence of (bi-)ventricular reentry was compared between the ST and NT groups. Second, focal sources were accumulated into heatmaps. The distribution of sources was compared to a randomly distributed model for the detection of preferred locations.

Results

Concerning reentry, during the time at which loops are present, a typical ST episode shows an average of 1.33(±0.66) reentry loops present at one time compared to an average of 2.72(±1.48) for a typical NT episode. Looking at the (bi-)ventricular reentry, only 1 of the 4 ST episodes (25%) shows the presence of this type of reentry and only 7.12 % of the total reentry duration, while all 9 NT episodes (100%) develop (bi-)ventricular reentry to a greater degree than in the one ST episode (Between 10.10% and 69.62% of their total reentry duration). Regarding the triggered activity, we see locations in the heatmaps containing up to 23% of all detected focal sources in the entire system. Compared to a random distribution of focal sources, the chances to get as many sources in one location as shown in the data are close to 0%.

Conclusion

Reentry in NT TdP differentiates itself from the reentry in ST cases on the basis of the number of simultaneous loops in the system and the presence of (bi-)ventricular reentry. Triggered activity in CAVB dogs occurs at preferred locations in the ventricles. Therefore, ablating these preferred regions could be a possible strategy to prevent TdP.

P-671 Progestin primed ovarian stimulation using dydrogesterone in oocyte donation cycles: a longitudinal study

Study question

Does progestin primed ovarian stimulation (PPOS) with dydrogesterone starting from stimulation day 6 yield similar outcomes compared with a GnRH antagonist protocol in oocyte donors?

Summary answer

The number of retrieved oocytes and metaphase II oocytes was similar in both stimulation protocols.

What is known already

The use of progestins in the follicular phase to suppress a premature LH surge as an alternative to the GnRH analogue is an emerging regimen for ovarian stimulation. There is robust evidence of the safety and efficacy of PPOS compared to conventional ovarian stimulation regimens in oocyte donation cycles. Progestins and gonadotropins are typically administered simultaneously from day 2 or day 3 of the cycle onwards. Reports on initiation of progestins at a later stage, from day 6 of stimulation, are scarce.

Study design, size, duration

This is a retrospective longitudinal cohort study comparing two strategies of ovarian stimulation in the same oocyte donors. Oocyte donors who had a PPOS protocol between January 2021 and December 2021 and who had another ovarian stimulation cycle using a GnRH antagonist protocol within the same year were included in the analysis. Dydrogesterone 10 mg twice daily was started on day 6 of stimulation onwards. In total, 68 cycles from 34 oocyte donors were Included.

Participants/materials, setting, methods

All oocyte donors had the same type of gonadotropin and daily dose in both stimulation cycles. The primary outcome was the number of retrieved cumulus oocyte complexes (COC) and the number of metaphase II oocytes. Secondary outcomes were the duration of stimulation, the total dose of gonadotropins, the occurrence of premature ovulation and the difference in total cost between the two stimulation protocols.

Main results and the role of chance

The average female age was 28.3 years (SD 4.3), BMI 24.0 kg/m2 (SD 2.9) and AMH 2.9 µg/l (SD 1.5). When comparing the PPOS cycle with the GnRH antagonist cycle, the mean number of retrieved COCs was 20.0 ± 9.9 and 20.2 ± 9.3, respectively (p = 0.33) and the number of metaphase II oocytes was also similar (15.6 ± 7.9 and 16.9 ± 8.0, respectively; p = 0.35). The duration of stimulation (10.6 ± 1.7 days versus 10.9 ± 1.7 days; p = 0.26) and cumulative dose of gonadotropins (2284.6 ± 494.9 IU versus 2338.2 ± 462.1 IU; p = 0.25) were comparable in the PPOS and the GnRH antagonist group. No events of premature ovulation were observed in both groups. There was a significant difference in total medication cost per cycle between both protocols, 903.3 ± 195.7 € for PPOS versus 1205.3 ± 243.9 € (p &lt; 0.001) for the GnRH antagonist protocol. This means a cost reduction of 25% for the PPOS group compared to the GnRH antagonist group. GEE multivariate regression analysis allowing adjustment for relevant confounders (age, BMI, AMH) showed that the type of protocol was not significantly associated with the number of MII oocytes retrieved (coefficient 1.23, p = 0.33).

Limitations, reasons for caution

The small sample and the retrospective design are limitations of this study.

Wider implications of the findings

PPOS is a patient friendly and well-tolerated protocol. A simplified protocol of ovarian stimulation with the advantage of cost reduction. The protocol can easily be applied in oocyte donation and cycles with elective freeze all. Adequately powered RCTs should be performed to confirm our results.

Trial registration number

not applicable

Struma ovarii: US and CT findings

We describe the ultrasound and CT findings in a case of struma ovarii. Ultrasound showed a multicystic mass with a well-vascularized solid part. CT demonstrated a multilocular cystic mass with calcifications and solid, enhancing components. To prevent radical surgery, struma ovarii should be included in the differential diagnosis when a mixed, multilocular, teratoma-like tumour of the ovary shows a well-vascularized, enhancing, central solid component.

Paracetamol and ketorolac pharmacokinetics and metabolism at delivery and during postpartum

During pregnancy, changes in renal elimination, body composition and metabolic activity occur. Since these important alterations in physiology also affect drug disposition, pregnancy warrants a focused approach. Despite these differences, even commonly administered drugs have not undergone pharmacokinetic evaluation in pregnant women or at delivery. This is also true for analgesics routinely administered by anesthesiologists during pregnancy or at delivery, like intravenous (i.v.) paracetamol or ketorolac. We report on our observations on i.v. paracetamol and ketorolac disposition following cesarean delivery to illustrate the feasibility of such focused studies and the impact of pregnancy on drug disposition. The clinical relevance of these observations are subsequently discussed, and some future research directions are suggested.