Non-university Teaching Hospital Research Articles

Long-term oncological outcomes after radical prostatectomy in a non-university teaching hospital

The evaluation of oncological outcomes after radical prostatectomy (RP) is a major component of quality control in prostate cancer (PCa) centres. To evaluate the oncological outcomes after RP in a non-university teaching hospital and compare them with other high-volume PCa centres. This study included 1,161 patients after RP who were divided into two risk groups. Low-risk: localised PCa (pT2) and prostate-specific antigen (PSA)≤ 20 ng/ml, Gleason score (GS) 6-7b and pN0. High-risk: locally advanced PCa (≥pT3a) and/or PSA >20 ng/ml and/or GS≥ 8 and/or pN1. Risk groups and clinicopathological features were correlated to biochemical recurrence (BCR)-free survival, cancer-specific survival (CSS) und overall survival (OS). The 10-year BCR-free survival, CSS und OS were 68.4%, 47.0% and 100% in the low-risk group and 87.4%, 89.0% and 73.9% in the high-risk group, respectively; the outcomes between risk groups were statistically significant (p<0.05). A multivariate Cox regression analysis was performed. GS was the most significant prognostic factor for CSS (p=0.00001) und BCR-free survival (p=0.00036). Nodal involvement (pN1) was strongly associated with CSS (p=0.00004). Age was the most important factor for overall survival in the high-risk group (p=0.0011). RP could be a curative treatment option for advanced PCa in selected cases. GS is the most important prognostic factor. Good oncological outcomes can also be achieved in non-university teaching hospitals.

Clinical teaching self-efficacy positively predicts professional fulfillment and negatively predicts burnout amongst Thai physicians: a cross-sectional survey

BackgroundClinician teachers (physicians who teach in clinical settings) experience considerable psychological challenges in providing both educational training and patient care. This study aimed to determine the prevalence of physician burnout and professional fulfillment, and to identify internal and external factors associated with mental health outcomes among Thai clinician teachers working in non-university teaching hospitals.MethodA one-time online questionnaire was completed by physicians at 37 governmental, non-university teaching hospitals in Thailand, with 227 respondents being assessed in the main analyses. Four outcomes were evaluated including burnout, professional fulfillment, quality of life, and intentions to quit.ResultsThe observed prevalence of professional fulfillment was 20%, and burnout was 30.7%. Hierarchical regression analysis showed a significant internal, psychological predictor (clinical teaching self-efficacy) and external, structural predictors (multiple roles at work, teaching support), controlling for the background variables of gender, years of teaching experience, family roles, and active chronic disease, with clinical teaching self-efficacy positively predicting professional fulfillment (b = 0.29, p ≤.001) and negatively predicting burnout (b = − 0.21, p =.003).ConclusionsResults highlight the importance of faculty development initiatives to enhance clinical teaching self-efficacy and promote mental health among Thai physicians.

Laparoscopic sacrocolpopexy versus vaginal sacrospinous fixation for vaginal vault prolapse: a randomised controlled trial and prospective cohort (SALTO-2 trial).

To determine whether laparoscopic sacrocolpopexy (LSC) or vaginal sacrospinous fixation (VSF) is the most optimal surgical treatment in patients with POP-Q stage ≥2 vaginal vault prolapse (VVP). Multicentre randomised controlled trial (RCT) and prospective cohort study alongside. Seven non-university teaching hospitals and two university hospitals in the Netherlands. Patients with symptomatic post-hysterectomy vaginal vault prolapse, requiring surgical treatment. Randomisation in a 1:1 ratio to LSC or VSF. Evaluation of prolapse was done using the pelvic organ prolapse quantification (POP-Q). All participants were asked to fill in various Dutch validated questionnaires 12 months postoperatively. Primary outcome was disease-specific quality of life. Secondary outcomes included composite outcome of success and anatomical failure. Furthermore, we examined peri-operative data, complications and sexual function. A total of 179 women, 64 women randomised and 115 women, participated in a prospective cohort. Disease-specific quality of life did not differ after 12 months between the LSC and VSF group in the RCT and the cohort (RCT: P = 0.887; cohort: P = 0.704). The composite outcomes of success for the apical compartment, in the RCT and cohort, were 89.3% and 90.3% in the LSC group and 86.2% and 87.8% in the VSF group, respectively (RCT: P = 0.810; cohort: P = 0.905). There were no differences in number of reinterventions and complications between both groups (reinterventions RCT: P = 0.934; cohort: P = 0.120; complications RCT: P = 0.395; cohort: P = 0.129). LSC and VSF are both effective treatments for vaginal vault prolapse, after a follow-up period of 12 months.

Virtual Reality Experience during Labour (VIREL); a qualitative study

BackgroundThere is increasing evidence that virtual reality (VR) is effective in the reduction of labour pain. The implementation of alternative methods like VR to reduce labour pain can contribute to reduce patient request for pharmacological pain management methods and associated side effects. The aim of this study is to examine women’s experiences, preferences and satisfaction in regard to the use of VR during labour.MethodsA qualitative interview study was conducted in a non-university teaching hospital in The Netherlands. Two VR applications, respectively a guided meditation and an interactive game were tested in eligible women with a singleton pregnancy, scheduled for induction of labour. For the primary outcome, patients’ VR experience and application preference (meditation vs. game) were examined using a post-intervention questionnaire and a semi-structured interview. Three categories (with sub-categories) were used to guide interviews: “The VR experience”, “Pain reduction”, and “Usability of the VR application”. Labour pain before and directly after VR was evaluated using the NRS score.ResultsTwenty-four women, of whom 14 were nulliparous and ten multiparous, were included and 12 of these women participated in semi-structured interviews. Using within-subject paired t-test comparisons, compared to pain pre-VR, patients reported a highly significant 26% decrease in mean NRS scores during VR meditation (pain pre-VR = 6.71 + − 1.65 vs. pain after VR = 4.96 + − 2.01) [p < 0.001]. Compared to pain before VR game, patients also reported a highly significant 19% decrease in mean NRS scores during VR game (pain before VR game = 6.89 + − 1.88 vs. pain after VR game = 5.61 + − 2.23) [p = 0.001].ConclusionAll women were highly satisfied with VR use during labour. Patients reported a highly significant reduction in pain during the interactive VR game and during meditation, patients preferred guided meditation. These results can contribute to the development of a potential promising new non-pharmacological tool to reduce labour pain.Trial registrationClinicalTrials.gov Identifier: NCT04858984, date of registration: 26/04/2021 (retrospectively registered).

Invasive Procedures Associated With Lung Cancer Screening in Clinical Practice

The harm associated with imaging abnormalities related to lung cancer screening (LCS) is not well documented, especially outside the clinical trial and academic setting. What is the frequency of invasive procedures and complications associated with a community based LCS program, including procedures for false-positive and benign, but clinically important, incidental findings? We performed a single-center retrospective study of an LCS program at a nonuniversity teaching hospital from 2016 through 2019 to identify invasive procedures prompted by LCS results, including their indication and complications. Among 2,003 LCS participants, 58 patients (2.9%) received a diagnosis of lung cancer and 71 patients (3.5%) received a diagnosis of any malignancy. Invasive procedures were performed 160 times in 103 participants (5.1%), including 1.7%of those without malignancy. Eight invasive procedures (0.4%of participants), including four surgeries (12%of diagnostic lung resections), were performed for false-positive lung nodules. Only 1%of Lung Imaging Reporting and Data System category 4A nodules that proved benign were subject to an invasive procedure. Among those without malignancy, an invasive procedure was performed in eight participants for extrapulmonary false-positive findings (0.4%) and in 19 participants (0.9%) to evaluate incidental findings considered benign but clinically important. Procedures for the latter indication resulted in treatment, change in management, or diagnosis in 79%of individuals. Invasive procedures in those without malignancy resulted in three complications (0.15%). Seventy nonsurgical procedures (6%complication rate) and 48 thoracic surgeries (4%major complication rate) were performed in those with malignancy. The use of invasive procedures to resolve false-positive findings was uncommon in the clinical practice of a nonuniversity LCS program that adhered to a nodule management algorithm and used a multidisciplinary approach. Incidental findings considered benign but clinically important resulted in invasive procedure rates that were similar to those for false-positive findings and frequently had clinical value.

1535. Harm Reduction: A Missing Piece in Holistic ID Care for Patients Who Inject Drugs

Abstract Background The rise in injection drug use (IDU) has led to an increase in drug-related infections and hospitalizations. Harm reduction is an important strategy for preventing infections among people who inject drugs (PWID). We set out to evaluate how infectious disease physicians counsel PWID with serious injection-related infections on harm reduction practices. Methods An electronic survey was distributed to 1,510 physician members of the Emerging Infectious Network (EIN) to determine which harm reduction principles ID physicians recommend to PWID to reduce infection risks. EIN members who do not care for PWID were excluded. Two weekly reminders were sent to increase the response rate. Results Three hundred ninety-nine (26%, still in progress) ID physicians responded to the survey. Practice settings included: university (37%), community (27%), non-university teaching (23%), or other (14%) hospital settings. Of those, 279 (70%) reported routinely caring for PWID. 274 (98%) performed screening for HIV and hepatitis, and 239 (86%) discussed the risk of these viral infections. 65% prescribed immunization against hepatitis and 44% discussed HIV PrEP. 57% (n=159) reported not counseling patients on safer injection strategies. Common reasons for not counseling included limited time and a desire to emphasize antibiotic therapy/medical issues (33%, n=91), lack of training (30%, n=85), and believing that it would be better addressed by other services (27%, n=75). Among physicians who reported counseling PWID, they recommended abstinence from IDU (38%, n=105), handwashing &amp; skin cleansing prior to injection (33%, n=92), avoiding injecting areas of skin breakdown (27%, n=76), and cleaning needles between use (26%, n= 73). Finally, 17% (N=47) reported no access to any addiction services. Conclusion Almost all ID physicians screen PWID for HIV and viral hepatitis and discuss the risks of these infections. Despite frequently encountering PWID, less than half of ID physicians provide safer injection advice. Opportunities exist to standardize education of PWID on harm reduction, emphasizing safer injection practices in conjunction with other strategies (e.g. HIV PrEP, HAV/HBV vaccination) to prevent infections. Disclosures All Authors: No reported disclosures.

Protamine titration to optimize heparin antagonization after cardiopulmonary bypass.

To optimize protamine titration for heparin antagonization after weaning from cardiopulmonary bypass (CPB). A prospective, observational trial. Single-center, non-university teaching hospital. Forty patients presenting for elective on-pump coronary artery bypass grafting with or without single valve surgery. At the end of CPB, the residual amount of heparin in the patient was estimated using a Bull-curve. The total protamine dose was calculated as 1unit of protamine for 1unit of heparin. Protamine was administered as 5 aliquots containing 20% of the total protamine dose each, with 2-min intervals. Activated Clotting Time (ACT) values were measured 2min after administration of each aliquot. ROTEM(®)-analysis was performed after the full dose of protamine had been administered. After 60% of the total protamine dose had been administered, ACT values were normalized in 86.5% of patients. After the complete dose of protamine had been administered, 61.1% of patients displayed signs of protamine overdose on ROTEM(®)-analysis. In patients who present for on-pump coronary artery bypass grafting with or without single valve surgery, a 0.6-to-1 ratio of protamine-to-heparin to antagonize heparin may be sufficient and beneficial for patients.

Institution Origin and Medical School Rank Impact the Citation Frequency and Publication Rate in Orthopaedic Sports Medicine Journals

PurposeTo examine the trends between various categories of institutions with their respective published orthopaedic sports medicine content and to determine the publication output and citation rate from the 25 highest-ranked medical schools compared with lower-ranked institutions.MethodsPublications between 2015 and 2019 from the American Journal of Sports Medicine, Journal of Bone and Joint Surgery, Journal of Shoulder and Elbow Surgery, Clinical Orthopaedics and Related Research, and Arthroscopy were categorized into university/university affiliated hospitals, non-university affiliated teaching hospitals, public/semi-government research institutes, nonprofit research institutes, private sector institutions, government institutions, and other institutions. Citation rates were collected from PubMed for the first and corresponding author. Similarly, corresponding authors were stratified by U.S. News and World Report 2021 medical school research rankings.ResultsOf the 12,152 publications identified, 5,044 publications met the inclusion criteria. Nonprofit research institutions garnered the greatest number of citations on average (6.44 based on first author, SD 8.83, n = 214; 6.62 based on corresponding author, SD 9.65, n = 208; P < .001), while university/university-affiliated hospitals produced the majority of published articles (77.0% based on first author, 76.8% based on corresponding author), but had lower average citation rates (4.48 based on first author, SD 6.67, n = 3,886; 4.44 based on corresponding author, SD 6.55, n = 3,873; P < .001). Furthermore, of 1953 medical school publications, the top 25 accounted for 53.1% of publications; however, there was no statistical difference between their citation rates and those of lower rankings (P = 0.47).ConclusionsPublications are cited at different rates, depending on their institution of origin. In addition, high-ranking medical schools produce a disproportionately greater output of publications than lower-ranking schools, but there is no statistically significant difference in citation rates on an individual publication basis.Clinical RelevanceKnowing how an institution’s ranking influences publication and citation rates can help us understand bias in the scientific literature.

Validity and utility of the questionnaire-based FRAIL scale in elderly patients with heart failure: findings from the FRAGILE-HF

IntroductionThe coexistence of heart failure (HF) and frailty leads to a worse prognosis. Frailty is generally diagnosed using the Fried criteria. To assess whether patients are frail according to the Fried scale, face-to-face physical examinations are required. However, with the COVID-19 pandemic, to avoid the spread of the virus in hospitals, it is important to screen hospitalized patients for frailty without contact. Therefore, non-contact measurement methods, such as questionnaires, should be used to screen for frailty in clinical practice. The FRAIL scale is a questionnaire used to screen for frailty. There are no studies regarding the consistency of the FRAIL scale with the Fried criteria, the impact on mortality, and physical dysfunction in elderly patients with HF.PurposeWe investigated whether the FRAIL scale questionnaire is consistent with the Fried criteria, predicts all-cause mortality, and reflects physical dysfunction in patients with HF.MethodsThe present study was secondary analysis of FRAGILE-HF, a cohort study that enrolled participants from 2016 to 2018 and followed up for 1-year of discharge. A prospective multicenter cohort study in which 15 hospitals in Japan (8 university hospitals and 7 non-university teaching hospitals) participated. We prospectively enrolled 1332 consecutive hospitalized patients with HF ≥65 years old and analyzed 1028 patients after excluding 304 patients with missing data on the FRAIL scale. The FRAIL scale, the Fried model, and physical function were measured before discharge. The endpoint was all-cause mortality.ResultsAccording to the FRAIL scale, 459 (44.6%) and 491 (47.8%) were classified as frail and pre-frail, respectively. The Kappa coefficient between the FRAIL scale and the Fried criteria were 0.39 (95% confidence interval [CI]: 0.34–0.44; P value: <0.001). The area under the receiver-operating characteristic curves for frailty diagnosed by the Fried criteria of the FRAIL scale was 0.74 (95% CI: 0.71–0.76; P value: <0.001). A total of 118 deaths occurred during 1 year of follow-up. After adjusting for the MAGGIC score and log-BNP, The FRAIL scale predicted all-cause mortality (hazard ratio: 1.17; 95% CI: 1.01–1.36; P value = 0.035). The FRAIL scale was also associated with various physical dysfunction that correlated with poor prognosis.ConclusionsThe FRAIL scale had moderate consistency with the Fried criteria, predicted all-cause mortality, and reflected clinically important physical dysfunction.FUNDunding AcknowledgementType of funding sources: Public grant(s) – National budget only. Main funding source(s): the Japan Society for the Promotion of Science Grant-in-Aid (JSPS KAKENHI, Grant Number 19K19884)

Clinical Practice Audit on the Management of Antineutrophil Cytoplasmic Antibody–Associated Vasculitis in the Netherlands

IntroductionManaging complex and rare systemic autoimmune diseases such as antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) can be challenging and is often accompanied by undesirable variations in clinical practice. Adequate understanding of clinical practice can help identify essential issues to improve the care for AAV patients. Therefore, we studied the real-life management and outcomes of AAV patients in the Netherlands.MethodsIn this cohort study, we investigated clinical practice in university and nonuniversity teaching hospitals with respect to patients with a clinical diagnosis of AAV. We retrospectively collected clinical data encompassing clinical variables, medication details, and outcome parameters.ResultsData of 230 AAV patients were collected in 9 Dutch hospitals. Of these, 167 patients (73%) were diagnosed with granulomatosis with polyangiitis, 54 (24%) with microscopic polyangiitis and 9 (4%) with eosinophilic granulomatosis with polyangiitis. One hundred sixty-six patients (72%) had generalized disease. The median year of diagnosis was 2013 (range 1987–2018). Besides steroids, oral cyclophosphamide was the most used drug (50%) for induction therapy and azathioprine (68%) for maintenance therapy. Adverse outcomes were major infections in 35%, major relapses in 23%, malignancy in 10%, major cardiovascular events in 8%, and end-stage renal disease in 7%.ConclusionOral cyclophosphamide was the most frequently used induction therapy, azathioprine for maintenance therapy; over time, the use of rituximab is increasingly employed. Major infection and relapses are the most prevalent adverse outcomes. This audit resulted in important indicators for treatment of AAV patients that can be implemented for future, national audits to improve the outcomes of AAV patients.

The role of postdoctoral qualification candidates in surgical teaching

ZielDie kompakte Übersicht skizziert die Verantwortung und das breite Aufgabenfeld der/s HabilitandIn in der chirurgischen Lehre im Rahmen des Humanmedizinstudiums.MethodeNarrative Kurzübersicht auf der Basis gewonnener individueller und einrichtungsspezifischer Lehrerfahrungen.Ergebnisse (Eckpunkte)Rolle der/des HabilitandIn in (Auswahl): (i) Abgrenzung zum nichthabilitierten ärztlichen Kollegen: Die im Rahmen des Habilitationsvorhabens gesammelten administrativen und wissenschaftlichen als auch Lehrerfahrungen lassen den/die HabilitandIn als geeigneteren, motivierteren und kompetenteren Promotionsverantwortlichen und -betreuer im Gegensatz zu Kollegen, die sich nicht habilitiert haben oder habilitieren möchten, erscheinen. (ii) Abhängigkeit medizinischer Disziplinen: Die Rolle, die in der Lehre eingenommen werden kann, ist durchaus stark fachabhängig. So bestehen die Möglichkeit und die Pflicht, in chirurgischen Fächern neben theoretischem Wissen stets auch kompetente praktische Fertigkeiten zu vermitteln. (iii) Universitäten und nichtuniversitäre Krankenhäuser: In nichtuniversitären (Lehr‑)Krankenhäusern können die/der chirurgische HabilitandIn die Aufgaben der chirurgischen Lehre durch eine komplette PJ- und Famulaturbetreuung erfüllen. An universitären Kliniken steht das Abhalten von Lehrveranstaltungen eher im Vordergrund.SchlussfolgerungDie/der HabilitandIn spielt in der chirurgischen Lehre eine zentrale Rolle. Ein breites Aufgabenspektrum mit Abhaltung und Gestaltung von Vorlesungen, Seminaren, Blockpraktika bis hin zu direkter studentischer Betreuung im Rahmen der Famulatur, des Praktischen Jahrs und der Promotion kann von der Habilitandin/vom Habilitand suffizient erfüllt werden neben der ideenreichen Gestaltung fakultativer Lehrkonzepte.

Validity and Utility of the Questionnaire-based FRAIL Scale in Older Patients with Heart Failure: Findings from the FRAGILE-HF

ObjectivesWe investigated whether the FRAIL scale questionnaire is consistent with the Fried criteria, predicts all-cause mortality, and reflects physical dysfunction in patients with heart failure (HF). DesignSecondary analysis of FRAGILE-HF, a cohort study that enrolled participants from 2016 to 2018 and followed-up for 1-year of discharge. Setting and ParticipantsA prospective multicenter cohort study in which 15 hospitals in Japan (8 university hospitals and 7 nonuniversity teaching hospitals) participated. We prospectively enrolled 1332 consecutive hospitalized patients ≥65 years old with HF and analyzed 1028 patients after excluding 304 patients with missing data on the FRAIL scale. MethodsThe FRAIL scale, the Fried model, and physical function were measured before discharge. The endpoint was all-cause mortality. ResultsAccording to the FRAIL scale, 459 (44.6%) and 491 (47.8%) were classified as frail and prefrail, respectively. The Kappa coefficient between the FRAIL scale and the Fried criteria were 0.39 [95% confidence interval (CI) 0.34–0.44; P < .001]. The area under the receiver-operating characteristic curves for frailty diagnosed by the Fried criteria of the FRAIL scale was 0.74 (95% CI 0.71–0.76; P < .001). A total of 118 deaths occurred during 1 year of follow-up. After adjusting for the MAGGIC risk score and log-BNP, The FRAIL scale predicted all-cause mortality (hazard ratio 1.17; 95% CI 1.01–1.36; P = .035). The FRAIL scale was also associated with various physical dysfunctions that correlated with poor prognosis. Conclusions and ImplicationsThe FRAIL scale had moderate consistency with the Fried criteria, predicted all-cause mortality, and reflected clinically important physical dysfunctions.

‘Care for Outcomes’: systematic development of a set of outcome indicators to improve patient-relevant outcomes for patients with lung cancer

ObjectivesMeasuring quality of care is important, however many of the quality indicators used do not focus on outcome of treatment and aspects which are valuable for patients and physicians. The...

Benign Gynaecological procedures by vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES): Complication data from a series of 1000 patients

To evaluate the safety and feasibility of vaginal natural orifice transluminal endoscopic surgery (vNOTES) for benign gynaecological indications. Prospective observational study (Canadian Task Force classification II-3) in a non-university teaching hospital. One thousand consecutive patients (2013-2018) who were eligible for vNOTES approach to benign gynaecological surgery were included. Patient data and perioperative outcomes were included for analysis after the vNOTES surgical approach was standardized and made the default route of surgery. Of the 1000 vNOTES cases performed during this study period, hysterectomy (73%) was the most common followed by adnexal surgery (18%) and salpingectomy (4%). The mean age of the patient cohort was 46 yrs of age (22-83) and mean BMI, 26 kg/m2(16.5-52). There was a conversion rate of 0.4% (4 cases), 3 to conventional laparoscopy and 1 to laparotomy. The mean operating time was 42 minutes (14-250 minutes). The total complication rate was 3.9% (39) of which 1% (10) was intraoperative complications and 2.9% (29) were post-operative complications. When the hysterectomy cohort was sub analyzed, the total complication rate was 5.2% in this group (intraoperative 1.4% and post-operative 3.8%) with only a 0.4% complication rate in the non-hysterectomy sub-group. Of the complications in the hysterectomy group there were 9 cystotomies (1.2%). The mean specimen weight for all hysterectomies was 172 g (20-3361 g) with an average operating time of 46 minutes (20-250). The perioperative outcomes of this large vNOTES case series for benign gynaecological indications is comparable to other vNOTES procedures reported in the literature apart from the risk of cystotomy which is a hysterectomy specific risk. The outcomes are that of a single high-volume surgeon incorporating cases within his respective learning curve of the surgical technique and as such should be interpreted accordingly. Since 2015 the International NOTES Society has initiated a prospective complication database where all vNOTES surgeons are invited to register their cases.

Hysteropexy in the treatment of uterine prolapse stage 2 or higher: laparoscopic sacrohysteropexy versus sacrospinous hysteropexy-a multicentre randomised controlled trial (LAVA trial).

To investigate whether laparoscopic sacrohysteropexy (LSH) is non-inferior to vaginal sacrospinous hysteropexy (SSHP) in the surgical treatment of uterine prolapse. Multicentre randomised controlled, non-blinded non-inferiority trial. Five non-university teaching hospitals in the Netherlands, one university hospital in Belgium. 126 women with uterine prolapse stage 2 or higher undergoing surgery without previous pelvic floor surgery. Randomisation in a 1:1 ratio to LSH or SSHP, stratified per centre and severity of the uterine prolapse. The predefined inferiority margin was an increase in surgical failure rate of 10%. Primary outcome was surgical failure, defined as recurrence of uterine prolapse (POP-Q≥2) with bothersome bulging/protrusion symptoms and/or repeat surgery or pessary at 12months postoperatively. Secondary outcomes were anatomical recurrence (any compartment), functional outcome and quality of life. Laparoscopic sacrohysteropexy was non-inferior for surgical failure (n=1, 1.6%) compared with SSHP (n=2, 3.3%, difference -1.7%, 95% CI: -7.1 to 3.7) 12months postoperatively. Overall, anatomical recurrences and quality of life did not differ. More bothersome symptoms of overactive bladder (OAB) and faecal incontinence were reported after LSH. Dyspareunia was more frequently reported after SSHP. Laparoscopic sacrohysteropexy was non-inferior to SSHP for surgical failure of the apical compartment at 12months' follow up. Following LSH, bothersome OAB and faecal incontinence were more frequent, but dyspareunia was less frequent. Laparoscopic sacrohysteropexy and vaginal sacrospinous hysteropexy have equally good short-term outcomes.

Comparing the Mutual Interchangeability of ECOM, FloTrac/Vigileo, 3D-TEE, and ITD-PAC Cardiac Output Measuring Systems in Coronary Artery Bypass Grafting

The aim of this study was to compare the mutual interchangeability of 4 cardiac output measuring devices by comparing their accuracy, precision, and trending ability. A single-center prospective observational study. Nonuniversity teaching hospital, single center. Forty-four consecutive patients scheduled for elective, nonemergent coronary artery bypass grafting (CABG). The cardiac output was measured for each participant using 4 methods: intermittent thermodilution via pulmonary artery catheter (ITD-PAC), Endotracheal Cardiac Output Monitor (ECOM), FloTrac/Vigileo System (FLOTRAC), and 3-dimensional transesophageal echocardiography (3D-TEE). Measurements were performed simultaneously at 5 time points: presternotomy, poststernotomy, before cardiopulmonary bypass, after cardiopulmonary bypass, and after sternal closure. A series of statistical and comparison analyses including ANOVA, Pearson correlation, Bland-Altman plots, quadrant plots, and polar plots were performed, and inherent precision for each method and percent errors for mutual interchangeability were calculated. For the 6 two-by-two comparisons of the methods, the Pearson correlation coefficients (r), the percentage errors (% error), and concordance ratios (CR) were as follows: ECOM_versus_ITD-PAC (r = 0.611, % error = 53%, CR = 75%); FLOTRAC_versus_ITD-PAC (r = 0.676, % error = 49%, CR = 77%); 3D-TEE versus ITD-PAC (r = 0.538, % error = 64%, CR = 67%); FLOTRAC_versus_ECOM (r = 0.627, % error = 51%, CR = 75%); 3D-TEE_versus ECOM (r = 0.423, % error = 70%, CR = 60%), and 3D-TEE_versus_FLOTRAC (r = 0.602, % error = 59%, CR = 61%). Based on the recommended statistical measures of interchangeability, ECOM, FLOTRAC, and 3D-TEE are not interchangeable with each other or to the reference standard invasive ITD-PAC method in patients undergoing nonemergent cardiac bypass surgery. Despite the negative result in this study and the majority of previous studies, these less-invasive methods of CO have continued to be used in the hemodynamic management of patients. Each device has its own distinct technical features and inherent limitations; it is clear that no single device can be used universally for all patients. Therefore, different methods or devices should be chosen based on individual patient conditions, including the degree of invasiveness, measurement performance, and the ability to provide real-time, continuous CO readings.

Quality of clinical direct oral anticoagulant prescribing and identification of risk factors for inappropriate prescriptions.

Even though the use of direct oral anticoagulants (DOACs) is safe based on clinical outcomes, drug safety also depends on appropriateness of drug prescription, which is challenging for DOACs since many patient factors need to be considered. The aim of this study was to assess the appropriateness of DOAC prescriptions and to identify risk factors of determinants for inappropriate DOAC prescriptions. A retrospective study in a nonuniversity teaching hospital was performed of hospitalized patients (≥18 years) who received an initial DOAC prescription between February and August 2018. Appropriateness of prescribing was evaluated on 8 criteria by using a modified version of the medication appropriateness index. A total of 770 initial DOAC prescriptions of inpatients were evaluated: 267 patients (34.6%) had at least met 1 inappropriate criterion for a DOAC prescription. The most frequent inappropriate criterion was dosage (17.4%). Of the 4 DOACs, dabigatran (21.6%) and apixaban (21.2%) were mostly inappropriate dosed. In a multivariable analysis, reduced renal function (estimated glomerular filtration rate <50 mL/min; odds ratio [OR] = 2.35; P < .001), a diagnosis of atrial fibrillation (OR = 1.87; P = .004), and 'prescribed by surgeons' (OR = 1.9; P = .013) were independently associated with inappropriateness of prescribing. This study has highlighted a high degree of inappropriate prescribing of DOACs. These results underline the need for targeted interventions to improve DOAC prescribing.

2813 Clinical Prediction of Unsuccessful Endometrial Ablation: Random Forest vs Logistic Regression

Study Objective To compare the performance of the prediction models of surgical re-intervention within 2 years after endometrial ablation (EA) by a multivariate random forest model vs the previously presented multivariate logistic regression model. Design Retrospective cohort study, minimal follow-up time of 2 years. Setting Data from Catharina Hospital, Eindhoven and Elkerliek Hospital, Helmond, both non-university teaching hospitals in the Netherlands, were used. Patients or Participants Pre-menopausal women (18+) who have had an EA for heavy menstrual bleeding between January 2004 & April 2013. A total number of 446 patients were eligible for analysis. Interventions Used ablation methods were Cavatherm (Veldana Medical SA, Morges, Switzerland), Gynecare Thermachoice (Ethicon, Sommerville, US.) and Thermablate EAS (Idoman, Ireland). Used interventions and other ablation techniques had the same outcomes according to previously published literature. Measurements and Main Results Data-analysis was done by using IBM SPSS statistics software version 21.0 (IBM Corp., Armonk, NY, USA). The random forest model was trained in MATLAB (2018b) using the TreeBagger function in the Statistics and Machine Learning Toolbox. The prediction model based on a multivariate logistic regression analysis had an AUC of 0.71. The machine learning model had an AUC of 0.63 and an AUC of 0.65 after hyperparameter optimization. Conclusion Based on the preliminary results, we can conclude that the random forest model in this case is not better than the logistic regression model to predict the outcome of surgical re-intervention within two years after EA. In summary, the performance of a random forest clinical prediction model is not necessarily superior to a logistic regression model. The performance of each model is influenced by the sample size, the number of predictors, hyperparameter tuning and the linearity of associations.

Models to Predict Unsuccessful Endometrial Ablation: External Validation

Study Objective External validation of previously presented prediction models to help counsel patients for failure of endometrial ablation (EA) or surgical re-intervention within 2 years after EA. Design Retrospective cohort study, minimal follow-up time of 2 years. Setting Data from Medisch Spectrum Twente, Enschede and Ziekenhuisgroep Twente, Almelo/Hengelo, both non-university teaching hospitals in the Netherlands, were used for external validation. Patients or Participants Premenopausal women (18+) who had an EA for complaints of heavy menstrual bleeding between January 2010 & November 2012. A total number of 329 patients were eligible for analysis. Interventions Novasure (Hologic, Marlborough, MA) and ThermaChoice III (Ethicon, Sommerville, NJ). Both interventions had the same outcomes according to the literature. Measurements and Main Results Data-analysis was done by using IBM SPSS statistics software version 21.0 (IBM Corp., Armonk, NY). Final results showed an area under the curve (AUC) of 0.59 for the outcome of failure within 2 years. Variables in this model were dysmenorrhea, low age, parity ≥5 and preoperative menorrhagia. The AUC for the outcome of surgical re-intervention within 2 years was 0.45. Variables in this model were dysmenorrhea, low age, menstrual duration> 7 days, parity ≥5 and a previous caesarean section. In both models the Hosmer-Lemeshow showed no significant difference between the observed and predicted outcome. Conclusion The failure-model can be used to predict the outcome of EA within two years. This model can contribute to improve shared decision-making regarding EA in the general population. The re-intervention model appeared to be not useful after external validation, but can still be used in our hospital, because of previous internal validation. We're working on a big data model that is able to support this most personalized form of patient counseling, so that both prediction models can be used in the general population. Furthermore, we're investigating the influence of prediction-outcomes on the decision-making of both the patient and doctor.

Sacrospinous hysteropexy versus vaginal hysterectomy with uterosacral ligament suspension in women with uterine prolapse stage 2 or higher: observational follow-up of a multicentre randomised trial

ObjectiveTo evaluate the effectiveness and success of uterus preserving sacrospinous hysteropexy as an alternative to vaginal hysterectomy with uterosacral ligament suspension in the surgical treatment of uterine prolapse five years...