High-risk Elderly Patients Research Articles

Curative management of malignant left-sided colorectal obstruction

Left-sided malignant colonic obstruction remains a challenging surgical problem despite recent advances. We aim to provide a concise overview of the relevant surgical options for this condition in the curative setting. A literature search of MedLine, PubMed, and Embase was performed to elucidate the latest evidence in the management of malignant left-sided colorectal obstruction, focusing on the risks and benefits of each approach and the appropriate patient selection. Primary resection and anastomosis are the intervention of choice for low-risk patients in the curative setting. Delayed resection with a bridge to surgery should be considered in unwell patients requiring medical optimization. While stenting has gained popularity, the risk of stent perforation carries a poor prognosis and must be carefully considered. Hartmann's procedure should be considered in high-risk elderly patients. Subtotal colectomy is preferred over segmental colectomy when there is extensive proximal colon damage but results in more frequent bowel actions postoperatively.

Randomized comparison of continuous spinal anesthesia versus continuous epidural anesthesia in high-risk elderly patients undergoing major orthopedic lower limb surgeries

Background Continuous spinal anesthesia (CSA) is a reliable method for providing effective anesthesia and offers considerable advantages over ‘single-shot’ spinal or epidural anesthesia, as it provides the performance of well-controlled anesthesia using small doses of local anesthetics and a definite end point with less failure rate. Materials and methods A total of 100 patients of American Society of Anesthesiology grades III–IV were scheduled for elective major orthopedic lower limb surgeries. They were divided into two groups: one received CSA using spinocath set, and the other group received continuous epidural anesthesia (CEA). The doses of local anesthetic used, hemodynamic variables, a degree of technical difficulties, and the incidence of complications were recorded. Results The performance time was significantly shorter in the CEA group. The total dose of bupivacaine and number of top-up doses were significantly smaller in the CSA group than in the CEA group. The onset of sensory blockade level and motor blockade was significantly longer with CEA. Regarding the mean arterial pressure, there was a statistically significant difference between the two groups. The number of patients treated for hypotension and total dose of ephedrine was more in CEA group, but there was no statistical difference between the two groups. No major complications were observed in any patient in both groups. Conclusion We conclude that CSA is an effective and safe choice with hemodynamic stability and negligible failure rate, for prolonged procedures in elderly high-risk patients and in those with possible difficulties in administration of general anesthesia.

Dementia and Cognitive Impairment on Coronary Artery Bypass Grafting Patients in Aging Society

Coronary artery bypass grafting (CABG) is strategy for complex coronary artery disease (CAD) practiced worldwide that has become to be performed in relatively elderly patients in recent years, regarding to the development of off-pump CABG. As the population of elderly patients with cognitive disorders increases, a certain proportion of CABG candidates are likely to have some degree of cognitive impairment, especially dementia. The discussions about the CABG candidates with dementia are still insufficient, although several reports have suggested that 9.6%&ndash20% of CABG candidates may have preoperative dementia. An analysis indicated higher rate of hospital mortality and delirium in dementia patients, but ideal strategies for managing such patients remain controversial. An estimated 20%&ndash35% of CABG patients may have preoperative mild cognitive impairment (MCI), which is associated with an increased risk of morbidity and poor physical recovery after CABG. This preoperative cognitive decline was identified as a predictive factor for post-operative cognitive decline (POCD). Several randomized control trial have compared the cognitive outcomes between elderly high-risk patients after CABG with or without cardiopulmonary bypass, finding no significant cognitive differences between on- and off-pump treatments at 3 to 12 months after CABG. In addition, any late cognitive decline is likely associated with the progression of underlying cerebrovascular disease rather than surgical procedure itself or cardiopulmonary bypass. Preoperative evaluations of the cognitive function may contribute to appropriate postoperative management, reduce the incidence of delirium and improve the overall surgical outcome.

VALIDITY OF MALNUTRITION UNIVERSAL SCREENING TOOL (MUST) IN GERIATRIC PATIENTS: APPROPRIATE SCREENING TOOL IN HOSPITAL; MUST OR FULL-MNA?

Background: Since malnutrition of geriatric hospitalized patients has an impact on treatment and care management, the aim was to define the accuracy of Malnutrition Universal Screening Test (MUST) for malnutrition screening in the Iranian hospitalized elderly. Methods: In this cross-sectional study elderly 60 ≥ years (N= 192) were selected from two hospitals, anthropometric measures (BMI, MAC, and CC), laboratory test (Albumin), and nutrition tool (Full-MNA) applied and analyzed at P<0.05 level. Results: Elderly participants had a mean age of 68.86 ± 7.46 years and BMI 24.08± 4.64. Elderly patients (28%) lost their weight (>10%) in the last six months and loss of appetite observed in (33.4%) participants. In MUST tool rating, high-risk elderly patients for malnutrition were 33.3%. The AUC for MUST, according to Full-MNA was obtained 90.41%, with sensitivity 90.0% and specificity 73.25%. The MUST showed the strongest correlation with Full-MNA (r = -0.7) and BMI (r = - 0.51); but, the lowest correlation observed with Alb (r= -0.274). Most AUC was belonging to weight loss (0.96) and BMI (0.94). NConclusion: The MUST tool like full-MNA could diagnose malnutrition in geriatric patients in the hospital setting.

Prediction and prevention of heart failure in high-risk elderly patients.

Prediction and prevention of heart failure in high-risk elderly patients.

Two-stage revision shoulder prosthesis vs. permanent articulating antibiotic spacer in the treatment of periprosthetic shoulder infections

IntroductionPeriprosthetic shoulder infections (PSIs) represent a serious complication following shoulder arthroplasty. No consensus exists regarding the optimal option. We conducted a retrospective case-control study to compare the outcomes of 2-stage revision shoulder arthroplasty and those of definitive articulating antibiotic spacer implantation with regards to eradication of the infection, improvement of pain and shoulder function. Materials and methodsThirty patients treated for an infected shoulder arthroplasty were retrospectively reviewed after a mean follow-up of 8 years (range, 2–10 years). Nineteen underwent definitive articulating antibiotic spacer implantation and 11 underwent 2-stage revision arthroplasty. Mean age at surgery was 68.8 years. Assessment included Constant-Murley score, visual analog scale pain score, objective examination, patient subjective satisfaction score as well as standard radiographs. ResultsAt the most recent follow-up, none of the patients had clinical or radiographic signs suggesting recurrent infection. Most patients reported satisfying subjective and objective outcomes. Follow-up examination showed significant improvement of all variables compared to preoperative values (p<0.001). Radiographs did not show progressive radiolucent lines or change in the position of the functional spacer. No statistically significant differences were reported between the two groups concerning Constant-Murley and VAS scores, while average forward flexion and abduction were significantly higher in patients undergoing 2-stage revision surgery. ConclusionsBoth surgical procedures provided infection eradication and satisfying subjective functional outcomes. Functional results were superior in patients treated with revision shoulder prosthesis, although a higher rate of complication was reported in this cohort of patients, thus suggesting the use of permanent spacer in high-risk or low-demanding elderly patients. Level of evidenceIII, Retrospective case-control study.

Ixazomib for the treatment of multiple myeloma

ABSTRACTIntroduction: Proteasome inhibitors (PIs) are among the backbones of multiple myeloma (MM) treatment; however, their long-term use can be limited by parenteral administration and treatment-related toxicities. Ixazomib, the first oral PI to enter the clinic, is approved around the world, in combination with lenalidomide and dexamethasone, for the treatment of patients with MM who have received at least one prior therapy.Areas covered: This review summarizes the clinical data leading to approval of ixazomib; its pharmacology, efficacy, and safety. Building on the data in relapsed/refractory MM (RRMM), it also reviews the available clinical trial data for ixazomib across the MM treatment algorithm in newly diagnosed MM, RRMM, and as maintenance therapy, and looks ahead to ongoing clinical trials and the expanding role of ixazomib in these indications.Expert opinion: Ixazomib is an efficacious and well-tolerated addition to the treatment armamentarium for RRMM, with benefit as a long-term, continuous therapy for all patients, including ‘poor prognosis’ patients, such as those with advanced stage disease, high-risk cytogenetic abnormalities, and elderly and frail patients. Data from ongoing clinical studies are expected to expand the role of ixazomib across the MM treatment algorithm and in a broader range of combination regimens.

OC14 CONCOMITANT TRANS-AORTIC TRANSCATHETER AORTIC VALVE IMPLANTATION AND COMPLETE OFF-PUMP CORONARY ARTERY REVASCULARIZATION IN HIGH-RISK PATIENTS

Treatment of concomitant aortic stenosis and coronary artery disease represents a challenge in elderly high-risk patients with unsuitable peripheral anatomy to percutaneous access for TAVI. Our aim was to investigate efficacy, safety and mid-term clinical outcomes of concomitant Trans-Aortic TAVI and OPCAB. Methods: Between April2011 and January2016, 41 patients underwent simultaneous Tao-TAVI through a median sternotomy and OPCAB. High surgical risk profile did not permit conventional AVR and surgical revascularisation. PCI was considered unsuitable, because of LAD-proximal lesions and/or high SYNTAX-score. Primary endpoints were mortality and cerebro-vascular event rate. Results: Mean age was 82.6 ± 4.1 years with logistic-EuroSCORE and STS-score 19.19 ± 13.58% and 6.28 ± 3.57%. Average number of distal anastomoses was 2.7; TAo-TAVI was performed using either Sapien XT or Sapien 3 devices in 85.4% and 14.6% respectively, with a success rate of 95.1%. None paravalvular leak (PVL) ≥2/4 was observed with mean prosthesis gradient of 9.6 ± 3.8 mmHg. Conversion to CPB was required in 4.9% and pace-maker implantation in 4.9%. No cerebro-vascular accident were noted neither in-hospital stay (14.9 ± 5.0 days) or during total follow up (mean 17,26 months). In-hospital mortality was 7,32% and survival rate at 6,18 months was 84,35% and 77,86%, respectively. Conclusions: Considering high surgical risk, Simultaneous TAo-TAVI and OPCAB have become realistic treatment alternative and could represent a reasonable option in high-risk patients with severe AS and CAD and unsuitable peripherical access, permitting CPB avoidance.

Incidental thoracic findings in computed tomography scans before transcatheter aortic valve implantation.

Preoperative computed tomography (CT) scans for transcatheter aortic valve implantation (TAVI) are used routinely. In elderly high-risk patients, incidental radiographic findings are frequently reported. The aim of this study was to investigate the impact of auxiliary findings on the patients' mid-term survival, which might affect the treatment strategy. Between March 2011 and April 2016, all radiological reports of contrast-enhanced CT scans of 976 patients scheduled for TAVI were analysed retrospectively for incidental thoracic findings including solitary pulmonary nodules (SPN) and thoracic lymphadenopathy (LAP). The minimum follow-up period was 1 year after TAVI. The median age of all patients was 79 years; 51.9% (n = 507) were women. Approximately 37% (n = 361) of patients showed 1 of the determined findings. An SPN ≥5 mm was diagnosed in 16.4% (n = 160) of patients. Four of them developed lung cancer and 2 nodules were identified as metastases during follow-up. In addition, 12% (n = 117) of the patients had thoracic LAP. Whereas SPN had no significant effect on the overall survival rate, evidence of LAP turned out to be a statistically significant factor regarding 4-year survival (P = 0.001; hazard ratio 1.66; 95% confidence internal 1.19-2.31). SPN ≥5 mm were detected in 16.4% of patients scheduled for TAVI. Nevertheless, the incidence of lung cancer was low and the effect on survival in this high-risk group of patients was statistically not significant. In contrast, thoracic LAP had a significant negative effect on survival. It needs to be proven if the outcome of this cohort can be enhanced by further diagnostics and therapy.

Percutaneous cholecystostomy as a nonsurgical option for treatment of acute cholecystitis in elderly patients

ObjectivesTo evaluate the efficacy and safety of percutaneous cholecystostomy (PC) in management of acute cholecystitis in elderly patients. MethodsRetrospective study of elderly patients (age ≥ 60 years) undergoing Ultrasound-guided PC for acute cholecystitis, over a period of two years. Patients were reviewed for demographic features, co-morbidity, resolution of symptoms and outcome and complications. ResultsSeventeen patients (11 women, 6 men; mean age, 66 ± 7 years) underwent PC for acute cholecystitis. PC was technically successful in all patients and showed positive clinical response within 72 h in 15 patients (88.2%). Complications of PC tube placement occurred in 2 (11.8%) of 17 patients, including bile leakage around the skin in 1 patient ,tube dislodgment in another one and were treated effectively with drain replacement. ConclusionPercutaneous cholecystostomy is a safe, effective and technically achievable procedure for treating elderly high-risk patients who present with acute cholecystitis.

The effect of telehealth, telephone support or usual care on quality of life, mortality and healthcare utilization in elderly high-risk patients with multiple chronic conditions. A prospective study

Background and objectiveTo assess the effect of home based telehealth or structured telephone support interventions with respect to usual care on quality of life, mortality and healthcare utilization in elderly high-risk multiple chronic condition patients. Patients and methods472 elderly high-risk patients with plurimorbidity in the region of Valencia (Spain) were recruited between June 2012 and May 2013, and followed for 12 months from recruitment. Patients were allocated to either: (a) a structured telephone intervention, a nurse-led case management program with telephone follow up every 15 days; (b) telehealth, which adds technology for remote self-management and the exchange of clinical data; or (c) usual care. Main outcome measures was quality of life measured by the EuroQol (EQ-5D) instrument, cognitive impairment, functional status, mortality and healthcare resource use. Inadequate randomization process led us to used propensity scores for adjusted analyses to control for imbalances between groups at baseline. ResultsEQ-5D score was significantly higher in the telehealth group compared to usual care (diff: 0.19, 0.08–0.30), but was not different to telephone support (diff: 0.04, −0.05 to 0.14). In adjusted analyses, inclusion in the telehealth group was associated with an additional 0.18 points in the EQ-5D score compared to usual care at 12 months (p<0.001), and with a gain of 0.13 points for the telephone support group (p<0.001). No differences in mortality or utilization were found, except for a borderline significant increase in General Practitioner visits. ConclusionsTelehealth was associated with better quality of life. Important limitations of the study and similarity of effects to telephone intervention call for careful endorsement of telemedicine. Clinicaltrials.gov (identifier: NCT02447562).

Treatment of intertrochanteric fracture femur by Ilizarov fixator in elderly patients

Objective To assess the effectiveness of fixation of intertrochanteric fracture femur in elderly high-risk patients using Ilizarov fixator. Background Internal fixation of intertrochanteric fractures is a routine procedure, but in patients with anesthetic risks, external fixation can be considered a semiconservative method to reduce operative time and complications. In this study, the functional and radiological results of management of intertrochanteric fracture femur in elderly patients using Ilizarov fixator is evaluated. Patients and methods A total of 20 elderly high-risk patients with intertrochanteric fracture were treated by Ilizarov fixator. All patients had uncontrolled concomitant medical disorders such as hypertension, diabetes mellitus, and chronic hepatic or renal failure. The age range was 50–85 years. Results The patients were followed up for a mean of 7.5 months with a range from 6 to 9 months. Excellent and good (satisfactory) results were found in 16 patients and fair and poor (unsatisfactory) results were found in four patients. The time of radiological union and fixator removal ranged from 10 to 16 weeks. Pin-tract infection occurred in all patients. Varus malalignment occurred in 20% of patients. Shortening ranged from 0 to 3°. There were two cases of penetration of the femoral head. Conclusion It was found that external fixation of intertrochanteric fractures in elderly high-risk patients is a reliable, effective, and safe treatment option. It offers minimal operative risk, no blood loss, early mobilization, short hospital stay, and low morbidity and mortality.

Long-term prognosis after biliary stenting for common bile duct stones in high-risk elderly patients.

To evaluate the long-term outcomes of complete common bile duct (CBD) stone removal and biliary stenting in elderly patients (≥85 years) with CBD stones. We retrospectively examined 65 patients who underwent complete CBD stone removal (the duct clearance group) and 40 patients who underwent biliary stenting (the biliary stenting group) between July 2006 and March 2016. To reduce selection bias, we also conducted a propensity score matching analysis and generated 30 pairs of patients. Cholangitis recurrence-free survival and overall survival were compared between the two groups and independent prognostic factors of survival were identified by univariate and multivariate analyses. Cholangitis recurrence-free survival was significantly better in the duct clearance group than in the biliary stenting group (P < 0.001). Their overall survival did not significantly differ after propensity score matching (P = 0.388). In all cohorts, univariate analysis demonstrated that poor performance status and biliary stenting were factors of poor prognosis, and in multivariate analysis only performance status remained associated with poor prognosis for survival. Similarly, in the propensity score-matched cohort, only performance status independently predicted poorer survival (hazard ratio [HR] 2.726, 95% confidence interval [CI] 1.105-6.675, P = 0.029). The choice of endoscopic treatment was not a significant factor associated with prognosis (HR 1.354, 95% CI 0.678-2.701, P = 0.391). Biliary stenting was similar to complete stone removal in terms of prognosis for long-term survival. Biliary stenting for CBD stones could be an effective therapeutic tool in high-risk elderly patients.

Comparative Fluid-Structure Interaction Analysis of Polymeric Transcatheter and Surgical Aortic Valves' Hemodynamics and Structural Mechanics.

Transcatheter aortic valve replacement (TAVR) has emerged as an effective alternative to conventional surgical aortic valve replacement (SAVR) in high-risk elderly patients with calcified aortic valve disease. All currently FDA-approved TAVR devices use tissue valves that were adapted to but not specifically designed for TAVR use. Emerging clinical evidence indicates that these valves may get damaged during crimping and deployment- leading to valvular calcification, thrombotic complications, and limited durability. This impedes the expected expansion of TAVR to lower-risk and younger patients. Viable polymeric valves have the potential to overcome such limitations. We have developed a polymeric SAVR valve, which was optimized to reduce leaflet stresses and offer a thromboresistance profile similar to that of a tissue valve. This study compares the polymeric SAVR valve's hemodynamic performance and mechanical stresses to a new version of the valve- specifically designed for TAVR. Fluid-structure interaction (FSI) models were utilized and the valves' hemodynamics, flexural stresses, strains, orifice area, and wall shear stresses were compared. The TAVR valve had 42% larger opening area and 27% higher flow rate versus the SAVR valve, while wall shear stress distribution and mechanical stress magnitudes were of the same order, demonstrating the enhanced performance of the TAVR valve prototype. The TAVR valve FSI simulation and Vivitro pulse duplicator experiments were compared in terms of the leaflets' kinematics and the effective orifice area. The numerical methodology presented can be further used as a predictive tool for valve design optimization for enhanced hemodynamics and durability.

Can Vulnerable Elders Survey-13 predict the impact of frailty on chemotherapy in elderly patients with gynaecological malignancies?

The management of gynaecological cancers in elderly women and high-risk patients is an even more relevant issue, because the increase in longevity and comorbidities. The assumption of frailty based on age alone may lead to inadequate and inappropriate treatment and frailty assessment is recommended. The aim of this study was to assess if Vulnerable Elders Survey-13 (VES-13), as indicator of frailty, can predict the toxicity of chemotherapy in gynaecological cancers.VES-13 was administered to patients aged ≥ 70 years with ovarian, endometrial and cervical cancers who underwent chemotherapy from 2010 to 2016.Eighty-four patients aged ≥ 70 years (mean age 74.6) were included, 36 patients (42.9%) resulted vulnerable (score ≥ 3). Thrombocytopenia and anaemia were more prevalent in the vulnerable subjects (81.3% versus 18.7%, P = .0005, and 81.8% versus 18.2%, P = .005, respectively), while neutropenia was similar between the 2 groups. Vulnerable women had higher risk of non-haematological toxicities. Most of the patients (77.4%) completed chemotherapy, but dose reductions and discontinuations were more common in the vulnerable group (66.7% versus 33.3%, P = .07 and 68.4% versus 31.6%, P = .01, respectively).To our knowledge, this is the first study to evaluate VES-13 exclusively in elderly women with gynaecological cancers. VES-13 may be useful to stratify this category of patients according to vulnerability in order to identify women at risk of toxicity and to prevent complications induced by chemotherapy.

Early Safety and Efficacy of Sapien 3 20 mm Transcatheter Heart Valve Implantation in Small Japanese Body Size.

Transcatheter aortic valve implantation (TAVI) is effective in treating severe aortic stenosis in inoperable or high-risk surgical patients, however, the little is known about outcomes after Sapien 3 20 mm transcatheter heart valve (THV) implantation. The purpose of this study was to investigate the short term outcomes of Sapien 3 20 mm THV implantation in Japanese people with a small body size. We retrospectively collected the hospital records of consecutive patients who underwent TAVI using the Sapien 3 20 mm THV between October 2016 and March 2017. Clinical and echocardiographic data from before and one week after TAVI were collected. Six Japanese patients (all female, mean age 89 ± 5 years, body surface area [BSA] 1.29 ± 0.16m2) received a Sapien 3 20 mm THV. All the procedures were feasible and successful, and the 30-day mortality rate was 0%. The functional class and the echocardiographic findings significantly improved (aortic valve area, 0.5 ± 0.1 cm2 to 0.8 ± 0.1cm2; mean pressure gradient, 55 ± 15 mmHg to 19 ± 7 mmHg; P = .043, respectively). However, the values of the indexed effective orifice area in all patients after Sapien 3 20 mm THV implantation were less than 0.85 cm2/m2, suggesting prosthesis-patient mismatch (PPM). The implantation of a Sapien 3 20 mm THV was safe and effective in high surgical risk elderly Japanese patients with a small body size. PPM after Sapien 3 20mm THV may be prevalent among Asians with small body sizes. Careful clinical follow-up will be necessary after Sapien 3 20 mm THV implantation.

Achievements in colorectal cancer care during 8 years of auditing in The Netherlands

IntroductionThe efficacy of auditing is still a subject of debate and concerns exist whether auditing promotes risk averse behaviour of physicians. This study evaluates the achievements made in colorectal cancer surgery since the start of a national clinical audit and assesses potential signs of risk averse behaviour. MethodsData were extracted from the Dutch ColoRectal Audit (2009–2016). Trends in outcomes were evaluated by uni and multivariable analyses. Patients were stratified according to operative risks and changes in outcomes were expressed as absolute (ARR) and relative risk reduction (RRR). To assess signs of risk averse behaviour, trends in stoma construction in rectal cancer were analysed. ResultsPostoperative mortality decreased from 3.4% to 1.8% in colon cancer and from 2.3% to 1% in rectal cancer. Surgical and non-surgical complications increased, but with less reintervention. For colon cancer, the high-risk elderly patients had the largest ARR for complicated postoperative course (6.4%) and mortality (5.9%). The proportion of patients receiving a diverting stoma or end colostomy after a (L)AR decreased 11% and 7%, respectively. In low rectal cancer, patients increasingly received a non-diverted primary anastomosis (5.4% in 2011 and 14.4% in 2016). ConclusionsNo signs of risk averse behaviour was found since the start of the audit. Especially the high-risk elderly patients seem to have benefitted from improvements made in colon cancer treatment in the past 8 years. For rectal cancer, trends towards the construction of more primary anastomoses are seen. Future quality improvement measures should focus on reducing surgical and non-surgical complications.

Transcatheter treatment of tricuspid regurgitation using edge-to-edge repair: procedural results, clinical implications and predictors of success.

The aim of this study was to analyse the feasibility, safety and effectiveness of tricuspid valve (TV) repair using the MitraClip system in patients at high surgical risk. Forty-two elderly high-risk patients (76.8±7.3 years, EuroSCORE II 8.1±5.7) with isolated TR or combined TR and mitral regurgitation (MR) underwent edge-to-edge repair of the TV (n=11) or combined edge-to-edge repair of the TV and mitral valve (n=31). Procedural details, success rate, impact on TR severity and predictors of success at 30-day follow-up were analysed. Successful edge-to-edge repair of TR was achieved in 35/42 patients (83%, 68 clips in total, 94% in the anteroseptal commissure, 6% in the posteroseptal commissure). In five patients, grasping of the leaflets was impossible and two patients had no decrease in TR after clipping. In those with procedural success, clipping of the TV led to a reduction in effective regurgitant orifice area by -62.5% (from 0.8±0.4 to 0.3±0.2 cm2; p<0.0001). In both patients with isolated TV and combined procedures, six-minute walking distance improved (from 285±118 to 344±81 m and from 225±113 to 261±130 m, p=0.02 and 0.03, respectively). Predominant anteroseptal or central TR was identified as a predictor of procedural success (p=0.025). Edge-to-edge repair of the TV is feasible with a promising reduction in TR, which could result in clinical improvement.

Percutaneous cholecystostomy for high-risk patients with acute cholangitis.

Percutaneous cholecystostomy (PC) is a well-established treatment for acute cholecystitis. We investigate the performance and role of PC in managing acute cholangitis.Retrospective review on all patients who underwent PC for acute cholangitis between January 2012 and June 2017 at a major regional hospital in Hong Kong.Thirty-two patients were included. The median age was 84 years and median American Society of Anaesthesiologists (ASA) physical status was Class III (severe systemic disease). All fulfilled Tokyo Guidelines 2013 (TG13) diagnostic criteria for moderate or severe cholangitis. Eighty-four percent of the patients were shown to have lower common bile duct stones on imaging. The majority had previously failed intervention by endoscopic retrograde cholangiopancreatography (38%), percutaneous transhepatic biliary drainage (38%), or both (13%)The technical success rate for PC was 100% with no procedure-related mortality. The overall 30-day mortality was 9%. Rest of the patients (91%) had significant improvement in clinical symptoms and could be discharged with median length of stay of 14 days. Significant postprocedural biochemical improvement was observed in terms of white cell count (P < .001), serum bilirubin (P < .001), alkaline phosphatase (P = .001), and alanine transaminase levels (P < .001). Time from admission to PC was associated with excess mortality (P = .002).PC is an effective treatment for acute cholangitis in high-risk elderly patients. Early intervention is associated with lower mortality. PC is particularly valuable as a temporising measure before definitive treatment in critical patients or as salvage therapy where other methods endoscopic retrograde cholangiopancreatography/percutaneous transhepatic biliary drainage (ERCP/PTBD) have failed.

P147: Clinical characteristics and system factors of elderly treated for agitation in the emergency department: a data driven approach

Introduction: Aligning health systems appropriately to the needs of the elderly is an urgent global priority, according to the WHO. In Canada, ED length of stay has risen 16% for elderly patients in the last year. Agitation requiring chemical restraint is a common, high-risk problem for elderly in the ED. Improving outcomes in this heterogeneous population remain difficult due to inability to effectively identify and evaluate delirium, frailty, multi-morbidity, and incompatibility with the ED system. A data-driven approach to complex health problems is a recognized emerging tool for healthcare innovation. New opportunities for targeted quality improvement in the ED will be uncovered by identifying the clinical characteristics of elderly patients with agitation, and the system process factors that influence their outcomes. Methods: We studied 400 patients in a case-control study at two tertiary-care EDs over five years. Patients were randomly selected if age was greater than 75 years. 200 cases of patients who received an intravenous dose of haloperidol, midazolam and/or lorazepam were selected as a surrogate data marker for having agitation. Controls were randomly matched by age and ED diagnosis. Standardized clinical, systems and process variables were collected. We conducted a univariate analysis. Results: Elderly given intravenous medications for agitation had increased mortality (OR 3.8 CI: 1.6-10.7, p&lt;0.001) and ED length of stay (27 vs. 15 hours, p&lt;0.001). No statistical significance was found in clinical characteristics, CTAS scores, PRISMA7 frailty scores nor sentinel or return visits. There was no statistical difference in median hospital length of stay (8 vs. 6 days, p&lt;0.70). No differences were found in median time from ED physician seeing a patient to first consultant request (73 vs. 83 mins, p=0.75). The largest time intervals contributing to ED length of stay were from first consultant request to hospital request (15 vs. 12 hours, p=0.056) and hospitalization delay (13 vs. 7 hours, p=0.45). Conclusion: Identification of high-risk elderly patients for targeted intervention through a data-driven approach is feasible and informative. Traditional clinical characteristics remain unhelpful in identifying and evaluating outcomes in elderly with agitation. We have identified a process factor that is clinically relevant and pragmatic to evaluate in our ED system. Future research focused on optimizing systems process factors to improve quality of elderly care should be prioritized.