Impact of dietary counseling on the perception of diet in patients with gestational diabetes mellitus.

AIMS/INTRODUCTION: Medical nutrition therapy is the cornerstone of gestational diabetes mellitus (GDM) treatment. Patients with GDM should receive dietary counseling regarding diet and exercise. MATERIALS AND METHODS: To study patients' perception level of diet and their level of understanding after dietary counseling, we analyzed 225 reports of dietary counseling of patients with GDM prepared by dieticians. We also assessed the patients' level of understanding after dietary counseling by asking questions regarding the counseling content. The answers to the questions were aggregated, and substantially similar answers were grouped and categorized. RESULTS: The dieticians' suggestions were well understood by the patients. Moreover, the patients also identified their previous incorrect eating habits, such as excessive carbohydrate restriction or inappropriate fruit intake. Although distributed frequent meals were recommended by the dieticians, few patients actually practiced this for various reasons. Some patients were apparently influenced by dietary information from the mass media. CONCLUSION: Dietary counseling was regarded as helpful and acceptable to most patients with GDM in our hospital, and many suggestions were recognized as informative for modification of previous dietary habits. By providing the results of the questionnaire survey to the dieticians, they can improve the quality of their counseling, which is expected to result in better individual care of the patients.

The utility of extracorporeal membrane oxygenation in patients with circulatory collapse by electrical storm.

In patients experiencing electrical storm, intensive care using extracorporeal membrane oxygenation (ECMO) is an efficient treatment to overcome a hemodynamically unstable condition. The aim of this study was to examine the utility of ECMO in patients with circulatory collapse by electrical storm. We retrospectively examined 17 consecutive patients receiving veno-arterial ECMO for electrical storm between January 2016 and December 2018 in our institution. We compared survivors (n = 11) and non-survivors (n = 6). Thirteen were weaned from ECMO, of whom 11 patients (64.7%) survived and were discharged from hospital, while 6 patients died (35.3%). In comparisons between survivors and non-survivors, blood pH before starting ECMO was significantly higher in survivors (pH 7.32) than in non-survivors (pH 6.89, p = 0.027). Blood lactate level was significantly lower in survivors (6.2 mmol/L) than in non-survivors (12.2 mmol/L, p = 0.044). Complications of hypoxic ischemic encephalopathy were found in 4 non-survivors (66.7%), compared to survivors (0%, p = 0.006). Durations of intensive care unit stay and hospital stay were significantly longer in survivors (271 h, 62 days) than in non-survivors (50 h, 3 days, respectively). Outcomes of treatment using ECMO in patients with circulatory collapse due to electrical storm proved satisfactory. Increases in blood lactate level and decreases in blood pH before starting ECMO were thought to be related to mortality due to suspected irreversible organ damage by hypoxia before ECMO.

Clinical evaluation of a new dispersive aortic cannula.

INTRODUCTION: Cerebral injury is a serious complication in open-heart surgery. Once it occurs, it causes significant disability and death. We developed a novel dispersive aortic cannula named the Stealth Flow cannula and used it as a standard aortic cannula in cardiopulmonary bypass. The aim of this study was to evaluate the efficiency of this aortic cannula. METHODS: A total of 182 consecutive patients undergoing cardiac surgery using cardiopulmonary bypass were studied. The patients were divided into two groups: the Soft-Flow cannula group (n = 89) and the Stealth Flow cannula group (n = 93). Patients with a shaggy aortic arch were excluded from this study because the cannulae were inserted at the ascending aorta with a cannula tip directed toward the aortic root in these cases. Patients with multiple arterial perfusion sites were also excluded. Complications including early mortality, perioperative stroke, and intraoperative aortic injury were compared between the two groups. RESULTS: Age, operative procedure, cardiopulmonary bypass time, and the Japan SCORE were not significantly different between the groups. In comparisons between the Stealth Flow and Soft-Flow groups, the incidences of early mortality, perioperative stroke, intraoperative aortic dissection, and all complications were 1.08% versus 1.12% (p = 0.98), 1.1% versus 2.2% (p = 0.53), 0% versus 1.1% (p = 0.33), and 1.1% versus 3.4% (p = 0.29), respectively. The incidence of major cardiovascular events, including early death, perioperative stroke, and aortic dissection, was not different. CONCLUSIONS: The Stealth Flow cannula, which was designed based on our previous experimental study, contributed to reducing cerebral and aortic events as much as the Soft-Flow cannula in the present clinical study.

Predicting live birth by combining cleavage and blastocyst-stage time-lapse variables using a hierarchical and a data mining-based statistical model.

Prolonged embryo culture is increasingly used as a way of improving pregnancy rates, especially in the context of single embryo transfer. So far, only a handful of studies examined the relation between implantation potential and time-lapse parameters extracted from later stages (morula and blastocyst) of embryo development. For this retrospective study all 285 single vitrified-thawed blastocyst transfers (SVBT) from all consecutive unselected patients whose fertilized oocytes were submitted to time-lapse monitoring (TLM) from a two-year cohort were analysed. Two different statistical models were created; a hierarchical one including the two strongest live birth (LB) predictors (t2 and texpB2) and a more complex model based on principal component analysis (PCA) and logistic regression methods. The first, four-category, hierarchical model effectively distinguished between blastocysts of increasing LB rates (8, 30, 40, 53%). For the second data-mining model quartiles of the created Sc parameter had increasing LB rates (12, 19, 40, 49%). AUC values were comparable for both models (0.723, 95CI%:0.66-0.79 versus 0.717, 95CI%:0.65-0.78). The combination of cleavage- and blastocyst-stage variables through hierarchical or data mining-based algorithms was used successfully to predict live birth. However, due to the lack of internal / external validation the predictive capacities of this model could differ largely in different datasets.

Interference with pulse oximetry by the Stealth Station™ Image Guidance System.

BACKGROUND: A pulse oximeter is one of the most important monitors to save patients undergoing anesthesia and monitored sedation. The authors report a case of orthopedic surgery, in which interference of pulse oximetry occurred when using a Stealth Station™ navigation system (Medtronic Sofamor Danek, Memphis, TN). Applying a black plastic shield (Masimo Ambient Shield: Masimo Corporation, Irvine, CA) completely eliminated the interference. CASE PRESENTATION: A 37-year-old male patient with a giant cell tumor of the left femur was scheduled to undergo curettage of the femur using an intraoperative CT three-dimensional imaging system (O-arm™) and Stealth Station™ navigation system. During the surgery, the SpO2 value, which was maintained between 97 and 99% until the time, disappeared suddenly with abnormal pulse wave. Because a distortion in the SpO2 value was reproduced by repeated movement of cameras on the head of the Stealth Station™ navigation system, we recognized that the interference signal was coming from the navigation system. To eliminate the infrared light, the pulse oximetry probe was covered with a black plastic shield and the interference was completely eliminated. CONCLUSIONS: The Stealth Station™ navigation system was found to interfere with the SpO2 value, and a black plastic shield was useful for eliminating the interfering signal. Anesthesiologists should understand the risk of interference by the neuro-navigation system and know how to solve the problem.

Blastocyst collapse is not an independent predictor of reduced live birth: a time-lapse study.

OBJECTIVE: To ascertain the rate of blastocyst collapse observed by time-lapse monitoring in a retrospective cohort of unselected infertile patients undergoing single blastocyst transfer and to determine its association with live birth. DESIGN: Blastocyst collapse and morphokinetic variables were scored according to previously published criteria. The association between blastocyst collapse and live birth was evaluated by a multivariate logistic regression analysis including morphokinetic variables and other confounders. SETTING: Private infertility clinic. PATIENT(S): Patients who underwent 277 consecutive single blastocyst transfers (mean age, 38.4 ± 3.9 years; range, 28-47 years) after minimal ovarian stimulation. INTERVENTION(S): Minimal ovarian stimulation, prolonged embryo culture in time-lapse monitoring incubator, elective vitrification with subsequent vitrified-warmed single blastocyst transfer. MAIN OUTCOME MEASURE(S): Live birth rate per single blastocyst transfer in different blastocyst collapse groups (no, single, multiple collapses). RESULT(S): No, single, or multiple blastocyst collapses occurred in 54% (150/277), 22% (61/277), and 24% (66/277) of the cohort, respectively. In the multiple collapse group on average 2.9 contractions were seen (range, 2-9 contractions). Live birth rate decreased progressively between blastocyst collapse groups (36%, 31%, 14%); significantly lower if multiple collapses occurred. In a multivariate analysis, however, blastocyst collapse was not found to be a significant predictor and was confounded by stronger predictors such as morphokinetic variables t2, texpB2, and female age. CONCLUSION(S): Blastocyst collapse pattern should not be evaluated alone without taking into account morphokinetic variables that are stronger predictors of reproductive outcome.

Time-lapse variables and embryo gender: a retrospective analysis of 81 live births obtained following minimal stimulation and single embryo transfer.

PURPOSE: The purpose of this study was to determine which morphokinetic variables are related to embryo gender in a cohort of consecutive live births obtained through single blastocyst transfer following mild ovarian stimulation. METHODS: Eighty-one live births (49 % of them females) from successfully treated, consecutive infertile patients (maternal age 36.9 ± 3.8 years, range 28-46) who underwent minimal ovarian stimulation, prolonged embryo culture in a time-lapse monitoring (TLM) incubator and elective single blastocyst transfers during 2012-2014. Early (PNf, t2-t9, cc2a, b, s2, s3) and late (tM, tSB, tfullB, texpB1, and texpB2) morphokinetic variables were scored according to published consensus criteria and were normalized to the time of pronuclear fading. For each variable, the ranges with the highest proportion of female embryos (optimal range) were determined by detailed examination of histograms. RESULTS: Female embryo gender was associated both with late cleavage (t8), morula (tM), and blastocyst stage morphokinetic variables. The strongest associations (adjusted ORs, 7.0-7.8) were found for late, expanded stage blastocyst parameters; tfullB, texpB1, and texpB2. The proportion of female embryos was 69-71 and 25-26 % inside and outside of the optimal ranges, respectively. This allowed to predict 74-78 % of them, increasing their proportion by 57 % compared to the average. CONCLUSIONS: Although the sample size of our cohort was limited, our findings suggest that several expanded blastocyst stage morphokinetic parameters are associated with female embryo gender. If confirmed on a larger sample these could be potentially used to increase the proportion of female embryos among non-invasively selected blastocysts following single embryo transfer.

Influence of different oocyte insemination techniques on early and late morphokinetic parameters: retrospective analysis of 500 time-lapse monitored blastocysts.

OBJECTIVE: To determine how standard IVF vs. intracytoplasmic sperm injection (ICSI) fertilization influences early and late morphokinetic parameters during prolonged embryo culture. DESIGN: Five-hundred expanded blastocysts that were monitored in a time-lapse monitoring incubator were analysed retrospectively. Early (pronuclear fading [PNf], t2-t9) and late (start of blastulation, expanded blastocyst) morphokinetic variables were scored according to published consensus criteria. SETTING: Private infertility clinic. PATIENT(S): A total of 209 consecutive infertile patients (mean ± SD age, 38.4 ± 4 years; range, 28-47 years) undergoing 238 natural IVF/minimal ovarian stimulation cycles during 2012-2014. INTERVENTION(S): Minimal ovarian stimulation, oocyte retrieval, fertilization with standard IVF or ICSI, prolonged embryo culture in a time-lapse monitoring incubator. MAIN OUTCOME MEASURE(S): Differences in morphokinetic parameters according to insemination techniques. RESULT(S): In total, 29% and 71% of the whole cohort was fertilized with standard IVF and ICSI, respectively. During early cleavage stages (PNf to t4) there was a statistically significant delay (+1.5 to +1.1 hours) among IVF-fertilized embryos. By contrast, at the expanded blastocyst stage IVF-fertilized embryos showed faster development (-3.3 to -4.1 hours). After normalizing to the time point of PNf, differences in cleavage-stage parameters disappeared, but those at all blastocyst stages increased even further in favor of IVF-fertilized embryos (-3.2 to -5.7 hours). CONCLUSION(S): The observed 1.5-hour time difference between standard IVF- and ICSI-fertilized embryos is an artificial phenomenon. At the blastocyst stages, however, genuine timing differences arise between IVF- and ICSI-fertilized embryos, possibly related to their different quality. Normalization to a common time point permits the joint analysis of IVF- and ICSI-fertilized embryos, thus increasing the size of studied cohorts.

Time-lapse monitoring of zona pellucida-free embryos obtained through in vitro fertilization: a retrospective case series.

OBJECTIVE: To report time-lapse monitoring of human oocytes in which the damaged zona pellucida was removed, producing zona-free (ZF) oocytes that were cultured until the blastocyst stage in time-lapse incubators. DESIGN: Retrospective case series. SETTING: Private infertility clinic. PATIENT(S): Infertile patients (n = 32) undergoing minimal ovarian stimulation or natural cycle IVF treatment between October 2012 and June 2014. INTERVENTION(S): Intracytoplasmic sperm injection (ICSI) fertilization of ZF oocytes, prolonged embryo culture in time-lapse incubators, elective vitrification, and subsequent single vitrified-thawed blastocyst transfer (SVBT). MAIN OUTCOME MEASURE(S): Rate of fertilization, cleavage and blastocyst development, live-birth rate per SVBT cycle. RESULT(S): In spite of advanced maternal age (39 ± 4.2; range, 30-46 years), good fertilization (94%), cleavage (94%), and blastocyst development rates (38%) were reached after fertilization and culturing of ZF oocytes/embryos. All thawed ZF blastocysts survived, and up to this date seven SVBT transfers were performed, yielding three (43%) term live births with healthy newborns. CONCLUSION(S): Time-lapse imagery gives a unique insight into the dynamics of embryo development in ZF embryos. Moreover, our case series demonstrate that an oocyte with a damaged zona pellucida that has been removed could be successfully fertilized with ICSI, cultured until blastocyst stage in a time-lapse incubator and vitrified electively for subsequent use.

Cumulative success rates following mild IVF in unselected infertile patients: a 3-year, single-centre cohort study.

A 3-year, retrospective, single-centre cohort study was conducted in a private infertility centre to determine cumulative live birth rates (LBR) per scheduled oocyte retrieval following minimal ovarian stimulation/natural-cycle IVF in unselected infertile patients. A total of 727 consecutive infertile patients were analysed who underwent 2876 (median 4) cycles with scheduled oocyte retrieval from November 2008 to December 2011. Natural-cycle IVF or clomiphene-based minimal ovarian stimulation was coupled with single-embryo transfer and increased use of delayed vitrified-warmed blastocyst transfer. Main outcome measures were crude and expected age-specific cumulative LBR per scheduled oocyte retrieval. Crude cumulative LBR were 65%, 60%, 39%, 15% and 5% in patients aged 26-34, 35-37, 38-40, 41-42 and 43-44 years, respectively. No live births occurred in patients aged ⩾ 45 years. Dropout rates per cycle were 13-25%. Success rates gradually reached a plateau, with few additional live births after six cycles. Most of the expected success rate was reached within 6 months with almost maximal rates within 15 months of the first oocyte retrieval. Acceptable cumulative LBR are reached with an exclusive minimal ovarian stimulation/single-embryo transfer policy especially in patients aged <38 years but also in intermediate aged patients (38-40 years).

Oocyte retrieval timing based on spontaneous luteinizing hormone surge during natural cycle in vitro fertilization treatment.

OBJECTIVE: To determine the efficiency of oocyte retrieval (OR) timing based on the occurrence of spontaneous LH surge during natural cycle IVF (ncIVF) treatment. DESIGN: Retrospective cohort study. The cohort was divided into five subgroups according to the presumed stage of spontaneous LH surge on scheduling day (1A: before onset; 1B: surge start; 2: ascending slope; 3: peak; and 4: descending slope). SETTING: Private infertility clinic. PATIENT(S): Three hundred sixty-five infertile patients who underwent 1,138 ncIVF treatment cycles during 2008-2011. INTERVENTION(S): Drug-free ncIVF treatment. MAIN OUTCOME MEASURE(S): Rate of successfully retrieved, fertilized oocytes, cleaved embryos, and live births per scheduled oocyte retrieval. RESULT(S): In 61% of the cycles OR was scheduled before or just at the start of the LH surge (groups 1A-1B), whereas in the remaining cases it was scheduled after the surge had already started (groups 2-4). The proportion of cycles with successfully recovered (range, 71%-86%), inseminated (range, 61%-78%), fertilized oocytes (range, 47%-68%), cleaved embryos (range, 45%-66%), and live births (range, 4.1%-9.2%) was not significantly different among subgroups. CONCLUSION(S): In ncIVF treatment OR timing based on the occurrence of spontaneous LH surge is feasible, yielding acceptable oocyte recovery, fertilization, and embryo cleavage rates. This strategy combined with a rapid and low-risk OR procedure permits the management of a large ncIVF program on a 7-days-per-week basis within working hours.