To determine the incidence of couples dropping out of the in vitro fertilization (IVF) waiting list and to describe the couples' reasons.
Prospective cohort study.
Fertility center in an academic ...hospital.
674 women placed consecutively on the IVF waiting list between June 2000 and July 2003.
None.
Number of dropouts and reasons for dropping out.
Follow-up information was collected in 2005 and 2008. Of the 674 couples on the waiting list, 87% started IVF, and 13% dropped out before starting their first IVF cycle. Follow-up data were obtained for 85 of 86 patients (98.8%): 37% dropped out because of spontaneous pregnancy, 36% for personal reasons (passive censoring), and 27% for medical reasons (active censoring). Most of the pregnancies occurred within 3 months after the patient had been placed on the waiting list (30 of 32, 94%). Of the 54 censored couples, four became pregnant.
On a 6-month waiting list for IVF, 13% of the couples dropped out before starting treatment. The single most important reason for dropout was (spontaneous) pregnancy. Most of these pregnancies occurred within 3 months, which suggests that psychological factors such as stress relief after being placed on the waiting list might be operative.
To assess the value of testing for ovarian reserve prior to a first cycle IVF incorporating patient and doctor valuation of mismatches between test results and treatment outcome. METHODS: A decision ...model was developed for couples who were considering participation in an IVF programme. Three strategies were evaluated: (I) withholding IVF without prior testing, (II) testing for ovarian reserve, and then deciding on IVF treatment if ovarian reserve was estimated to be sufficient, and (III) treatment with IVF without prior ovarian reserve testing. The outcome considered was the birth of a child. The valuation of the combination of the strategy conducted and the outcome accomplished was expressed on a distress scale in units of ‘IVF cycles that were performed in vain’. Correct treatment with IVF and correct withholding of IVF were considered to bring no distress. The distress of withholding IVF in case pregnancy occurred is consequently specified by the ratio of the expected distress after incorrect withholding IVF to the expected distress after incorrect performing IVF (distress ratio). We interviewed both patients and doctors to determine realistic estimates for this distress ratio. RESULTS: The value of testing for ovarian reserve depends strongly on the expected pregnancy rate after IVF as well as on the valuation of the incorrect decisions from testing. For realistic ranges of the success rate after IVF and for distress ranges as were measured, treatment of all couples without testing was found to generate less distress than testing for ovarian reserve. The sensitivity and specificity of testing for ovarian reserve has to improve to 50 and 96% respectively, to make testing a valuable strategy. CONCLUSION: Based on the decision analysis, where current test accuracy and preference inventory among patients and physicians were used, testing for ovarian reserve seems not useful for current IVF programmes.
Early plasma transfusion for women with severe postpartum hemorrhage (PPH) is recommended to prevent coagulopathy. However, there is no comparative, quantitative evidence on the association of early ...plasma transfusion with maternal outcomes.
To compare the incidence of adverse maternal outcomes among women who received plasma during the first 60 minutes of persistent PPH vs women who did not receive plasma for similarly severe persistent PPH.
This multicenter cohort study used a consecutive sample of women with persistent PPH, defined as PPH refractory to first-line measures to control bleeding, between January 1, 2011, and January 1, 2013. Time-dependent propensity score matching was used to select women who received plasma during the first 60 minutes of persistent PPH and match each of them with a woman who had shown the same severity and received the same treatment of PPH but who had not received plasma at the moment of matching. Transfusions were not guided by coagulation tests. Statistical analysis was performed from June 2018 to June 2019.
Transfusion of plasma during the first 60 minutes of persistent PPH vs no or later plasma transfusion.
Incidence of adverse maternal outcomes, defined as a composite of death, hysterectomy, or arterial embolization.
This study included 1216 women (mean SD age, 31.6 5.0 years) with persistent PPH, of whom 932 (76.6%) delivered vaginally and 780 (64.1%) had PPH caused by uterine atony. Seven women (0.6%) died because of PPH, 62 women (5.1%) had a hysterectomy, and 159 women (13.1%) had arterial embolizations. Among women who received plasma during the first 60 minutes of persistent PPH, 114 women could be matched with a comparable woman who had not received plasma at the moment of matching. The incidence of adverse maternal outcomes was similar between the women, with adverse outcomes recorded in 24 women (21.2%) who received early plasma transfusion and 23 women (19.9%) who did not receive early plasma transfusion (odds ratio, 1.09; 95% CI, 0.57-2.09). Results of sensitivity analyses were comparable to the primary results.
In this cohort study, initiation of plasma transfusion during the first 60 minutes of persistent PPH was not associated with adverse maternal outcomes compared with no or later plasma transfusion, independent of severity of PPH.
Prophylactic coronary revascularization in vascular surgery patients with extensive coronary artery disease was not associated with an improved immediate postoperative outcome. However, the potential ...long-term benefit was unknown. This study was performed to assess the long-term benefit of prophylactic coronary revascularization in these patients. Of 1,880 patients scheduled for major vascular surgery, 430 had ≥3 risk factors (age >70 years, angina pectoris, myocardial infarction, heart failure, stroke, diabetes mellitus, and renal failure). All underwent cardiac testing using dobutamine echocardiography or nuclear stress imaging. Patients with extensive stress-induced ischemia (≥5 segments or ≥3 walls) were randomly assigned to additional revascularization. In total, 101 patients showed extensive ischemia and were assigned to revascularization (n = 49) or no revascularization (n = 52). After 2.8 years, the overall survival rate was 64% for patients randomly assigned to no preoperative coronary revascularization versus 61% for patients assigned to preoperative coronary revascularization (hazard ratio HR 1.18, 95% confidence interval CI 0.63 to 2.19, p = 0.61). Rates for survival free of all-cause death, nonfatal myocardial infarction, and coronary revascularization were similar in both groups at 49% and 42% for patients allocated to medical treatment or coronary revascularization, respectively (HR 1.51, 95% CI 0.89 to 2.57, p = 0.13). Only 2 patients assigned to medical treatment required coronary revascularization during follow-up. Also, in patients who survived the first 30 days after surgery, there was no apparent benefit of revascularization on cardiac events (HR 1.35, 95% CI 0.72 to 2.52, p = 0.36). In conclusion, preoperative coronary revascularization in high-risk patients undergoing major vascular surgery was not associated with improved postoperative or long-term outcome compared with the best medical treatment.
Objectives This study evaluated timing of β-blocker initiation before surgery and its relationship with: 1) pre-operative heart rate and high-sensitivity C-reactive-protein (hs-CRP) levels; and 2) ...post-operative outcome. Background Perioperative guidelines recommend β-blocker initiation days to weeks before surgery, on the basis of expert opinions. Methods In 940 vascular surgery patients, pre-operative heart rate and hs-CRP levels were recorded, next to timing of β-blocker initiation before surgery (0 to 1, >1 to 4, >4 weeks). Pre- and post-operative troponin-T measurements and electrocardiograms were performed routinely. End points were 30-day cardiac events (composite of myocardial infarction and cardiac mortality) and long-term mortality. Multivariate regression analyses, adjusted for cardiac risk factors, evaluated the relation between duration of β-blocker treatment and outcome. Results The β-blockers were initiated 0 to 1, >1 to 4, and >4 weeks before surgery in 158 (17%), 393 (42%), and 389 (41%) patients, respectively. Median heart rate at baseline was 74 (±17) beats/min, 70 (±16) beats/min, and 66 (±15) beats/min (p < 0.001; comparing treatment initiation >1 with <1 week pre-operatively), and hs-CRP was 4.9 (±7.5) mg/l, 4.1 (±.6.0) mg/l, and 4.5 (±6.3) mg/l (p = 0.782), respectively. Treatment initiated >1 to 4 or >4 weeks before surgery was associated with a lower incidence of 30-day cardiac events (odds ratio: 0.46, 95% confidence interval CI: 0.27 to 0.76, odds ratio: 0.48, 95% CI: 0.29 to 0.79) and long-term mortality (hazard ratio: 0.52, 95% CI: 0.21 to 0.67, hazard ratio: 0.50, 95% CI: 0.25 to 0.71) compared with treatment initiated <1 week pre-operatively. Conclusions Our results indicate that β-blocker treatment initiated >1 week before surgery is associated with lower pre-operative heart rate and improved outcome, compared with treatment initiated <1 week pre-operatively. No reduction of median hs-CRP levels was observed in patients receiving β-blocker treatment >1 week compared with patients in whom treatment was initiated between 0 and 1 week before surgery.
Acute kidney injury is an independent predictor of short- and long-term survival; however, data on the relationship between reversible transitory decline of kidney function and chronic kidney disease ...(CKD) are lacking. We assessed the prognostic value of temporary renal function decline on the development of long-term CKD.
The study included 1308 patients who were undergoing major vascular surgery (aortic aneurysm repair, lower extremity revascularization, or carotid surgery), divided into three groups on the basis of changes in Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) estimated GFR (eGFR) on days 1, 2, and 3 after surgery, compared with baseline: Group 1, improved or unchanged (change in CKD-EPI eGFR+/-10%); group 2, temporary decline (decline>10% at day 1 or 2, followed by complete recovery within 10% to baseline at day 3); and group 3, persistent decline (>10% decrease). Primary end point was the development of incident CKD during a median follow-up of 5 years.
Perioperative renal function was classified as unchanged, temporary decline, and persistent decline in 739 (57%), 294 (22%), and 275 (21%) patients, respectively. During follow-up, 272 (21%) patients developed CKD. In multivariate logistic regression analyses, temporary and persistent declines in renal function both were independent predictors of long-term CKD, compared with unchanged renal function.
Vascular surgery patients have a high incidence of temporary and persistent perioperative renal function declines, both of which were independent predictors for development of long-term incident CKD.
Anemia is common in patients scheduled for vascular surgery and is a risk factor for adverse cardiac outcome. However, it is unclear whether this is an independent risk factor or an expression of ...underlying co-morbidities. In total, 1,211 patients (77% men, 68 ± 11 years of age) were enrolled. Anemia was defined as serum hemoglobin levels <13 g/dl for men and <12 g/dl for women and was divided into tertiles to compare mild (men 12.2 to 13.0, women 11.2 to 12.0), moderate (men 11.0 to 12.1, women 10.2 to 11.1), and severe (men 7.2 to 11.0, women 7.5 to 10.1) anemia with nonanemia. Outcome measurements were 30-day and 5-year major adverse cardiac events (MACEs; cardiac death or myocardial infarction). All risk factors were noted. Multivariable logistic and Cox regression analyses were used, adjusting for all cardiac risk factors, including heart failure and renal disease. Data are presented as hazard ratios with 95% confidence intervals. In total, 74 patients (6%) had 30-day MACEs and 199 (17%) had 5-year MACEs. Anemia was present in 399 patients (33%), 133 of whom had mild anemia, 133 had moderate anemia, and 133 had severe anemia. Presence of anemia was associated with renal dysfunction, diabetes, and heart failure. After adjustment for all clinical risk factors, 30-day hazard ratios for a MACE per anemia group were 1.8 for mild (0.8 to 4.1), 2.3 for moderate (1.1 to 5.4), and 4.7 for severe (2.6 to 10.9) anemia, and 5-year hazard ratios for MACE per anemia group were 2.4 for mild (1.5 to 4.2), 3.6 for moderate (2.4 to 5.6), and 6.1 for severe (4.1 to 9.1) anemia. In conclusion, the presence and severity of preoperative anemia in vascular patients are significant predictors of 30-day and 5-year cardiac events, regardless of underlying heart failure or renal disease.
Background:
Cardiac events are the predominant cause of late mortality in patients with peripheral arterial disease (PAD). In these patients,
mortality decreases with increasing body mass index ...(BMI). COPD is identified as a cardiac risk factor, which preferentially
affects underweight individuals. Whether or not COPD explains the obesity paradox in PAD patients is unknown.
Methods:
We studied 2,392 patients who underwent major vascular surgery at one teaching institution. Patients were classified according
to COPD status and BMIs ( ie , underweight, normal, overweight, and obese), and the relationship between these variables and all-cause mortality was determined
using a Cox regression analysis. The median follow-up period was 4.37 years (interquartile range, 1.98 to 8.47 years).
Results:
The overall mortality rates among underweight, normal, overweight, and obese patients were 54%, 50%, 40%, and 31%, respectively
(p < 0.001). The distribution of COPD severity classes showed an increased prevalence of moderate-to-severe COPD in underweight
patients. In the entire population, BMI (continuous) was associated with increased mortality (hazard ratio HR, 0.96; 95%
confidence interval CI, 0.94 to 0.98). In addition, patients who were classified as being underweight were at increased
risk for mortality (HR, 1.42; 95% CI, 1.00 to 2.01). However, after adjusting for COPD severity the relationship was no longer
significant (HR, 1.29; 95% CI, 0.91 to 1.93).
Conclusions:
The excess mortality among underweight patients was largely explained by the overrepresentation of individuals with moderate-to-severe
COPD. COPD may in part explain the âobesity paradoxâ in the PAD population.
body mass index
COPD
mortality
peripheral arterial disease
Background Endovascular abdominal aortic aneurysm (AAA) repair (EVAR) is associated with a decreased incidence of perioperative cardiac complications compared with open repair. However, EVAR is not ...associated with long-term survival benefit. This study assessed the effect of perioperative asymptomatic cardiac damage after EVAR on long-term prognosis. Methods In 220 patients undergoing elective EVAR, routine sampling for levels of cardiac troponin T and electrocardiography (ECG) were performed on days 1, 3, and 7 during the patient's hospital stay. Elevated cardiac troponin T was defined as serum concentrations ≥0.01 ng/mL. Asymptomatic cardiac damage was defined as cardiac troponin T release without symptoms or ECG changes. The median follow-up was 2.9 years. Survival status was obtained by contacting the Office of Civil Registry. Results Release of cardiac troponin T (median, 0.08 ng/mL) occurred in 24 of 220 patients, of whom 20 (83%) were asymptomatic and without ECG changes. Patients with asymptomatic cardiac damage had a mortality rate of 85% after 2.9 years vs 51% for patients without perioperative cardiac damage ( P < .001). Also after adjustment for clinical risk factors and medication use applying multivariate Cox regression analysis, asymptomatic cardiac damage was associated with a 2.3-fold increased risk for death (95% confidence interval, 1.1-5.1). Statin use was associated with a reduced long-term risk for death (hazard ratio, 0.5; 95% confidence interval, 0.3-0.9). Conclusion Asymptomatic cardiac damage in patients undergoing EVAR is associated with poor long-term outcome. Routine perioperative cardiac screening after EVAR might be warranted.
Background The pathophysiology of new-onset cardiac arrhythmias is complex and may bring about severe cardiovascular complications. The relevance of perioperative arrhythmias during vascular surgery ...has not been investigated. The aim of this study was to assess risk factors and prognosis of new-onset arrhythmias during vascular surgery. Methods A total of 513 vascular surgery patients, without a history of arrhythmias, were included. Cardiac risk factors, inflammatory status, and left ventricular function (LVF; N-terminal pro–B-type natriuretic peptide and echocardiography) were assessed. Continuous electrocardiography (ECG) recordings for 72 hours were used to identify ischemia and new-onset arrhythmias: atrial fibrillation, sustained ventricular tachycardia, supraventricular tachycardia, and ventricular fibrillation. Logistic regression analysis was applied to identify preoperative risk factors for arrhythmias. Cox regression analysis assessed the impact of arrhythmias on cardiovascular event-free survival during 1.7 years. Results New-onset arrhythmias occurred in 55 (11%) of 513 patients: atrial fibrillation, ventricular tachycardia, supraventricular tachycardia, and ventricular fibrillation occurred in 4%, 7%, 1%, and 0.2%, respectively. Continuous ECG showed myocardial ischemia and arrhythmias in 17 (3%) of 513 patients. Arrhythmia was preceded by ischemia in 10 of 55 cases. Increased age and reduced LVF were risk factors for the development of arrhythmias. Multivariate analysis showed that perioperative arrhythmias were associated with long-term cardiovascular events, irrespective of the presence of perioperative ischemia (hazard ratio 2.2, 95% CI 1.3-3.8, P = .004). Conclusion New-onset perioperative arrhythmias are common after vascular surgery. The elderly and patients with reduced LVF show arrhythmias. Perioperative continuous ECG monitoring helps to identify this high-risk group at increased risk of cardiovascular events and death.
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