Cancellation Rate Research Articles

Operating room efficiency in a low resource setting: a pilot study from a large tertiary referral center in Ethiopia

BackgroundThe operating room (OR) is one of the most expensive areas of a hospital, requiring large capital and recurring investments, and necessitating efficient throughput to reduce costs per patient encounter. On top of increasing costs, inefficient utilization of operating rooms results in prolonged waiting lists, high rate of cancellation, frustration of OR personnel as well as increased anxiety that negatively impacts the health of patients. This problem is magnified in developing countries, where there is a high unmet surgical need. However, no system currently exists to assess operating room utilization in Ethiopia.MethodologyA prospective study was conducted over a period of 3 months (May 1 to July 31, 2019) in a tertiary hospital. Surgical case start time, end time, room turnover time, cancellations and reason for cancellation were observed to evaluate the efficiency of eight operating rooms.ResultsA total of 933 elective procedures were observed during the study period. Of these, 246 were cancelled, yielding a cancellation rate of 35.8%. The most common reasons for cancellation were related to lack of OR time and patient preparation (8.7% and 7.7% respectively). Shortage of facilities (instrument, blood, ICU bed) were causes of cancelation in 7.7%. Start time was delayed in 93.4% (mean 8:56 am ± 52 min) of cases. Last case completion time was early in 47.9% and delayed in 20.6% (mean 2:54 pm ± 156 min). Turnover time was prolonged in 34.5% (mean 25 min ± 49 min). Total operating room utilization ranged from 10.5% to 174%. Operating rooms were underutilized in 42.7% while overutilization was found in 14.6%.ConclusionWe found a high cancellation rate, most attributable to late start times leading to delays for the remainder of cases, and lack of preoperative patient preparation. In a setting with a high unmet burden of surgical disease, OR efficiency must be maximized with improved patient evaluation workflows, adequate OR staffing and commitment to punctual start times. We recommend future quality improvement projects focusing on these areas to increase OR efficiency.

Effects of the Zishen Yutai Pill Compared With Placebo on Live Births Among Women in a Fresh Embryo Transfer Cycle: A Randomized Controlled Trial.

To assess the efficacy of the Zishen Yutai Pill compared with placebo on live birth rates among women after fresh embryo transfer cycles. We conducted a double-blind, multicenter, placebo-controlled, randomized trial to investigate whether administration of the Zishen Yutai Pill would improve pregnancy outcomes among women undergoing fresh embryo transfer after in vitro fertilization or intracytoplasmic sperm injection. The primary outcome was live birth rate. Secondary outcomes were rates of implantation, biochemical pregnancy, clinical pregnancy, pregnancy loss, cycle cancellation, and maternal, fetal, and neonatal complications. A total sample size of 2,265 women (1:1 in two groups) was used to detect a live birth rate difference between the Zishen Yutai Pill and placebo. Participants were enrolled and randomized to receive 5 g of the Zishen Yutai Pill or placebo orally, three times per day during the study. Recruitment was completed between April 2014 and June 2017, with 2,580 patients screened. Two thousand two hundred sixty-five patients were randomized: 1,131 to the Zishen Yutai Pill and 1,134 to placebo. Characteristics were similar between groups. In intention-to-treat analysis, the rates of live birth in the Zishen Yutai Pill (ZYP) group and placebo group were 26.8% and 23.0% (rate ratio [RR], 1.16; 95% CI 1.01-1.34; P=.038), respectively. The implantation rates were 36.8% and 32.6% in the ZYP and placebo groups, respectively (RR 1.13; 95% CI 1.01-1.25; P=.027). The biochemical pregnancy rate for the ZYP group was 35.5% compared with 31.1% in the placebo group (RR 1.14; 95% CI 1.02-1.28; P=.026). The rates of clinical pregnancy in the ZYP and placebo groups were 31.2% compared with 27.3%, respectively (RR 1.14; 95% CI 1.00-1.30; P=.043). There were no significant between-group differences in the rates of pregnancy loss, maternal, or neonatal complications (all P>.05). The Zishen Yutai Pill increased the rate of live birth after fresh embryo transfer compared with placebo. Chictr.org.cn, Chictr-TRC-14004494.

Enhanced PAtient Clinical Streamlining (EPACS): Quality Initiative to Improve Healthcare for New Surgical Outpatient Visits.

PurposeFor patients who select a specialty hospital for cancer treatment, the wait time until the initial consultation leaves patients anxious and delays treatment. To improve quality of care, we implemented an enhanced patient clinical streamlining (EPACS) process that establishes an early connection and coordinates care before the first surgical outpatient visit at our specialty cancer center.MethodsDuring a pre-visit EPACS phone call to new patients, an advanced practice provider (APP) collected medical history and ordered work-up tests or consultations if feasible. First visit cancellation rate, number of patients who started treatment, time to start of treatment, and satisfaction by the care team and patient were compared between patients treated with versus without EPACS.ResultsAmong 5062 consecutive new patients, 720 (14%) received an EPACS call and 4342 did not (86%); work-up was ordered pre-visit in 34% and 16%, respectively. Fewer EPACS patients cancelled the first visit (4.6% vs. 12%, p < 0.001), more started treatment (55% vs. 50%, p = 0.037), and their time to treatment was shorter, but not significantly (median 17 vs. 19 days, p = 0.086). Patient interaction was considered to be improved by EPACS by 17 of 17 APPs and 14 of 16 surgeons, and outpatient clinic efficiency by 14 of 17 APPs and 13 of 16 surgeons. EPACS reduced anxiety and increased preparedness for the first visit in 29 of 31 patients.ConclusionsEPACS improved effectiveness, timeliness, and physician and patient satisfaction with health care at our cancer center.Supplementary InformationThe online version contains supplementary material available at 10.1245/s10434-021-11126-3.

Overrepresentation of Indigenous students in school suspension, exclusion, and enrolment cancellation in Queensland: is there a case for systemic inclusive school reform?

Well-established evidence of the ill-effects of exclusionary school discipline, its disproportionate use on students of colour, and association with the “school-to-prison pipeline” has, in the last decade, led to systemic reforms in the United States, which are successfully reducing exclusion and improving outcomes. Few studies, however, have similarly investigated overrepresentation in Australia, with little attention to systemic reform as a result. In this study, we analysed suspension, exclusion, and enrolment cancellation rates in Queensland (QLD) government schools between 2013 and 2019 and found Indigenous students were consistently overrepresented. Suspension incidents proportionate to enrolments increased for all students, but this increase was faster for Indigenous than non-Indigenous students and driven primarily by steep rises in short suspensions during primary school (Preparatory-6). Exclusions increased—again disproportionately—for Indigenous students, chiefly in secondary school (7–12). During 2019, Physical Misconduct had the highest incident rate for both groups; however, Indigenous students were most overrepresented in suspensions for Disruptive/Disengaged behaviours. Further, while Indigenous students were overrepresented in all QLD regions, one region’s Indigenous suspension rate was higher than all others despite no difference in the distribution of Indigenous/non-Indigenous enrolments across regions. The scale and nature of Indigenous overrepresentation in exclusionary discipline incidents in QLD indicate clear need for further research to secure political commitment to systemic inclusive school reform, as well as to produce high-quality evidence capable of guiding that reform.

Factors for Postponement or Cancellation of Operating Programs Set in the Orthopedics-Traumatology Department of Yalgado Ou&amp;#233;draogo University Teaching Hospital in Ouagadougou (Burkina Faso)

Objective: The purpose of this work was to study the factors of cancellations or postponement of regulated operating programs of the Orthopedic-Traumatology unit of Yalgado Ouédraogo University Teaching Hospital. Materials and Methods: This was a prospective descriptive study over a period of six months. All interventions postponed or canceled during the study period were included. Patients who died or were lost to follow-up before surgery were not included. Results and Comments: the postponement/ cancellation rate was 24.5%. Out of 83 operations cancelled, 72.3% of patients were under 50 years old [extreme 15 and 88 years old]. ASA classes I and II were dominant with 57% and 37% of patients canceled, respectively. There were more postponed interventions (67.5%) than definitive cancellations (32.5%). The causes found were avoidable in 68.7% of cases. The most common was the unavailability of labile blood products (57%), the lack of financial means (36%) and the absence of the patient (28%). The results of our study show that 53% of the causes of cancellations were related to the organization of the hospital. Conclusion: the cancellation rate of orthopedic surgeries remains high at Yalgado Ouédraogo University Teaching Hospital. Most of the causes of cancellations are potentially preventable and the vast majority of them are related to the organization of the hospital. Financial accessibility to care plays an important role in cancellations.

Flexible Antagonist versus Agonist Flare Protocol in Women above 40 Undergoing IVF, A retrospective Cohort Study.

Several strategies have been proposed for ovarian stimulation in older women, such as using an increased daily dose of gonadotropins (300-450 IU per day) with GnRH agonist (long or micro dose flare protocols), or using GnRH antagonist protocols. The objective of this study is to compare the efficacy of flexible GnRH antagonist protocol and GnRH agonist flare - pituitary block protocols for ovarian stimulation in women above 40 years old undergoing IVF. This study was performed between January 2016 and February 2019. One hundred and fourteen women aged between 40 and 42 years who underwent IVF were divided into two groups; group I were treated by Flexible GnRH antagonist protocol (Antagonist group, n=68); and group II were treated by Flare GnRH agonist protocol (Flare group, n=46). Patients treated with the antagonist protocol had a significantly lower cancellation rate when compared with patients treated with flare agonist protocol (10.3% vs. 21.7%, p value 0.049). The other parameters evaluated did not show statistically significant differences. Our finding showed that both Flexible antagonist and Flare agonist protocols had comparable outcomes, with lower cycle cancellation rates for older patients treated with the antagonist protocol.

Interventions to Increasing Test Cancellation Rates in Blood Bank Based on a Multi-Year Review.

Apart from the wasted resource, canceled tests cause delay of test results thus affecting patient care. The study aimed to identify the reasons for the test cancellation of samples received in a blood bank laboratory and determine the improvement target. The study retrospectively reviewed the canceled tests in a blood bank laboratory of a hospital in Hail, Saudi Arabia, from January 2017 to December 2020. Records of the canceled test taken from the quality assurance database were utilized to identify the various reasons. A total of 2,017 (2.7%) test cancellations were recorded in the 4-year study period with increasing rates noted. The two primary reasons were specimen quality issues (61.9%) and problems related to test orders (33.9%). The main reason for test cancellation was clotted specimen (48.5%) followed by incorrect test order (15.6%) and duplicate test order (13.9%). Statistically, a significant difference exists between the annual rates and reasons of cancellation, X2 (6, n = 2,017) = 83.24, p < 0.001. Test cancellations due to various reasons remain a significant challenge for clinical laboratories. Detailed analyses on these major reasons can aid in displaying an effective approach to decrease the cancellation rates. Harmonization among inter-professional health workers concerning specimen collection and handling, and involving clinical laboratory personnel could minimize laboratory errors and avoid test cancellations.

Customized middleware experience in a tertiary care hospital hematology laboratory

BackgroundIn the clinical laboratory, middleware is a software application that sits between the analyzer and the laboratory information system (LIS). One of the more common uses of middleware is to perform more efficient result autoverification than can be achieved by the LIS or analyzer alone. In addition to autoverification, middleware can support highly customized rules to handle samples and results from specific patient locations. The objective of this study was to review the impact of customized middleware rules that were designed and implemented in the hematology laboratory of a 1000-bed tertiary care adult academic center hospital. MethodsThree novel initiatives using middleware rules to achieve workflow efficiencies were retrospectively reviewed over different audit periods: preliminary neutrophil resulting for oncology patients, microcytosis interpretive comments, and 1 white blood cell differential (WBCD) reported per day. In addition, autoverification rates for complete blood count and differential (CBCD) and coagulation tests were calculated. ResultsA preliminary neutrophil count was released from middleware on average 64 min before the final CBCD for Leukemia/Bone Marrow Transplant (L/BMT) outpatients, and on average 59 min earlier for oncology patients. Reflexing interpretive comments for select instances of microcytosis removed on average 500 slides per month from technologist review with an estimated cost savings of approximately $3383.33 CAD per month. The 1 WBCD per day rule resulted in a 5.1% cancelation rate, resulting in an estimated monthly cost savings of $943.46 CAD in reagents and technologist time. Finally, middleware rules achieved very high autoverification rates of 97.2% and 88.3% for CBC and CBCD results, respectively. ConclusionsImplementation of customized middleware hematology rules in our institution resulted in multiple positive impacts on workflow, achieving high autoverification rates, reduced slide reviews, cost savings, and improved standardization.

Cancellation Causes of Elective Surgical Procedures in a Major Pediatric Surgery Department

Introduction: Cancellation of surgical operation is a surgical operation registered in the official schedule the day before or added to the list after and not carried out on the operating day. The purpose of this work was to determine the causes of cancellation of elective surgical operations in a major pediatric surgery department in Senegal. Patients and methods: It was a prospective and descriptive study of 278 patients scheduled during a period of 13 weeks. The study took place between April 3rd, 2017, and January 31st, 2018. Mean age was 2.9 years with extremes of 3 days and 15 years. The age group of 29 days to 30 months was the most represented (62.2%). Sex ratio was 1.41. Causes of cancellation were categorized into administrative and organizational causes, patient-related causes and staff-related causes. Results: Cancellation rate was 29.4%. Patient-related causes were most common (51.2%). Upper Respiratory tract infection (URTI) was commonest reason within this category (57.5%). Organizational causes (28.1%) came second and were mainly represented by the unavailability of the operating room (60.8%) related to breakdowns of anesthesia equipment. Finally, staff-related causes (20.7%) were due for most to the unavailability of the anesthesiologist (12 cases/17). Conclusion: Majority of causes that led to cancellation of elective surgical operations in our Pediatric surgery department are related to intercurrent illnesses affecting the patient, in particular URTI.

Predictors of poor bowel preparations and colonoscopy cancellations in inpatient colonoscopies, a single center retrospective study.

An adequate bowel preparation prior to colonoscopy is a major quality-limiting factor that determines both the diagnostic and therapeutic yield of a colonoscopy. Colonoscopy is considered the gold standard for colon cancer screening and it is the primary approach to the workup of hematochezia, diarrhea and iron deficiency anemia (IDA). Several modifiable factors of bowel prep adequacy have been identified, that account for around 25% of inadequate bowel preparations in outpatient colonoscopies. However, the literature is sparse when examining the factors associated with inadequate preparations and procedure cancellations in an inpatient hospital setting. We aim to identify factors that affect bowel preparation adequacy and procedure cancellations among diagnostic colonoscopies performed during hospitalization. We retrospectively reviewed the electronic medical records of 1,500 consecutive patients who had a diagnostic colonoscopy as an inpatient at a tertiary level hospital over a 2-year period. All patients were administered a clear liquid diet the day prior to the colonoscopy. Patients were then instructed to drink 4 L of polyethylene glycol (PEG, Golytely) between 5 am to 9 am on the day of the procedure. The clinical course of each case was followed to identify quality of preparations, cancelled procedures and the reasons for cancellations. We applied univariate and multivariate logistic regression analysis to identify variables to predict cancellation and poor preparation. A total of 1,029 patients were included in the study. 194 (18.8%) patients had colonoscopy cancellations and 268 (26.0%) had poor bowel preparations. Multivariate analysis revealed these factors to be associated with colonoscopy cancellations: education at the graduate school level [odds ratio (OR) =1.93, P=0.04], Hispanic ethnicity (OR =0.47, P<0.01), hemoglobin level <10 g/dL (OR =1.41, P=0.05) and if the colonoscopy was done for other indications (OR =0.53, P=0.04). Factors associated with poor bowel preparation on multivariate analysis, were dementia (OR =2.44, P=0.02), gastroparesis (OR =3.97, P=0.01) and inpatient opioids use (OR =1.69, P=0.04). The rate of colonoscopy cancellations and poor bowel preparations in inpatient colonoscopies were high, and we were able to identify predictors of inadequate colon preparation and procedure cancellations. Exploring more individualized colon preparation regimens based on personal risk factors could reduce the number of inadequate and cancelled colonoscopies in an inpatient setting.

Effect of preoperative telephone interview in the cancellation rate of daytime surgery in eye hospitals

Effect of preoperative telephone interview in the cancellation rate of daytime surgery in eye hospitals

A High-resolution Study of Magnetic Field Evolution and Spicular Activity around the Boundary of a Coronal Hole

Abstract In this study, we analyze high-spatial-resolution (0.″24) magnetograms and high-spatial-resolution (0.″10) Hα off-band (± 0.8 Å) images taken by the 1.6 m Goode Solar Telescope to investigate the magnetic properties associated with small-scale ejections in a coronal hole boundary region from a statistical perspective. With one and a half hours of optical observations under excellent seeing, we focus on the magnetic structure and evolution by tracking the magnetic features with the Southwest Automatic Magnetic Identification Suite (SWAMIS). The magnetic field at the studied coronal hole boundary is dominated by negative polarity with flux cancellations at the edges of the negative unipolar cluster. In a total of 1250 SWAMIS-detected magnetic cancellation events, ∼39% are located inside the coronal hole with an average flux cancellation rate of 2.0 × 1018 Mx Mm−2 hr−1, and ∼49% are located outside the coronal hole with an average flux cancellation rate of 8.8 × 1017 Mx Mm−2 hr−1. We estimated that the magnetic energy released due to flux cancellation inside the coronal hole is six times more than that outside the coronal hole. Flux cancellation accounts for ∼9.5% of the total disappearance of magnetic flux. Other forms of its disappearance are mainly due to fragmentation of unipolar clusters or merging with elements of the same polarity. We also observed a number of significant small-scale ejections associated with magnetic cancellations at the coronal hole boundary that have corresponding EUV brightenings.

Poor ovarian response and the possible role of natural and modified natural cycles.

About 20% of women undergoing in vitro fertilization struggle with poor ovarian response, indicating a poor prognosis related to low response following ovarian stimulation. Indeed, poor ovarian response, that is associated with both high cancelation rates and low live birth rates, still represents one of the most important therapeutic challenges in in vitro fertilization. In this context, natural cycle/modified natural cycle–in vitro fertilization, as a ‘milder’ approach, could be a reasonable alternative to high-dose/conventional ovarian stimulation in poor ovarian responders, with the aim to retrieve a single oocyte with better characteristics that may result in a single top-quality embryo, transferred to a more receptive endometrium. Moreover, modified natural cycle–in vitro fertilization may be cost-effective because of the reduced gonadotropin consumption. Several studies have been published during the last 20 years reporting conflicting results regarding the use of natural cycle/modified natural cycle–in vitro fertilization in women with poor ovarian response; however, while most of the studies concluded that mild stimulation regimens, including natural cycle/modified natural cycle–in vitro fertilization, have low, but acceptable success rates in this difficult group of patients, others did not replicate these findings. The aim of this narrative review is to appraise the current evidence regarding the use of natural cycle/modified natural cycle–in vitro fertilization in poor ovarian responders.

Aspiration of excess follicles before intrauterine insemination in high response cycles.

PurposeTo assess the outcome of excess follicle aspiration before intrauterine insemination (EFABI) in intrauterine insemination (IUI) cycles with 4–6 follicles ≥14 mm.MethodsA retrospective case–control study with 1559 patients undergoing IUI (donor and husband's sperm), of whom 86 underwent EFABI. We studied also an historical series of 2213 patients before EFABI implementation. For 3.5 years, all women undergoing IUI developing 4–6 follicles ≥14 mm were offered EFABI on the day of hCG administration. Pregnancy rates (PRs), multiple PRs, and adverse effects were measured.ResultsEFABI was associated with a similar multiple PR (17.8% vs 17.5% in non‐EFABI cases), with no triplets in EFABI patients. Live birth rates were significantly higher in EFABI cycles in IUI overall (25.5% vs 15.2%). When considered separately, the performance of EFABI resulted in significantly increased live birth rates in IUI‐donor cycles (32.5% vs 18.5%), whereas the differences in IUI‐husband cycles (19.5% vs 12.9%) did not reach statistical significance. The PR was 21.2% during the EFABI implementation period and 19.4% in the pre‐EFABI period.ConclusionsEFABI in cycles in which 4–6 follicles reach ≥14 mm is a simple option that reduces cycle cancellation rates, results in higher PRs than cycles with 1–3 follicles, and lowers the risk of multiple pregnancy.

Inventory Optimization in the Perioperative Care Department Using Kotter's Change Model.

Perioperative services have been scrutinized in the context of cost containment in health care, particularly in the procurement and reprocessing of surgical instruments. Although solutions such as surgical instrument inventory optimization (IO) have been proposed, there is a paucity of literature on how to implement this change. The purpose of this project was to describe the implementation of an IO using Kotter's Change Model (KCM). This study was conducted at a tertiary academic hospital across the four highest-volume surgical services. The IO was implemented using the steps outlined by KCM: (1) create coalition, (2) create vision for change, (3) establish urgency, (4) communicate the vision, (5) empower broad-based action, (6) generate short-term wins, (7) consolidate gains, and (8) anchor change. This process was evaluated using inventory metrics, operational efficiency metrics, and clinician satisfaction. Total inventory was reduced by 37.7%, with an average tray size reduction of 18.0%. This led to a total reprocessing time savings of 1,333 hours per annum and labor cost savings of $39,995 per annum. Depreciation cost savings were $64,320 per annum. Case cancellation rate due to instrument-related errors decreased from 3.9% to 0.2%. The proportion of staff completely satisfied with the inventory was 1.7% pre-IO and 80.0% post-IO. This is the first study to describe the successful implementation of KCM to facilitate change in the perioperative setting. This success contributes to the growing body of literature supporting KCM as a valuable change management tool in health care.

Incidence and Reasons for a Surgical Cancellation at a Hospital in Rwanda

BackgroundSurgery cancellation is a challenging and costly event resulting in operating theatre inefficiency and psychological and financial problems for the patients and their families. This study aimed to find out the incidence and reasons for surgical cancellation at a Rwandan hospital.MethodsA retrospective study was conducted on 736 patients’ files obtained from theatre registry lists of surgical operations done from January to March 2017. The American Association of Perioperative Nurses (AORN) checklist for documenting cancelled surgical cases was used to establish the rate and reasons for cancellation. Data were analyzed using frequency and percentage descriptive statistics.ResultsOut of the 736 surgeries booked, 179 (24.3%) were cancelled as follows: Orthopedic and general surgeries (28.2%) respectively, gynecology and obstetrics (27.4%), urology surgeries (15.5%), maxillofacial surgeries (15.9%), ENT (15.6%) and plastic surgeries (13.3%). Time constrain/long list (19.6%), acute change in medical status (10.6%), non-turn-up of the patient (8.4%), and abnormal lab findings (7.8%) were the most prevalent reasons.ConclusionThe surgical cancellation rate at the study hospital was 24%, increasing with the number of patients booked and the type of surgical procedure. A prospective study is required to gain more insight into the reason for cancellations, mostly amenable to mitigation measures.Rwanda J Med Health Sci 2021;4(3):379-386

Telepsychology May Improve Treatment Adherence in Patients with Psychogenic Nonepileptic Seizures

Introduction: Access to mental health care is a significant challenge in patients with psychogenic nonepileptic seizures (PNES). Telepsychology can curb the access barriers and improve adherence but the role of telepsychology in improving adherence has not been well investigated. The current study examines the utility of telepsychology during the COVID-19 pandemic and treatment adherence in PNES patients. Materials and Methods: Patients with PNES admitted to a 12-week counseling program were offered two visit types: telepsychology and in-office. Visit type, visit status, and demographic information were obtained from department database. Follow-up visits in 6 months were used to examine the effect of visit type on visit status. Adherence to treatment was measured by higher attendance of scheduled visits and less cancellation and no-show rates. Results: Two hundred fifty-seven (n) patients who scheduled virtual or telepsychology visits were included in the study. After adjusting for demographic variables, and accounting for repeated measures, telepsychology visits were significantly more likely to be attended (odds ratio [OR] = 2.40, 95% confidence interval [CI] = 1.69-3.41, p < 0.001) and were significantly less likely to be canceled (OR = 0.43, 95% CI = 0.29-0.64, p < 0.001). The regression model showed patients in the telepsychology visit group attended more than three times as many visits as in-office patients (incidence rate ratios = 3.16, 95% CI = 2.13-4.73, p < 0.001). Conclusions: Patients with PNES have logistical and psychological barriers that can impede their ability to attend counseling treatment. Receiving care remotely may have been associated with higher engagement with mental health treatment compared to having to travel to counseling clinics. Considering the symptom-related restrictions patients with PNES have and the barriers presented by the COVID-19 pandemic, telepsychology played a key role for continuation of mental health treatment.

Nurse-run preanaesthesia assessment clinics: an initiative towards improving the quality of perioperative care at the ambulatory care centre

IntroductionNurse-run preanaesthesia assessment is well established in ambulatory surgery. However, in the Middle East the implementation of such a service is new and needed careful preparation. Aim of this audit...

The interaction effect between advanced paternal age and paternal obesity is associated with the low implantation rate in couples with unexplained recurrent pregnancy loss

ObjectiveTo explore the roles of advanced paternal age (APA) and abnormal paternal weight on embryo quality and pregnancy outcomes for unexplained recurrent pregnancy loss (uRPL) couples who underwent preimplantation genetic testing for aneuploidies (PGT-A). MethodsThis study included 779 uRPL couples who underwent their first PGT-A cycles between 2014 and 2018. Male patients’ aging and nutritional status were quantified by paternal age and body mass index (BMI). Routine semen parameters and sperm DNA fragmentation index (DFI) were used to reflect the seminal quality. Blastocyst formation rate and aneuploidy rate were used to reflect the embryo quality. Cycle cancellation rate, implantation rate, pregnancy loss rate, and live birth rate were measured to evaluate the treatment efficiency from IVF. To remove the interference of maternal age, only the women younger than 38 years old were included. After univariate screening, interaction tests were performed in a generalized linear model (GLM) to further examine the effects of paternal age and BMI on each outcome indicator. ResultsIn the total population (779 cycles), there were no statistical differences in aneuploidy rate, cycle cancellation rate, implantation rate, pregnancy loss rate, and live birth rate, whether stratified by paternal age or paternal BMI. Similar results occurred in the younger men (<40 y.o., 633 cycles). Conversely, among the men with advanced age (≥40 y.o., 146 cycles), there were statistical differences between the three BMI groups in four semen parameters (total sperm number, total motility, progressive motility, and total motile sperm count), implantation rate, and live birth rate. After interaction testing, the results of GLM suggested that the interaction effect between APA and paternal obesity was associated with the low implantation rate of uRPL couples. ConclusionsFor the uRPL couples seeking for PGT-A treatment, if the male patients have both advanced age and obesity, their spouses are at higher risks for embryo implantation failure.

Cancellation of outpatient appointments in patients with attention-deficit/hyperactivity disorder

BackgroundRegular visit to psychiatric clinic is essential for successful treatment of any psychiatric condition including attention-deficit/hyperactivity disorder (AD/HD). However, cancellation of outpatient appointments in patients with AD/HD, which represents a significant medical loss, has not been systematically investigated to our knowledge.MethodsA systematic chart review was conducted for patients visiting the Shimada Ryoiku medical Center for Challenged Children in Japan at the age of ≤15 years from January to December 2013. The primary outcome measure was the cancellation rate, defined as the number of missed visits divided by the number of scheduled visits. The cancellation rates during 24 months after the first visit were compared between outpatients with AD/HD and other psychiatric disorders, including pervasive developmental disorders (PDD), and developmental coordination disorders and/or communication disorders (DCD-CD). A generalized linear model with binomial distribution was used to examine factors associated with cancellation rates exclusively in the AD/HD group.ResultsWe included 589 patients (mean ± SD age, 5.6 ± 3.4 years; 432 males) in the analysis. The cancellation rate in patients with AD/HD was 12.3% (95% confidence interval [CI]: 10.0–15.1), which was significantly higher than in those with PDD (5.6%, 95% CI: 3.8–8.3) and DCD-CD (5.3%, 95% CI: 3.6–7.8). Prescriptions of osmotic-release oral system-methylphenidate (OROS-MPH) and antipsychotics were associated with fewer cancellations in AD/HD patients (odds ratios: 0.61, 95% CI: 0.39–0.95 and 0.49, 95% CI: 0.25–0.95, respectively), although these significances did not find in the subgroup analysis including only patients with ≥ 6 years old.ConclusionsPatients with AD/HD were more likely to miss appointments compared to those with other psychiatric disorders. The impact of AD/HD medications as well as potential psychiatric symptoms of their parents or caregivers on appointment cancellations needs to be evaluated in more detail in future investigations.