Liposomal bupivacaine versus conventional anesthetic or placebo for hemorrhoidectomy: a systematic review and meta-analysis

BACKGROUND

Liposome bupivacaine (LB) is a long-acting anesthetic to enhance postoperative analgesia. Studies evaluating the efficacy of the LB against an active comparator (bupivacaine or placebo) on acute postoperative pain control in hemorrhoidectomy procedures are few and heterogeneous. Therefore, we performed a systematic review and meta-analysis comparing LB's analgesic efficacy and side effects to conventional/placebo anesthetic in hemorrhoidectomy patients.

METHODS

We performed a systematic review and meta-analysis of randomised controlled trials investigating the use of LB after haemorrhoidectomy. We searched the literature published from the time of inception of the datasets to August 19, 2022. The electronic databases included English publications in Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, and Scopus.

RESULTS

A total of 338 patients who underwent a hemorrhoidectomy procedure enrolled in three randomized clinical trials were included. The overall mean age was 45.84 years (SD ± 11.43), and there was a male predominance (53.55% male). In total 194 patients (52.2%) received LB and 144 (47.8%) received either bupivacaine or placebo. Pain scores at 72 h in the LB (199, 266, and 300 mg) were significantly lower than in the bupivacaine HCl group (p = 0.002). Compared to the bupivacaine/placebo group, the time to first use of opioids in the LB group was significantly longer at LB 199 mg (11 h vs. 9 h), LB 266 mg (19 h vs. 9 h), and LB 300 mg (19 h vs. 8 h) (p < 0.05). Moreover, compared to the bupivacaine/epinephrine group, it was significantly lower in the LB 266 mg group (3.7 vs. 10.2 mg) and at LB 300 mg (13 vs. 33 mg) (p < 0.05). Finally, regarding adverse effects, the conventional anesthetic/placebo group reported more pain in bowel movement than LB groups (OR 2.60, 95% CI 1.31-5.16).

CONCLUSIONS

Comparing LB to conventional anesthetic/placebo anesthetic for hemorrhoidectomy, we found a statistically significant reduction in pain through 72 h, decreased opioid requirements, and delayed time to first opioid use. Moreover, the conventional anesthetic/placebo group reported more pain in bowel movement than LB groups.

Clinical utility of repeat fetal echocardiography in congenital heart disease

OBJECTIVES

To investigate the utility of repeat fetal echocardiography (FE) following a diagnosis of structural congenital heart disease (CHD) on the initial FE. We evaluated how often changes in management and counseling occurred based on subsequent FE findings and sought to determine which types of CHD were more likely to have changes in management and/or counseling based on repeat FE.

METHODS

This was a retrospective review of all patients who presented to our center between January 2012 and January 2019 and who had more than one FE performed for structural CHD. We reviewed consultation notes to determine whether management or counseling had changed based on FE findings at follow-up visits. Management variables included a change in location or mode of delivery, plan for atrial septostomy, initiation of prostaglandin infusion, umbilical line placement and planned admission location (nursery vs neonatal intensive care unit). We defined a counseling change as any of the above changes in management as well as any meaningful refinements in the cardiac diagnosis that led to a change in the overall prognosis or future management. Initial diagnoses were grouped into anatomically/hemodynamically relevant subgroups. Fisher's exact test was used to assess the relationship between the initial diagnosis and changes in management. Post-hoc pairwise comparisons were performed using Dunnett's test.

RESULTS

Between January 2012 and January 2019, 267 patients underwent 534 follow-up FE assessments performed for structural CHD. Management change based on repeat FE occurred in 41/267 (15.4%) cases. A change in management was associated with the diagnosis made at the initial visit (P < 0.001). The proportion of cases with a management change was highest among those with an initial diagnosis of pulmonary valve abnormality/non-critical pulmonary stenosis (4/11 (36.4%)), followed by balanced atrioventricular canal (AVC) defect (5/17 (29.4%)) and left ventricular outflow tract obstruction/aortic valve abnormality or coarctation/interrupted aortic arch (19/68 (27.9%)). No management change occurred in fetuses diagnosed with isolated ventricular septal defect (VSD), truncus arteriosus, pulmonary vein anomaly or isolated arch sidedness/branching abnormality. Compared to those with a VSD, management was significantly more likely to be changed in fetuses with a balanced AVC defect (P = 0.025) and left heart lesions (P = 0.002). Right heart lesions showed a trend towards an increased incidence of management change (P = 0.05). A counseling change based on repeat FE occurred in 108/267 (40.4%) cases. The proportion of cases with a counseling change was highest among those with an initial diagnosis of pulmonary valve abnormality/non-critical pulmonary stenosis (8/11 (72.7%)) and hypoplastic left heart syndrome/critical aortic stenosis (5/9 (55.6%)).

CONCLUSIONS

The clinical utility of follow-up FE is associated with the type of CHD diagnosed. Follow-up FE led to changes in management in several types of CHD, most commonly in cases with an initial diagnosis of right and left outflow obstructive lesions and balanced AVC defect. When developing programmatic protocols for the frequency of FE assessments, the type of CHD should be a major determinant, but additional studies are required to reach a consensus on how often serial FE should be performed for each type of CHD. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Reflections of maternity service users and midwives' on the co-creation of interventions to support midwives addressing alcohol during antenatal care

BACKGROUND

There are divergent perspectives between midwives and pregnant women on how alcohol consumption during pregnancy could be addressed. Co-creation is an approach where lay people and professionals work together as equal partners, offering the opportunity to bridge the gap.

OBJECTIVES

Our aim was to evaluate how well we carried out authentic co-creation of an intervention to support midwives have a dialogue about alcohol consumption with pregnant women.

PATIENT INVOLVEMENT

Recent maternity service users including women with experience of harm due to alcohol during pregnancy provided feedback on the design, conduct and dissemination of the study.

METHODS

An iterative co-creation approach rooted in participatory research methods was used. Five online workshops were carried out with thirteen midwives and six maternity service users via Zoom July-August 2021. Data were analysed using the core values of co-create as a framework: equality, inclusivity, holistic, resource, positivity, transparency, iterative, and sustainability.

RESULTS

The co-creation process was productive and rewarding to midwives and maternity service users. There were positive experiences across the co-creation framework with some unintended positive consequences for maternity-service users.

DISCUSSION

This evaluation provides new knowledge on how well the co-creation process worked in relation to research involving a sensitive topic that can invite stigma. Co-creation projects require generous time and financial resources to ensure a high-quality process and robust outcome for all.

PRACTICAL VALUE

Co-creation of strategies involving both service providers and service users have potential to facilitate evidence-based practice.

FUNDING

This research is funded by the National Institute for Health Research (Reference: NIHR201128).

Patterns of endocardial fibroelastosis without atrioventricular block in fetuses exposed to anti-Ro/SSA antibodies

Anti-Ro/SSA-antibody-mediated endocardial fibroelastosis (EFE) without atrioventricular (AV) block at presentation is a rare cardiac phenotype. We report on 11 fetuses with this rare type of anti-Ro/SSA-antibody-mediated cardiac involvement, presenting with a distinctive echocardiographic pattern of EFE. Eleven fetuses with isolated EFE at presentation were included from four cardiac centers, and experienced fetal cardiologists reached a consensus regarding EFE location on echocardiography at presentation. Interval changes to subsequent fetal and postnatal echocardiograms were assessed to evaluate response to therapy. Echocardiographic markers of cardiac performance, including diastolic function and AV conduction, were reviewed. Ten fetuses were found to have EFE of the aortic root, proximal aorta and/or left ventricular outflow tract. In the same 10 cases, EFE of the pulmonary root, pulmonary artery and/or right ventricular outflow tract was identified. Six cases had atrial EFE and six had EFE of the crux. Four cases were known to be positive for anti-Ro/SSA antibodies prior to diagnosis, whereas, in the remaining seven, echocardiographic findings prompted testing, which was positive in all cases. The AV interval at presentation was normal in all cases, but one fetus subsequently developed AV block. Nine patients were treated with transplacental dexamethasone, five of which also received intravenous immunoglobulin (IVIG), and one received IVIG only. Of the 10 treated cases, six had improvement in EFE as shown by serial imaging and, in four cases, the severity was unchanged. All patients were liveborn. In our cohort, EFE of the aortic and pulmonary arteries and outflow tracts was nearly universal, and involvement of the atria and the crux of the heart was also common. The high survival rate and low burden of AV block are also suggestive of a distinct phenotype of anti-Ro/SSA-antibody-mediated cardiac disease with a favorable prognosis. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Statistical and agent-based modelling of the transmissibility of different SARS-CoV-2 variants in England and impact of different interventions

The English SARS-CoV-2 epidemic has been affected by the emergence of new viral variants such as B.1.177, Alpha and Delta, and changing restrictions. We used statistical models and the agent-based model Covasim, in June 2021, to estimate B.1.177 to be 20% more transmissible than the wild type, Alpha to be 50-80% more transmissible than B.1.177 and Delta to be 65-90% more transmissible than Alpha. Using these estimates in Covasim (calibrated 1 September 2020 to 20 June 2021), in June 2021, we found that due to the high transmissibility of Delta, resurgence in infections driven by the Delta variant would not be prevented, but would be strongly reduced by delaying the relaxation of restrictions by one month and with continued vaccination. This article is part of the theme issue 'Technical challenges of modelling real-life epidemics and examples of overcoming these'.

Statistical and agent-based modelling of the transmissibility of different SARS-CoV-2 variants in England and impact of different interventions

The English SARS-CoV-2 epidemic has been affected by the emergence of new viral variants such as B.1.177, Alpha and Delta, and changing restrictions. We used statistical models and the agent-based model Covasim, in June 2021, to estimate B.1.177 to be 20% more transmissible than the wild type, Alpha to be 50-80% more transmissible than B.1.177 and Delta to be 65-90% more transmissible than Alpha. Using these estimates in Covasim (calibrated 1 September 2020 to 20 June 2021), in June 2021, we found that due to the high transmissibility of Delta, resurgence in infections driven by the Delta variant would not be prevented, but would be strongly reduced by delaying the relaxation of restrictions by one month and with continued vaccination. This article is part of the theme issue 'Technical challenges of modelling real-life epidemics and examples of overcoming these'.

P-249 The location of fragments and degraded zones in blastocysts is associated with ploidy: moving towards explaining an AI-based morphology tool trained on euploidy outcomes

Study question

Is the location of degraded areas or fragments an indication of ploidy in blastocyst images?

Summary answer

Degradation traces observed in a blastocyst’s inner cell mass correlates with aneuploidy when confirmed by trophectoderm biopsy.

What is known already

The interaction between humans and Artificial Intelligence (AI) augmented intelligence, (AuI) is dependent on the AI’s ability to be self-explainable and interpretable. This is a highly desired feature of AI’s in healthcare, given that blindly trusting it to make a decision has serious ethical considerations and potential consequences. Currently, most available AI’s provide “black-box” advice that might cause difficult interaction with their human counterparts. ERICA (IVF2.0 Limited, UK), was designed to rank blastocysts using euploid status as ground truth, and although initially a “black-box,” we describe results from an initial attempt towards making it explainable.

Study design, size, duration

This study was designed as a proof-of-concept on retrospectively collected images. De-identified images (n = 329) with known ploidy status (euploid or aneuploid) were retrieved (November 2021) from ERICA. The images were processed from December 2021 to January 2022.

Participants/materials, setting, methods

A senior embryologist identified visual degenerative traces from blastocyst images for areas of cell degradation and cell fragments. Ploidy status was blinded to the embryologist. Images were segmented for trophectoderm (TE), blastocoele (BC), and inner cell mass (ICM) using the automated tool of ERICA’s algorithm. The distance between the centre of each degenerative trace and the ICM was measured. The Dice Similarity Coefficient (DSC) and the proportion of degenerative traces in each zone were computed.

Main results and the role of chance

We identified some level of degradation in 60% of the blastocysts, particularly in BC:44%, ICM:38%, TE:26%, and ICM+BC:55%, and the presence of fragments in 103, particularly in BC:21%, ICM:10%, and TE:24%. Our database contained 52% euploid blastocyst images.

We found that when DSC between degradation and ICM is more than 10% (44/78 aneuploids) the chances of aneuploidy increase by 25% (Z=-1.76, p &lt; 0.05).

We also found a 13% increased chance of an embryo being aneuploid (92/157 aneuploidy) if the area of ICM+BC has any presence of degradation (Z=-1.14, p = 0.13), and an increased risk of aneuploidy if DSC (U = 12401, p = 0.09), and also if the proportion of degradation was found in ICM+BC (U = 12397, p = 0.09).

Our data also suggests that aneuploid embryos have closer fragments (mean=51um, 95% CI: 42.2-59.9) than euploids (mean=63.4um 95% CI:51.1-75.7) (U = 988,=0.19).

Mann-Whitney U test and Z-test for proportions were used accordingly, both under the hypothesis that increased degenerative traces means a higher probability of being aneuploid (one-tailed test).

Limitations, reasons for caution

Analyzing degenerative traces using a single image from a single focal plane might be limiting. Identifying fragments and degradation might not be a replicable process inter- or intra- embryologist. More annotators are needed to reduce this bias.

Wider implications of the findings

Correlation between aneuploidy and cell degradation was stronger in the ICM than TE, although ploidy status is obtained via TE biopsy. Our data suggest that fragments that are closer to the ICM might increase the chances of aneuploidy. A larger prospective multicentre study should be conducted to confirm these findings.

Trial registration number

not applicable

P-241 ‘Augmented intelligence’ to possibly shorten euploid identification time: A human-machine interaction study for euploid identification using ERICA, an Artificial Intelligence software to assist embryo ranking

Study question

What is the mean number of transfers needed to achieve a euploid transfer selected by embryologists plus ERICA’s assistance?

Summary answer

Augmented intelligence (ERICA plus human collaboration) outperforms both the embryologists and artificial intelligence's individual performance alone.

What is known already

Euploid embryos are more likely to implant successfully. Artificial intelligence (AI) could improve embryo selection over current techniques, but scepticism exists. Augmented intelligence (AuI) combines both the mathematical reproducibility of machine learning and the knowledge and experience of humans. This approach employs AI tools as an assistant, where the user shall learn to interpret the AI. A recent study suggested that embryologists assisted by AI improved the embryo selection of euploid transfers. ERICA (IVF2.0 Limited, UK) was designed to rank blastocysts according to their probability of euploidy.

Study design, size, duration

We prospectively studied embryo selection for ERICA alone, embryologists only and when interacting (embryologists and ERICA) in 150 synthetically generated (reconstructed on real-data) embryo transfer cycles. Embryos were ranked in order, and performance was assessed by time to identify a euploid embryo within each cycle cohort correctly. Embryologists were allowed to rank a maximum of 10 cycles per day for three weeks starting in January 2022, using a mobile phone application designed for this purpose.

Participants/materials, setting, methods

Using real-life cycle distributions of euploid/aneuploid blastocysts and the number of embryos in a cycle (according to ERICA’s database), we created 150 synthetic cycles, 30 for each age bracket (&lt; 35, 35-37, 38-40, 41-42, and &gt;42). These were randomly populated with blastocyst images preserving their actual ploidy status correspondingly. Each synthetic cycle contained between 2 to 6 authentic embryo images with at least one euploid and one aneuploid.

Main results and the role of chance

The total database had a euploid rate of 37.4% (n = 513), and by age brackets from 1 to 5 were 45.7% (n = 116), 43.8% (n = 105), 35.9% (n = 92), 31.2% (n = 96), and 28.8% (n = 104) respectively.

The mean number of cycles analysed by each participant was 113.5 (CI: 100.8-126.2). The mean time-to-euploid transfer for embryologists alone was 2.07 (CI:2.00-2.13); for the ERICA alone was 1.86 (CI:1.82-1.91); and for embryologists assisted by ERICA was 1.62 (CI:1.55-1.68). All study groups compared to each other were statistically significant using a paired two-tailed student’s t-test (p &lt; 0.001).

The proportion of euploid transfer at the first try for embryologists alone was 0.40 (CI:0.37-0.43), for ERICA alone was 0.54 (CI:0.53-0.54), and for embryologists assisted by ERICA was 0.47 (CI:0.44-0.50). All study groups compared with each other were statistically significant with a paired two-tailed student’s t-test (p &lt; 0.01).

Limitations, reasons for caution

Although our findings suggest that Aul outperforms both AI and humans alone, this study needs to be replicated with a larger cohort of embryologists with different experience levels in different countries to confirm these results.

Wider implications of the findings

Combining machine-human interaction through a well-designed process could improve embryo selection and reduce inter-operator variability amongst staff with different experience levels. It could also set a frame for adequate agency and accountability, and enhance trust and adoption.

Trial registration number

NA

P-085 Use of an artificial intelligence tool to assess single-sperm motility variables related to bias preference of ICSI sperm selection practice, normal fertilization, and blastocyst formation

Study question

Which single-sperm WHO motility variables are associated with ICSI sperm selection preference, normal fertilization, and blastocyst formation when assessed by an artificial intelligence platform?

Summary answer

Injected sperm had higher VSL, VAP, and LIN compared with non-injected. Higher STR was associated with fertilization and higher WOB and less HMP with blastulation.

What is known already

Sperm selection for intracytoplasmic sperm injection (ICSI) is key to its success. Currently, the procedure may be subjective although the embryologist selects rapidly from a small population of sperm. There is no consensus on specific motility variables for single-sperm selection.

SiD (IVF 2.0 Limited, UK) software is able to assess all sperm in a visual field and accurately compute the motility variables for each sperm in real-time. SiDTM could help to understand the association between motility variables related to ICSI success and to assess the differences in sperm selection practice between different clinics and operators.

Study design, size, duration

473 ICSI videos and their corresponding outcome were retrospectively analyzed using SiD software and assessed against normal fertilization (2PN), and blastocyst formation (BF), from four fertility clinics in different countries between July 2021 to December 2021. Ethical approval was obtained. This study was non-interventional. The study parameters were defined as sperm that were selected or non-selected, 2PN, and BF.

Participants/materials, setting, methods

Motility variables were computed from ICSI videos for VSL, VCL, LIN, VAP, ALH, WOB, STR as defined by the WHO manual for the examination and processing of human semen; and HMP, a metric associated with sperm-head movements. Injected sperm were manually identified and the injection was visually verified by a senior embryologist. Extracted motility variables were standardized according to each clinic and PVP concentration. Study groups were tested with a two-sided Mann-Whitney U test.

Main results and the role of chance

Video analysis identified 304 selected and 9543 non-selected sperm. 2PN and BF status was known for 302 and 301 injected oocytes respectively (2PN rate: 79%, BF rate: 53%).

Embryologists used VSL, VAP, and LIN as the preferred motility criteria to select sperm (p &lt; 0.001). Using data from all clinics, we found a tendency for STR (p = 0.12) and LIN (p = 0.14) for 2PN and WOB (p = 0.11) and VAP (p = 0.18) for BF.

There was partial consistency on sperm selection criteria amongst clinics: Clinic1 selected VSL, VAP, and LIN as the main variables to select sperm; Clinic2 VSL, WOB, and LIN; Clinic3 VSL, VAP, and VCL; and Clinic4 ALH, VCL, and VAP (p &lt; 0.001).

For Clinic1 higher HMP showed a correlation (p = 0.06, n = 21) to 2PN, while higher WOB (p = 0.12, n = 21) did for BF. Clinic2 showed a limited association to higher STR and 2PN (p = 0.12, n = 120), and a significant association between higher WOB and BF (p &lt; 0.05, n = 120). Clinic3’s data suggested that higher STR was associated with 2PN (p &lt; 0.05, n = 97) and low HMP with BF (p &lt; 0.05, n = 97).

Limitations, reasons for caution

This retrospective study needs to be repeated prospectively with larger numbers in more locations using embryologists with different levels of ICSI experience. Clinical outcome data such as clinical pregnancy, miscarriage, and live birth impact is still required.

Wider implications of the findings

SiD was able to track and extract motility features from single sperm. SiDTM could assist embryologists in real-time to select sperm during ICSI and could be used as a training tool to reduce variability among embryologists.

Trial registration number

RPA-2021-03

Oocyte ERM and EWI Proteins Are Involved in Mouse Fertilization

In mammalian fertilization, the link between the oocyte plasma membrane and underneath cytoskeleton has often been associated to key elements of successful gamete fusion, like microvilli shaping or CD9 function, but its effective role has poorly been studied. EWI-2 and EWI-F as cis partners of CD9, and ERM proteins (Ezrin, Radixin and Moesin) that both attach to the actin cytoskeleton and to the EWI are part of the molecules that make the link between the oocyte membrane and its cytoskeleton. This study aims to assay through siRNA inhibition, the involvement of these ERM and EWI molecules in mouse fertilization, their role in the microvilli morphology of the egg but also their possible contribution to the cortical tension, a parameter that reflects the mechanical behavior of the oocyte cortex. Whereas inhibiting separately the expression of each protein had no effect on fertilization, the combined inhibition of either EWI-2/EWI-F or the three ERM triggered a significant decrease of the fertilization index. This inhibition seems to correlate with an increase in the radius of curvature of the oocyte microvilli. It also causes a decrease of the oocyte cortical tension. These results show the importance of EWI-2 and EWI–F and ERM proteins in the smooth running of a fertilization event and support their involvement in the microvilli architecture of the oocyte and in its mechanical properties.

The role of premorbid transthoracic echocardiogram in identifying adverse clinical outcomes in patients admitted with COVID-19

Background/Introduction

The novel coronavirus disease (COVID-19) inpatient mortality rate is approximately 20% in the United States. Reports have described a wide pattern of abnormalities in echocardiograms performed in patients admitted with COVID-19. The role of premorbid transthoracic echocardiogram (TTE) in the prediction of COVID-19 severity and mortality is yet to be fully assessed.

Purpose

To assess whether a pre-COVID TTE can identify patients at high risk of adverse outcomes who are admitted with COVID-19.

Methods

All patients who underwent a TTE from one year to one month prior to an index inpatient admission for COVID-19 were retrospectively enrolled across five clinical sites. Demographic information, medical history, and laboratory data were included for analysis. Echocardiograms were analyzed by an observer blinded to clinical data. Linear and logistic regressions were performed to detect the association of variables with death, invasive mechanical ventilation, initiation of dialysis, and a composite of these endpoints during the COVID-19 admission. Outcomes were then adjusted for a risk score using inverse propensity weighting incorporating age, sex, diabetes, hypertension, obstructive sleep apnea, history of atherosclerotic cardiovascular disease, atrial fibrillation, diuretic use, and angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use.

Results

There were 104 patients (68±15 years old, 49% male, BMI 31.4±9.1kg/m2) who met inclusion criteria (baseline characteristics in Table 1). Mean time from TTE to positive SARS-CoV-2 PCR test was 139±91 days. Twenty-nine (28%) participants died during the index COVID-19 admission. There was no association of pre-COVID echocardiographic measures of systolic ventricular function with any endpoint. Diastolic function, as assessed by LV e', was associated with mortality (Table 2). There were 25 patients (24%) with a normal lateral e' (≥10cm/s); none died. There were 35 (34%) patients with LV e' lateral velocity &lt;8 cm/s, of whom 15 (43%) died. LV e' lateral velocity &lt;8 cm/s was associated with an unadjusted odds ratio of 7.69 (95% confidence interval [CI] 2.26–26.19) for death and 3.25 (95% CI 1.11–9.54) for the composite outcome. The odds ratio for death was 4.76 (95% CI 1.10–20.61) and 3.78 (95% CI 0.98–14.6) for the composite outcome after adjustment for clinical risk factors (Table 2).

Conclusion

In patients with an echocardiogram prior to COVID-19, impaired diastolic function as represented by an abnormal LV e' lateral velocity was associated with both inpatient COVID-19 mortality and a composite outcome of death, mechanical ventilation, and initiation of dialysis, even after adjustment for multiple co-morbidities and medication use. Knowledge of the pre-COVID TTE results may help clinicians identify patients at higher risk of adverse outcomes during an admission for COVID-19.

Funding Acknowledgement

Type of funding sources: None.

P–243 Improving ERICA’s (Embryo Ranking Intelligent Classification Assistant) performance. Should we train an AI to remain static or dynamic, adapting to specific conditions?

Study question

Can ERICA’s deep-learning capabilities allow it to learn specifics from individual clinics, and improve its performance through a quality assurance and fine-tuning process?

Summary answer

Quality assurance and fine-tuning allowed ERICA to adapt to unique specifications of individual clinics, resulting in an improved performance at each clinic.

What is known already

Machine learning (ML) solutions to real-life problems have shown that generalizability (applicability of a model to different scenarios) of a single model is fundamentally a suboptimal approach, due to the risk of underspecification. Under-specification becomes relevant in environments where there is a myriad of protocols and approaches, like during IVF treatments. It is naïve to assume that different features extracted from embryos to predict treatment success weigh the same along the overall heterogeneity of protocols. This underspecification problem takes special relevance when deploying an ML-based product, like ERICA, in a clinical setting.

Study design, size, duration

Retrospective analysis of results from the quality assurance (QA) and fine-tuning (adaptation) process performed for a deep learning algorithm named ERICA (Embryo Ranking Intelligent Classification Assistant) at five clinics (1879 embryos) between August and September 2020.

Participants/materials, setting, methods

QA and fine-tuning consist of a transfer-learning approach (of the ERICA Core model) and re-training using embryos of each clinic exclusively. Results are assessed by a 10-fold cross validation approach, which splits the database in 10 and iteratively validates on each by training on the rest. Performance of ERICA is assessed both before and after the fine-tuning process and results are presented as averages per clinic. Embryos considered for QA and fine-tuning had known outcome.

Main results and the role of chance

After the fine-tuning, ERICA showed an average improvement of 13% in accuracy (from 50.2% to 63.2%); 36.6% in specificity (from 22.4% to 59%); 11% for Positive Predictive Value (from 51% to 62); 19.6% for Negative Predictive Value (from 44.6% to 64.2%), and 3.4% for F1 score (from 60% to 63.4%). Sensitivity decreased from 78% to 65.4%.

Our results suggest ERICA’s Core is robust lending itself to be fine-tuned. It learns from individual laboratory specifics, and in this way adapts to new clinics. The results demonstrate that the Core model tends to classify embryos from new clinics as having a good prognosis, since it showed a high sensitivity and low specificity, both showing an improved balance following the fine-tune process. Additionally, the probability of finding a good prognosis embryo in the different labels, behaved as expected, decreasing its probability from Optimal (65.8%) to Poor prognosis (37.4%).

Limitations, reasons for caution

underspecification is a challenge to Artificial Intelligence (AI) based solutions pursuing a general model. For this study, our approach of QA followed by a fine-tuning process to overcome underspecification, was successful. However, it was only applied to 5 clinics, and the findings remain to be proven on a larger scale.

Wider implications of the findings: Performance of QA should be considered standard before clinical implementation of any AI based solution. Our results should be interpreted as the theoretical/expected future performance of ERICA for each clinic. Regular assessments on performance for all models generated after fine-tuning are encouraged.

Trial registration number

Not applicable

O-235 ERICA (Embryo Ranking Intelligent Classification Assistant) AI predicts miscarriage in poorly ranked embryos from one static, non-invasive embryo image assessment

Study question

Does ERICA’s prognosis ranking based on ploidy, predict early miscarriage following positive biochemical pregnancy test?

Summary answer

The lower ERICA grades embryos, the higher the likelihood of early miscarriage, irrespective of age group.

What is known already

The vast majority of early miscarriages are due to aneuploidy, but preimplantation genetic testing for aneuploidy (PGTA) is potentially invasive, expensive, time-consuming and usually necessitates cryopreservation. Current methods for embryo selection based on morphology and morphokinetics are poorly correlated with ploidy. ERICA is a deep-learning non-invasive tool for embryo ranking, trained to identify ploidy, and has previously been shown to be similar or better than experienced embryologists in assessing implantation potential. AI-based tools capable of embryo ranking and assessment could help save laboratory time and costs, avoiding risk to embryos from invasive techniques.

Study design, size, duration

Retrospective analysis of 599 blastocysts transferred over 12 months in which ERICA was used to assist embryologists during the embryo selection process. ERICA’s prognosis based on ploidy potential is presented as groups labelled as “optimal”, “good”, “fair”, or “poor”. Embryo transfers (ET) reaching biochemical pregnancy (beta-hCG ≥ 20iu) were considered for the study. Early pregnancy loss (EPL) was defined as a biochemical pregnancy failing to develop a gestational sac and/or failure to show heartbeat (FHR).

Participants/materials, setting, methods

ETs resulting in biochemical pregnancies at two IVF clinics were followed-up to FHR till 8 weeks gestation. EPLs were divided into groups according to the presence or absence of a pregnancy sac. ERICA’s suggested prognosis during the embryo selection process was tested against pregnancy outcomes. Further analysis of pregnancy outcomes and their relation to ERICA’s labels was also performed based on age groups. Z-test for two proportions was used to assess statistical significance.

Main results and the role of chance

506 ETs were performed for 599 embryos (mean 1.2 embryos), from which 285 resulted in positive pregnancy tests (56.3%). Thirty-one (10.9%) EPLs happened before the identification of a gestational sac (GS). Ten pregnancies failed to develop FHR after initial GS identification (3.9%), for an overall EPL of 14.4%. The average age in this group was 35.4 years. When evaluated using ERICA’s labels “optimal”, “good”, “fair, and “poor”, chances of miscarriage before GS were 8.9% (8/89); 14.1% (11/78); 18.5% (5/27); and 18.7% (9/48) respectively, where denominator represents total number within a label (i.e. EPL/n). When including all EPLs, chances of miscarriage according to the same labels were 11.2%; 17.9%; 22.2%; and 22.9% respectively.

ERICA’s performance to anticipate the risk of EPL showed statistical significance when the optimal label was compared against all other labels (Z -1.786, p &lt; 0.05), and against the poor prognosis label (Z=-1.653, p &lt; 0.05). After stratifying the dataset according to age groups, increasing miscarriage rates were maintained as ERICA’s prognosis for an embryo worsened, regardless of age groups. The most notable performance was for ≤35-year-olds, where embryos ranked as optimal had an EPL rate of 14.3% in contrast to lowest ranked embryos having a 33.3% EPL rate.

Limitations, reasons for caution

The retrospective nature of this study along with its sample-size might limit the reach of our conclusions, in particular for older patients. The results we present must still be confirmed prospectively, and on a larger dataset.

Wider implications of the findings

Most EPLs are attributed to genetic factors, hence ERICA’s training for embryo ranking was based on ploidy. We conclude that ERICA’s AI is able to identify embryos at a higher risk of EPL non-invasively. Cytogenetic studies from products of miscarriage would help to confirm the hypothesis.

Trial registration number

Not applicable

P–244 ERICA’s (Embryo Ranking Intelligent Classification Assistant) ranking, based on ploidy prediction, is strongly correlated with pregnancy outcomes

Study question

How does ERICA perform when ranking the most suitable embryos for transfer in terms of clinical pregnancy, and the presence of a fetal heartbeat (FHB)?

Summary answer

ERICA’s Artificial Intelligence ranking system was positively correlated with outcomes defined as implantation and presence of FHB. Best-ranking embryos outperformed lower-ranking embryos by statistical significance.

What is known already

ERICA, the Embryo Ranking Intelligent Classification Assistant, is a deep learning AI system trained to rank embryos based on their ploidy status, which is highly correlated with successful treatments.

ERICA ranks the embryos according to their prognosis predictions and labels them into four quality categories: optimal, good, fair, and poor. ERICA’s performance in the clinic remains to be tested.

Study design, size, duration

Retrospective analysis on ERICA’s performance over 4 consecutive months after quality assurance and fine-tuning processes. We compared both the ranking and prognosis of the AI algorithm against clinical outcomes in IVF cycles and subsequent embryo transfers. For this study, all cycles where ERICA was used to assist embryologists during the embryo selection process were included. Double embryo transfers with a single FHB where excluded.

Participants/materials, setting, methods

Total 77 cycles with 81 transfers of 98 embryos (17 cases underwent a double embryo transfer) from two IVF clinics. Evaluated clinical outcomes included biochemical pregnancy test (defined as beta human chorionic gonadotropin &gt;20 mUI/ml), and presence/absence of FHB. We compared the ERICA rankings and predictions against outcome and a sub-analysis was performed on transferred embryos with known ploidy status (14 embryos).

Main results and the role of chance

The distribution of embryos within the ERICA categories are 42% for optimal, 38% for good, 19% for fair, and 6% for poor. The observed biochemical pregnancy rate was 51%, 25%, 47% and 33% respectively, and 39%, 22%, 42%, 17% for FHB. We found statistical significance (Z = 1.78; p = 0.0378) for the proportion of biochemical pregnancy between transfers labelled by ERICA as optimal (51%) and all lower rankings (33%). The proportion of transfers with presence of FHB within the optimal group was 39%, compared with 29% for the rest of the embryos. This did not show statistical significance (Z = 1.141; p = 0.127). Additionally, we observed that the proportion of biochemical pregnancy and presence of FHB in the group of transfers with known ploidy (n = 14) was 50% and 36% respectively, and the transfers with unknown ploidy and labelled as optimal by ERICA (n = 35) was 54% and 43% respectively.

Limitations, reasons for caution

This is the first report on ERICA’s performance on real clinical data, and despite being a relatively small dataset, we observed statistical significance of the embryos labelled by ERICA as having optimal quality. Further studies should be conducted with larger datasets and more clinics included to strengthen the evidence.

Wider implications of the findings: This is the first report on ERICA’s performance on real clinical data, and despite being a relatively small dataset, we observed statistical significance of the embryos labelled by ERICA as having optimal quality. Further studies should be conducted with larger datasets and more clinics included to strengthen the evidence.

Trial registration number

Not applicable

P–096 Real-time ranking of single spermatozoa using artificial vision analysis of complex motility patterns during ICSI aimed at improving fertilization and blastocyst development

Study question

Can real-time artificial vision identify beneficial movement patterns of single spermatozoa in a cohort visualized in PVP during ICSI possibly enhancing fertilization and embryo development?

Summary answer

Artificial vision seems able to identify advantageous movement patterns of individual spermatozoa having a significant impact on both normal fertilization and blastocyst formation.

What is known already

Spermatozoa isolated from poor semen may reduce the quality of embryo development and blastocyst formation. Normal motility is dependent on general sperm morphology and characteristic movement of the flagellum enabling forward mobility. Spermatozoa roll as they swim. It is known that this rotational motion around their longitudinal axis promotes rheotaxis, which is a mechanism that allows the sperm to navigate to the site of fertilization. Therefore, it is possible that the characteristics of the rotational movement are related to sperm quality.

Study design, size, duration

Non-intervention study based on a cohort of 132 videos of in-vitro fertilization treatments with ICSI during which the sperm selection process was recorded up to sperm injection. The study was performed at one IVF center within a 6-month period. Injected spermatozoa and their corresponding oocytes were individually assessed from fertilization to blastocyst formation. Videos, where spermatozoa selected for injection could not be identified, were excluded. Relevant outcomes included normal fertilization (2PN), and blastocyst formation.

Participants/materials, setting, methods

Using a digitizer attached to an optical microscope (640 x 480 pixels), videos were recorded to include the sperm selection process, immobilization, and subsequent injection following standard ICSI protocols. Individual spermatozoa motility features were extracted using a proprietary computer-vision algorithm (SID, IVF 2.0 LTD). The rotational movements of spermatozoa were inferred by computing the variations of the mean intensity of the sperm in the video-sequence across time (MI).

Main results and the role of chance

Based on SID’s analysis, we found statistically significant differences between the median prominences of the MI of those injected spermatozoa that resulted in successful fertilization in comparison to those with failed fertilization (p-value=0.029, 28 negative fertilization, and 71 positive fertilization) using a one-tailed t-Student test with a significance level of 5%. We also found statistically significant differences between the median prominences of the MI of those spermatozoa that resulted in blastocysts in comparison with the spermatozoa-oocyte cohorts which didn’t reach the blastocyst stage (p-value 0.004, 51 with negative blastocyst formation and 48 with blastocyst formation).

Limitations, reasons for caution

The size of this database is modest, therefore a larger study with multiple clinics will be necessary to confirm the findings. Large prominence does not necessarily assurance successful fertilization or blastocyst formation since there may be other factors such as oocyte quality or the ICSI technique.

Wider implications of the findings: Objective assessment of sperm rotational movement is difficult to quantify and to be objectively assessed during standard sperm selection. Real-time artificial vision tools such as SID could assist embryologists during the sperm selection process for ICSI.

Trial registration number

NA

Factors of the human embryo culture system that may affect media evaporation and osmolality

STUDY QUESTION

Which lab-related factors impact the culture system's capacity to maintain a stable osmolality during human embryo culture?

SUMMARY ANSWER

Incubator humidity, the volume of mineral oil, the type of culture media and the design of time-lapse dishes have been identified as important parameters that can cause an impact on media evaporation and consequently osmolality during culture.

WHAT IS KNOWN ALREADY

Culture medium is a critical component in human embryo culture. Minimizing its evaporation during culture is an adequate strategy to stabilize osmolality and, as a result, improving culture conditions and clinical outcomes.

STUDY DESIGN, SIZE, DURATION

The studied variables included media composition and supplementation; volume of mineral oil; incubator humidification; and the type of dish and incubator used. Additionally, six time-lapse dish models were compared in their ability to prevent evaporation.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Dishes were incubated in parallel to analyze osmolality during culture between groups: synthetic oviductal medium enriched with potassium versus human tubal fluid medium; protein versus no protein supplementation; dry versus humid atmosphere; high versus low volume of mineral oil. Additionally, media evaporation was compared between six models of time-lapse dishes with distinct designs, cultured in a joint incubator. Two of them were retested in their corresponding incubator to analyze the dish-incubator fit. Daily osmolality measurements were compared between groups. Linear regression was performed to analyze evaporation rates.

MAIN RESULTS AND THE ROLE OF CHANCE

Protein supplementation did not significantly affect evaporation. Contrarily, humidity levels inside the incubators, the volume of mineral oil and the type of culture media, played an important role in osmolality stabilization. The design of time-lapse dishes and their recommended preparation protocol heavily influenced their evaporation rates, which were further altered by each incubator's characteristics. Media with initially high osmolalities had a bigger risk of reaching hypertonic levels during culture.

LIMITATIONS, REASONS FOR CAUTION

While numerous, the studied variables are limited and therefore other factors could play a role in osmolality dynamics, as well. Incontrollable atmospheric factors could also result in some variation in the observed results between different centers and laboratories.

WIDER IMPLICATIONS OF THE FINDINGS

Published literature has extensively described how hypertonic media may impair embryo development and negatively affect clinical outcomes; therefore, maintaining a stable osmolality during culture should be considered essential. This work is of interest both for embryologists when analyzing their culture system and methodologies, as well as manufacturers in charge of designing IVF consumables.

STUDY FUNDING/COMPETING INTEREST(S)

This study was privately funded.

TRIAL REGISTRATION NUMBER

N/A.

Management of abdominal compartment syndrome in acute pancreatitis

Abdominal compartment syndrome (ACS), defined by the presence of increased intra-abdominal pressure>20mmHg in association with failure of at least one organ system, is a common and feared complication that may occur in the early phase of severe acute pancreatitis (AP). This complication can lead to patient death in the very short term. The goal of this review is to provide the surgeon and intensivist with objective information to help them in their decision-making. In the early phase of severe AP, it is essential to monitor intra-vesical pressure (iVP) to allow early diagnosis of intra-abdominal hypertension or ACS. The treatment of ACS is both medical and surgical requiring close collaboration between the surgical and resuscitation teams. Medical treatment includes vascular volume repletion, prokinetic agents, effective curarization and percutaneous drainage of large-volume ascites. If uncontrolled respiratory or cardiac failure develops or if maximum medical treatment fails, most teams favor performing an emergency xipho-pubic decompression laparotomy with laparostomy. This procedure follows the principles of abbreviated laparotomy as described for abdominal trauma.

Partisan pandemic: How partisanship and public health concerns affect individuals' social mobility during COVID-19

Rampant partisanship in the United States may be the largest obstacle to the reduced social mobility most experts see as critical to limiting the spread of the COVID-19 pandemic. Analyzing a total of just over 1.1 million responses collected daily between 4 April and 10 September reveals not only that partisanship is more important than public health concerns for explaining individuals' willingness to stay at home and reduce social mobility but also that the effect of partisanship has grown over time-especially among Republicans. All else equal, the relative importance of partisanship for the increasing (un)willingness of Republicans to stay at home highlights the challenge that politics poses for public health.

Future mechanisms for funding research on unhealthy commodities – criteria for industry-supported research funding programs

Research funding is scarce and some argue that commercial enterprises not only can, but should, fund extramural research. Others are concerned by the evidence that commercial funding of research is used by these commercial interests to subvert the scientific process, to gain credibility and to advance their own financial interests, without regard to broader societal values and needs. A key question is whether there might be a funding model whereby industry-supported research funding programs are acceptable to the public health community and that support broader societal goals. We developed eight criteria for evaluating research funding programs that include support from the tobacco industry: (1) transparency and independence; (2) competitive funding process; (3) ownership of data and freedom to publish; (4) independent research agenda; (5) governance; (6) protection against conflict of interest; (7) industry public relations gains that counteract public health; and, (8) feasibility. We will discuss the applicability of similar programs for funding research on other unhealthy commodities, and on the practices of other harmful industries such as the fossil fuels industry.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Effects of sustained hyperprolactinemia in late gestation on mammary development of gilts

The objective of this project was to determine the effects of sustained hyperprolactinemia for 7 or 20 d on mammary development in late-pregnant gilts. On day 90 of gestation, gilts were assigned to one of 3 groups to receive intramuscular (IM) injections of (1) canola oil (CTL, n = 18) until day 109 ± 1 of gestation; (2) a dopamine receptor antagonist, domperidone (0.5 mg/kg of body weight [BW]) until day 96 ± 1 of gestation (T7, n = 17); or (3) domperidone (0.5 mg/kg BW) until day 109 ± 1 of gestation (T20, n = 17). Domperidone-treated gilts also received 100 mg of domperidone per os twice daily from days 90 to 93 of gestation. Blood was sampled on days 89, 97, 104, and 110 for prolactin (PRL), insulin-like growth factor 1 (IGF1), lactose, urea, and glucose assays. Mammary glands were collected at necropsy, on day 110, for compositional and cell proliferation analyses. Abundance of mRNA for selected genes was also determined in the mammary gland and the pituitary gland. On day 97 of gestation, PRL concentrations were 3 times greater for T20 and T7 than CTL gilts and were also greater for T20 than T7 and CTL gilts on days 104 and 110 (P < 0.001). Concentrations of IGF1 in T20 and T7 gilts were elevated relative to controls on days 97 and 104 and were greater for T20 vs T7 and CTL gilts on day 110 (P < 0.05). There were no treatment effects (P > 0.1) on parenchymal or extraparenchymal tissue weights, or on epithelial proliferation as measured by immunohistochemistry for Ki-67. Treatments did not alter concentrations of dry matter (DM), fat, or DNA (P > 0.1) in parenchyma. Concentrations of RNA (P < 0.05) and protein (P < 0.10) as well as total parenchymal protein, RNA, and DNA (P < 0.05) were lower, or tended to be, in T20 than T7 or CTL gilts. Hyperprolactinemia for 20 d in late gestation increased mRNA abundance of the milk protein genes beta-casein (CSN2) and whey acidic protein (WAP) (P < 0.05) in mammary parenchyma and also decreased mRNA abundance of the long form of the prolactin receptor (PRLR-LF). Increasing PRL concentrations for 7 or 20 d in late gestation had no beneficial effects on the composition of the mammary gland, and sustained exposure to domperidone for 20 d reduced metabolic activity either by a lower expression of the long form of the PRL receptor in mammary parenchymal tissue or, most likely, by the early involution of parenchymal tissue. In conclusion, results do not support the hypothesis that a sustained hyperprolactinemia in late gestation could enhance mammary development of gilts.

Assessment and treatment of dysthymia. The development of the Cornell dysthymia rating scale

The understanding and classification of persistently depressed mood has undergone many changes since the term ‘dysthymia’ was first used nearly 150 years ago. Originally it was applied to both melancholia and mania; later it was applied to depressive personality. The Diagnostic and Statistical Manual (DSM)-III in 1980 and in subsequent updates classified dysthymia as a mood disorder, characterized by a frequently insidious onset and a course that is chronic and unremitting. The assessment of clinical response in the pharmacologic treatment of dysthymia has been more difficult than that for major depression. The Hamilton Rating Scale for Depression, among others, is oriented towards episodic rather than chronic states of depression. A new rating scale, the Cornell Dysthymia Rating Scale, has been developed to better assess milder symptomatology in chronically depressed patients. Early studies suggest its utility, but further validation of the scale is needed in patients with dysthymia and without major depression.

Baseline parameters for rotational thromboelastometry in healthy labouring women: a prospective observational study

OBJECTIVE

The aim of this study was to establish rotational thromboelastometry (ROTEM^® ) baseline parameters in labouring women at term gestation. The secondary aim was to compare these reference ranges with those from previous studies on labouring women and from the manufacturer.

DESIGN

A prospective, observational study.

SETTING

Tertiary referral hospital.

PARTICIPANTS

Healthy women in labour.

METHODS

Ethics approval was granted for an opt-out recruitment approach. ROTEM^® testing was performed in labouring women at term gestation. Women with any condition affecting coagulation were excluded. ROTEM^® Delta reference ranges were derived by calculating the 2.5% and 97.5% centiles for INTEM/EXTEM/FIBTEM parameters including amplitude at 5 minutes (A5), coagulation time (CT) and maximum clot firmness (MCF).

MAIN OUTCOME MEASURES

ROTEM^® parameters were measured in labouring women before delivery. The following tests were performed: FIBTEM, EXTEM and INTEM.

RESULTS

One hundred and twenty-one women met the inclusion criteria, with a mean (± SD) age of 29.6 ± 5.4 years and median (interquartile range) gestation of 39.4 weeks (37.4-40.4 weeks). Seventy-five (62.0%) women were nulliparous and 71 (58.7%) delivered vaginally. The median and interquartile ranges for selected ROTEM^® parameters were: FIBTEM A5, 21 mm (IQR 18-23 mm); EXTEM A5, 55 mm (52-58 mm); and EXTEM CT, 52 seconds (48-56 seconds).

CONCLUSIONS

The FIBTEM/EXTEM/INTEM amplitudes were higher than the manufacturer's reference ranges for non-obstetric patients. The FIBTEM MCF upper and lower limits were higher and the EXTEM/INTEM CT was shorter and narrower in range. This study provides reference ranges for ROTEM^® values in healthy labouring women at term gestation with uncomplicated pregnancies.

TWEETABLE ABSTRACT

This is the first study to report on ROTEM^® reference ranges with over 120 healthy labouring women of normal weight at term gestation.

Why do women deliver where they had not planned to go? A qualitative study from peri-urban Nairobi Kenya

Background

In urban Kenya, couples face a wide variety of choices for delivery options; however, many women end up delivering in different facilities from those they had intended while pregnant. One potential consequence of this is delivering in facilities that do not meet minimum quality standards and lack the capacity to provide treatment for obstetric and neonatal complications.

Methods

This study investigated why women in peri-urban Nairobi, Kenya deliver in facilities they had not intended to use. We used 60 in-depth audio-recorded interviews in which mothers shared their experiences 2–6 months after delivery. Descriptive statistics were used to summarize socio-demographic characteristics of participants. Qualitative data were analyzed in three steps i) exploration and generation of initial codes; ii) searching for themes by gathering coded data that addressed specific themes; and iii) defining and naming identified themes. Verbatim excerpts from participants were provided to illustrate study findings. The Health Belief Model was used to shed light on individual-level drivers of delivery location choice.

Results

Findings show a confluence of factors that predispose mothers to delivering in unintended facilities. At the individual level, precipitate labor, financial limitations, onset of pain, complications, changes in birth plans, undisclosed birth plans, travel during pregnancy, fear of health facility providers, misconception of onset of labor, wrong estimate of delivery date, and onset of labor at night, contributed to delivery at unplanned locations. On the supply side, the sudden referral to other facilities, poor services, wrong projection of delivery date, and long distance to chosen delivery facility, were factors in changes in delivery location. Lack of transport discouraged delivery at a chosen health facility. Social influences included others’ perspectives on delivery location and lack of aides/escorts.

Conclusions

Results from this study suggest that manifold factors contribute to the occurrence of women delivering in facilities that they had not intended during pregnancy. Future studies should consider whether these changes in delivery location late in pregnancy contribute to late facility arrival and the use of lower quality facilities. Deliberate counseling during antenatal care regarding birth plans is likely to encourage timely arrival at facilities consistent with women’s preferences.

Baseline parameters for rotational thromboelastometry (ROTEM®) in healthy pregnant Australian women: a comparison of labouring and non-labouring women at term

BACKGROUND

Rotational thromboelastometry (ROTEM®) is a point-of-care coagulation test. Reference ranges in non-labouring women have recently been established from a cohort of women presenting for elective caesarean delivery using the recommended minimum sample size of 120. This study aimed to present baseline parameters for labouring and non-labouring women and to compare the mean values of these ROTEM® parameters.

METHODS

Ethical approval was granted for an opt-out recruitment approach for labouring women and written consent was obtained from non-labouring women (data published previously). ROTEM® testing was performed in these two cohorts at term gestation. Women with any condition affecting coagulation were excluded. ROTEM® Delta reference ranges were derived by calculating the 2.5 and 97.5 percentiles for INTEM/EXTEM/FIBTEM amplitude at 5 min (A5), coagulation time (CT), maximum clot firmness (MCF) and clot formation time (CFT).

RESULTS

One hundred and twenty-one labouring and 132 non-labouring women met inclusion criteria. The mean values for selected ROTEM® parameters for labouring and non-labouring women respectively were: FIBTEM A5, 21.05 and 19.7 mm (P=0.008); EXTEM A5, 54.8 and 53.2 mm (P=0.025); and EXTEM CT, 52.2 and 53.7 s (P=0.049). Significant differences between the groups were observed in measures of clotting onset and clot firmness.

CONCLUSIONS

We demonstrated a significant decrease in the mean time-to-clotting onset in labouring women compared with non-labouring women. Mean values for measures of clot firmness were greater in labouring women. In comparison to previously established ROTEM® baseline parameters for non-labouring women, this study provides evidence that there is greater hyper-coagulability in labouring women.

Fetal cardiac findings and hemodynamic changes associated with severe lower urinary tract obstruction in utero

OBJECTIVES

To describe fetal echocardiographic findings associated with lower urinary tract obstruction (LUTO) and to compare anatomic and hemodynamic measurements between fetuses with LUTO and gestational age (GA)-matched controls, with an emphasis on quantitative indices of diastolic function and cardiac output.

METHODS

This was a retrospective cohort study of fetuses diagnosed with severe LUTO with giant bladder, which underwent at least one fetal echocardiogram at our center between January 2005 and June 2018. Fetuses with major congenital heart disease were excluded. Control fetuses did not have any structural or functional abnormalities and were GA-matched to the LUTO fetuses based on the time of the first fetal echocardiogram. Cardiac anatomy and hemodynamic measurements were compared between fetuses with LUTO and controls. In infants with LUTO, serial fetal and postnatal echocardiographic data were assessed, when available, and clinical outcomes were reviewed.

RESULTS

Twenty-six fetuses with LUTO and at least one fetal echocardiogram available were identified, one of which was excluded due to hypoplastic left heart syndrome, leaving 25 LUTO fetuses in the final cohort. The mean GA at the first fetal echocardiogram was 25.4 ± 5.1 weeks in the LUTO group and 25.3 ± 5.0 weeks in the control group. Common findings in fetuses with LUTO included cardiomegaly (40%), pericardial effusion (44%), right ventricular (RV) hypertrophy (64%) and left ventricular (LV) hypertrophy (48%). Compared with GA-matched controls, LUTO fetuses had lower ascending aorta Z-score (-0.10 ± 0.94 vs -0.93 ± 1.03; P = 0.02) and aortic isthmus Z-score (-0.14 ± 0.86 vs -1.62 ± 1.11; P < 0.001), shorter mitral valve inflow time indexed to cardiac cycle length (0.46 ± 0.04 vs 0.41 ± 0.06; P = 0.002), and worse (increased) LV myocardial performance index (0.39 ± 0.03 vs 0.44 ± 0.04; P < 0.001). In addition, the ratio of RV to LV cardiac index was higher in LUTO fetuses compared with controls (1.62 ± 0.13 vs 1.33 ± 0.11; P < 0.001). Of the 25 LUTO pregnancies, two were lost to follow-up, three underwent elective termination of pregnancy and three ended in intrauterine fetal demise. Four (16%) patients had mildly hypoplastic left-heart structures, comprising two with aortic arch hypoplasia and two with mitral and aortic stenosis.

CONCLUSION

In addition to presenting with cardiomegaly, pericardial effusion and ventricular hypertrophy, fetuses with LUTO demonstrate LV diastolic dysfunction and appear to redistribute cardiac output as compared to control fetuses, which may contribute to the development of left-heart hypoplasia. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Circulating tumor DNA as a potential marker of adjuvant chemotherapy benefit following surgery for localized pancreatic cancer

BACKGROUND

In early-stage pancreatic cancer, there are currently no biomarkers to guide selection of therapeutic options. This prospective biomarker trial evaluated the feasibility and potential clinical utility of circulating tumor DNA (ctDNA) analysis to inform adjuvant therapy decision making.

MATERIALS AND METHODS

Patients considered by the multidisciplinary team to have resectable pancreatic adenocarcinoma were enrolled. Pre- and post-operative samples for ctDNA analysis were collected. PCR-based-SafeSeqS assays were used to identify mutations at codon 12, 13 and 61 of KRAS in the primary pancreatic tumor and to detect ctDNA. Results of ctDNA analysis were correlated with CA19-9, recurrence-free and overall survival (OS). Patient management was per standard of care, blinded to ctDNA data.

RESULTS

Of 112 patients consented pre-operatively, 81 (72%) underwent resection. KRAS mutations were identified in 91% (38/42) of available tumor samples. Of available plasma samples (N = 42), KRAS mutated ctDNA was detected in 62% (23/37) pre-operative and 37% (13/35) post-operative cases. At a median follow-up of 38.4 months, ctDNA detection in the pre-operative setting was associated with inferior recurrence-free survival (RFS) [hazard ratio (HR) 4.1; P = 0.002)] and OS (HR 4.1; P = 0.015). Detectable ctDNA following curative intent resection was associated with inferior RFS (HR 5.4; P < 0.0001) and OS (HR 4.0; P = 0.003). Recurrence occurred in 13/13 (100%) patients with detectable ctDNA post-operatively, including in seven that received gemcitabine-based adjuvant chemotherapy.

CONCLUSION

ctDNA studies in localized pancreatic cancer are challenging, with a substantial number of patients not able to undergo resection, not having sufficient tumor tissue for analysis or not completing per protocol sample collection. ctDNA analysis, pre- and/or post-surgery, is a promising prognostic marker. Studies of ctDNA guided therapy are justified, including of treatment intensification strategies for patients with detectable ctDNA post-operatively who appear at very high risk of recurrence despite gemcitabine-based adjuvant therapy.