Evaluation of artificial intelligence using time-lapse images of IVF embryos to predict live birth.

RESEARCH QUESTION: Can artificial intelligence (AI) improve the prediction of live births based on embryo images? DESIGN: The AI system was created by using the Attention Branch Network associated with deep learning to predict the probability of live birth from 141,444 images recorded by time-lapse imaging of 470 transferred embryos, of which 91 resulted in live birth and 379 resulted in non-live birth that included implantation failure, biochemical pregnancy and clinical miscarriage. The possibility that the calculated confidence scores of each embryo and the focused areas visualized in each embryo image can help predict subsequent live birth was examined. RESULTS: The AI system for the first time successfully visualized embryo features in focused areas that had potential to distinguish between live and non-live births. No visual feature of embryos were visualized that were associated with live or non-live births, although there were many images in which high-focused areas existed around the zona pellucida. When a cut-off level for the confidence score was set at 0.341, the live birth rate was significantly greater for embryos with a score higher than the cut-off level than for those with a score lower than the cut-off level (P < 0.001). In addition, the live birth rate of embryos with good morphological quality and confidence scores higher than 0.341 was 41.1%. CONCLUSIONS: The authors have created an AI system with a confidence score that is useful for non-invasive selection of embryos that could result in live birth. Further study is necessary to improve selection accuracy.

Attitudes toward preimplantation genetic testing for aneuploidy among patients with recurrent pregnancy loss in Japan.

AIM: To examine attitudes toward preimplantation genetic testing for aneuploidy (PGT-A) in patients with recurrent pregnancy loss (RPL) because it has been performed worldwide in spite of little evidence regarding whether it can improve the live birth rate and prevent miscarriage. There has been no study to examine attitudes toward PGT-A in patients with RPL. METHODS: We conducted a cross-sectional study that used a questionnaire to examine attitudes toward PGT-A, the desire for PGT-A and the factors associated with this desire in 386 patients with RPL between November 2014 and January 2019. RESULTS: Overall, 25.1% of patients desired PGT-A and 35.2% answered that they knew about it. Regarding the reasons for wanting PGT-A, 42.3% thought that it would insure a live birth and with complete case analysis, showed that the patients' wish for PGT-A as a means of giving live birth was affected by their IVF-ET history (adjusted odds ratio 2.7, 95% CI 1.2-7.2) and whether they had any knowledge of PGT-A (2.4, 1.1-5.3). Those with a higher total family income (3.5, 1.2-10.1) and a previous IVF-ET (4.6, 2.0-10.3) tended to want PGT-A as a means of avoiding miscarriage. CONCLUSION: The majority had no opinion or a poor knowledge of PGT-A. More patients who self-assessed as knowing about PGT-A or who had undergone IVF-ET had the above type of misunderstanding. Accurate and up-to-date information from facilities different from those in which PGT-A is performed is necessary before reaching a decision on PGT-A.

The Development of Medical Markup Language Version 4 as a Clinical Document Exchange Format for Nationwide EHR Systems.

Medical Markup Language (MML) is a standard format for exchange of healthcare data among healthcare providers. Following the last major update (version 3), we developed new modules and discussed the requirements for the next major updates. Subsequently, in 2016 we released MML version 4 and used it to obtain clinical data from healthcare providers for a nationwide electronic health records (EHR) system. In this article we provide an overview of this major update of MML version 4 and discuss its interoperability for clinical data.

Danaparoid is effective and safe for patients with obstetric antiphospholipid syndrome.

Objectives: The objective is to evaluate whether danaparoid is effective in improving the live birth rate in patients with obstetric antiphospholipid syndrome (oAPS).Methods: This prospective study included 91 pregnancies of 60 patients with oAPS diagnosed according to criteria of the International Congress on APS. Live birth rates, adverse pregnancies and perinatal outcomes were compared among patients treated with danaparoid and low dose aspirin (danaparoid group, LDA), unfractionated heparin (UFH) and LDA (UFH group) and LDA and/or prednisolone (LDA group).Results: After excluding 11 miscarriages with abnormal embryonic chromosomes, one chemical pregnancy and one ectopic pregnancy, live birth rates were 87.5% (14/16) for the danaparoid group, 90.0% (36/40) for the UFH group and 63.6% (14/22) for the LDA group, respectively. The live birth rates of patients treated with danaparoid and UFH were similar and tended to be higher than that of patients treated with LDA, respectively (OR 4.0, 95% confidence interval 0.72-22.22 and 5.15, 1.33-20.00). No patient given danaparoid and one patient with UFH developed heparin-induced thrombocytopenia which resulted in a stillbirth. Another patient with UFH suffered a lumbar compression fracture.Conclusion: Danaparoid is effective for improving the live birth rate and is safe for patients with oAPS.

National trends and in-hospital outcomes in patients with rheumatoid arthritis undergoing elective atlantoaxial spinal fusion surgery.

OBJECTIVES: Atlantoaxial subluxation is a well-known cervical spinal disorder in rheumatoid arthritis (RA) and certain patients with this condition may need to receive atlantoaxial spinal fusion (AASF). However, there is limited information available regarding demographics and outcome trends. The purpose of this study is to present an analysis of RA patients who underwent elective AASF using national in-hospital data. METHODS: Clinical data were derived from the US Nationwide Inpatient Sample (NIS) between 2000 and 2009. Patients who had a diagnosis of RA and underwent elective AASF, total hip arthroplasty (THA), and total knee arthroplasty (TKA) were identified. Data regarding patient- and healthcare system-related characteristics, comorbidities, in-hospital complications, and mortality were retrieved. The trends of the procedures were analysed. RESULTS: There were 1,460 RA patients aged ≥18 who underwent elective AASF between 2000 and 2009. During the last decade, the incidence of elective AASF in RA patients remained stable. The overall in-hospital complication rate of AASF in RA patients was 10.9%, which was more than twice that of THA and TKA in RA patients (THA: 4.8%; TKA: 4.9%). Respiratory complication rate (5.3%) was the highest among the complications. In-hospital mortality rate of such patients was 1.1%. CONCLUSIONS: During the last decade, the incidence of elective AASF in RA patients remained stable. In-hospital morbidity and mortality rates of AASF in RA patients were higher than those of other major orthopaedic surgeries in RA patients. Respiratory management is particularly important after AASF in RA patients.

Rheumatoid arthritis patients undergoing total hip and knee arthroplasty have better in-hospital outcomes compared with non-rheumatoid arthritis patients.

OBJECTIVES: Rheumatoid arthritis (RA) is known to be associated with multiple comorbidities and, therefore, overall management is critical for those patients undergoing elective major orthopaedic surgeries, such as total hip arthroplasty (THA) and total knee arthroplasty (TKA). The purpose of this study was to compare in-hospital outcomes of elective THA and TKA between patients with and without RA in the US during the last decade. We hypothesised that patients with RA would have similar perioperative outcomes after elective THA and TKA. METHODS: Clinical data were derived from the US Nationwide Inpatient Sample (NIS) between 2000 and 2009. Patients who underwent elective THA and TKA were identified. Data regarding patient- and healthcare system-related characteristics, comorbidities, in-hospital complications, and mortality were retrieved. In-hospital outcomes of the procedures were compared between patients with and without RA. RESULTS: Comparison between patients with and without RA showed that patients with RA had significantly lower overall in-hospital complication rates following THA and TKA, and lower in-hospital mortality rate following THA. Patients with RA undergoing THA and TKA had decreased risk of overall in-hospital complications compared to those without RA. CONCLUSIONS: Contrary to our hypothesis, perioperative outcomes of elective THA and TKA in patients with RA were better than those in patients without RA. These results may indicate that patient selection and pre- and perioperative management of patients with RA undergoing elective THA and TKA were well conducted in the US during the last decade.

Prostaglandin E1 Treatment for Lumbar Spinal Canal Stenosis: Review of the Literature.

BACKGROUND: The important pathophysiologic factor of neurogenic intermittent claudication (NIC) in lumbar spinal canal stenosis (LSCS) has been reported to be the reduction in intraneural blood flow and a state of relative ischemia in nerve tissues. Prostaglandin E1 (PGE1) presumably improves symptoms in patients with LSCS by improving the blood flow in the cauda equina and nerve roots through its vasodilation and antiplatelet aggregation effects. The purpose of the study was to summarize the results of previous studies regarding PGE1 treatment for LSCS and to describe the details of PGE1 treatment to all physicians who take care of patients with LSCS. METHODS: Review of the literature. RESULTS: There are 3 PGE1-related products that have been used clinically for the treatment of LSCS: PGE1, lipo-PGE1, and limaprost (PGE1 derivative). Experimental studies have been performed to verify the efficacy of PGE1 treatment for LSCS. Many studies have reported clinical outcomes of PGE1 treatment in patients with LSCS. Overall, previous studies examining PGE1 treatment for LSCS demonstrate improvement in several clinical outcome measures such as the visual analog scale, Japanese Orthopaedic Association score, and NIC distance, although most of the studies have only short-term follow-up. CONCLUSIONS: Based on the results of previous studies, PGE1 treatment may be an option as a conservative treatment for LSCS. However, future studies with high-quality and long-term follow-up are necessary. Future studies also should include refinement of indications, administration period, as well as comparisons between PGE1 treatment and other conservative treatments such as epidural injection.

Incidental dural tear in cervical spine surgery: analysis of a nationwide database.

STUDY DESIGN: This was a retrospective study. OBJECTIVE: To report the incidence of incidental dural tear (DT) in cervical spine surgery, risk factors, and in-hospital patient outcomes on a national level. SUMMARY OF BACKGROUND DATA: DT during cervical spine surgery is not as common as that during lumbar spine surgery; however, DT is still a difficult complication. METHODS: Clinical data were obtained from the US Nationwide Inpatient Sample for 2009. Patients who underwent cervical spine surgery were identified and divided into those with and without DT according to the International Classification of Diseases, 9th revision, Clinical Modification codes. The patient and health care system-related demographic data were retrieved. The incidence of DT and patient outcomes were analyzed. A multivariate logistic regression analysis was performed to identify the risk factors for DT. RESULTS: The incidence of DT was 0.45% (855/190,021). The multivariate analysis revealed that a diagnosis of myelopathy and ossification of the posterior longitudinal ligament; posterior approach, anterior and posterior approach; and insurance status were the significant risk factors for DT. Comparison between patients with and without DT showed that those with DT had significantly higher overall in-hospital complications (21.6% vs. 7.3%), longer hospital stays (6.0 vs. 3.2 d), a lower proportion who were discharged home routinely (66.3% vs. 83.9%), increased total hospital costs ($96,424 vs. $62,416), and similar in-hospital mortality (0.6% vs. 0.4%). CONCLUSIONS: The incidence of DT in cervical spine surgery was 0.45% in the United States. The risk of DT was highest with a primary diagnosis of the ossification of the posterior longitudinal ligament (58.4 times). DT significantly increased the rate of in-hospital complications and health care burden.

Blood transfusion in primary total shoulder arthroplasty: incidence, trends, and risk factors in the United States from 2000 to 2009.

BACKGROUND: Total shoulder arthroplasty (TSA) may be associated with substantial blood loss, and some patients require perioperative blood transfusion. Possible blood transfusion methods include predonated autologous blood transfusion, perioperative autologous blood transfusion, and allogeneic blood transfusion (ALBT). The purposes of the present study were to assess the incidence and recent trends over time of blood transfusion in TSA and analyze patient and hospital characteristics that affect the risk of ALBT. METHODS: This study used national hospital discharge data from the National Inpatient Sample between 2000 and 2009. The data were used to generate the overall blood transfusion rate, and linear regression was used to assess trends in transfusion patterns over time. Logistic regression analysis was performed to analyze which patient and hospital characteristics independently influence the likelihood that a given patient undergoes ALBT. RESULTS: The overall blood transfusion rate (ie, the proportion of patients who received at least 1 transfusion of any kind) was 6.7%. This rate increased over time, from 4.9% in 2000 to 7.1% in 2009 (P < .001). Risk factors associated with ALBT included age, gender, race, insurance status, hospital region, and hospital annual caseload. CONCLUSIONS: The increase in overall blood transfusion rate in TSA found in the present study may be related to factors specific to TSA, such as the introduction of reverse total shoulder arthroplasty during the study period. A variety of patient and hospital characteristics contribute to the risk of undergoing ALBT.