Cancellation Rate Research Articles

Cancellation of Elective Cases in Songklanagarind Hospital: Identification of Reason: A Retrospective Study

Background: The operating theatre is the most important department of a hospital as it involves significant resources. One of the significant obstacles in overseeing a theater managing system is scheduled elective case cancellation. Objective: The present study was conducted to identify preventable reasons for cancellation. Materials and Methods: A retrospective study was conducted between January and December 2018. Data from scheduled elective cases were retrieved from a database of the Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University. All patients who required anesthetization for surgery were divided into two groups, proceeding with the operation, and case cancellation. Baseline characteristics of the two groups were compared using the chi-square test, Fisher’s exact test, and analysis of variance. All statistical analyses were performed using the R software, and the correlation was considered significant at p of less than 0.05. The reason for case cancellations was categorized into three groups, preventable, unpreventable, inconclusive, then displayed as percentages. Results: In all, 12,423 patients were identified as being scheduled elective cases. The case cancellation rate was 6.4%. Cancellation rates of males and females were 7.3% and 5.6%, respectively. Patients aged 65 to 79 years exhibited a 7.6% cancellation rate, and the cancellation rate was the highest at 17.3% in the American Society of Anesthesiologists (ASA) physical status classification 4. Of the 797 canceled surgeries, 397 cases (50%) were preventable, 192 cases (24%) were unpreventable, and 208 cases (26%) involved inconclusive reasons. The preventable reasons for cancellation comprised incomplete medical evaluations in 179 cases (22.5%), overtime in 74 cases (9.3%), and the patient refused surgery in 52 cases (6.5%). Conclusion: The most common cause of elective case cancellation is an incomplete preoperative evaluation, which is a preventable reason.Therefore, preoperative evaluation protocol as a one-stop service preoperative clinic should be established to prevent and decrease the cancellation rate of elective cases. Keywords: Cancellation case; Elective surgery; Preventable reason

Is in situ simulation in emergency medicine safe? A scoping review

ObjectivesTo provide an overview of the available evidence regarding the safety of in situ simulation (ISS) in the emergency department (ED).DesignScoping review.MethodsOriginal articles published before March 2021 were included if...

Telemedicine Visits Can Generate Highly Accurate Diagnoses and Surgical Plans for Spine Patients.

A Retrospective cohort study. To (1) assess whether diagnoses and surgical plans established during a new patient telemedicine visit changed following an in-person evaluation and (2) determine any differences in perioperative outcomes between patients who only had a telemedicine visit before surgery versus those who had a telemedicine visit followed by an in-person evaluation before surgery. Data on capability of telemedicine to deliver high-quality preoperative assessment without a traditional in-person interaction and physical examination is lacking. Records of patients who had a new patient telemedicine visit and indicated for surgery with documented specific diagnosis as well as surgical plans from a spine department at an urban tertiary center from April 2020 to April 2021 were reviewed. For a subset of patients that had a follow-up in-person evaluation before surgery, these diagnoses and plans were compared. Perioperative outcomes were compared between patients who only had a telemedicine visit before surgery versus those who had a telemedicine visit followed by an in-person evaluation before surgery. A total of 166 patients were included. Of these, 101 patients (61%) only had a new patient telemedicine visit before surgery while 65 (39%) had a telemedicine visit followed by an in-person evaluation. There were no differences in the rate of case cancellations before surgery and patient-reported outcome measures between these two groups ( P >0.05). Of 65 patients who had both a telemedicine followed by an in-person visit, the diagnosis was unchanged for 61 patients (94%) and the surgical plan did not change for 52 patients (80%). The main reason for surgical plan change was due to updated findings on new imaging, 10 patients, (77%). The current study suggests that telemedicine evaluations can provide an effective means of preoperative assessment for spine patients. Level 3.

Impact of Telehealth on the Current and Future Practice of Lipidology: A Scoping Review

<h3>Lead Author's Financial Disclosures</h3> Nothing to disclose. <h3>Study Funding</h3> None. <h3>Background/Synopsis</h3> Telehealth services have been implemented in many chronic conditions with the expectation to improve care for patients and has expanded greatly due to the COVID pandemic. Little is known about the impact that telehealth on the practice of lipidology. <h3>Objective/Purpose</h3> To determine the current utilization of telehealth for lipid management and explore barriers and enablers to telehealth's future impact on the practice of lipidology. <h3>Methods</h3> The PubMed database was searched from inception to June 25, 2021, to identify all relevant articles published utilizing telehealth for lipid management. This search returned 376 articles when using the following key words: "lipids or cholesterol" and "telehealth". Articles were included at abstract screening if they mentioned telehealth and lipids. The definition of telehealth was refined during full-text screening as a synchronous visit between a patient and a clinician that replaced an in-office appointment. All other types of telehealth were excluded including those that only implemented mobile health technologies, remote monitoring, or call backs for return of laboratory results. Additionally, articles had to measure lipid levels. Article findings were synthesized into one of the following categories: 1) barriers to implementing and delivery of telemedicine visits, 2) facilitators to implementing and delivery of telemedicine visits, 3) clinician perspectives on telemedicine, or 4) mention future utility of telemedicine. <h3>Results</h3> Of the 376 articles found, 128 abstracts were included, and 79 articles were included after full text screening. The main reason for exclusion were not meeting the definition for telemedicine. Of the 81 articles, 18 were reviews, 31 were randomized clinical trials, 15 were pre-post evaluations, and 15 were categorized as other study designs. About half of the articles reported telehealth services for individuals with diabetes. Barriers reported include lack of evidence that supports telemedicine's impact or sustainability, technology cost, high appointment cancelation rates, and lack of reimbursement for clinicians. Enablers reported positive to no-negative impact on health outcomes, cost savings for health systems, and easier implementation of multidisciplinary approaches to care. Clinicians had mixed feelings on their ability to deliver clinical care, but report improved patient satisfaction. Future use of telemedicine included mentions of the need for new reimbursement structures, technology literacy programs, and revisions to current clinician licensing laws. <h3>Conclusions</h3> Telemedicine use to provide care for individuals with lipid conditions has expanded during the COVID pandemic, but more research is needed to determine whether it is a sustainable model for lipid management.

Quantifying Properties of Photospheric Magnetic Cancellations in the Quiet Sun Internetwork

We analyzed spectropolarimetric data from the Swedish 1 m Solar Telescope to investigate the physical properties of small-scale magnetic cancellations in the quiet Sun photosphere. Specifically, we looked at the full Stokes polarization profiles along the Fe i 557.6 nm and of the Fe i 630.1 nm lines measured by the CRisp Imaging SpectroPolarimeter to study the temporal evolution of the line-of-sight magnetic field during 42.5 minutes of quiet Sun evolution. From this magnetogram sequence, we visually identified 38 cancellation events. We then used the Yet Another Feature Tracking Algorithm to characterize the physical properties of these magnetic cancellations. We found on average 1.6 × 1016 Mx of magnetic flux canceled in each event with an average cancellation rate of 3.8 × 1014 Mx s−1. The derived canceled flux is associated with strong downflows, with an average speed of V LOS ≈ 1.1 km s−1. Our results show that the average lifetime of each event is 9.2 minutes with an average of 44.8% of initial magnetic flux being canceled. Our estimates of magnetic fluxes provide a lower limit since studied magnetic cancellation events have magnetic field values that are very close to the instrument noise level. We observed no horizontal magnetic fields at the cancellation sites and therefore cannot conclude whether the events are associated with structures that could cause magnetic reconnection.

P-132 Does intracytoplasmic injection (ICSI) improve the outcome of ART (Assisted Reproductive Technologies) cycles in non-male factor infertility cases compared to conventional in-vitro fertilisation (IVF)?

Abstract Study question The aim of this study is to analyse the efficiency of IVF and ICSI cycles in non-male factor infertility cases according to the female age. Summary answer There were no statistical differences in clinical pregnancy rate, implantation rate and live birth rate found between ICSI and IVF in both age groups. What is known already ICSI was introduced to ART clinical routine in 1992 to treat couples with male factor infertility. According to the international reports, in 2017 use of ICSI opposed to IVF reached 69.3% globally, fluctuating in regions between 62.1% up-to 90.1%. There was ongoing debate whether to use the ICSI in non-male factor cycles: a number of clinics prefer ICSI to avoid total fertilisation failure (TFF), however there are studies (2020) that suggest the method of fertilisation does not affect the results. In contrast, there are research works that claim that IVF improves the clinical results in cycles with non-male factors. Study design, size, duration The retrospective analysis included 2505 cycles that were performed from 2012 to 2018. All selected patients were diagnosed with non-male factor infertility and underwent ART cycle in the Institute of Reproductive Medicine. The cycles with mixed insemination IVF/ICSI were uxcluded as well as cycles with preimplantation genetic testing for aneuploidy, previously failed IVF, freezed oocytes and/or other ICSI indications. Frozen embryo transfers were excluded and fresh transfers were performed on a Day 5. Participants/materials, setting, methods The selection of cycles were divided into main two groups IVF (n = 1693) and ICSI (n = 812). Due to the infuence of age the studied group were further divided by female age: &amp;lt;35 and &amp;gt;35; Fertilisation rate and abnormal fertilisation rate of inseminated oocytes, embryo transfer cancelation rate due to the quality or abcense of blastocyst, implantation rate, clinical pregnacy rate, live birth rate were considered as main efficency indicators. The results were analysed by Student's t-test. Main results and the role of chance There was a significant statistical difference (P &amp;lt; 0.0001) in fertilisation rate between the methods in females &amp;lt;35 (IVF - 68.43% and ICSI - 82.36% ). Same results were among females &amp;gt;35 (P &amp;lt; 0.0001, IVF - 67.68% and ICSI - 80.7%). However, the clinical pregnancy rate didn’t differ substantially (p &amp;gt; 0,05) in both age groups (&amp;lt;35: 50.62% vs. 46.02% and &amp;gt;35: 43.05% vs 44.1% in IVF vs. ICSI, respectively). Moreover, there was no notable difference in live birth rate (p &amp;gt; 0.05) in either age groups (&amp;lt;35: 32.54% vs. 33.62% and &amp;gt;35: 24.88% vs. 28.31% in IVF vs ICSI, respectively). Implantation rate between fertilisation methods demonstrated comparable results (p &amp;gt; 0.05, &amp;lt;35: 34.18% vs. 33.97% and &amp;gt;35: 27.02% vs. 27.72% in IVF vs ICSI, respectively). It’s important to note that IVF had a considerably higher abnormal fertilisation rate (P &amp;lt; 0.0001, &amp;lt;35: 9.25% vs. 2.5% and &amp;gt;35: 8.92% vs. 2.43% in IVF vs ICSI, respectively). Nonetheless, the cancellation rate was remarkably higher (p &amp;lt; 0.05) in ICSI among females &amp;lt;35 (4.23% vs. 7.72% in IVF vs ICSI, respectively). There was no statistical difference in cancelation rate in &amp;gt; 35 age group (11.35% vs. 14.55% in IVF vs. ICSI, respectively; p &amp;gt; 0.05). Limitations, reasons for caution Due to the retrospective nature of the study, there were limitations that substantially decreased the selection of available patients. Also it’s important to note that group IVF was significantly larger than group ICSI. Wider implications of the findings Shift towards the IVF as the fertilisation method of choice in non-male factor cycles could potentially decrease the cost of ART treatment for patients, as well as facilitate laboratory processes for embryologists. In view of the fact that an overworked environment can potentially increase the risk of human factor mistakes. Trial registration number n/a

P-642 Low responders may benefit from undergoing ovarian stimulation with a long GnRH-agonist protocol with corifollitropin-alpha followed by hMG

Abstract Study question Can women with a suboptimal response benefit from undergoing ovarian stimulation with a long GnRH-agonist protocol with corifollitropin-alpha followed by hMG? Summary answer Women with a suboptimal response to ovarian stimulation may have better outcomes with a long GnRH-agonist protocol with corifollitropin-alpha and hMG. What is known already Low responders correspond to 9-24% of the women submitted to ovarian stimulation and represent one of the major challenges in assisted reproduction techniques. Currently, the evidence does not favor the short GnRH-antagonist or the long GnRH-agonist regimens for ovarian stimulation in poor ovarian responders. However, some studies have shown a higher number of retrieved oocytes with the long agonist protocol. Corifollitropin-alpha has been studied in both short and long ovarian stimulation regimens with promising results for poor responders, based on the lower cancellation rate and the higher number of retrieved oocytes and cryopreserved embryos. Study design, size, duration Retrospective cohort study. All women (n = 79) enrolled in an assisted reproductive treatment with a) suboptimal ovarian response, defined as &amp;lt; 4 oocytes (subgroup A) or 4-9 oocytes (subgroup B) obtained after a short GnRH-antagonist protocol (SP) using rFSH/hMG and b) submitted to a second ovarian stimulation cycle with a long GnRH-agonist protocol using a single dose of triptorelin 3.75mg and corifollitropin-alpha followed by hMG - “simplified long protocol” (SLP), were included in the study. Participants/materials, setting, methods Demographic/clinic characteristics were recorded, including age, body mass index (BMI), anti-müllerian hormone (AMH), antral follicle count (AFC), cause of infertility, “Poseidon” classification, number of retrieved oocytes, mature oocytes, and embryos, pregnancy rate (per cycle) and live-birth rate (per embryo transfer). The outcomes of the second ovarian stimulation cycle (SLP) were compared with the outcomes of the first cycle (SP) in the same women/couple using the paired T-test/Wilcoxon for numerical and McNemar’s test for categorical data. Main results and the role of chance The age of women was 35.3±2.9 years old [29-40], the BMI was 23.7±4.1 kg/m2 [15.2-38.5], the AMH was 1.75±1.21 ng/mL [0.32-7.30] and the AFC was 9.5±3.7 [2-20]. The mean number of retrieved oocytes (8.46 versus 4.97, p&amp;lt;0.001), mature oocytes (5.70 versus 2.93, p&amp;lt;0.001), and embryos (1.21 versus 0.48, p&amp;lt;0.001) were significantly higher with the SLP in comparison with the SP. The pregnancy (18.8% versus 5.1%, p = 0.008) and live-birth rates (28.9% versus 0%, p&amp;lt;0.001) were significantly higher with the SLP. The cancellation rate was 3.8% and 7.6% in the SLP and SP, respectively (ns). There were 18 women (22.8%) in the subgroup A and 55 (69.6%) in the subgroup B. The other 6 cases (7.6%) correspond to cancellation cycles (absence of follicular response). Similar results were obtained in both subgroups, A and B, with a significantly higher numbers of retrieved oocytes, mature oocytes, and embryos. In the subgroup A, no clinical pregnancies were obtained with the SP while a2 cases occurred with the SLP (p&amp;lt;0.001). One of those couples had a live birth (ns). The pregnancy (21.8% versus 7.4%, p = 0.033) and live-birth rates (31.0% versus 0, p=0.03) were significantly higher with the SLP in the subgroup B. Limitations, reasons for caution This was a cohort study with a relatively low number of patients. Future studies with a higher population size and a different design are needed to give robustness to our findings. Wider implications of the findings Women with a suboptimal response to ovarian stimulation with a short antagonist protocol may have a higher number of oocytes, higher number of mature oocytes and higher pregnancy and live-birth rates when undergoing treatment with a long GnRH-agonist protocol with corifollitropin-alpha and hMG. Trial registration number Not applicable

O-130 Reproductive outcomes of normal ovarian reserve patients after progestin-primed ovarian stimulation with chlormadinone acetate vs GnRH antagonist: A retrospective study with inverse-probability-of-treatment weighting

Abstract Study question To evaluate the effectiveness of chlormadinone acetate (CMA) for preventing premature LH surge in patients with normal ovarian reserve compared to cetrorelix. Summary answer In progestin-primed ovarian stimulation (PPOS) than GnRH antagonist (GnRH-ant), the incidence of premature LH surge was significantly lower, without significant difference in oocyte maturation rate. What is known already The GnRH-ant protocol is one of the conventional protocols which has some disadvantages including increased premature LH surge rate and cancelation rate. In recent years, the PPOS protocol has attracted attention as a new ovarian stimulation using progestin as an alternative to GnRH analog for suppressing a premature LH surge, however its efficacy is still controversial. In addition, many studies have investigated the reproductive outcomes of PPOS using medroxy-progesterone acetate or dydrogesterone; however, there are few reports of CMA, an oral progestin, which is inexpensive and widely used in Japan. Study design, size, duration This retrospective cohort study was performed in a reproduction center between March 2018 and October 2020 which included 977 Japanese patients with normal ovarian reserve undergoing PPOS with CMA (n = 299), or GnRH antagonist (GnRH-ant) with cetrorelix (n = 608) in their first IVF cycle at the reproduction center. In subgroup analysis, pregnancy outcomes after frozen embryo transfers (FET) between PPOS (n = 284) and GnRH-ant (n = 579) were also compared. Participants/materials, setting, methods The inclusion criteria were patients aged &amp;lt; 40 years and AMH ≧ 1.1 ng/mL, who underwent autologous oocyte retrieval in their first IVF cycle with freeze-all strategy. The primary outcome was the incidence of premature LH surge, the secondary outcomes was oocyte maturation rate. To reduce the impact of treatment bias and potential confounding factors, we conducted logistic regression models with inverse-probability-of-treatment weighting (IPTW). Main results and the role of chance After IPTW, baseline clinical data were well-balanced between the two groups, including age, AMH, BMI, the duration, type, and cause of infertility, antral follicle count, the history of recurrent spontaneous abortion, and previous IVF attempts. The premature LH surge rate was significantly lower with PPOS (3.1%) compared to GnRH-ant (20.1%) (odds ratio, 0.21; 95% confidence interval, 0.11–0.36). No significant differences were found in total gonadotropin dose (2400IU for PPOS vs 2400IU for GnRH-ant, p = 0.136), the number of oocyte retrieval (n = 15 vs n = 15, p = 0.484), oocyte maturation rate (78.8% vs 77.8%, p = 0.275), fertilization rate (73.0% vs 72.0%, p = 0.412), viable embryo rate per oocyte retrieval (40% vs 40%, p = 0.890), and good quality blastocyst rate (72.0% vs 69.6%, p = 0.092). However, the good quality day-3 embryo rate was significantly lower with PPOS (37.2% vs 49.1%, p &amp;lt; 0.05). There were no differences in the incidence of moderate-to-severe OHSS (0.3% vs 0.7%, p = 0.481). In FET cycles, the pregnancy outcomes, such as implantation rate (43.1 % vs 51.9 %, p = 0.013) and clinical pregnancy rate (46.5% vs 54.7%, p = 0.027) were significantly lower with PPOS, however, no significant differences were found in ongoing pregnancy rate (75.6% vs 80.5%, p = 0.325), and live birth rate (72.4% vs 79.5 %, p = 0.142). Limitations, reasons for caution This was a retrospective cohort study conducted in a single center. The participants in this study were limited to Japanese ethnicity. The results need to be validated across different centers and other ethnicities. Wider implications of the findings This is the first report assessing the reproductive outcomes on PPOS using CMA, widely used in Japan. The PPOS with CMA significantly suppressed the premature LH surge rate compared to GnRH-ant protocol, without decrease in oocyte maturation rate. Trial registration number N/A

P-691 Assessment of ovarian vascularity by three-dimensional vaginal power Doppler on day seven of menstrual cycle to predict the number of eggs collected in antagonist cycle

Abstract Study question Could ovarian vascularity indices on day 2 and 7 of stimulation, measured by 3-dimensional (3D) vaginal power Doppler, predict after controlled ovarian stimulation? Summary answer Ovarian vascularity index (VI) on day 7 may be an indicator of poor (&amp;lt;three mature eggs collected) ovarian responses to gonadotropins. What is known already Poor and/or hyper ovarian responses to gonadotropins may be related to cycle cancellation during controlled ovarian stimulation (COS). In this context, gonadotropin dose is often individualized using patient features that predict ovarian response (such as age, antral follicular count (AFC) and anti-Müllerian hormone (AMH)). In parallel, ovarian vascularity color doppler is a valuable evaluation method to predict the ovarian hyperstimulation syndrome and the growth/maturity of Graafian follicles. The aim of the present study is to estimate the utility of 3-dimensional vaginal power Doppler and ovarian vascular flow indices in the prediction of the number of mature occytes collected after COS. Study design, size, duration A prospective study was conducted on 296 couples undergoing intracytoplasmic sperm injection cycle at Al Hadi Laboratory and Medical center, Beirut, Lebanon. It was performed between January 2020 and dec 2021. Couples were categorized into poor responders group (3 or less metaphase II (MII) eggs collected) (36.1%), high responders group (16 or more MII eggs collected) group ( 6.7%), and normal responders group (more than 3 and less than 16 MII eggs collected) (57,2%). Participants/materials, setting, methods On the second and seventh day of the menstrual cycle, ovarian volume and vascularity parameters (vascularity index (VI), flow index (FI), and vascularity flow index (VFI)) were measured using the 3D power Doppler and the Virtual Organ Computer-Aided Analysis. On day 2 , the antral follicle count was evaluated and a blood sample for AMH testing was collected. Women included in the study have undergone COS using GnRH antagonist protocol. Main results and the role of chance Mean age was 35,88+/- 6 year , day2 VI and day2 VFI correlates with the number of egg collected (p = 0.014 and 0.045 respectively). 9 parameters were used to predict poor and high ovarian responses (Age, AMH, AFC, day2 VI, day2 FI , day2 VFI , day7 VI, day7 FI and day7 VFI) in a Receiver operator characteristics (ROC) curve model . Ovarian day7 FI significantly predicted poor ovarian response to gonadotropins (p = 0.038) with an area under the curve of 0.679. AFC predicted also poor ovarian response to gonadotropins (p = 0.006) . In parallel, AFC significantly predicted high ovarian response to gonadotropins (p = 0.002) and AUC (0.778) while all other 3D doppler parameters couldn’t predict high responders. Limitations, reasons for caution It will be necessary to perform a prospective analysis on a broad sample size to validate these findings. In addition, it will be interesting to assess the impact of ovarian vascularity on pregnancy outcomes. Wider implications of the findings Assessing ovarian vascularity during ovarian stimulation can help reduce the rate of cycle cancellation. In addition, more studies are welcomed in the field to unravel the mechanisms behind altered ovarian vascularity and to test the possibility of restoring normal ovarian physiology. Trial registration number Not Applicable

O-131 Progesterone Primed Ovarian Stimulation (PPOS) Vs Clomiphene Primed Ovarian Stimulation (CPOS) in high responder (HR) patients undergoing controlled ovarian stimulation - A Randomized Control Trial

Study questionIn high responder individuals, stimulation with PPOS or CPOS would offer better outcomes?Summary answerData from this trial concludes that stimulation with CPOS or PPOS seem to offer comparable outcomes in high responders individuals.What is known alreadyProgesterone and Clomiphene Citrate have been used to suppress premature LH surge in patients undergoing controlled ovarian stimulation (COS) for In Vitro Fertilization. Their use will negate the need of using additional injections and thereby would improve the patient acceptability and reduce pain and drop out rates. This Randomized Control Trial (RCT) intends to look at the efficiency of these protocols.Study design, size, durationThis is a Prospective RCT conducted between September 2020-December 2021 with prior approval from Institutional Ethical committee (ECR/1312/INST/TG/2019). HR patients as defined by Antral Follicular Count (AFC), Anti-Mullerian hormone (AMH) or previous response were randomized into PPOS (n = 50) & CPOS (n = 50) arm at start of stimulation based on a computer generated randomization sheet.Exclusion criteriaAge > 35 yrs, history of Total Fertilization Failure, Inadequate post-trigger hormonal values, incomplete retrieval of oocytes.Participants/materials, setting, methodsAfter randomization, all patients were started on Inj rFSH & Inj HP-HMG (dosage depending upon BMI). PPOS arm- Tab.Medroxy Progesterone Acetate10 mg/day started from day 2 of the cycle along with gonadotropins and continued until trigger. CPOS arm- Clomiphene citrate 150 mg/day (divided doses) starting from the 8thday of stimulation or when lead follicle reached 12 mm diameter and continued until trigger.All the subjects underwent Frozen Embryo replacement cycle with two good grade blastocysts.Main results and the role of chanceBaseline variables of patients were comparable between both arms. There were 6-dropouts in PPOS arm and 8 dropouts in CPOS arm due to Covid -19 infection. Hence a total of 44 patients in PPOS arm and 42 patients in CPOS arm were available for analysis.Premature LH surge rates, cycle cancellation rate, blastocyst rate (BR), Implantation Rate (IR) per initiated FET cycle were the primary outcomes.Dose and duration of gonadotropins, number of oocytes, maturation rate, fertilization rate (FR), and OHSS rate were the secondary outcomesOutcomes between PPOS Vs CPOS were as follows: LH Surge – 2.3% vs 2.5% (p = 1)Cycle cancellation rate – 9.1% Vs 10% (p = 1)BR – 57% vs 56% (p = 0.547)IR – 44% Vs 49% (p = 0.687)Secondary outcomes - Dose and duration of gonadotropins, number of oocytes retrieved, fertilization rate, maturation rate & OHSS rate were comparable in both groups.All the outcomes compared between the two arms seemed to be similar with no statistical significance. Progesterone or Clomiphene priming seems to offer optimal outcomes with no superiority of one protocol over the other.Limitations, reasons for cautionThe RCT was performed on a small sample size and should be confirmed on a larger cohort. Moreover, this is the first study comparing both the drugs in high responders and confirms the efficacy of both drugs as LH suppressants without compromising outcomes.Wider implications of the findingsThis study provides assuring data on using the two oral agents, progesterone and clomiphene citrate with equal efficacy and without affecting the outcomes. These agents can help in reducing the dosage of gonadotropins and this in turn can help in minimizing the complications like OHSS during controlled ovarian stimulation.Trial registration numberNot applicable

P-655 Insulin like growth factor-1 levels in follicular fluids of patients with poor ovarian response undergoing in vitro fertilization

Abstract Study question Does follicular fluid insulin like growth factor level (IGF-1) in poor responders (PR) differ from normoresponders? Is there a correlation between IGF-1 and IVF outcomes? Summary answer Follicular IGF-1 levels are decreased in poor-responders A positive correlation exists between IGF-1 and number of metaphase II (MII) oocytes, fertilized oocytes and transferred embryos What is known already IGFs are mainly synthesized in liver with growth hormone stimulation. IGF-1 component in follicular fluid has been reported to play a crucial role in follicular and embryonic development. In addition to previously reported positive correlation between follicular IGF-I levels and number of high quality embryos, a significant decrease in IGF-1 levels with PR and advanced maternal age has also been reported. GH supplementation in poor responders undergoing IVF has been suggested to improve IVF outcomes. A recent Cochrane analysis reported that GH slightly increases the number of oocytes retrieved and there is an uncertain effect on live birth rates (LBR). Study design, size, duration Study was designed prospectively. A power analysis, of 91% determined a need for 186 patients. Therefore 186 women undergoing IVF between October 2019 and December 2020 were included. 72 (%38,7) patients were assigned to PRs group according to Bologna criteria (BC) and 114 patients (%61.3) were recruited as controls. Antagonist protocol was used for controlled ovarian hyperstimulation. hCG was administered for ovulation trigger. Participants/materials, setting, methods Following the ovarian hyperstimulation follicular fluid samples were collected during oocyte retrieval. When the total desired number of patients was reached, frozen and preserved follicle fluids were thawed at room temperature. IGF-1 levels in samples were measured using hIGF-1 ELISA kit (BT®, China). Follicular IGF-1 levels in PRs were compared to normoresponders and correlation between IGF-1 levels and AMH levels, number of retrieved oocytes, MII and fertilized oocytes, transferred embriyos and LBR were evaluated. Main results and the role of chance Mean IGF-1 levels of normoresponders and Bologna subgroups (B1, B2, B3, B4) were 13.79±14.50 ng/ml vs 5.75±1.86, 5.47±2.83, 5.96±2.16 and 5.03±1.85 ng/ml respectively (p &amp;lt; 0.001). There was no statistically significant difference in clinical pregnancy (CP) per transfer and LBR per transfer between normoresponders and PRs (CPR/ET: 55.1% vs 43.7%, p:0.375; 26.5% vs 12.5% , p: 0.257). In the ROC analysis for the prediction of collection of fewer than 4 oocytes at retrieval (according to BC definition of PR), statistically determined IGF-1 value was 7.02 with a sensitivity of 83% and a specificity of 38.6%. Patients with an IGF-1 value below 7.02 had a higher risk of having an oocyte number less than 4According to the results of Spearman's correlation analysis, IGF-1 levels were negatively correlated with age and number of previous failed cycles (r:-0.250, p:0,001; r:-0.153, p:0,039 respectively). IGF-1 levels were positively correlated with AMH levels, oocyte, MII oocyte, fertilized oocyte numbers and number of transferred embriyos (r: 0.221, p: 0.007; r: 0.283, p &amp;lt; 0.001; r: 0.293, p &amp;lt; 0.001; r: 0.282, p &amp;lt; 0.001; r: 0.194, p: 0.008 respectively). There was a positive correlation between IGF-1 levels and cycle cancellation rates (r: 0.637, p &amp;lt; 0,001). There was no correlation between IGF-1 levels and LBR (p:0.118). Limitations, reasons for caution Small number of patients was the main limitation of study.Results were not interpreted as LBR in all cases, as 21% (n:24) of the cases had still ongoing pregnancies Wider implications of the findings Detecting lower follicular levels of IGF-1 which plays a crucial role in GH activity may highligt the effect of GH supplementation in poor responders undergoing IVF in terms of improved outcomes. However, there is need for more solid data to employ GH in IVF treatment modalities of poor-responders. Trial registration number not applicable

O-069 Does dual stimulation with continuous FSH administration increase the total number of metaphase II oocytes in poor responders?

Abstract Study question Is there an increase in the total number of metaphase II (MII) oocytes between a conventional ovarian stimulation and a dual uninterrupted stimulation? Summary answer Dual stimulation with continuous follicle stimulating hormone (FSH) administration is not superior to conventional stimulation in terms of number of MII oocytes. What is known already In the last decade, the concept of multiple follicular waves during one menstrual cycle has gained a lot of interest. Translated into clinical practice, combining two stimulations in the same ovarian cycle has appeared beneficial with regard to the number of retrieved oocytes, without affecting the embryo quality or ploidy status. Usually, this so-called dual stimulation approach is characterized by a discontinuation of FSH administration for approximately 5 days between two consecutive stimulations. The role of dual uninterrupted ovarian stimulation has not yet been studied. Study design, size, duration This was an open-label randomized controlled trial (RCT) with superiority design, performed in a single tertiary center. Power analysis indicated a required sample of 46 patients to detect superiority (defined as two surplus MII oocytes) of the dual stimulation group. Between October 2020 and September 2021, 70 patients were screened, 48 were randomized and 46 completed the study. Participants/materials, setting, methods Women aged 25-40 with a serum anti-Müllerian hormone (AMH) level of ≤ 1.5 ng/mL, antral follicle count (AFC) of ≤ 6, or ≤ 5 oocytes after a previous stimulation, were eligible for inclusion. Randomization occurred only in case of ≤ 9 follicles of ≥ 11mm on the trigger day. In the control group, patients underwent one round of ovarian stimulation and oocyte retrieval only, while the study group had two uninterrupted rounds of ovarian stimulation and two retrievals. Main results and the role of chance Baseline characteristics were similar between both groups. The cumulative number of COC and MII oocytes after completion of the second oocyte retrieval was similar in the control and study group [5.3 ± 2.7 versus 5.3 ± 3.1 [difference 95%CI (-1.7 to 1.7), p = 0.92] and 4.1 ± 2.5 versus 4.3 ± 2.7 [difference 95%CI (-1.7 to 1.3), p = 0.82]. Likewise, a comparable number of good quality embryos at day 3 was available (3.0 ± 2.0 versus 2.7 ± 2., p = 0.63). In the study group, the cancellation rate due to insufficient response to the second round of stimulation was 39.1%. When focusing on the first stimulation in both groups, there were no significant differences regarding basal FSH, FSH consumption and the number of preovulatory follicles. After the first oocyte retrieval, the mean number of COC and MII oocytes was significantly higher in the control group (who had human chorionic gonadotropin (hCG) triggering), compared to the study group (who had Gonadotropin Releasing Hormone (GnRH) agonist triggering) (5.3 ± 2.7 versus 3.3 ± 2.2, p = 0.004 and 4.2 ± 2.4 versus 2.9 ± 2.2, p = 0.05). Likewise, the number of good quality embryos on day 3 was significantly higher (3.0 ± 2.0 versus 1.9 ± 1.7, p = 0.04). Limitations, reasons for caution This study was powered to demonstrate superiority for number of MII oocytes. Investigating the impact of dual stimulation on pregnancy rates would have required a larger sample size. Wider implications of the findings The observed suboptimal oocyte yield after agonist triggering in poor responders is a reason for concern and further scrutiny, given that previous RCTs have shown similar outcomes in normal and high responders after hCG and GnRH agonist trigger. Trial registration number NCT03846544

P-080 Intrauterine insemination (IUI) success rates in patients with suboptimal total processed motile sperm count (TPMSC) using a second consecutive semen sample

Abstract Study question Is it effective to request a second consecutive semen sample in patients with less than 1 million TPMSC in a first semen sample for IUI? Summary answer In men with TPMSC under one million, the issuing of a second consecutive sample reached pregnancy rates similar to those published for IUI. What is known already IUI offers a comparable cumulative live birth rate in 3-4 cycles compared to IVF and can be preferred as a cost-effective first-line treatment in mild male factor or unexplained infertility. The quality of the processed semen sample is an important factor for the IUI success. The WHO recommends an abstinence period to ensure best quality of semen samples. However, it has been observed that when men with moderate male factor who are unable to meet the minimum requirements for IUI are asked to produce a second sample better counts are obtained; questioning the time correlation between abstinence and semen quality. Study design, size, duration This was a retrospective study conducted in the reproductive medicine unit of a private hospital in Chile between July 2015 and March 2021. All patients who underwent IUI in the study period that had an TPMSC less than 1 million in the eyaculate and to whom a second consecutive sample was requested were included. Participants/materials, setting, methods 118 patients who underwent 140 IUI cycles were included in the study. All the patients with an PMSC under 1 million at the time of the IUI were requested a second consecutive semen sample within an hour or two from the previous eyaculate. The second samples were processed and used for insemination. The primary outcome was pregnancy rate. The secondary outcomes were semen quality (TPMSC of first and second semen samples). Main results and the role of chance Between 2015 and 2021 there were 140 IUI cycles in which a second consecutive semen sample was requested, including 118 patients. Overall 17 pregnancies were achieved. The pregnancy rate per cycle was 12,14% and the pregnancy rate per patient was 14,4%. The live birth rate per patient was 10,2%. Regarding the sperm sample analysis, the median TPMSC of the first semen sample was 261.437. The median PMSC of the second consecutive sample was 7.315.000. 126 patients had an TPMSC of 0 in the first semen sample while only 9 patients had an IMSC of 0 in the second sample. In five cases a third consecutive sample was requested of which 4 patients had their cycles canceled because they did not meet the target PMSC. One patient had an TPMSC of 1.687.000 in the third sample. Finally, of the 118 patients who did not meet the requirements for IUI with the first sample, only 19 cycles were canceled. Limitations, reasons for caution The study has the limitation of being a retrospective and descriptive study with no contol group. Also the group is heterogeneous because it includes patients with different female factors for infertility. Wider implications of the findings In developing countries and low-income settings the IUI remains a more accessible alternative in patients with infertility. Routinely recollecting a second semen sample in men with TPMSC &amp;lt;1 million would reduce cycle cancellation rates due to not achieving an optimal TPMSC, reaching pregnancy rates similar to those published for IUI. Trial registration number Not applicable

O-180 Body mass index (BMI) is not associated with ovarian response to gonadotropin during IVF/ICSI treatment: An evaluation of 4499 IVF/ICSI cycles

Abstract Study question Is there an association between body mass index (BMI) and ovarian response in IVF/ICSI treatment? Summary answer BMI does not seem to be associated with the ovarian response to gonadotropin. What is known already Obesity is becoming an increasingly widespread health problem. Elevated BMI in patients who undergo assisted reproduction technology has been associated with higher doses of gonadotropins, higher risks of ovarian hyperstimulation syndrome, increased cancellation rates, and lower oocyte recovery compared to women with normal BMI. In addition, overweight and obese women submitted to IVF may present reduced rates of clinical pregnancy and live births and an increased miscarriage rate. However, population differences should be considered. Study design, size, duration This prospective cohort study included 4499 women who underwent IVF/ICSI cycles. Only one cycle per couple was considered. Inclusion criteria included normal karyotype, presence of two ovaries as observed by ultrasound examination, and no history of ovarian surgery, endometriosis, hydrosalpinx, infection, or endocrine disorders. Patients were stratified into four groups by BMI: &amp;lt;18.5 kg/m2 (underweight); 18.5-24.9 kg/m2 (normal weight); 25-29.9 kg/m2 (overweight); and ≥30 kg/m2 (obesity). Participants/materials, setting, methods The BMI values were associated with age, anti-Müllerian hormone (AMH) levels, antral follicle counts (AFC), total dose of FSH and LH, number of follicles and number of retrieved oocytes (total and metaphase II) of IVF/ICSI cycles. The statistical analyses for group comparisons were performed using t test, Mann–Whitney test and the Kruskal–Wallis test. Main results and the role of chance No statistically significant differences were observed between BMI groups regarding age, AMH levels, AFC, dose of gonadotropin used (FSH and LH), days of stimulation, number of follicles and number of retrieved eggs (total and metaphase II). Table 1 summarizes the results. Limitations, reasons for caution A possible limitation is the cross-sectional nature of the data. Differences in sample size between BMI groups may have influenced the results. Wider implications of the findings Against common sense in the literature, the results did not reveal a relationship between BMI and the ovarian response to gonadotropins. BMI as an additional tool in the individualization of ovarian stimulation protocols should be reviewed. Trial registration number Not applicable.

P-678 Does gonadotropin dose adjustment in inadequate ovarian response during controlled ovarian hyperstimulation improve the live birth rates of patients with diminished ovarian reserve?

Abstract Study question Does gonadotropin dose adjustment in inadequate ovarian response during controlled ovarian hyperstimulation improve the live birth rates of patients with diminished ovarian reserve? Summary answer The increasing dose adjustment of the gonadotropin according to the ovarian response during COH in DOR provides similar live birth rates to the fixed-dose group. What is known already Since the poor ovarian response is associated with low pregnancy rates and high cycle cancellation rates, the ovarian response should be predicted, especially for stimulation protocol and gonadotropin dose adjustment before COH is initiated. On the other hand, the predicted gonadotropin dose may not be enough for the ovarian response, and the dose adjustment may be required. Nevertheless, the literature has conflicting results on whether dose adjustment during COH improves the pregnancy results. Study design, size, duration This retrospective cohort study was conducted at a tertiary university hospital's ART (assisted reproductive technologies) center. The electronic database of the ART center was screened between the years 2012-2021, and the DOR patients who underwent ICSI-ET (intra-cytoplasmic sperm injection – embryo transfer) were selected. Bologna criteria were used to determine the diminished ovarian reserve. Patients were divided into two groups depending on the presence of dose adjustment on the first ultrasound control during COH. Participants/materials, setting, methods Women who underwent single–fresh good quality (Gardner A or B) blastocyst transfer and aged between 18-40 years, without male infertility and endometrial pathology were included in, and after exclusion, 498 patients were enrolled in the study. Flexible antagonist protocol was used for COH. A vaginal micronized progesterone capsule (3x200 mg) was prescribed for luteal phase support after oocyte retrieval. Live birth rate was determined as the singleton live birth after the 24th week of pregnancy. Main results and the role of chance There were 188 patients in the dose adjustment (DA) group and 310 patients in the fixed-dose (FD) group. The demographic parameters were similar between the groups (Age, Body Mass Index, Ovarian Reserve Parameters). The mean women age was 33.8+4 in the DA group and 33.6+4.1 in the FD group (p = 0.6). The started gonadotropin dose was similar in both groups (300 IU). The type of gonadotropin was mostly HMG in the DA group (67% in DA vs. 48% in the FD group, p = 0.01). The median dose adjustment on the first control was +75 IU in the DA group, and as expected, the total gonadotropin consumption was significantly higher in the DA group (Median values; 3900 vs. 3000 IU, p &amp;lt; 0.01). The follicle output rates, follicle to oocyte indexes, and the embryology parameters were comparable between the groups (number of picked up oocytes, metaphase-2 oocytes, and 2PN embryos). The positive pregnancy rate was 19.7% (36/188) in the DA group vs. 19.1% (61/310) in the FD Group (p = 0.4). The primary outcome of the study; live birth rates were 12% in the DA group vs. 9% in the FD group, and the results were statistically similar (p = 0.3). Limitations, reasons for caution Retrospective design and the sample size limit the power of the study. Wider implications of the findings Our study showed that the gonadotropin dose adjustment in inadequate ovarian response during COH provides similar live birth rates to the fixed-dose group. In patients with inadequate response, dose adjustment may be a necessary action. Trial registration number Not applicable

O-127 Higher probability of live birth after testosterone pretreatment in women with poor ovarian response undergoing IVF: a systematic review and meta-analysis

Abstract Study question Does testosterone pretreatment increase the probability of pregnancy in poor responders undergoing ovarian stimulation with gonadotrophin-releasing hormone (GnRH) analogues and gonadotrophins for in-vitro fertilization (IVF)? Summary answer Testosterone pretreatment increases clinical pregnancy and live birth rates in poor responders undergoing ovarian stimulation for IVF. What is known already Androgens have been shown to stimulate early stages of follicular growth, increase the number of primary, pre-antral and antral follicles as well as increase ovarian sensitivity to follicle stimulating hormone (FSH). Although androgen supplementation has been evaluated in several randomized controlled trials (RCTs) and meta-analyzed in six systematic reviews until today currently no solid conclusions can be drawn regarding its effectiveness. Study design, size, duration A literature search was performed until September 2021 aiming to identify RCTs evaluating testosterone pretreatment in poor responders. Outcome measures included achievement of pregnancy, total dose of gonadotrophins required, duration of stimulation, estradiol levels, endometrial thickness and number of follicles ≥17 mm on the day of triggering final oocyte maturation, number of cumulus–oocyte complexes (COCs) retrieved, embryos transferred, metaphase II (MII) and 2-pronuclei oocytes (2pn) and the proportion of patients having an embryo transfer (ET). Participants/materials, setting, methods Eight RCTs published between 2006 and 2021 were analyzed, including 760 women. Pretreatment with transdermal testosterone gel was performed in all studies with a dose ranging from 10 to 12.5 mg/day for 10 to 56 days. In dichotomous data, estimates were expressed as risk ratio (RR) with 95% confidence intervals (CIs), using the fixed or random effects method. In continuous data, differences were pooled across resulting in a weighted mean difference (WMD) with 95% CI. Main results and the role of chance Testosterone pretreatment was associated with a significantly higher live birth (RR: 2.07, 95%CI: 1.09 to 3.92) and clinical pregnancy rate (RR: 2.25, 95%CI: 1.54) in women with POR undergoing IVF, while there was also a significant increase in the number of COCs retrieved (WMD: +0.88, 95% CI: +0.22 to + 1.54). Significantly less days to complete ovarian stimulation (WMD: -0.81 days, 95% CI: -1.46 to −0.16), a lower total dose of gonadotrophins (WMD: -368.8 IUs, 95% CI: −612.4 to -125.2), a thicker endometrium on the day of triggering final oocyte maturation (WMD: +0.83 mm, 95% CI: +0.13 to + 1.53) and a lower cancellation rate due to poor ovarian response (RR: 0.37, 95%CI: 0.20 to 0.71) were observed. No significant differences were observed in estradiol levels (WMD: -8.12 pg/mL, 95% CI: -118.2 to + 101.96), in the numbers of follicles ≥17 mm on the day of triggering final oocyte maturation (WMD: +0.82, 95%CI: -0.11 to + 1.74), of MII oocytes (WMD: +0.50, 95% CI: -0.17 to + 1.17), of 2pn oocytes (WMD: +0.49, 95% CI: -0.11 to + 1.10), of embryos transferred (WMD: +0.21, 95%CI: -0.07 to + 0.49) and in the proportion of patients with ET (RR: 1.00, 95% CI: 0.96 to 1.04). Limitations, reasons for caution The definition of poor ovarian response varied among studies and a considerable heterogeneity regarding the type, dose and duration of testosterone pretreatment was present. Although the present study is currently the largest meta-analysis evaluating testosterone pretreatment, the total number of patients is still not large enough to draw solid conclusions. Wider implications of the findings The current study suggests that the probability of pregnancy is increased in poor responders pretreated with transdermal testosterone. This increase, in the absence of other proven beneficial interventions in these patients, justifies the conduction of further relevant RCTs. Trial registration number CRD42021262098

Which Factors Are Associated With Reproductive Outcomes of DOR Patients in ART Cycles: An Eight-Year Retrospective Study.

IntroductionWomen with diminished ovarian reserve (DOR) have a lower pregnancy rate and higher cancellation rate compared to those without DOR when seeking assisted reproductive technology. However, which factors are associated with reproductive outcomes and whether AMH is a predictor of clinical pregnancy remain unclear.ObjectiveThis retrospective study was designed to find factors associated with reproductive outcomes in DOR patients and then discuss the role of AMH in predicting cycle results among this population.MethodA total of 900 women were included in the study. They were diagnosed with DOR with the following criteria: (i) FSH > 10 IU/L; (ii)AMH < 1.1 ng/ml; and (iii) AFC <7. They were divided into different groups: firstly, based on whether they were clinically pregnant or not, pregnant group vs. non-pregnant group (comparison 1); secondly, if patients had transferrable embryos (TE) or not, TE vs. no TE group (comparison 2); thirdly, patients undergoing embryo transfer (ET) cycles were divided into pregnant I and non-pregnant I group (comparison 3). The baseline and ovarian stimulation characteristics of these women in their first IVF/ICSI cycles were analyzed. Logistic regression was performed to find factors associated with clinical pregnancy.ResultsOf the 900 DOR patients, 138 women got pregnant in their first IVF/ICSI cycles while the rest did not. AMH was an independent predictor of TE after adjusting for confounding factors (adjusted OR:11.848, 95% CI: 6.21-22.62, P< 0.001). Further ROC (receiver operating characteristic) analysis was performed and the corresponding AUC (the area under the curve) was 0.679 (95% CI: 0.639-0.72, P< 0.001). Notably, an AMH level of 0.355 had a sensitivity of 62.6% and specificity of 65.6%. However, there was no statistical difference in AMH level in comparison 3, and multivariate logistic regression showed female age was associated with clinical pregnancy in ET cycles and women who were under 35 years old were more likely to be pregnant compared to those older than 40 years old (adjusted OR:4.755, 95% CI: 2.81-8.04, P< 0.001).ConclusionAMH is highly related to oocyte collection rate and TE rate,and 0.355 ng/ml was a cutoff value for the prediction of TE. For DOR patients who had an embryo transferred, AMH is not associated with clinical pregnancy while female age is an independent risk factor for it.

Prevalence of surgery cancelation and challenges in restarting elective surgery in the pandemic: A cross-sectional study

ObjectivesThe COVID-19 pandemic caused primary disruption of health services, especially to elective surgery. As the pandemic goes in waves of high and low infection rates in a country, restarting elective surgery must be dynamic while balancing patients’ needs, staff safety and the hospital capacity. We aim to report the prevalence of elective surgery and minimally invasive procedures cancelation due to positive Covid-19 screening and describe steps in restarting elective cases after the third wave of Covid-19 infection. MethodsThis study was a descriptive cross-sectional study in Indonesia's tertiary referral and teaching hospital from January to September 2021. Subjects were patients scheduled for elective surgery or minimally invasive procedures from our outpatient clinic. Subjects were screened for SARS-CoV-2 using real-time polymerase chain reaction (rRT-PCR) 24-48 hours before scheduled surgery or intervention. Data was taken from the hospital information system and the central operating theatre online surgical list. Statistical analysis is presented in percentage. ResultsThere were 5286 subjects identified for the study, and 3088 were included with an available PCR result from the outpatient department. The average elective cancelation rate was 7.4%, and the highest cancelation was on August 2021, with 14.7%. All subjects with positive results were asymptomatic, with more than 90% cycle time rRT-PCR above 30. ConclusionElective surgery cancelation can reflect a trend in community infection, and monitoring its values is crucial for saving elective surgery plans during a pandemic.

Virtual clinic for positive faecal occult blood tests enhances early access to bowel cancer screening and is well received by patients.

Colorectal cancer is the second most common cause of cancer-related mortality in Australia. As such, timely access to colonoscopy following a positive faecal occult blood test (FOBT) is an important aspect of the National Bowel Cancer Screening Program to reduce morbidity and mortality related to this condition. To reduce waiting times, a Sydney-based referral centre introduced a nurse-led virtual clinic (VC) in order to facilitate direct access colonoscopy for patients referred with a positive FOBT. To evaluate the efficacy of a nurse-led VC model to reduce waiting time to colonoscopy and to determine the patient experience of the model. The VC model, piloted for a 14-month period, was compared with the standard outpatient clinic (SOC) model over the 14-month period preceding the VC. Primary outcomes included time to colonoscopy and secondary outcomes included adverse events, bowel preparation and cancellation rates. Patient experience was evaluated through an emailed survey. Compared to the SOC model, the VC model reduced waiting time to colonoscopy from date of positive FOBT by 71 days (P = 0.0006) and from date of referral by 66 days (P < 0.0001). There was no significant difference in secondary outcomes. All respondents to the survey (n = 30) reported a positive experience. Nursing-led VC, with direct access colonoscopy for patients at increased risk of colorectal cancer, reduce waiting times to colonoscopy without an increase in adverse events and is well received by patients.

Improvement of Umbilical Cord Blood Gas Analysis with Implementation of Clot Catchers.

Umbilical cord blood gas testing is a key component of objective pre- and perinatal evaluation of fetal acid base status to determine presence of intrapartum asphyxia and risk of neonatal encephalopathy. Heparinized cord blood is more likely to form small clots than other blood sources, which can interfere with, or preclude, sample analysis. Cord blood samples are irreplaceable and cannot be recollected, thereby compromising clinical decision-making when analysis is not possible. We evaluated processes to prevent excessive rates of cord blood clotting and quantified their impact on successful testing of blood gas specimens. Verified result and cancellation data were obtained retrospectively from the laboratory information system. Clot catchers were evaluated using noncord remnant specimens. Collection syringes were compared via collection from remnant cord sections. Prior to implementation of any interventions, retrospective analysis indicated a cancellation rate of 18.6% for umbilical cord blood gas specimens (arterial and venous) and 0.7% for noncord blood arterial and venous samples. Clot catchers were validated for clinical use, with a bias of <±4% for all analytes. After clot catchers were implemented for all cord specimens, cancellation rate decreased approximately 5-fold in the first month and remained <5% a year after implementation. A limited comparison of two heparin syringe types revealed a small difference in the overall rate of specimen clotting. Implementation of clot catchers was acceptable for analysis of cord blood samples, and when implemented resulted in a sustained 5-fold decrease in the rate of cord blood gas order cancellation.