Granda Ospedale Maggiore Policlinico Research Articles

UNRAVELING GENDER DISPARITIES AND PROGNOSTIC INSIGHTS IN MODERATE AORTIC STENOSIS: A RETROSPECTIVE STUDY

Abstract Aortic stenosis (AS) is the most prevalent valvular heart disease in developed countries, associated with reduced survival if severe AS remains untreated. Recent reports note unfavorable outcomes in moderate AS (mAS) patients, challenging optimal intervention timing. Variations in pathophysiology linked to sex differences, involving sex hormones, activation of the renin–angiotensin–aldosterone system, and dysregulation in collagen synthesis, have been observed. Yet, limited data exists on sex–specific differences in mAS outcomes. This single–center, retrospective study included 150 patients (median age 79±13 years, female sex 48%) diagnosed with mAS who underwent comprehensive echocardiography in IRCCS Fondazione Ca’ Granda Ospedale Maggiore Policlinico of Milan from July 2022 to October 2023. Clinical data, encompassing demographics details and therapy, were obtained via record reviews and phone interviews. Death verification relied on the ‘Sistema Informativo Socio–Sanitario Regione Lombardia’ database. Echocardiographic records were digitally stored and post–processed by four independent investigators using Medimatic ComPACS workstation. Men were significantly younger than women (75±10 vs 79±9.7 years, p= 0.016). They exhibited lower left ventricular (LV) ejection fraction, larger LV end–systolic volume and stroke volume compared to women (54±7 vs 59±10%; p=0.028. 55±36 vs 31±13 ml; p<0.001. 83±18 vs 75±18 ml; p=0.030). Men had significantly smaller aortic valve (AV) area index to body surface area (BSA) (0.6±0.09 vs 0.7±0.1 cmq/mq; p<0.001) and lower doppler velocity index (0.32±0.07 vs 0.38±0.11; p<0.001) than women. Coronary artery disease and smoking were more frequent in men (53.3 vs 46.7%; p=0,002. 52.6 vs 47.4%; p<0.001). In survival analysis, 15% of women and 30.8% of men experienced events, with male gender independently associated with the composite outcome (all–cause mortality and AV replacement) over a mean follow–up time of 200 ± 133 days, showing a median survival of 244±16 vs 255±15 days for females (p–value=0.025). In multivariable analysis including relevant clinical variables (hemoglobin and AV index to BSA), male sex remained independently associated with the composite outcome (hazard ratio 2,01; CI 1.0–4.17; p=0.05). Women diagnosed with mAS exhibited a lower incidence of AV replacement and all–cause mortality. These findings may suggest the existence of different clinical and echocardiographic phenotypes among patients with AS.

Paediatric cutaneous lymphomas including rare subtypes: A 40-year experience at a tertiary referral centre.

Primary cutaneous lymphomas are neoplasms of the immune system with a distinct tropism for the skin and an absence of extracutaneous manifestations at the time of diagnosis. Studies focusing on cutaneous lymphomas in children and adolescents remain scarce and often do not encompass the rare subtypes. To address this knowledge gap by describing the clinical, histological and molecular characteristics of a large group of paediatric patients affected by primary cutaneous lymphoma. We also provided the Paediatric Primary Cutaneous Lymphoma Atlas that illustrates the clinicopathological spectrum of observed presentations, in the hope of supporting other physicians in the diagnostic process. Retrospective chart review of paediatric patients diagnosed with primary cutaneous lymphomas between 1980 and 2022 at the Paediatric Dermatology Unit of Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan. A total of 101 patients (58 males, 43 females) met the inclusion criteria. The most common subtypes were lymphomatoid papulosis (n = 48) and mycosis fungoides (n = 31). These were followed by primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorders (n = 7), primary cutaneous anaplastic large-cell lymphomas (n = 5), primary cutaneous marginal zone B-cell lymphomas (n = 3), primary cutaneous follicle centre lymphomas (n = 2), subcutaneous panniculitis-like T-cell lymphomas (n = 2), primary cutaneous peripheral T-cell lymphoma not otherwise specified (n = 1), primary cutaneous precursor B-lymphoblastic lymphoma (n = 1) and Sézary syndrome (n = 1). Clinical follow-up data covering a median of 70.8 months (range 1-324) were available for 74 patients, of whom three died due to cutaneous lymphoma. Our findings shed light on the peculiar aspects and long-term outcomes of paediatric cutaneous lymphomas, particularly emphasizing their distinctive features in comparison to their adult counterparts and exploring the less common subtypes. Further larger-scale studies are warranted to better characterize these entities and to achieve a more rapid and accurate diagnosis.

Recurrence in acromegaly: two tertiary centers experience and review of the literature.

Recurrence of acromegaly after successful surgery is a rare event, but no clear data are reported in the literature about its recurrence rates. This study aimed to evaluate the recurrence rate in a series of acromegalic patients treated by transsphenoidal surgery (TSS) with a long follow-up. We retrospectively analyzed data from 283 acromegalic patients who underwent TSS at two pituitary units in Milan (Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and IRCCS Humanitas Research Hospital). The diagnosis and recurrence of acromegaly were defined by both elevated IGF-1 levels and a lack of GH suppression based on appropriate criteria for the assay used at the time of diagnosis. After surgery, 143 patients (50%) were defined as not cured, 132 (47%) as cured and 8 (3%) as partially cured because of normalization of only one parameter, either IGF1 or GH. In the cured group, at the last follow-up (median time 86.8months after surgery), only 1 patient (0.7%) showed full recurrence (IGF-1 + 5.61 SDS, GH nadir 1.27µg/l), while 4 patients (3%) showed only increased IGF1. In the partially cured group at the last follow-up, 2/8 (25%) patients showed active acromegaly (IGF-1 SDS + 2.75 and + 3.62; GH nadir 0.6 and 0.5µg/l, respectively). In the literature, recurrence rates range widely, from 0 to 18%. In our series, recurrence occurred in 3.7% of patients, and in fewer than 1%, recurrence occurred with elevation of both IGF-1 and the GH nadir. More frequently (25%), recurrence came in the form of incomplete normalization of either IGF-1 or GH after surgery.

The role of immune suppression in COVID-19 hospitalization: clinical and epidemiological trends over three years of SARS-CoV-2 epidemic.

Specific immune suppression types have been associated with a greater risk of severe COVID-19 disease and death. We analyzed data from patients >17 years that were hospitalized for COVID-19 at the "Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico" in Milan (Lombardy, Northern Italy). The study included 1727 SARS-CoV-2-positive patients (1,131 males, median age of 65 years) hospitalized between February 2020 and November 2022. Of these, 321 (18.6%, CI: 16.8-20.4%) had at least one condition defining immune suppression. Immune suppressed subjects were more likely to have other co-morbidities (80.4% vs. 69.8%, p < 0.001) and be vaccinated (37% vs. 12.7%, p < 0.001). We evaluated the contribution of immune suppression to hospitalization during the various stages of the epidemic and investigated whether immune suppression contributed to severe outcomes and death, also considering the vaccination status of the patients. The proportion of immune suppressed patients among all hospitalizations (initially stable at <20%) started to increase around December 2021, and remained high (30-50%). This change coincided with an increase in the proportions of older patients and patients with co-morbidities and with a decrease in the proportion of patients with severe outcomes. Vaccinated patients showed a lower proportion of severe outcomes; among non-vaccinated patients, severe outcomes were more common in immune suppressed individuals. Immune suppression was a significant predictor of severe outcomes, after adjusting for age, sex, co-morbidities, period of hospitalization, and vaccination status (OR: 1.64; 95% CI: 1.23-2.19), while vaccination was a protective factor (OR: 0.31; 95% IC: 0.20-0.47). However, after November 2021, differences in disease outcomes between vaccinated and non-vaccinated groups (for both immune suppressed and immune competent subjects) disappeared. Since December 2021, the spread of the less virulent Omicron variant and an overall higher level of induced and/or natural immunity likely contributed to the observed shift in hospitalized patient characteristics. Nonetheless, vaccination against SARS-CoV-2, likely in combination with naturally acquired immunity, effectively reduced severe outcomes in both immune competent (73.9% vs. 48.2%, p < 0.001) and immune suppressed (66.4% vs. 35.2%, p < 0.001) patients, confirming previous observations about the value of the vaccine in preventing serious disease.

External validation of a clinical prediction tool for the use of manual therapy for patients with temporomandibular disorders: a protocol for a prospective observational study

IntroductionClinical guidelines recommend conservative treatment for the management of temporomandibular disorders (TMD), and manual therapy directed to temporomandibular structures is commonly applied to reduce pain and improve function. In a...

Diabetes and orthostatic hypotension: are all patients created equal?

aDepartment of Medicine and Surgery, University of Milano-Bicocca bDepartment of Cardio-Thoracic-Vascular Diseases, Foundation IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy cDepartment of Cardiology, University Hospital ‘Dr Dragisa Misovic-Dedinje’, Belgrade, Serbia Correspondence to Professor Cesare Cuspidi, University of Milano-Bicocca Meda, Milan, 20821, Italy. E-mail: [email protected]

P-226 Conventional IVF rather than ICSI when only on oocyte is retrieved: time to overcome irrational fears

Abstract Study question Is the use of conventional-IVF (c-IVF) a viable option in single oocyte retrieved cycles? Summary answer The use of c-IVF on single oocyte seems to be a successful strategy in terms of laboratory performance indicators outlined in the Vienna Consensus. What is known already Intracytoplasmic Sperm Injection (ICSI) has greatly improved the chances of reproductive success in cases of male factor infertility, but it is often used without strong evidence, such as in cases of low numbers of retrieved oocytes, assuming it will avoid unexpected total fertilization failure (TFF). On these bases, several ART centers irrationally opt for ICSI when few oocytes are retrieved. This approach is due to the fear of facing TFF the following day. This situation is boosted when only one oocyte is available. Available studies on c-IVF in these circumstances are generally reassuring, but evidence is limited and inconclusive. Study design, size, duration This is a monocentric retrospective observational study performed at the Infertility Unit of the Fondazione Ca' Granda Ospedale Maggiore Policlinico between 2014 and 2021. The primary outcome of the study is normal fertilization rate, which is expected to be ≥ 60% according to the Vienna Consensus. The study sample (about 300 cycles) was calculated to obtain a 95% CI within the range of ± 5%. A binomial distribution model was used to determine the 95%CI of proportions. Participants/materials, setting, methods Only women who had recovered one oocyte at the oocyte retrieval were included in the study. Collected data included age of both partners, previous pregnancies, female BMI, antral follicle count, total motile sperm count. A multivariate analysis was performed to identify predictive factors for fertilization. Based on the policy of our Center, c-IVF was performed only in case of normal sperm variables according to WHO 2010 manual and in the absence of history of TFF. Main results and the role of chance Out of 700 cycles with single oocyte retrievals, 304 were treated with c-IVF, which resulted in normal fertilization (2PN) in 209 cases, corresponding to a fertilization rate of 69% (95%CI: 63-74%). In 13 cycles, oocytes were shown to be immature (germinal vesicle or metaphase I) at the time of fertilization check. In these cases, fertilization could not occur. If we exclude them, the fertilization rate raised to 72% (209/291) (95%CI: 66-77%). This fertilization rate was within the Vienna Consensus KPI for competency range and was no more than 5% lower compared to the benchmark value. Clinical pregnancy and live birth rates per cycle were 14% and 11%, respectively. Finally, we compared baseline characteristics of cycles with normal fertilization to those with failed fertilization. Both univariate and multivariate analyses failed to identify predictive factors of fertilization. Limitations, reasons for caution The retrospective nature and the absence of a control group do not allow us to draw robust and definitive conclusions. However, the large sample sized allowed us a precise estimation of the fertilization rate. Wider implications of the findings Fear about TFF is not a valid reason to opt for ICSI in women retrieving only one oocyte. The use of ICSI increases costs without providing benefits. We also failed di identify predictive factors of fertilization, hampering the possibility to select a subgroup of women who may benefit from ICSI. Trial registration number Not applicable

P-353 possible correlation between the second-to-four digit ratio (2d:4d) and endometriosis: a case-control study

Abstract Study question This study investigates a possible association between the second-to-four digit ratio and endometriosis. Summary answer There is an association between a higher 2D:4D ratio and the presence of endometriosis. What is known already Endometriosis is characterised by the presence of endometrium epithelium and/or stroma outside the uterus. Recent findings suggest that endocrine disruptors during intrauterine life could determine the onset of the disease.The ratio between the length of the index finger (2D) and the ring finger (4D) is a sexually dimorphic feature. Moreover, it has been proposed as a marker of prenatal hormonal exposure since high level of androgens results in a lower 2D:4D ratio, whereas a prenatal oestrogenic environment results in a higher one. Therefore, a longer 2D:4D ratio could be considered as a silent sign of the disease. Study design, size, duration This study was conducted at the Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico. Participants were recruited from July 2021 to October 2022. Cases included women with a past surgical diagnosis of endometriosis or with a current nonsurgical diagnosis of the disease. Women attending the outpatient clinics for periodic visits, contraception, severe male infertility, and cervical cancer screening programme and without a previous clinical or surgical diagnosis of endometriosis were enrolled as the control group. Participants/materials, setting, methods Women with endometriosis were divided into two groups: deep infiltrating endometriosis (DIE) and ovarian endometrioma (OMA) depending on the lesion localization. Among controls, endometriosis was excluded based on gynaecological history, pelvic transvaginal ultrasound, gynaecological bimanual examination and vaginal inspection.The digit lengths were measured on the right hand's ventral surface because previous studies suggested that the right hand is more sensitive to androgens. In addition, other clinical details were collected on standardised forms. Main results and the role of chance A total of 424 participants (endometriosis n = 212; controls n = 212) were recruited for this study. The group of cases included 114 women with ovarian endometriomas and 98 patients with deep infiltrating endometriosis.Although the median age in the endometriosis group was 37 years, significantly higher than controls (p &amp;lt; 0.01), other variables (such as BMI, ethnicity, smoking habit, age at menarche, parity, previous miscarriages and previous IVF) did not differ between the study groups.The right hand 2D:4D digit ratio resulted significantly higher in women with endometriosis compared to controls with 2D:4D ratio of 1.00 [0.97 - 1.03] and 0.99 [0.96 - 1.02] respectively (p = 0.002).The significant association remained when exclusively focussing on women with ovarian endometriomas (p = 0.002). In contrast, the association was no more significant when the analysis was restricted to women with deep infiltrating forms (p = 0.07).These findings support the potential role of intrauterine exposure of estrogen in the pathogenesis of the disease. A low ratio of testosterone-to-estradiol during fetal life may play a crucial role in endometriosis onset and progression. Limitations, reasons for caution The selection of controls may represent a source of bias since endometriosis was ruled out based on gynaecological and ultrasonography examination. Therefore, it could not be excluded having inadvertently included some cases among controls. Wider implications of the findings In conclusion, there is an association between a higher 2D:4D ratio and the presence of endometriosis. Our results support the hypothesis claiming potential influences of intrauterine hormonal and endocrine disruptors exposure during fetal life on the onset of the disease. Trial registration number not applicable

P-247 Total Fertilization Failure after conventional IVF: it is not the end of the story

Abstract Study question Could Rescue IntraCytoplasmatic Sperm Injection (R-ICSI) coupled with frozen transfers be an effective treatment for Total Fertilization Failure (TFF) after conventional InVitro Fertilization (c-IVF) cycles? Summary answer Applying R-ICSI after TFF of c-IVF, a blastulation rate of 28% could be obtained, allowing the cycle rescue in a consistent proportion of couples. What is known already Conventional IVF is to date the most indicated technique in infertile couples in the absence of male factor. However, the incidence of TFF following c-IVF, in presence of normozoospermic samples, ranges from 5 to 20%. TFF leaves experts with limited alternatives, which include cancelling the cycle with subsequent indication to proceed with ICSI in the next cycle or attempting R-ICSI in the current cycle. R-ICSI coupled with frozen embryo transfer may overcome most of the technical and biological issues associated with fresh transfer after R-ICSI, possibly representing an efficient procedure for couples experiencing TFF following c-IVF. Study design, size, duration Our retrospective study included 33 couples who underwent assisted reproduction techniques (ART) at the Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico of Milan from October 2021 to December 2022 and that experienced TFF after c-IVF, regardless the number of oocytes retrieved. Overall, TFF was reported in 7% of c-IVF cycles (33/439). An indication for male factor infertility was an exclusion criterium. World Health Organization (WHO) reference values for human semen characteristics have been adopted. Participants/materials, setting, methods Fertilization failure was considered in terms of absence of the two pronuclei and the second polar body. Out of 158 unfertilized oocytes, 128 MII oocytes were microinjected after c-IVF in the same cycle. R-ICSI consists of performing ICSI 22-24 hours after insemination with an unsuccessful c-IVF, using the same semen sample maintained at room temperature overnight. Fertilized oocytes after R-ICSI were cultured to the blastocyst stage according to our standard protocol. Main results and the role of chance The fertilization rate was 42% (95%CI: 34-51%). Fertilization failure was still observed in 9 patients (27%, 95%CI: 13-46%) after R-ICSI, with a median value of 2 [2-5] oocytes available for insemination. In the 24 patients who obtained at least one zygote, the blastulation rate was 28% (95%CI: 16-42%). A total of 15 blastocysts were cryopreserved in 10 patients on day 5 or 6 after R-ICSI. Of these 10 patients, 6 have undergone frozen/thawed single embryo transfer, and the success rate (ongoing pregnancy) was 50% (95%CI: 12-88%). Limitations, reasons for caution One of the limitations is the small sample size, since this is an emergency procedure. However, the study is still ongoing. Women were not subjected to inclusion criteria, thus fertilization failure could be attributed to several factors different from semen quality. Wider implications of the findings This study turns out to be important in light of the interesting implantation rate obtained. With the advantage of reducing both costs and psychological burden of the couple, the technique can be proposed as a rescue strategy in cases of TFF allowing to confidently increase the number of c-IVF procedure. Trial registration number not applicable

P-344 Prevalence and maternal risk factors for neonatal uterine bleeding (NUB): a possible origin of endometriosis?

Abstract Study question What is the prevalence and the cause of neonatal uterine bleeding, also known as “genital crisis”? Is it associated with maternal lifestyle and obstetric history? Summary answer The prevalence of NUB has been estimated as 29% and it seems to be correlated to some aspects of the maternal lifestyle What is known already NUB is considered a physiological phenomenon characterized by a menstrual-like bleeding occurring during the first days of life in female newborns, with an estimated incidence of 3-5%. It seems to be related to the reduction of steroid hormones in the baby after the separation from the maternal placenta, although, actually, some theories hypothesize NUB as a consequence of the exposure to molecular disruptors during intrauterine life. However, data regarding NUB still remain uncertain. Interestingly, recent theories assume a correlation between NUB and endometriosis onset, considering it as a consequence of the retrograde menstruation of stem cells during the genital crisis Study design, size, duration This is a prospective cohort study performed in a population of 105 mothers-to-be who delivered their babies at Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico of Milan between March 2022 and December 2022. Inclusion criteria were: gestation of a single female fetus, age between 18 and 42, being in healthy condition and undergoing a low-risk pregnancy. Women with endometriosis had also been included Participants/materials, setting, methods At the time of recruitment few days before delivery, patients were asked to fill a questionnaire regarding general clinical characteristics (BMI, smoking habits, diet). After two weeks from delivery, a follow up was performed asking them information about pregnancy outcomes (time to pregnancy, complications and type of delivery), a possible vaginal bleeding for the baby and its duration, the type of lactation (breastfeeding, formula or both) and clinical neonatal information. Main results and the role of chance NUB frequency was unexpectedly high. Twenty-nine percent of the babies experienced NUB with a duration of 3 days and insurgence 2 days post-partum. Among the variables analyzed, genital crisis resulted higher in newborns from women with significantly higher BMI compared to women with a lower BMI (BMI 23 vs 21.5 respectively, p&amp;lt;0.05). Smoking during pregnancy was associated with a higher incidence of newborns with NUB (20% vs 4% in controls; p &amp;lt; 0.05). According to the type of lactation, in newborns with genital crisis, 43% of them received maternal breastfeeding while the same type of feeding has been reported in 69% of controls (p&amp;lt;0.05). Lastly, soy consumption by the mothers was observed only in 41% of cases of genital crisis while among mothers whose newborns did not experience NUB, 58% declared presence of soy in their diet (p&amp;lt;0.05). Limitations, reasons for caution The population size is relatively small. Also, as prospective cohort study, loss of individuals at follow up and recall bias may occur Wider implications of the findings Collecting more information on the hormonal determinants of NUB could be useful for future studies on intrauterine life and reproductive disorders. If a link between NUB and endometriosis is confirmed, NUB might lead to the understanding of the onset of this pathological condition Trial registration number not applicable

P-435 HPV and infertility in couples requiring Assisted Reproduction Techniques (ART).

Abstract Study question How frequent is Human Papilloma Virus (HPV) infection in both partners of infertile couples referring to our ART center and whats its impact? Summary answer Only 6% of infertile couples are positive for HPV and infection has no impact on embryologic parameters. What is known already There is limited and conflicting evidence about the relationship between HPV infection in male partners and infertility. Notably, most of the previous studies did not assess the presence of the infection in both partners in the context of ART. Furthermore, even if considered, the influence of the infection of the female partner may be underestimated because only data on adverse pregnancy outcomes were evaluated. Elucidating the HPV-positive status of the two individuals belonging to the couple could open up new scenarios. Study design, size, duration This prospective cohort study was performed on 81 couples. The analysis was conducted on semen samples of male patients and on cervical samples of female partners who underwent assisted reproduction techniques (ART) treatment at the infertility unit of Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico of Milan from February 2022 to November 2022. Participants/materials, setting, methods The female partecipants were recruited before the beginning of the controlled ovarian stimulation (COS) while male participants were recruited on the day of the female ovum pick-up (OPU). The technique used to assess the presence of the HPV virus was the Real Time PCR (RT-PCR). Personal characteristics, lifestyle habits and sexual habits were investigated as possible favoring elements for the insurgence of HPV infection. Main results and the role of chance Among 81 couples recruited, 12 men and 22 women tested positive for high- and low risk HPV viruses. This streins corrisponds to a prevalence of about 15% (95% CI: 9-24%) for males and 27% (95% CI: 19-38%) for females. Among these positive couples, only 5 cases (6%, 95% CI: 3-14%) simultaneously tested positive for both partners: in two pairs they were positive for the same viral strains, in two other pairs there was no concordance between the viral strains found, and in one pair there was only a partial concordance. McNemar's test (a dichotomous evaluation test for data paired aimed at assessing possible associations) was not significant. No differences in embryo developmental failure, “top-quality” embryo formation and “top-quality” blastocyst formation were found between the two groups (positive vs negative couples). Limitations, reasons for caution A possible limitation of the study is the small sample size. Additionally we mainly focused on the impact of infection by HPV on embryological variables, without considering developmental pregnancies and live birth rate. Wider implications of the findings The very low concordance observed suggests that infection follows intricate pathways, far beyond the trivial view of a ping-pong effect between partners of the couple. These results suggest that HPV infection probably develops independently in the two individuals of the couple, as if there is not a mutual influence. Trial registration number NOT APPLICABLE

Low ovarian reserve and risk of miscarriage in pregnancies derived from assisted reproductive technology.

Do low levels of anti-Müllerian hormone (AMH) or antral follicle count (AFC) properly predict miscarriage in young women conceiving with ART? Low ovarian reserve, as indicated by AMH or AFC, is not associated with miscarriage in young women conceiving with ART. Presently, the impact of low ovarian reserve on the risk of miscarriage remains controversial. Some studies have reported an association between serum AMH levels and AFC and miscarriage, but others have failed to confirm these findings. The main limitation that undermines the reliability and consistency of the results is the confounding effect of female age. Indeed, after 35 years of age, on the one hand, the risk of miscarriage starts increasing because of impaired oocyte quality while, on the other, the physiological decline in AMH and AFC levels continues, thus hampering the possibility to properly explore the real effects of reduced ovarian reserve. Indeed, the two processes, i.e. the gradual loss of resting primordial follicles and the loss of oocyte quality, progress in parallel. In other words, the older the woman becomes, the higher is the risk of miscarriage, but one cannot distinguish between the effects of biological aging on oocyte quality and those mediated by a lower ovarian reserve. The present retrospective monocentric cohort study was carried out at Fondazione IRCSS Ca Granda Ospedale Maggiore Policlinico, Milan. All women referred to the ART Unit between 2014 and 2021 and who underwent either conventional IVF (c-IVF), ICSI, or IUI were reviewed. Only women younger than 35 were eligible because, up to this age, the risk of miscarriage is steady and not strictly related to age. Women younger than 35 who achieved a singleton clinical pregnancy with c-IVF, ICSI, or IUI were selected. Women with patent causes of recurrent miscarriage were excluded, as well as those undergoing pregnancy termination for fetal or medical causes. Women who did and did not have a pregnancy loss before 20 weeks' gestation were compared. Detailed information was obtained from charts of the consulting patients. ART procedures were performed according to the standardized policy of our Unit. All women underwent serum AMH measurement and a transvaginal assessment of AFC prior to initiation of treatment. AMH levels were measured by a commercially available ELISA assay. To assess AFC, all identifiable antral follicles 2-10 mm in diameter at ultrasound were recorded. The primary outcome was the risk of miscarriage for women with serum AMH levels below 5 pmol/l. There were 538 women were included, of whom 92 (17%) had a miscarriage. The areas under the ROC curves for prediction of miscarriage based on AMH levels and AFC were 0.51 (95% CI: 0.45-0.58) and 0.52 (95% CI: 0.45-0.59), respectively. The odds ratio (OR) of miscarriage for women with serum AMH levels below 5.0 pmol/l was 1.10 (95% CI: 0.51-2.36); the adjusted OR was 1.12 (95% CI: 0.51-2.45). Analyses were repeated considering other thresholds for AMH (2.9, 3.6 and 7.9 pmol/l) and for AFC (thresholds of 7 and 10). No associations emerged. The retrospective design of the study hampered the collection of more precise but potentially relevant clinical information of the couples. We did not exclude women suffering from PCOS, a condition possibly associated with miscarriage. Moreover, the baseline characteristics of women who did and did not have a miscarriage differed in some characteristics. Thus, we adjusted the OR using a multivariate analysis, but we cannot fully exclude residual confounding effects. Finally, our results cannot be inferred to women older than 35. The mechanisms causing premature exhaustion of ovarian reserve may be different in younger and older women and this may lead to a different impact on the risk of miscarriage. Women embarking on ART with low ovarian reserve should be informed of their likely poor response to ovarian stimulation but can be reassured that, if conception occurs, their risk of miscarriage is not increased. This study was partially funded by Italian Ministry of Health-Current research IRCCS. E.S. reports grants from Ferring and honoraria for lectures from Merck-Serono and Gedeon-Richter. All the other authors do not have any competing interest to declare. N/A.

P87 GENETIC CARDIOMYOPATHIES: THE FIRST YEAR OF THE FONDAZIONE IRCCS CÀ GRANDA OSPEDALE MAGGIORE POLICLINICO OF MILAN DEDICATED CLINICAL SERVICE

Abstract Objectives Cardiac genetic counselling and testing for inherited cardiomyopathies have become essential aspects of cardiovascular care. A genetic diagnosis in a family can offer an invaluable tool for cascade genetic testing of at–risk relatives. A careful clinical and individualized approach to genetic cardiomyopathies is now needed to guarantee the best care possible. We report the results of our first–year genetic cardiomyopathies single–centre experience. Methods From September 2021, 69 genetic tests have been carried out at Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico of Milan by the staff of a new specific clinical service dedicated to genetic cardiomyopathies. Results The present study collects the data of 69 patients who underwent genetic testing and clinical follow up at our centre in suspicion of underlying genetic etiology of disease. Next generation sequencing was adopted to conduct genetic testing either by a customized panel of 54 specific genes for cardiomyopathies or by a clinical exome (180 genes). Time required for reporting and patient communication were 8 and 12 weeks, respectively. Female sex was 36%, mean age was of 53.2 ± 21.3 years. The main indications for genetic testing were dilated cardiomyopathy (DCM) and hypertrophic cardiomyopathy (HCM). Figure 1. 41% of DCM and 50% of HCM patients tested positive for a pathogenic or likely pathogenetic mutation. Cascade genetic tests conducted on at–risk relatives were 21 (30%). Among these subjects, 38% resulted positive at genetic screening and 57% were in turn positive at phenotypic screening. The genes hit by pathogenic or likely pathogenetic mutations are illustrated in Figure 2. Conclusion The first year of a specific clinical service dedicated to genetic cardiomyopathies made it possible to identify a substantial number of patients and at–risk relatives affected by pathogenic or likely pathogenetic genetic mutations.

Mitigating the economic burden of GnRH agonist therapy for progestogen-resistant endometriosis: why not?

Is it possible to reduce the cost of GnRH agonist treatment for endometriosis by using non-standard dosing regimens? An extended-interval dosing regimen of a 3.75 mg depot formulation of triptorelin injected every 6 weeks instead of every 4 weeks reduces the cost by one-third without compromising the effect on pain relief. Cost constitutes a limit to prolonged GnRH agonists use. Alternative modalities to reduce the economic burden of GnRH agonist treatment have been anecdotally attempted. A systematic review was conducted to evaluate and compare the effect of three alternative modalities for GnRH use in women with endometriosis, i.e. intermittent oestrogen deprivation therapy, reduced drug dosage, and extended-interval dosing regimens of depot formulations. A PubMed and Embase search was initially conducted in October 2022 and updated in January 2023 using the following search strings: (endometriosis OR adenomyosis) AND (GnRH-agonists OR gonadotropin-releasing hormone agonists OR triptorelin OR leuprorelin OR goserelin OR buserelin OR nafarelin). Full-length articles published in English in peer-reviewed journals since 1 January 1980, and reporting original data on GnRH agonist treatment of pain symptoms associated with endometriosis were selected. Information was extracted on study design, GnRH-agonist used, dosage, total duration of therapy, side effects, treatment adherence, and pelvic pain relief. Reviews, commentaries, conference proceedings, case reports, and letters to the editor were excluded. Of the 1664 records screened, 14 studies regarding clinical outcomes associated with the 3 considered alternative modalities for GnRH agonist use were eventually included (intermittent oestrogen deprivation therapy, n = 2; low-dose or 'draw-back' therapy, n = 8; extended-interval dosing regimen, n = 4). Six studies were randomized controlled trials (RCTs) (double blind, n = 2) and eight adopted a prospective cohort design (non-comparative, n = 6; comparative, n = 2). A total of 776 women with endometriosis were recruited in the above studies (intermittent oestrogen deprivation therapy, n = 77; low-dose or 'draw-back' therapy, n = 528; extended-interval dosing regimen, n = 171). Robust data demonstrating cost saving without detrimental clinical consequences were available for the extended-interval dosing regimen only. In particular, the 3.75 mg triptorelin depot preparation inhibits ovarian function for a longer period compared with the 3.75 mg leuprorelin depot preparation, allowing injections every 6 instead of 4 weeks. Based on the cost indicated by the Italian Medicine Agency for the 3.75 mg triptorelin depot preparation, this would translate in a yearly saving of €744.60 (€2230.15-€1485.55; -33.4%). The quality of the evidence reported in the selected articles was not formally evaluated and a quantitative synthesis could not be performed. Some studies were old and the tested therapeutic approaches were apparently obsolete. Only cost containment associated with GnRH analogue use, and not cost-effectiveness, has been addressed. Consuming less resources without negatively impacting on health outcomes carries ethical and practical implications for individuals and the community, as this approach may result in overall increased healthcare access. This study was supported by the Italian Ministry of Health (Ricerca Corrente 2023, IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano). E.S. discloses payments from Ferring for research grants and honoraria from Merck-Serono for lectures. All other authors declare they have no conflict of interest. N/A.

Anti-Sars-CoV-2 vaccination campaign in children aged 5-11 years: the experience of a mass vaccination center in the city of Milan.

After the approval of the anti-Sars-CoV-2 vaccines for the pediatric population, it is necessary to encourage the immunization of children aged 5-11 years, as this can reduce intergenerational transmission. Therefore, this goal has become a priority for the COVID 19 vaccination campaign in Italy. In the city of Milan, the mass vaccination center (MVC) Fiera Milano City, previously settled for general population, became the main site to host pediatric vaccinations. The center was consequently remodeled to ensure a suitable space for children. This paper provides an overview on the organization strategy implemented by Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico. The modular structure and the wide surface available in the center allowed the administration of hundreds of vaccines per day, especially in the first opening phase. All the data for the entire period of activity of Fiera MCV, from December 16th 2021 to February 20th 2022, were analyzed using descriptive statistics. During the entire period of activity, from 16 December 2021 to 20 February 2022, 23% of the population in the province of Milan aged 5-11 years has been reached and vaccinated with at least one shot of vaccine in this center. Despite an enthusiastic response in the first weeks of the campaign, a progressive reduction in vaccination adherence was observed, maybe due to the absence of restrictive measures for unvaccinated children in Italy.

SARS-CoV-2 Vaccination Effectiveness in Rituximab-Treated Patients Affected by Pemphigus Vulgaris

SARS-CoV-2 Vaccination Effectiveness in Rituximab-Treated Patients Affected by Pemphigus Vulgaris

Surgical site infections in liver transplantation in the era of multidrug-resistant bacteria.

Surgical site infection (SSI) is the major complication in orthotopic liver transplantation (LT). It is of prime importance to assess the incidence of infections in liver transplants and to analyze the risk factors associated with morbidity and mortality. Between 2014 and 2019, we performed a retrospective cohort study at the Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy. The liver transplant procedure and its related infections were examined in 4 timepoints, both prior and post-surgery. Multiple random-intercept Poisson regression models with robust variance were fitted to calculate the adjusted risk ratios (RR) and the 95% confidence intervals (CI) according to selected recipient and donor variables. We included in the analysis 249 transplants (in 241 patients). The SSIs (mostly due to S. aureus, E. faecium, and K. pneumoniae) were 7 (2.8%) in the days following LT, increasing to 61 (24.5%) within the first month after LT, and declining to 35 (14.1%) between 31 and 60 days, and to 19 (7.6%) afterwards. The factors associated with increased risk of infection were age (RR=1.17 per 10 years, CI: 0.99-1.38), BMI (RR=1.04 per BMI Unit, CI: 0.99-1.08), donor age (RR=0.88 per 10 years, CI: 0.78-0.98), re-interventions (30 infections, RR=2.02, CI: 1.21-3.38) and the Roux-en-Y approach (25 infections, RR=2.75, CI: 1.47-5.15). The risk of infection occurred mainly in the first two months after LT. Important determinants were age and BMI, donor age, reinterventions, and Roux-en-Y procedure. Our study suggests that these factors should be assessed when performing LT.

High-grade vaginal intraepithelial neoplasia and recurrence risk: analysis of an Italian regional referral center series.

The main aim of this study was to investigate the long-term risk of disease recurrence in women treated for high-grade vaginal intraepithelial neoplasia (HG-VaIN). We conducted a retrospective analysis on a cohort of 82 women diagnosed with HG-VaIN between 2010 and 2021 at the "Regional Referral Center for Prevention, Diagnosis and Treatment of HPV-related Genital Disorders", Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy. All women underwent either ablative treatment (CO2 laser ablation or electrocoagulation) or cold-knife excision. In our series, the recurrence rate following treatment was 17%. The 5-year cumulative probability of recurrence was 30.4% and the median time to recurrence was 15.5months. None of the patients progressed to invasive vaginal cancer during follow-up. A concomitant cervical or vulvar intraepithelial lesion was significatively associated with an increased risk of recurrence (p = 0.006). The results of our study suggest that women with HG-VaIN are at high risk of developing disease recurrence after treatment, especially patients with a concomitant cervical or vulvar intraepithelial lesion. In these women strict monitoring is mandatory to obtain an early identification of recurrence.

The impact of small and asymptomatic intramural and subserosal fibroids on female fertility: a case-control study.

Do small and asymptomatic intramural and subserosal uterine fibroids affect female fertility? Small and asymptomatic fibroids that do not encroach the endometrial cavity appear to not markedly affect female fertility. The available evidence on uterine fibroids and fertility is limited. Most information has been obtained in IVF settings by comparing the success in women affected and not affected by fibroids. These studies have shown a detrimental effect of submucosal and possibly intramural fibroids. However, this study design provides information only on embryo implantation, not on female fertility in general. A retrospective observational case-control study on 200 women whose partner was diagnosed with severe male infertility and 200 women with unexplained infertility was conducted. If the null hypothesis (that fibroids do not affect fertility) is valid, one would expect a similar prevalence of fibroids in the two study groups. Conversely, if fibroids do impact fertility, one would expect a higher prevalence among women with unexplained infertility. The study was carried out at the Infertility Unit of the Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico covering a 5-year period between January 2014 and June 2020. We retrospectively recruited women seeking pregnancy whose partner was repeatedly documented to have a sperm concentration below 1 million/ml and matched them by age and study period to a group of women with unexplained infertility. The latter group of women was considered as a case group (infertile subjects), while the former group of women was considered as a control group (reflecting the general female population). Women with fibroids could be included in both study groups; only those with submucosal lesions were excluded. Fibroids were diagnosed in 31 women (16%) with unexplained infertility and in 32 women (16%) with severe male factor infertility. The adjusted odds ratio of carrying fibroids in women with unexplained infertility was 0.91 (95% CI: 0.52-1.58). Subgroup analyses according to number, dimension and location of fibroids failed to highlight an increased risk of infertility in any group. This is a retrospective study and some inaccuracies in fibroids detection cannot be ruled out. Moreover, the relatively small sample size hampers robust subgroup analyses. Even though we excluded women with patent causes of infertility, some women with specific causes of infertility could have been included among controls (yet are expected to account for <10% of the group). This study suggests that small fibroids that do not encroach the endometrial cavity do not markedly affect female fertility. This information is clinically relevant when counseling infertile women with small fibroids and an otherwise unremarkable diagnostic work-up. Surgery may still be considered but only in selected cases. This study was partially funded by Italian Ministry of Health: current research IRCCS. E.S. reports grants from Ferring, grants and personal fees from Merck, and grants and personal fees from Theramex outside the submitted work. All the other authors do not have any competing interest to declare. N/A.

Dermoscopy Use Leads to Earlier Cutaneous Melanoma Diagnosis in Terms of Invasiveness and Size? A Single-Center, Retrospective Experience.

Background: The incidence of cutaneous melanoma has risen in recent years. The aim of this study was to compare cutaneous melanomas diagnosed at the Dermatology Unit of Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy, from 2006 to 2020 and between two specific biennia, i.e., 2006–2007 and 2019–2020. Methods: Retrospective chart review, with dermoscopic image collection, of cutaneous melanomas diagnosed at the Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy, from 1 January 2006 to 31 December 2020 Results: A statistically significant increase was shown in the proportions of in situ melanoma and melanoma measuring less than 6 mm, i.e., small-diameter melanoma (SDM), across the studied period (p < 0.001). Moreover, in the biennium 2006–2007, among 220 melanoma diagnoses, 6 were in situ (2.7%), as compared with 68 melanomas in situ out of a total of 236 (28.8%) melanomas diagnosed in the biennium 2019–2020. A statistically significant difference in the proportion of in situ melanoma between the two biennia was demonstrated (p < 0.001). Furthermore, during the first biennium, 27/220 (12.3%) SDM were identified, as compared with 61/236 (25.9%) in the last. A statistically significant difference was shown in the proportion of SDM between the two (p < 0.001). Conclusions: The percentage of in situ melanomas and those that can be detected at a diameter <6 mm has increased. The latter has been shown to be around one-third of excised lesions, thus undermining the practicality of the ABCD mnemonic. Dermoscopic criteria for SDM are needed to help further refine melanoma diagnosis.