Standard Of Care Guidelines Research Articles

Barriers of Palliative Care in Neonatal Intensive Care Units

Neonatal nurses face numerous barriers in providing end-of-life (EOL) care for neonates and their families. Addressing neonatal nurses' attitudes could provide insight into barriers that impede neonatal palliative care (NPC). This study thus conducted to examine neonatal nurses' attitude toward barriers in providing NPC in Southeast Iran. In this cross-sectional study, a translated modified version of Neonatal Palliative Care Attitude Scale was used to examine attitudes of 70 nurses toward barriers of palliative care in 3 neonatal intensive care units in Southeast Iran. Findings indicated that overall 42.63% of nurses were strongly agreed or agreed with the proposed barriers in NPC. Among all categories, the highest and the lowest scores belonged to the categories of "insufficient resources" (3.42 ± 0.65) and "inappropriate personal and social attitudes" (2.33 ± 0.48), respectively. Neonatal nurses who had less education and study regarding NPC reported the presence of more barriers to NPC in the categories of "inappropriate organizational culture" and/or "inadequate nursing proficiency." Also, younger nurses had more positive attitudes toward the category of inappropriate organizational culture as being a barrier to provision of NPC (4.62). The findings suggest that developing a context-based instrument is required to represent the barrier more precisely. Neonatal palliative care can be improved by establishing a special environment to focus on infants' EOL care. This establishment requires standard palliative care guidelines and adequate NPC-trained nurses.

The development and current status of Intensive Care Unit management of prospective organ donors

Introduction:Despite continuous advances in transplant medicine, there is a persistent worldwide shortage of organs available for donation. There is a growing body of research that supports that optimal management of deceased organ donors in Intensive Care Unit can substantially increase the availability of organs for transplant and improve outcomes in transplant recipients.Methods:A systematic literature review was performed, comprising a comprehensive search of the PubMed database for relevant terms, as well as individual assessment of references included in large original investigations, and comprehensive society guidelines.Results:In addition to overall adherence to catastrophic brain injury guidelines, optimization of physiologic state in accordance with established donor management goals (DMGs), and establishment of system-wide processes for ensuring early referral to organ procurement organizations (OPOs), several specific critical care management strategies have been associated with improved rates and outcomes of renal transplantation from deceased donors. These include vasoactive medication selection, maintenance of euvolemia, avoidance of hydroxyethyl starch, glycemic control, targeted temperature management, and blood transfusions if indicated.Conclusions:Management of deceased organ donors should focus first on maintaining adequate perfusion to all organ systems through adherence to standard critical care guidelines, early referral to OPOs, and family support. Furthermore, several specific DMGs and strategies have been recently shown to improve both the rates and outcomes of organ transplantation.

The Health Care Sector Response to Intimate Partner Violence in Kenya: Exploring Health Care Providers' Perceptions of Care for Victims.

Intimate partner violence (IPV) is prevalent in Kenya, yet few studies have examined the role of health care providers (HCPs) in addressing IPV. Interviews with 18 Kenyan HCPs explored how they recognize and support IPV victims, including barriers to care. HCPs most commonly see victims of physical abuse. Medical responses to victims included counseling, treatment, and referrals, although rural HCPs reported fewer available services than in urban settings. HCPs attributed the limited response to IPV victims to unclear laws and fragmented care, especially in a culture where IPV remains largely unspoken and underreported. These results underscore the need for increased training on IPV assessment and response for HCPs in Kenya, with emphasis on standardized care guidelines for victims.

Multidisciplinarité et formation des spécialistes à l’oncologie et à l’hématologie maligne pédiatrique

According to the European Society of Pediatric Oncology (SIOPE) standard of care guidelines, high-quality care of children and adolescents with cancer needs to be delivered by well-trained multidisciplinary teams in specialist centers working with designated shared-care local centers in a so-called hub-and-spoke model. The Diplôme Inter-Universitaire d'Oncologie Pédiatrique (DIUOP) is the only European training program in pediatric oncology in French for all physicians involved in care of patients with pediatric malignancies. In agreement with the SIOPE syllabus, the DIUOP is composed of training courses (120h), on-site practical training in a specialist center, and a research project to be defended before an examining board. All graduates received a questionnaire to describe their current professional position. A comprehensive PubMed analysis retrieved all papers published form DIUOP research projects. From 2000 to 2011, 290 physicians were trained: 242 pediatricians, 21 surgeons, and 19 radiation therapists. Eight had another specialty including imaging, hematology, and pathology. Ninety-two were initially trained outside of France: 50% in Europe (mainly in Italy, Belgium, and Switzerland), 42% in Africa and the Middle East, and 8% in South America. Of the 266 graduates, 74% answered the questionnaire, and 90% of them take care of children and adolescents with cancer. Sixty-nine articles, i.e., one out of four research projects, were published in 34 journals with a median impact factor of 3.5 (0-22.6), 85% in English. DIUOP is the only French-speaking European education program providing a high-quality, professionalizing, and comprehensive multidisciplinary training program for French and international specialists taking care of children and adolescents with cancer.

Cystic Fibrosis. Edited by Marcus A. Mall and J. Stuart Elborn

Cystic Fibrosis. Edited by Marcus A. Mall and J. Stuart Elborn

MP51-10 DYSLIPIDEMIA AND OTHER METABOLIC SYNDROME TRAITS ARE ASSOCIATED WITH LOW TESTOSTERONE LEVEL IN MEN REGARDLESS THEIR AGE

INTRODUCTION AND OBJECTIVES: Over 18,000 Stem Cell Transplants (SCT) are performed each year. Such patients routinely receive gonadotoxic therapies. Chemotherapy, total body irradiation (TBI), and chronic steroid use are well-recognized causes of Leydig cell damage. Our aim was to characterize total testosterone (TT) profiles of men who underwent SCT, and identify any correlations between decline in T and subsequent diagnosis of decreased bone density. METHODS: All men who underwent an allogeneic SCT at a single institution in the past 15 years who had at least one TT level measured within 90 days prior to their SCT and one within three years following their treatment were included. Men who were on T replacement therapy pre-SCT were excluded. Bone densitometry (DXA) was performed per institution standard of care guidelines. Descriptive statistics are provided and a within subjects t-test was used to compare pre and post T values. RESULTS: 32 men were included. Mean age 1⁄4 55 14 (range 24-71) years. 28% died a mean of 14 8 months post SCT. 100% of patients received at least one alkylating agent, and 63% received two alkylating agents as part of their chemotherapy regimen. The most common chemotherapeutic regimens were Fludarabine/Busulfan/ Melphalan (38%), Thiotepa/Cyclophosphamide (16%), and Fludarabine/Melphalan (13%). 28% received TBI in addition to their chemo. 100% of patients were on long-term or intermittent corticosteroids. Mean T pre-SCT 1⁄4 401 154, post-SCT 1⁄4 389 205 ng/dL, p1⁄40.65. Pre-SCT, 66% had TT levels >300, and 47% had TT levels 200ng/dL decrease after treatment. Mean LH was 12.9 (SD 8.2) at 13 months post-SCT. On DXA, 42% had a diagnosis of osteopenia or osteoporosis. 6% of men had a documented non-pathologic fracture during study follow-up period, all of whom had post-SCT TT levels <150 ng/dL. CONCLUSIONS: Men post-SCT are at a significant risk for testosterone deficiency and bone mineral density loss. There is evidence of testicular damage early after SCT. The fracture risk appears greatest in men with the lowest TT levels post-SCT.

MP51-09 CHARACTERIZING TESTOSTERONE AND BONE DENSITY PROFILES OF MEN AFTER STEM CELL TRANSPLANT

INTRODUCTION AND OBJECTIVES: Over 18,000 Stem Cell Transplants (SCT) are performed each year. Such patients routinely receive gonadotoxic therapies. Chemotherapy, total body irradiation (TBI), and chronic steroid use are well-recognized causes of Leydig cell damage. Our aim was to characterize total testosterone (TT) profiles of men who underwent SCT, and identify any correlations between decline in T and subsequent diagnosis of decreased bone density. METHODS: All men who underwent an allogeneic SCT at a single institution in the past 15 years who had at least one TT level measured within 90 days prior to their SCT and one within three years following their treatment were included. Men who were on T replacement therapy pre-SCT were excluded. Bone densitometry (DXA) was performed per institution standard of care guidelines. Descriptive statistics are provided and a within subjects t-test was used to compare pre and post T values. RESULTS: 32 men were included. Mean age 1⁄4 55 14 (range 24-71) years. 28% died a mean of 14 8 months post SCT. 100% of patients received at least one alkylating agent, and 63% received two alkylating agents as part of their chemotherapy regimen. The most common chemotherapeutic regimens were Fludarabine/Busulfan/ Melphalan (38%), Thiotepa/Cyclophosphamide (16%), and Fludarabine/Melphalan (13%). 28% received TBI in addition to their chemo. 100% of patients were on long-term or intermittent corticosteroids. Mean T pre-SCT 1⁄4 401 154, post-SCT 1⁄4 389 205 ng/dL, p1⁄40.65. Pre-SCT, 66% had TT levels >300, and 47% had TT levels 200ng/dL decrease after treatment. Mean LH was 12.9 (SD 8.2) at 13 months post-SCT. On DXA, 42% had a diagnosis of osteopenia or osteoporosis. 6% of men had a documented non-pathologic fracture during study follow-up period, all of whom had post-SCT TT levels <150 ng/dL. CONCLUSIONS: Men post-SCT are at a significant risk for testosterone deficiency and bone mineral density loss. There is evidence of testicular damage early after SCT. The fracture risk appears greatest in men with the lowest TT levels post-SCT.

Rubinstein-Taybi syndrome: clinical features, genetic basis, diagnosis, and management.

BackgroundRubinstein-Taybi syndrome (RSTS) is an extremely rare autosomal dominant genetic disease, with an estimated prevalence of one case per 125,000 live births. RSTS is characterized by typical facial features, microcephaly, broad thumbs and first toes, intellectual disability, and postnatal growth retardation. However, no standard diagnostic criteria are available for RSTS. In this review, we summarized the clinical features and genetic basis of RSTS and highlighted areas for future studies on an appropriate diagnostic protocol and follow-up care for RSTS.DiscussionRSTS is primarily characterized by delayed growth in height and weight, microcephaly, dysmorphic facial features, and broad thumbs and big toe. Over 90% RSTS individuals with disabilities survive to adulthood, but healthcare for these patients is particularly complex, time-consuming, and costly. In addition, no standard diagnostic criteria and follow-up care guidelines are available for RSTS. It has been shown that mutations in the genes encoding the cyclic-AMP-regulated enhancer binding protein (CREBBP) and the E1A-binding protein p300 (EP300) contributed to the development of RSTS. Therefore, genetic tests are useful for the diagnosis of RSTS, although most RSTS cases are currently diagnosed based on clinical features.SummaryThe clinical features of RSTS have been extensively studied, which significantly contributes to the diagnosis of this extremely rare syndrome. However, the pathogenesis and genotype-phenotype associations of RSTS are largely unknown. Therefore, multicenter studies and international cooperation are highlighted for better understanding of this disease, establishing standard diagnostic criteria, and providing professional management and follow-up care of RSTS.

Role of Mesothelin Measurement in Patients With Cytology-Negative Pleural Effusion Undergoing Medical Thoracoscopy

Background: Malignant pleural mesothelioma (MPM) is a rapidly fatal tumor of increasing worldwide incidence. Diagnosis of MPM may be difficult and is an area of academic and clinical interest. Diagnosis by effusion cytology is controversial, and the clinical utility of soluble biomarkers, particularly mesothelin, remains unexplored in the difficult to diagnose patient. Objectives: We studied the diagnostic value of measuring mesothelin in patients with cytology-negative pleural effusion undergoing medical thoracoscopy. Methods: Patients were enrolled prospectively and underwent medical thoracoscopy. Biopsy samples were reviewed following standard care guidelines. Soluble mesothelin was quantitated by commercial enzyme-linked immunosorbent assay in effusion and serum samples collected at the time of thoracoscopy. Patients were followed up until death or for a median of 28 (interquartile range 18-43) months. Results: Biopsy for thoracoscopy was definitive for malignancy in 17 of the 36 cases (16 MPM and 1 lung adenocarcinoma) and suspicious of malignancy in 6 cases. A final diagnosis of malignancy was made for 27 cases (24 MPM, 2 lung adenocarcinoma, and 1 primary pleural T-cell lymphoma). At thoracoscopy, soluble mesothelin was elevated in the effusion of 13 cases all of which were MPM. Serum mesothelin was elevated in 6 cases with MPM. One case with elevated mesothelin on whom thoracoscopic biopsy demonstrated a pleural plaque was diagnosed with metastatic MPM 9 months later. Conclusion: Elevated effusion mesothelin had a positive predictive value of 100% for a final diagnosis of MPM. Elevated mesothelin, in effusion or serum, should raise the index of suspicion of malignancy and warrants continued clinical follow-up.

Health care workers' knowledge and practices regarding the prevention of central venous catheter-related infection

Central venous catheter-related infection (CVC-RI) is considered a common cause of increased morbidity, mortality, and medical care costs in intensive care units (ICUs). The objective in this descriptive study was to assess the knowledge of health care workers in ICUs about guidelines for the prevention of CVC-RI and their adherence to these guidelines in practices. Health care workers were assessed for their actual practices during central venous catheter (CVC) insertion and care. Then a questionnaire was distributed to the health care workers to assess their knowledge regarding the prevention of CVC-RI. All the health care workers (N= 100; 40 physicians, 60 nurses) in the ICUs (levels I and III and triage) of Alexandria Main University Hospital participated in the present study. The response rate was 100%. The total percentage of correct answers of the health care workers about the guidelines for the prevention of CVC-RI was low. There was no significant difference between physicians' and nurses' knowledge regarding the total score on the questionnaire (P=.134). However, physicians had a significantly higher knowledge about the pathophysiology of CVC-RI and skin antisepsis items than nurses. There were no significant differences between the knowledge of physicians and nurses in other items except for CVC care, where nurses showed significantly higher knowledge than physicians (P=.001). The results of the present study revealed health care worker's low knowledge regarding the prevention of CVC-RI and low compliance with the standard guidelines of CVC care. Therefore, health care workers should be periodically evaluated for their knowledge and practices regarding guidelines for the prevention of CVC-RI.

Treating a Transgender Patient: Overview of the Guidelines

Transgenderism and gender dysphoria are becoming more prevalent diagnoses and the patient population is increasing. Primary care practitioners, endocrinologists, and mental health professionals are all part of the medical care team that treats these patients, but family and internal medicine physicians continue to deliver the care in the long term. Transgender medicine is not a strong part of the medical curriculum, and recent studies have shown there is anxiety in new physicians in taking care of these patients. There are many aspects to transgender care that involve different specialities, including, but not limited to, mental health, primary care, endocrinology, surgery, and obstetrics and gynecology. This article gives an overview of the current guidelines for standards of care of transgender patients as delineated by the World Professional Association for Transgender Health and the Endocrine Society.

The Long Road Home: Neonatal Long-term Care

The Long Road Home: Neonatal Long-term Care

Temporal representation of care trajectories of cancer patients using data from a regional information system: an application in breast cancer

BackgroundEnsuring that all cancer patients have access to the appropriate treatment within an appropriate time is a strategic priority in many countries. There is in particular a need to describe and analyse cancer care trajectories and to produce waiting time indicators. We developed an algorithm for extracting temporally represented care trajectories from coded information collected routinely by the general cancer Registry in Poitou-Charentes region, France. The present work aimed to assess the performance of this algorithm on real-life patient data in the setting of non-metastatic breast cancer, using measures of similarity.MethodsCare trajectories were modeled as ordered dated events aggregated into states, the granularity of which was defined from standard care guidelines. The algorithm generates each state from the aggregation over a period of tracer events characterised on the basis of diagnoses and medical procedures. The sequences are presented in simple form showing presence and order of the states, and in an extended form that integrates the duration of the states. The similarity of the sequences, which are represented in the form of chains of characters, was calculated using a generalised Levenshtein distance.ResultsThe evaluation was performed on a sample of 159 female patients whose itineraries were also calculated manually from medical records using the same aggregation rules and dating system as the algorithm. Ninety-eight per cent of the trajectories were correctly reconstructed with respect to the ordering of states. When the duration of states was taken into account, 94% of the trajectories matched reality within three days. Dissimilarities between sequences were mainly due to the absence of certain pathology reports and to coding anomalies in hospitalisation data.ConclusionsThese results show the ability of an integrated regional information system to formalise care trajectories and automatically produce indicators for time-lapse to care instatement, of interest in the planning of care in cancer. The next step will consist in evaluating this approach and extending it to more complex trajectories (metastasis, relapse) and to other cancer localisations.

Abstract W P288: Stroke Central: An Innovative Approach to Coordinated Comprehensive Stroke Care

Background: Stroke care involves a costly and time-sensitive interdisciplinary approach, which requires a supportive platform in order to explore novel patient care strategies. Our initiative aims to reduce costs and poor outcomes for stroke patients through increased coordination across the continuum of care. Methods: This innovative care model includes an inpatient component, Stroke Central. Stroke Central utilizes an intra-professional team of specialists, including vascular neurologists, advance practice nurses, and a registered nurse (RN) coordinator who serves as the central contact to handle all stroke-related concerns from staff and patients. The goal of Stroke Central is to provide comprehensive monitoring of patients throughout care, resulting in early detection and intervention in any complications. The role of the RN coordinator is vital as a facilitator for Stroke Central communication, care monitoring, and ongoing education and training among patients and healthcare professionals. The RN coordinator is charged with improving compliance with standard of care guidelines throughout the continuum of care and collaborating with other team members to monitor patients both remotely and directly. Results: After initiation of Stroke Central, results show improved patient outcomes for the 434 patients seen in the first two quarters of 2013 compared with the 822 patients seen in 2012. Lengths of stay indices have decreased in cases of hemorrhagic stroke (10%), ischemic stroke (19%) and transient ischemic attacks (31%). Complication and mortality rates in hospitals have also decreased; expected complication rate index for ischemic stroke decreased 10%, while the risk adjusted mortality index for ischemic stroke decreased 40%. Initial cost analyses indicate decreased costs for the inpatient component. Conclusion: Having a dedicated staff member, as a first and continual facilitator for contact has been essential in this innovative model. Incorporating this key role into primary stroke care can lead to an overall improvement in stroke outcomes in diverse hospital settings.

Challenges in the implementation of "end-of-life care" guidelines in India: How to open the "Gordian Knot"?

Challenges in the implementation of "end-of-life care" guidelines in India: How to open the "Gordian Knot"?

Service Learning: Priority 4 Paws Mobile Surgical Service for Shelter Animals

The increasing attention given to competencies needed to enter the workforce has revealed a need for veterinary students to gain more experience in performing small-animal elective surgery before graduation. In addition, guidelines for standards of care for shelter animals recommend that all dogs and cats should be spayed or neutered before adoption. Teaching surgical skills while serving the needs of local animal shelters represents an ideal service-learning opportunity. Following a pilot study and the benchmarking of other programs, an elective course in shelter medicine and surgery was created at Purdue University College of Veterinary Medicine (PVM) to allow senior DVM students an opportunity to spend 2 weeks on a mobile surgery unit (Priority 4 Paws) and 1 week at an animal shelter. With financial assistance from sponsors and donors, PVM purchased and equipped a mobile surgery unit, hired a full-time veterinarian and a registered veterinary technician, and established relationships with 12 animal shelters. From July 30, 2012, to March 22, 2013, 1,941 spays and neuters were performed with excellent postsurgical outcomes while training 33 veterinary students on rotation and 26 veterinary technician students. The program was well accepted by both students and the shelters being served. The Priority 4 Paws program is an example of an integrated, community-based service-learning opportunity that not only helps to improve the surgical skills of veterinary students but also helps to meet an identified community need.

Abstract 1172: Phase I study of histone deacetylase inhibitor belinostat in combination with warfarin in patients with solid tumors or hematological malignancies.

Abstract Background: The family of Histone Deacetylase (HDAC) enzymes serves as important epigenetic regulators of gene expression through modulation of acetylation on important histone and non-histone proteins. Aberrant acetylation of histones can alter gene expression believed to be important in the tumorigenic process. Belinostat, a potent inhibitor of HDAC proteins has demonstrated anti tumor activity in animal models and in humans. The purpose of this study was to examine the pharmacokinetic and pharmacodynamic properties of warfarin in combination with belinostat and to evaluate the safety profile of belinostat with concomitant warfarin. Methods: Eligible patients enrolled on the study received 5 mg PO warfarin 14 days prior to administration of belinostat. Belinostat was administered as an iv infusion, 1000mg/m2 over 30 minutes for 5 consecutive days every 21 days. On day 3, cycle 1 of belinostat treatment, a second dose of 5mg PO warfarin was administered 2 hours prior to belinostat. Pharmacokinetic blood samples were obtained during cycle 1 of the study to measure warfarin and belinostat metabolism. Toxicities were monitored regularly throughout treatment and response was monitored according to standard of care guidelines. Results: 18 patients, with solid tumors or hematologic malignancies, treated with belinostat and warfarin were included in this analysis. Median age was 55 years (31-77). 11 (61%) patients were male and 7(39%) patients were female. The most common Grade 1 or 2, toxicities observed during the study were anemia (78%), fatigue (72%) and nausea (61%). The most frequent Grade 3 or 4 toxicities were nausea (11%) and hyperuricemia (11%). No Grade 3 or 4 thrombocytopenia or neutropenia were reported. No treatment related Grade 5 toxicities were reported. During cycle 1 no patient experienced treatment delays or discontinued study as result of treatment related toxicity. Conclusion: Belinostat was generally well tolerated in patients with solid tumors or hematologic malignancies with the major toxicity being anemia, fatigue or nausea. Pharmacokinetic results will be presented at the conference. Citation Format: Neeraj Agarwal, Mark L. Wade, Julia Batten, Cynthia Davidson, Show-Li Sun, Sunil Sharma. Phase I study of histone deacetylase inhibitor belinostat in combination with warfarin in patients with solid tumors or hematological malignancies. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 1172. doi:10.1158/1538-7445.AM2013-1172

Indirect Traumatic Optic Neuropathy Following Head Injury: Report of Five Patients and Review of the Literature

Indirect traumatic optic neuropathy (ITON) is a rare occurrence in patients with head injuries, mostly affecting young people. Loss of vision is a feared consequence. Its natural history and optimal care remain undetermined. Randomized controlled studies are missing. Treatment alternatives include mere observation, corticosteroid administration, or surgical decompression of the optic canal. Among these options, an individual approach is considered. We report five patients with head injury and ITON: a 63-year-old woman was left permanently blind after a fall; a 33-year-old man lost his vision of the left eye immediately after a car accident; and three young men (aged 26, 21, and 22 years) who were intubated after a road accident noted loss of vision from one eye after they became conscious. The 26-year-old patient in the last group regained his sight 1 month later, whereas the other two never had it returned. All of our patients were treated conservatively: Methylprednisolone was administrated. Patients with ITON are managed on an individual basis. Informed consent must be obtained for mere observation or administration of corticosteroids and/or optic canal decompression. The natural history of this disorder is unknown. Only randomized controlled studies can fix standard guidelines of care. Preventive measures to decrease the incidence of head injured patients are mandatory.

The State of Genomic Health Care and Cancer Are We Going Two Steps Forward and One Step Backward?

As the application of genomic information and technology crosses the horizon of health care into our everyday lives, expanding genomic knowledge continues to affect how health care services are defined and delivered. Genomic discoveries have led to enhanced clinical capabilities to predict susceptibility to common diseases and conditions such as cancer, diabetes, cardiovascular disease, and Alzheimer's disease. Hundreds of genetic tests are now available that can identify individuals who carry one or more gene mutations that increase their risk of developing cancer or other common diseases. Increased availability and direct-to-consumer marketing of genetic testing is moving genetic testing away from trained genetics health professionals and into the hands of primary care providers and consumers. Genetic tests available on the Internet are being directly marketed to individuals, who can order these tests and receive a report of their risk for numerous health conditions and diseases. Health care providers are expected to interpret these test results, evaluate their accuracy, address the psychosocial consequences of those distressed by receiving their results, and translate genomic information into effective care. However, as we move two steps forward, we are also moving one step backward because many health care providers are unprepared for this genomic revolution. A number of international education, practice, and policy efforts are underway to address the challenges health care providers face in providing competent genomic health care in the context of unprecedented access to information, technology, and global communication. Efforts to integrate standard of care guidelines into electronic medical records increases health care providers' access to information for individuals at risk fo or diagnosed with a genomic condition. Development of genomic competencie for health care providers has led to increased genomic content in academic pro grams. These and other efforts will keep the state of genomic health care stepping forward as we face the challenges of health care in the genomic era.

Complications in MS Patients after CCSVI Procedures Abroad (Calgary, AB)

The "chronic cerebrospinal venous insufficiency" or "CCSVI" hypothesis, namely that multiple sclerosis (MS) is caused by abnormalities in the azygous and internal jugular veins with subsequent alterations in venous hemodynamics in the central nervous system, has been a dominant topic in MS care in Canada over the past year. Although there is no methodologically rigorous evidence to support this hypothesis presently, a considerable number of MS patients have undergone endovascular CCSVI procedures. Such procedures include angioplasty or stent placement in jugular and azygous veins. The safety and efficacy of these procedures is unknown, but not without risk. Chart and patient review of five patients with confirmed MS followed in Calgary were undertaken after patients came to medical attention by referral or admission secondary to complications believed to be associated with CCSVI procedures. Complications upon investigation and review included internal jugular vein stent thrombosis, cerebral sinovenous thrombosis, stent migration, cranial nerve injury and injury associated with venous catheterization. As the debate about CCSVI and its relationship to MS continues, the complications and risks associated with venous stenting and angioplasty in jugular and azygous veins are becoming clearer. As increasing numbers of MS patients are seeking such procedures, these five cases represent the beginning of a wave of complications for which standardized care guidelines do not exist. Our experience and that of our colleagues will be used to develop guidelines and strategies to monitor and manage these patients as their numbers increase.