Modified natural cycle allows a window of 7 days for frozen embryo transfer planning.

RESEARCH QUESTION: Should ovulation be triggered in a modified natural cycle (mNC) with recombinant human chorionic gonadotrophin (rHCG) as soon as a mean follicle diameter of 17 mm is visible, or is more flexible planning possible? DESIGN: This multicentre, retrospective, observational study of 3087 single frozen blastocyst transfers in mNC was carried out between January 2020 and September 2022. The inclusion criteria included endometrial thickness ≥7 mm and serum progesterone <1.5 ng/ml. The main outcome was ongoing pregnancy rate. Secondary end-points were pregnancy rate, implantation rate, clinical pregnancy rate and miscarriage rate. The mean follicle size at triggering was stratified into three groups (13.0-15.9, 16.0-18.9 and 19.0-22 mm). RESULTS: The baseline characteristics between the groups did not vary significantly for age, body mass index and the donor's age for egg donation. No differences were found in pregnancy rate (64.5%, 60.2% and 57.4%; P = 0.19), clinical pregnancy rate (60.5%, 52.8% and 50.6%; P = 0.10), implantation rate (62.10%, 52.9% and 51.0%; P = 0.05) or miscarriage rate (15.0%, 22.2%; and 25.0%; P = 0.11). Although ongoing pregnancy rate (54.9%, 46.8% and 43.1%; P = 0.02) varied significantly in the univariable analysis, it was no longer significant after adjustment for the use of preimplantation genetic testing for aneuploidies and egg donation. CONCLUSIONS: The findings showed rHCG could be flexibly administered with a mean follicle size between 13 and 22 mm as long as adequate endometrial characteristics are met, and serum progesterone is <1.5 ng/ml. Considering the follicular growth rate of 1-1.5 mm/day, this approach could allow a flexibility for FET scheduling of 6-7 days, simplifying mNC FET planning in clinical practice.

[Foot and ankle pathologies during pregnancy]. / Pathologies du pied et de la cheville pendant la grossesse.

Foot and ankle pain and oedema are a common complaint among pregnant women. A range of hormonal and anatomical changes during pregnancy can cause modifications in foot and ankle's biomechanics and anatomy. The main foot and ankle pathologies encountered in pregnancy are progressive collapsing foot deformity, plantar fasciitis, heel pain, oedema, and fractures. Workup includes the use of radiological evaluation that could pose a risk to the fetus, depending on the gestational age. Treatment plans range from symptomatic conservative to surgical options and a multidisciplinary approach is often recommended and warranted. Our paper aims to present these different pathologies and propose a structured treatment plan to address them.

La douleur et l'œdème du pied et de la cheville sont fréquents chez les femmes enceintes. Plusieurs changements hormonaux et anatomiques pendant la grossesse entraînent des modifications dans la biomécanique et l'anatomie du pied et de la cheville. Les pathologies les plus fréquentes concernant cette localisation rencontrées pendant la grossesse sont le pied plat progressif, la fasciite plantaire, la douleur au talon, l'œdème et les fractures. Le bilan demande souvent une évaluation radiologique pouvant présenter un risque pour le fœtus, en fonction de l'âge gestationnel. Les plans de traitement vont du traitement conservateur à la chirurgie et une approche multidisciplinaire est souvent recommandée et justifiée. Cet article présente ces différentes pathologies et propose un plan de traitement structuré.

Natural proliferative phase frozen embryo transfer-a new approach which may facilitate scheduling without hindering pregnancy outcomes.

STUDY QUESTION: How does a natural proliferative phase (NPP) strategy for frozen embryo transfer (FET) compare with the conventional artificial (AC) and natural (NC) endometrial preparation protocols in terms of live birth rates (LBR)? SUMMARY ANSWER: This study supports the hypothesis that, just as for NC, NPP-FET may be a superior alternative to AC in terms of LBR. WHAT IS KNOWN ALREADY: Although FETs are increasing worldwide, the optimal FET protocol is still largely controversial. Despite recent evidence supporting a possibly higher efficacy and safety of NC FETs, their widespread use is limited by the difficulties encountered during cycle monitoring and scheduling. STUDY DESIGN, SIZE, DURATION: In this single center retrospective cohort study, we describe the NPP-FET protocol, in which vaginal progesterone is initiated during the proliferative phase as soon as an endometrium with a thickness of at least 7 mm is identified and ovulation is ruled out, regardless of mean diameter of the dominant follicle. PARTICIPANTS/MATERIALS, SETTING, METHODS: For comparison, we considered all blastocyst stage FET cycles preformed at a private infertility center between January 2010 and June 2022, subdivided according to the following subgroups of endometrial preparation: AC, NPP, and NC. We performed multivariable generalized estimating equations regression analysis to account for the following potential confounding variables: oocyte age at retrieval, oocyte source (autologous without preimplantation genetic testing for aneuploidies (PGT-A) versus autologous with PGT-A versus donated), number of oocytes retrieved/donated, embryo developmental stage (Day 5 versus Day 6), number of embryos transferred, quality of the best embryo transferred, and year of treatment. The main outcome measure was LBR. The secondary outcomes included hCG positive, clinical pregnancy and miscarriage rates, and the following perinatal outcomes: first trimester bleeding, second/third trimester bleeding, preterm rupture of membranes, gestational diabetes, gestational hypertensive disorders (GHD), and gestational age at delivery. MAIN RESULTS AND THE ROLE OF CHANCE: A total of 5791 FET cycles were included in this analysis (2226 AC, 349 NPP, and 3216 NC). The LBR for FET was lower in the AC subgroup when compared to the NPP and NC (38.4%, 49.1%, and 45.2%, respectively; P < 0.01 AC versus NPP and AC versus NC). The rates of miscarriage were also lower in the NPP and NC subgroups when compared to AC (19.7%, 25.0%, and 34.9%, respectively; P < 0.01 NPP versus AC and NC versus AC). Considering perinatal outcomes, NPP-FET and NC were associated with a significantly lower first trimester bleeding compared to AC (17.3%, 14.7%, and 37.6%, respectively; P < 0.01 NPP versus AC and NC versus AC). Additionally, NC was associated with a lower rate of GHD when compared with AC (8.6% versus 14.5%, P < 0.01), while the rate following NPP-FET was 9.4%. LIMITATIONS, REASONS FOR CAUTION: This study is limited by its retrospective design. Moreover, there was also a low number of patients in the NPP subgroup, which may have led the study to be underpowered to detect clinically relevant differences between the subgroups. WIDER IMPLICATIONS OF THE FINDINGS: Our study posits that the NPP-FET protocol may be an effective and safe alternative to both NC and AC, while still allowing for enhanced practicality in patient follow-up and FET scheduling. Further investigation on NPP-FET is warranted, with prospective studies including a larger and more homogeneous subsets of patients. STUDY FUNDING/COMPETING INTEREST(S): This research was supported by the IVI-RMA-Lisbon (2008-LIS-053-CG). The authors did not receive any funding for this study. The authors have no competing interests. TRIAL REGISTRATION NUMBER: Not applicable.

Being a heritage speaker matters: the role of markedness in subject-verb person agreement in Italian.

This study examines online processing and offline judgments of subject-verb person agreement with a focus on how this is impacted by markedness in heritage speakers (HSs) of Italian. To this end, 54 adult HSs living in Germany and 40 homeland Italian speakers completed a self-paced reading task (SPRT) and a grammaticality judgment task (GJT). Markedness was manipulated by probing agreement with both first-person (marked) and third-person (unmarked) subjects. Agreement was manipulated by crossing first-person marked subjects with third-person unmarked verbs and vice versa. Crucially, person violations with 1st person subjects (e.g., io *suona la chitarra "I plays-3rd-person the guitar") yielded significantly shorter RTs in the SPRT and higher accuracy in the GJT than the opposite error type (e.g., il giornalista *esco spesso "the journalist go-1st-person out often"). This effect is consistent with the claim that when the first element in the dependency is marked (first person), the parser generates stronger predictions regarding upcoming agreeing elements. These results nicely align with work from the same populations investigating the impact of morphological markedness on grammatical gender agreement, suggesting that markedness impacts agreement similarly in two distinct grammatical domains and that sensitivity to markedness is more prevalent for HSs.

Hallux Valgus: The Influence of Intersesamoid Crista's Osteoarthritis on Frontal Plane Pronation.

A frontal plane metatarsal rotational (pronation) has been documented in a high percentage of hallux valgus patients. Pathoanatomical concepts leading to pronation are still debated. Nevertheless, there is no consensus on how to measure this component of the deformity. The aim of the present study was to find potential associations between sesamoid's crista osteoarthritis and the frontal plane deformity in HV cases. Our study showed a moderate correlation between the crista's OA and the intermetatarsal angle (IMA), the hallux valgus angle (HVA) and the alpha angle. In severe hallux vulgus deformed specimens, with an eroded intersesamoid crista, frontal plane pronation was not as prevalent nor severe as in those without osteoarthritic degeneration. Severe hallux valgus cases with a completely eroded crista, showed lower pronation, and higher IMA, when compared to specimens with a preserved anatomy. This brings to light the intersesamoid crista's unique function in retaining the IMA. Understanding the role the frontal plane plays in hallux valgus' biomechanics and in its radiographic appearance is vital to change the current paradigm.

Nature (almost) always prevails - challenging the status quo of artificial cycle frozen embryo transfers.

Frozen embryo transfers (FET) have become increasingly popular in assisted reproductive technology (ART) due to advancements in cryopreservation techniques and the implementation of the 'freeze-all' strategy. The choice between artificial or natural cycles for FET preparation has been a subject of debate, considering factors such as endometrial receptivity, flexibility of scheduling and pregnancy outcomes. While artificial cycle protocols offer convenience and flexibility, studies have suggested potential drawbacks, including higher miscarriage rates and a greater risk of hypertensive disorders during pregnancy. In contrast, natural cycle protocols involve a frequently demanding monitoring of both endometrial proliferation and follicular growth, which may lead to increased clinic visits and scheduling issues. Multiple strategies have been proposed to enhance the usage of natural cycle FET, including addressing anovulation through minimal stimulation, reducing cycle monitoring and exploring novel FET approaches. These novel approaches, such as widening the window for human chorionic gonadotrophin administration and the natural proliferative phase protocol, offer promising outcomes and increased convenience for patients. However, further research is needed to establish the optimal timing and effectiveness of these strategies. Overall, enhancing the practicality of natural cycle FETs is crucial for expanding their utilization during ART.

Total Scapular Prosthesis, an Option for the Treatment of Scapular Chondrosarcoma.

Introduction: Chondrosarcoma has the highest prevalence among the primary malignant bone tumors in adults over the age of 50, and the scapular region is the most affected anatomical site. Case Report: We report the case of a 66-year-old female patient, with no previous medical history, who consulted for aggravating mixed, non-specific, and atraumatic pain in the right shoulder, evolving for a year. The radiological assessment, including a computed tomography (CT) scan, a magnetic resonance imaging, and a tumor CT-guided biopsy, confirmed the diagnosis of a Grade 2 chondrosarcoma. A curative surgical treatment was performed, by an extended tumor resection and simultaneous joint reconstruction by a reversed total shoulder prosthesis with a custom-made total scapular prosthesis. This option allows to maintain survival prognosis, associated with the preservation of upper limb function. Conclusion: The results were conclusive at the curative level and very encouraging from the functional point of view with progressive and partial recovery of the articular amplitudes, allowing the preservation of patient's autonomy and quality of life. No complications such as scapular dislocation or tumor recurrence were documented at 3-year postoperative follow-up.

Shared IVF among female couples: clinical outcomes of the Reception of Oocytes from the Partner (ROPA) method.

RESEARCH QUESTION: What is the population undergoing the ROPA (Reception of Oocytes from Partner) method and what are the outcomes of the technique? DESIGN: Case series of all ROPA treatments carried out between 2011 and 2020 in 18 fertility clinics in Spain. Demographic characteristics, cycle features, laboratory and clinical outcomes, and the intentions regarding the disposition of surplus embryos were analysed. RESULTS: Donor patients were on average 3.5 years younger than recipients (P = 0.001). No significant differences were found in body mass index or anti-Müllerian hormone. In 13% of cases, fertility issues were found: poor ovarian reserve (6.8%); endometriosis (2.9%); and polycystic ovary syndrome (2.2%). Including cases of advanced age (38 years old or older), more than one-half of couples (53.6%) had some condition that could affect fertility. Mean number of mature oocytes per cycle was 10 (+/- 5.7), and fertilization rate was 74.5% (+/- 18.8). Mean number of viable embryos was 3.2 (+/- 1.5). Surplus embryos were cryopreserved in 50.4% of cycles. Outcomes after embryo transfers from ROPA, and subsequent frozen cycles were as follows: positive pregnancy test (61.0%), clinical pregnancy (54.1%) and miscarriage rate (16.1%). Other outcomes were live birth rate per embryo transfer (44.7%); multiple pregnancy rate (5.4%); per cumulative ROPA cycle (48.6%); and per couple (61.6%). CONCLUSION: The outcomes of the ROPA method are reassuring. About one-half of the ROPA cycles resulted in a live birth and one-quarter of the cycles had surplus embryos after achieving a live birth. Main neonatal outcomes were also reassuring.

Screening for diminished ovarian reserve in Portugal: a cost-saving answer to shorten the fertility journey.

Aim: Assess the budget impact of nationwide screening for diminished ovarian reserve (OR), via anti-Müllerian hormone (AMH) levels, to the Portugal National Health System (NHS). Patients & methods: The clinical journey was determined using literature and the family planning decision-making process/response using survey results. A panel of four local clinicians validated all assumptions/inputs. Results: Screening for OR led to an expected savings of € 9.4 million for the NHS, driven by a 24% reduction in medically assisted reproduction (MAR) use. When needed, referral for MAR was earlier and more women used first-line versus second-line techniques. The model estimated a 12% decrease in failure. Conclusion: This model shows AMH screening may allow more informed decisions, leading to a shorter fertility journey, more efficient use of treatments, and substantial cost-savings for the NHS.

Anatomy of the Ankle and Subtalar Joint Ligaments: What We Do Not Know About It?

Understanding of the ankle and subtalar joint ligaments is essential to recognize and manage foot and ankle disorders. The stability of both joints relies on the integrity of its ligaments. The ankle joint is stabilized by the lateral and medial ligamentous complexes while the subtalar joint is stabilized by its extrinsic and intrinsic ligaments. Most injuries to these ligaments are linked with ankle sprains. Inversion or eversion mechanics affect the ligamentous complexes. A profound knowledge of the ligament's anatomy allows orthopedic surgeons to further understand anatomic or nonanatomic reconstructions.

Female couples undergoing assisted reproduction - choices and the importance of pregnancy and genetics.

OBJECTIVE: To evaluate female couples' reproductive choices, the importance given to genetics and pregnancy and their expectations regarding mother-child relationship. METHODS: Observational study based on an anonymous survey applied to 217 patients during 2021. The survey was given to female couples under reproductive treatment in a private fertility clinic. The outcomes were divided into 3 main groups: the choice of their reproductive treatment, motherhood and biological links, and their plans for future reproductive treatments. RESULTS: Most patients found it easy to choose their treatments and roles. The choice was mainly driven by success rates, costs, and simplicity, except for ROPA for which sharing biological motherhood was the main reason. Most couples consider genetics and pregnancy important but, in the end, they believe they will have a similar connection to their child, regardless of the role played. In the future, some couples consider doing the same treatment while others consider inverting roles. CONCLUSIONS: Most female couples have no difficulty when it comes to choosing a reproductive treatment or role to play, mainly based on costs, success rates and the possibility of sharing biological motherhood with the ROPA method. These patients give great importance to genetics and pregnancy, but they expect a similar connection to their child regardless of the type of treatment and the roles played.

Current Concepts of Foot and Ankle Angioleiomyoma.

Angioleiomyoma is a benign tumor, which arises from the smooth muscle. It comprises approximately 4.4% of all benign soft tissues' neoplasms and they are commonly located at the lower extremities. They are most frequently found in middle-aged women. Angioleiomyoma is usually presented as a painful solitary lesion in the subcutaneous tissue. Due to the lack of evidence in the literature, the aim of this current concepts review was to provide foot and ankle surgeons the most updated and useful information for diagnosis and management of foot or ankle's angioleiomyoma. The possible diagnosis of angioleiomyoma is rarely thought of before surgery. X-ray, US, MRI, aspiration, scintigraphy, CT and EMG make part of the diagnostic tools available and angioleiomyoma's main characteristics in each of the exams are detailed. Angioleiomyoma cannot be neglected as consequence of delay or mistreatment increases morbidity and the potential risk to malignant transformation.

The combined effect of BMI and age on ART outcomes.

STUDY QUESTION: For a woman with infertility and overweight/obesity, can infertility treatment be postponed to first promote weight loss? SUMMARY ANSWER: Advice regarding a delay in IVF treatment to optimize female weight should consider female age, particularly in women over 38 years for whom only substantial weight loss in a short period of time (3 months) seems to provide any benefit. WHAT IS KNOWN ALREADY: Body weight excess and advanced age are both common findings in infertile patients, creating the dilemma of whether to promote weight loss first or proceed to fertility treatment immediately. Despite their known impact on fertility, studies assessing the combined effect of female age and BMI on cumulative live birth rates (CLBRs) are still scarce and conflicting. STUDY DESIGN, SIZE, DURATION: We performed a multicentre retrospective cohort study including 14 213 patients undergoing their first IVF/ICSI cycle with autologous oocytes and subsequent embryo transfers, between January 2013 and February 2018 in 18 centres of a multinational private fertility clinic. BMI was subdivided into the following subgroups: underweight (<18.5 kg/m2), normal weight (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), and obesity (≥30.0 kg/m2). PARTICIPANTS/MATERIALS, SETTING, METHODS: The primary outcome was CLBR. The secondary outcome was time to pregnancy. To assess the influence of female age and BMI on CLBR, two multivariable regression models were developed with BMI being added in the models as either an ordinal categorical variable (Model 1) or a continuous variable (Model 2) using the best-fitting fractional polynomials. CLBR was estimated over 1-year periods (Model 1) and shorter timeframes of 3 months (Model 2). We then compared the predicted CLBRs according to BMI and age. MAIN RESULTS AND THE ROLE OF CHANCE: When compared to normal weight, CLBRs were lower in women who were overweight (adjusted odds ratio (aOR) 0.86, 95% CI 0.77-0.96) and obese (aOR 0.74, 95% CI 0.62-0.87). A reduction of BMI within 1 year, from obesity to overweight or overweight to normal weight would be potentially beneficial up to 35 years old, while only a substantial reduction (i.e. from obesity to normal BMI) would be potentially beneficial in women aged 36-38 years. Above 38 years of age, even considerable weight loss did not compensate for the effect of age over a 1-year span but may be beneficial in shorter time frames. In a timeframe of 3 months, there is a potential benefit in CLBR if there is a loss of 1 kg/m2 in BMI for women up to 33.25 years and 2 kg/m2 in women aged 33.50-35.50 years. Older women would require more challenging weight loss to achieve clinical benefit, specifically 3 kg/m2 in women aged 35.75-37.25 years old, 4 kg/m2 in women aged 37.50-39.00 years old, and 5 kg/m2 or more in women over 39.25 years old. LIMITATIONS, REASONS FOR CAUTION: This study is limited by its retrospective design and lower number of women in the extreme BMI categories. The actual effect of individual weight loss on patient outcomes was also not evaluated, as this was a retrospective interpatient comparison to estimate the combined effect of weight loss and ageing in a fixed period on CLBR. WIDER IMPLICATIONS OF THE FINDINGS: Our findings suggest that there is potential benefit in weight loss strategies within 1 year prior to ART, particularly in women under 35 years with BMI ≥25 kg/m2. For those over 35 years of age, weight loss should be considerable or occur in a shorter timeframe to avoid the negative effect of advancing female age on CLBR. A tailored approach for weight loss, according to age, might be the best course of action. STUDY FUNDING/COMPETING INTEREST(S): No specific funding was obtained for this study. All authors have no conflicts to declare. TRIAL REGISTRATION NUMBER: N/A.

Radiological and Anatomical Evaluation of First Metatarsal Pronation in Hallux Valgus Deformity: A Comparison Between Three Different Methods.

A frontal plane metatarsal rotational (pronation) has been documented in a high percentage of hallux valgus patients. Pathoanatomical concepts leading to pronation are still debated. Nevertheless, there is no consensus on how to measure this component of the deformity. The aim of the present study was to compare three commonly used radiographic methods to measure the frontal plane deformity in hallux valgus deformity, such as 1. Round sign of the lateral edge of the first metatarsal head on anterior-posterior radiograph, 2. Non-weightbearing CT-scan and 3. Bernard's axial projection of the first metatarsal head. Afterwards, feet were dissected, and a direct measurement of the pronation was done. Our data showed that alpha angle measurements made through the Bernard's axial projection were closer with those obtained during the dissection compared to those made through the CT-scan. The main finding of our study is that osteoarthritic changes at the metatarso-sesamoid joint play an important role in severe hallux valgus cases. The proposed radiographic methods allow surgeons to verify whether rotation can be corrected during Hallux Valgus procedures and to determine which procedure may be the best for each patient.

Type of bilingualism conditions individual differences in the oscillatory dynamics of inhibitory control.

The present study uses EEG time-frequency representations (TFRs) with a Flanker task to investigate if and how individual differences in bilingual language experience modulate neurocognitive outcomes (oscillatory dynamics) in two bilingual group types: late bilinguals (L2 learners) and early bilinguals (heritage speakers-HSs). TFRs were computed for both incongruent and congruent trials. The difference between the two (Flanker effect vis-à-vis cognitive interference) was then (1) compared between the HSs and the L2 learners, (2) modeled as a function of individual differences with bilingual experience within each group separately and (3) probed for its potential (a)symmetry between brain and behavioral data. We found no differences at the behavioral and neural levels for the between-groups comparisons. However, oscillatory dynamics (mainly theta increase and alpha suppression) of inhibition and cognitive control were found to be modulated by individual differences in bilingual language experience, albeit distinctly within each bilingual group. While the results indicate adaptations toward differential brain recruitment in line with bilingual language experience variation overall, this does not manifest uniformly. Rather, earlier versus later onset to bilingualism-the bilingual type-seems to constitute an independent qualifier to how individual differences play out.

Anatomy of the tibial nerve in relation to the tarsal tunnel: A cadaveric study.

BACKGROUND: Tarsal tunnel syndrome (TTS) is typically caused by an anatomical variant or mechanical compression of the tibial nerve (TN) with variable success after surgical treatment. METHOD: 40 lower-leg specimens were obtained. Dissections were appropriately conducted. Extremities were prepared under formaldehyde solution. The tibial nerve and branches were dissected for measurements and various characteristics. RESULTS: The flexor retinaculum had a denser consistency in 22.5% of the cases and the average length was 51.9 mm. The flexor retinaculum as an independent structure was absent and 77.2% of cases as an undistinguished extension of the crural fascia. The lateral plantar nerve (LPN) and abductor digiti minimi (ADM) nerve shared same origin in 80% of cases, 34.5% bifurcated proximal to the DM (Dellon-McKinnon malleolar-calcaneal line) line 31.2% distally and 34.3% at the same level. CONCLUSION: Understanding the tibial nerve anatomy will allow us to adapt our surgical technique to improve the treatment of this recurrent pathology.

Skiing and snowboarding related deep laceration injuries. A five-season cross-sectional analysis from a level-1 trauma centre in the Swiss Alps.

OBJECTIVES: Lacerations comprise 5.6-33.6% of skiing/snowboarding related injuries. This study aimed to investigate the mechanism of injury and the location of these lacerations and propose preventive measures. METHODS: After our state ethics committee approval, we retrospectively reviewed the medical records and surgical protocols of 46 patients (mean age (±SD) 34.6 (±15.3); 71.4% men) treated for severe skiing/snowboarding lacerations at our level-1 trauma centre between 2016 and 2021. Patients were asked to answer a questionnaire on their skiing experience, equipment used and the circumstances of the accident. RESULTS: Lacerations around the hip, thigh, and knee accounted for 94%. The latter was the most common location (45%). Although 91.3% of patients wore appropriate clothing and full standard protection equipment, it did not offer any extra-resistance against skiing/snowboarding's edges. Skiers were more affected (91.3%) than snowboarders (8.7%). The most common mechanism of injury was inadvertent release of the bindings (52.2%), followed by insufficient ski level for the slope (21.7%) and collisions (17.4%). Long-term trends demonstrated an increasing incidence. CONCLUSION: Identification of body areas at risk and the mechanisms of injury were the most significant findings of this work. These data encourage the development of specific injury prevention programs as the occurrence of these lesions tended to increase over the last few years. To reduce their incidence, we propose skiers to have their bindings regularly adjusted and manufacturers to develop cut-resistant skiwear. LEVEL OF EVIDENCE: IV.