P-280 Potential for improvement and current limitations of Artificial Intelligence (AI) for embryo selection: analysis of external validation data

Study question

What are the prospects of improvement and the limitations of an AI system for embryo selection?

Summary answer

The predictive performance of AI can be enhanced by including additional factors, on top of embryo images, and by assessing images with centered blastocysts.

What is known already

We previously reported the external validation of IVFvision.ai, an AI algorithm that differentiates between Day-5 blastocysts with a positive or negative implantation outcome. IVFvision.ai had higher AUC and overall accuracy in predicting implantation compared to KIDScoreD5 and senior embryologists. Here we report a secondary analysis of external validation data, focusing on a) the improvement of the predictive ability of IVFvision.ai by incorporating data from additional sources, and b) the impact of the blastocyst image quality on the performance of IVFvision.ai.

Study design, size, duration

This is a secondary analysis of external validation data. External validation of IVFvision.ai was performed at a University IVF Clinic using 113 anonymised Embryoscope images of single D5 blastocyst transfers with known implantation outcome.

Participants/materials, setting, methods

The performance of IVFvision.ai and three senior Embryologists to correctly classify blastocysts according to implantation outcome were compared in images in which the whole blastocyst was visible (centred blastocysts, n = 62) vs images in which part of the blastocyst was not visible (off-centred blastocysts, n = 51). Logistic regression models were created: a) IVFvision alone, b) IVFvision+age, c) IVFvision+fertilisation_method, d) IVFvision+KIDScoreD5, e) IVFvision+age+Fertilisation_method+KIDScoreD5. The AUC of each model in predicting implantation was estimated using ROC curve analysis.

Main results and the role of chance

The AUC of IVFVision.ai (0.675 vs 0.432), Embryologist 1 (0.570 vs 0.390), Embryologist 2 (0.663 vs 0.448) and Embryologist 3 (0.628 vs 0.485) were higher for images with centered blastocysts compared to non-centered blastocysts, respectively. There was a progressive increase of AUC with the addition of more factors in the predictive models. a) IVFvision alone: AUC=0.675, b) IVFvision+age: AUC=0.675 c) IVFvision+KIDScoreD5: AUC=0.721 d) IVFvision+fertilisation_method=0.740, e) IVFvision+age+Fertilisation_method+KIDScoreD5=0.768.

Limitations, reasons for caution

The retrospective nature of the study and the small sample of the study raise the need for further prospective studies with a larger number of embryos.

Wider implications of the findings

The highest performance of IVFvision.ai is achieved in images with centred blastocysts, suggesting that implantation cannot be predicted accurately in images with non-centred blastocysts. In addition, we provide provide proof of concept that training AI systems using data from different sources, in addition to embryo images, may increase overall accuracy.

Trial registration number

not applicable

Use of rapid cardiac magnetic resonance imaging to guide chelation therapy in patients with transfusion-dependent thalassaemia in India: UMIMI study

Aims

To explore the impact of incorporating a faster cardiac magnetic resonance (CMR) imaging protocol in a low–middle-income country (LMIC) and using the result to guide chelation in transfusion-dependent patients.

Methods and results

A prospective UK–India collaborative cohort study was conducted in two cities in India. Two visits 13 months apart included clinical assessment and chelation therapy recommendations based on rapid CMR results. Participants were recruited by the local patient advocate charity, who organized the patient medical camps. The average scanning time was 11.3 ± 2.5 min at the baseline and 9.8 ± 2.4 min (P < 0.001) at follow-up. The baseline visit was attended by 103 patients (mean age 25 years) and 83% attended the second assessment. At baseline, 29% had a cardiac T₂* < 20 ms, which represents significant iron loading, and 12% had left ventricular ejection fraction <60%, the accepted lower limit in this population. Only 3% were free of liver iron (T₂* ≥ 17 ms). At 13 months, more patients were taking intensified dual chelation therapy (43% vs. 55%, P = 0.002). In those with cardiac siderosis (baseline T₂* < 20 ms), there was an improvement in T₂*—10.9 ± 5.9 to 13.5 ± 8.7 ms, P = 0.005—and fewer were classified as having clinically important cardiac iron loading (T₂* < 20 ms, 24% vs. 16%, P < 0.001). This is the first illustration in an LMIC that incorporating CMR results into patient management plans can improve cardiac iron loading.

Conclusion

For thalassaemia patients in an LMIC, a simplified CMR protocol linked to therapeutic recommendation via the patient camp model led to enhanced chelation therapy and a reduction in cardiac iron in 1 year.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

Oral vaccination of dogs with a monovalent live-avirulent vaccine confers 1 year of immunity against Bordetella bronchiseptica challenge

This experimental challenge study assessed immune protection 1 year after a single dose of live-attenuated oral Bordetella bronchiseptica (Bb) vaccine in dogs. Forty Bb-seronegative 7-9-week-old puppies were randomly assigned at Day 0 to receive a single oral dose of either Bb vaccine (n = 20; vaccinated group) or sterile water (n = 20; control group). Groups were housed separately until comingling 1 day pre-challenge (Day 365). Challenge with virulent aerosolized Bb occurred at Day 366. Clinical scores were obtained at Days 1-7, and 366-380. Bb microagglutination test (MAT) titers were obtained at Days -7, 0, monthly post-vaccination, and Days 358, 365, and 380. Nasal swabs were collected for microbiological assessment at Days -7, 0, 365, and 367-380. Oral Bb vaccination was not associated with side effects. Pre-challenge, vaccinated dogs developed persistent Bb MAT titers and control dogs remained seronegative. Post-challenge, duration of cough was longer in control dogs (least square means [LSM], 8.6 days) than vaccinated dogs (LSM, 1.5 days; P < 0.0001), with more control dogs having cough on 2 or more consecutive days (control group, n = 17/19, 89.5%; vaccinated group, n = 3/19, 15.8%; P = 0.0011). Post-challenge, Bb shedding occurred in all control dogs and 5/19 (26%) vaccinated dogs. Average duration of Bb shedding was longer in the control group (11.9 days vs. 0.6 days; P < 0.0001) and nasal Bb loads were higher in the control group (P < 0.00001). Orally administered Bb vaccine stimulated immunity that was still protective against virulent Bb challenge after 1 year.

Bone turnover markers as determinants of bone density and fracture in men with distal forearm fractures: the pathogenesis examined in the Mr F study

The pathogenesis for low-trauma wrist fractures in men is not fully understood. This study found that these men had evidence of significantly higher bone turnover compared with control subjects. Bone turnover markers were negative predictors of bone mineral density and were a predictor of fracture.

INTRODUCTION

Men with distal forearm fractures have reduced bone density, an increased risk of osteoporosis and of further fractures. The aim of this study was to investigate whether or not men with distal forearm fractures had evidence of altered bone turnover activity.

METHODS

Fifty eight men with low-trauma distal forearm fracture and 58 age-matched healthy control subjects were recruited. All subjects underwent a DXA scan of the forearm, both hips, and lumbar spine, biochemical investigations, and health questionnaires. Measurements of beta crosslaps (βCTX), procollagen type I N-terminal propeptide (PINP), sclerostin, Dickkopf-1 (Dkk1), and fibroblast growth factor 23 (FGF 23) were made.

RESULTS

Men with fracture had significantly higher PINP than controls at 39.2 ng/ml (SD 19.5) versus 33.4 ng/ml (SD13.1) (p<0.001). They also had significantly higher βCTX at 0.45 ng/ml (SD 0.21) versus 0.37 ng/ml (SD 0.17) (p= 0.037). Fracture subjects had significantly lower aBMD and PINP was a negative predictor of aBMD at the total hip and βCTX a negative predictor of forearm aBMD. Sclerostin was a positive predictor of aBMD at the lumbar spine and hip sites. Sex hormone binding globulin (SHBG) at 37nmol/L (SD 15.0) was lower in fracture cohort compared to 47.9 nmol/L (SD 19.2) (p=0.001) in control. Multiple regression revealed that the best model for prediction of fracture included SHBG, P1NP, and ultra-distal forearm aBMD. The likelihood of distal forearm fracture was decreased by 5.1% for each nmol/L increase in SHBH and by 1.4% for every mg/cm² increase in ultra-distal forearm aBMD, but increased by 6.1 % for every ng/ml increase in P1NP. Men in the highest quartile of PINP had a significantly greater likelihood of distal forearm fracture than those in the lowest quartile.

CONCLUSION

The fracture group had significantly higher PINP and βCTX compared with the control group, and these markers were negative predictors of aBMD at the total hip and forearm sites, respectively. Sclerostin was a positive predictor of the variance of spinal and hip aBMD. Likelihood of forearm fracture was best predicted by a combination of SHBG, PINP, and ultra-distal forearm aBMD. Findings of such cross-sectional data should be treated with caution, as longitudinal studies would be required to confirm or refute them.

1037 Early Detection and Management of Preoperative Anaemia in An Elective Vascular Surgery Cohort

Introduction

Iron deficiency anaemia is the most common cause of anaemia in the surgical population. Patients receiving transfusions during major surgery encounter more adverse outcomes compared to those that do not, indicating the early management of pre-operative anemia is likely to reduce major surgical patient morbidity and mortality. Previous studies have demonstrated that 33% of patients undergoing major vascular surgery operations are anaemic (haemaglobin, Hb, &lt;130g/L).

Aim

We aim to reduce the proportion of anaemic patients undergoing major vascular surgery by 50%.

Method

A point-of-care HemoCue machine was used to measure Hb in patients who were referred for elective major surgery in 11 vascular clinics. Patients with Hb &lt; 130g/L were prescribed a 1-month course of Ferrous Sulfate (200mg TDS), and a letter was sent to their GP requesting iron function tests. Post-intervention Hb levels were rechecked following the preoperative anaesthetics review.

Results

11 patients were referred for major surgery, of which 4 were identified as anaemic (36%). The mean Hb concentration was 121.3g/L, which increased to 137.3g/L following oral iron therapy. The mean duration of follow up was 36 days (range 0-94 days).

Conclusions

The implementation of a HemoCue machine to identify and manage preoperative anaemia was successful in our pilot study. Further work should include full integration of our pathway into current vascular clinics without student support. This will enable evaluation of the impact of our intervention on a wider scale.

423 Patient Perspective on the Use of the Independent Sector to Maintain Elective NHS Services During the COVID-19 Pandemic

Introduction

COVID-19 resulted in the suspension of planned treatments for patients worldwide leaving millions suffering the physical and mental effects of delay. Reports indicate that when services have been re-established, patients have been afraid to take up appointments. Hospitals put processes in place to counter this, notably separating emergency and elective patient cohorts. Most notably seen by the co-operation between the NHS and independent private healthcare providers in March 2020 at the height of the pandemic. We undertook a study to ascertain the perceptions of NHS patients who underwent elective treatment at independent ‘cold’ sites during the COVID-19 pandemic.

Method

A cross-sectional study with structured telephone interviews of patients who had planned elective treatments at ‘cold’ independent hospitals between March and September 2020. 1150 patients were identified, and a 20% sample formed a 230 patient study group, with 158 (70%) agreeing to participate.

Results

30% of patients delayed their treatment due to COVID related concerns, with 76% of these only accepting treatment because this was at a ‘cold’ site. 46% of patients perceived treatment at a ‘cold’ site as the most important factor contributing to their safety. 153 patients (97%) supported the paid arrangement between the NHS and the independent sector to provide separate ‘cold’ sites for elective treatments.

Discussion

Safely restarting elective services to allow important planned treatments to take place, as was the pandemic continues, is a priority. Our study indicates that physical separation of patient pathways impacted most on patient confidence, and that the use of ‘cold’ sites is a viable option.

Clinical Outcome of Transfemoral Direct Socket Interface (Part 2)

BACKGROUND

Amputation at the transfemoral (TF) level reduces the rate of successful prosthetic fitting, functional outcome, and quality of life (QoL) compared with transtibial amputation. The TF socket interface is considered the most critical part of the prosthesis, but socket discomfort is still the most common user complaint. Direct Socket for transfemoral prosthesis users is a novel interface fabrication process where the socket is shaped and laminated directly on the residual limb and delivered in a single visit.

OBJECTIVES

The aim of this study was to investigate if prosthetic users' quality of life (QoL), comfort, and mobility with a Direct Socket TF interface were comparable to their experience with their previous prostheses.

METHODOLOGY

The pre/post design prospective cohort study included 47 subjects. From this cohort, 36 subjects completed the 6-months follow-up (mean age 58 years, 27 males). Outcomes at baseline included EQ-5D-5L®, PLUS-M™, CLASS, ABC, AMPPRO, and TUG. At 6-weeks and 6-months, subjects repeated all measures. Seven Certified Prosthetist (CP) investigators performed observations and data collection at six different sites (from July 2018 to April 2020).

FINDINGS

Results showed significant improvement in all outcome measures for the 36 subjects that completed both 6-weeks and 6-months follow-ups. CLASS sub-scales showed significantly improved stability, suspension, comfort, and socket appearance. Improvement in K-Level and less use of assistive devices were observed with the AMPPRO instrument, indicating improved user mobility and performance. QoL was also increased, as measured in Quality-Adjusted-Life-Years (QALY) from the EQ-5D-5L.

CONCLUSIONS

Evidence from the findings demonstrate that the Direct Socket TF system and procedure can be a good alternative to the traditional method of prosthetic interface delivery.

POS0262 IDENTIFYING EROSIVE DISEASE FROM RADIOLOGY REPORTS OF VETERANS WITH INFLAMMATORY ARTHRITIS USING NATURAL LANGUAGE PROCESSING

Background:

The presence of erosive disease influences diagnosis, management, and prognosis in inflammatory arthritis (IA).Research of IA in large datasets is limited by a lack of methods for identifying erosions.

Objectives:

To develop methods for identifying articular erosions in radiology reports from veterans with IA.

Methods:

Included veterans had ≥2 ICD codes for ankylosing spondylitis (AS), psoriatic arthritis (PsA), or rheumatoid arthritis (RA) between 2005- 2019, in Veterans Affairs Corporate Data Warehouse. Chart review & annotation of radiology notes produced the reference standard, & identified erosion terms that informed classification rule development. A rule-based natural language processing (NLP) model was created & revised in training snippets. The NLP method was validated in an independent reference sample of IA patients at the snippet & patient levels

StepDescriptionNumber & example1 Radiology notesa.Select note titles potentially relevant to IAa. 35,141 notes titlesb.Extract notes with titles potentially related to IAb. 2,926,113 radiology notes2 Possible meaningful termsa.Compile list of root terms that may indicate erosiona. 11 root terms (i.e. ero*, pencil*cup, irreg*)b.Query radiology notes for root term variationsb. 1178 variations (i.e. erosion, erotic, erode)c.Select possible meaningful termsc. 179 possible terms (i.e. erosion, erode)3 Annotationa.Extract snippets^ containing possible meaningful termsa.5000 snippets from radiology notesb.Classify snippets according to: 1) Meaningful term, 2) Relevance to joint, 3) Attribution to IA, 4) Affirmationb.4068 classifications with 1017 snippets (in rounds of 50-417 snippets for NLP training & testing)4 Rule developmenta.Identify meaningful terms representing erosiona. 6 terms (pencil * cup, erosion, erosive, etc.)b.Exclude erosive processes irrelevant to joint(s)b. 28 irrelevant processes (i.e. gastric erosion)c. Exclude articular erosive processes not attributed to IAc. 5 non-IA processes IA (i.e. infection)d. Classify as affirmed/negated (erosion present/absent)d. 83 affirmation/negation rules5 NLP trainingDesign & revise NLP model until accuracy ≥90%6 rounds, 817 snippets (AS 417, RA 200, PsA 200)6 NLP testingTest NLP model200 snippets (AS 100, RA 50, PsA 50)7 Pt classificationa. Develop rules for classifying pts with discordant snippetsa. 5 rules developed in 368 ptsb. Build reference sample (pts classified as erosive or non-erosive via chart review)b. 30 IA pts (10 AS, 10 RA, 10 PsA)8 NLP validationValidate NLP model in reference sample at snippet level149 snippets (29 AS, 76 RA, 44 PsA)9 Method validationValidate methods (NLP+pt classification) at pt level30 IA pts (reference sample)

pt= patient. ^Snippets include text containing 30 words before & after meaningful terms

Results:

In 168,667 veterans with IA, the mean age was 63.1 & 90.3% were male. Method development involved radiology note & erosion term selection, rule development, NLP model building, & method validation. The NLP model accuracy was 94.6% at the snippet level & 90.0% at the patient level, for all IA patients.

Accuracy of methods.

Conclusion:

The methods accurately identify erosions from radiology reports of veterans with IA. They may facilitate a broad range of research involving cohort identification & disease severity stratification

References:

[1]Walsh JA, et al. J Rheumatol. 2020;47(1):42-49

Disclosure of Interests:

Gopi Penmetsa: None declared, Shaobo Pei: None declared, Brian Sauer Grant/research support from: I have been an investigator on research contracts supported by Abbvie., Jessica A. Walsh Consultant of: AbbVie, Amgen, Janssen, Lilly, Novartis, Pfizer, UCB, Grant/research support from: AbbVie, Merck, Pfizer, Bingjian Feng Grant/research support from: Bing-Jian Feng reports funding and sponsorship to his institution on his behalf from Pfizer Inc., Regeneron Genetics Center LLC, and Astra Zeneca (UK). The PERCH software, for which Bing-Jian Feng is the inventor, has been non-exclusively licensed to Ambry Genetics for clinical genetic testing services and research., Jodi Walker Shareholder of: Abbvie and mutual funds containing various pharmaceutical companies, Employee of: Abbvie, Kevin Douglas Shareholder of: employed by Abbvie, Employee of: employed by Abbvie, Jerry Clewell Shareholder of: Own Abbvie Shares and mutual funds that hold pharmaceutical and other health care stocks, Employee of: I am current Abbvie Inc employee and past employee of Eli Lilly co

A Placebo-Controlled, Parallel-Group, Randomized Clinical Trial of AC-1204 in Mild-to-Moderate Alzheimer's Disease

BACKGROUND

Alzheimer's disease (AD) is characterized by amyloid-β plaques, neurofibrillary tangles, and regional cerebral glucose hypometabolism. Providing an alternative metabolic substrate, such as ketone bodies, may be a viable therapeutic option.

OBJECTIVE

The objective was to determine the efficacy and safety of the AC-1204 formulation of caprylic triglyceride administered daily for 26 weeks in APOE4 non-carrier participants with mild-to-moderate AD.

METHODS

In a double-blind, placebo-controlled, randomized study (AC-12-010, NOURISH AD, NCT01741194), 413 patients with mild-to-moderate probable AD were stratified by APOE genotype and randomized (1 : 1) to receive either placebo or AC-1204 for 26 weeks. The primary outcome was the change from baseline to week 26 on the 11-item Alzheimer's Disease Assessment Scale - Cognitive subscale (ADAS-Cog11) among APOE4 non-carriers. The key secondary outcome was the change from baseline to week 26 in the Alzheimer's Disease Cooperative Study - Clinician's Global Impression of Change scale.

RESULTS

Administration of AC-1204 was safe and well-tolerated. Mean changes from baseline in the primary outcome at 26 weeks in ADAS-Cog11 for placebo (n = 138) was 0.0 and for AC-1204 (n = 137) was 0.6 (LS differences of mean - 0.761, p = 0.2458) and secondary outcome measures failed to detect any drug effects.

CONCLUSION

The AC-1204 formulation of caprylic triglyceride failed to improve cognition or functional ability in subjects with mild-to-moderate AD. The lack of efficacy observed in this study may have several contributing factors including a lower ketone body formation from AC-1204 than expected and a lack of decline in the patients receiving placebo.