High-complexity Procedures Research Articles

Tratamento Radioterápico no Sistema Único de Saúde: uma Análise do Período 2012 a 2016

Introdução: A radioterapia é uma das modalidades terapêuticas no tratamento do câncer. Objetivo: Descrever o perfil epidemiológico e assistencial do tratamento radioterápico no Sistema Único de Saúde no período 2012-2016. Método: Estudo descritivo sobre as Autorizações de Procedimentos de Alta Complexidade em Oncologia do Sistema de Informação Ambulatorial. Avaliaram-se o quantitativo de Cartão Nacional de Saúde nas autorizações de radioterapia do tipo inicial, o número de autorizações por cartão, as neoplasias mais frequentes, o número de campos de radioterapia aplicados, a idade mediana e a finalidade do tratamento por estabelecimento habilitado em oncologia. Resultado: Identificaram-se 509.708 cartões com uma razão de duas autorizações/cartão. Mama (24,3%) e próstata (18,5%) foram as neoplasias mais frequentes. O número de campos por neoplasia foi superior ao preconizado. A mediana de idade foi menor para encéfalo (48 anos) e maior para próstata (70 anos). Maior parte do tratamento (85,2%) foi para finalidade não paliativa e foram realizadas em Centro de Assistência de Alta Complexidade em Oncologia com serviço de Oncologia Pediátrica. Conclusão: O estudo demonstrou um incremento no número de casos/ano tratados com radioterapia, evidenciando a importância dessa modalidade terapêutica. Estudos que caracterizem o perfil dos casos em tratamento de câncer são necessários para qualificar a gestão da rede de atenção a saúde.

GeoCancer: A Tool Designed in the SUS Manager

Background and context: Nowadays, there is a great amount of information to analyze the situation of care and the accomplishment of the SUS procedures for diagnosis and treatment of cancer. The tool GeoCancer will enable the manager (state and/or municipal) to analyze this assistance situation and the performance of SUS procedures for oncology, based on the public information available in DATASUS, in an agile, direct and specific way. Aim: The Cancer Foundation technical team has developed an online platform to organize the public databases of information on provider registration and procedures performed. This tool was called GeoCancer®. Strategy/Tactics: The GeoCancer® tool compiles and displays information on hospital admission procedures and high complexity procedures (SIH and APAC) and SADT (diagnostic and therapeutic support services) in the public databases of DATASUS. In addition, it organizes the providers and procedures performed in oncology on a georeferenced basis, making the results available in electronic address. Program/Policy process: This tool can be useful to the manager. With this, the manager will be better acquainted with the cancer profile of his specific area, so he can propose more effective measures throughout the cancer care line. Outcomes: The tool allows the choice of map visualization by procedures or SADT, in addition to being able to make analyzes by age, sex, type of cancer and health regionals. Information can be quantitative or by population distribution. What was learned: It is hoped that the tool fulfills the role of structuring, in a dynamic and georeferenced way, the assistance information on oncology in Brazil.

Generalist versus Subspecialist Workforce Characteristics of Invasive Procedures Performed by Radiologists.

Purpose To explore subspecialty workforce considerations surrounding invasive procedures performed by radiologists. Materials and Methods The 2015 Centers for Medicare & Medicaid Services Physician and Other Supplier Public Use File was used to identify all invasive procedures (Current Procedural Terminology code range, 10000-69999) billed by radiologists for Medicare fee-for-service beneficiaries. Radiologists were categorized by subspecialty according to the majority of their billable work-relative value units (wRVUs). Those without a single subspecialty majority work effort were deemed generalists. Procedures were categorized into three tiers of complexity (high, ≥4.0 wRVUs; mid, 1.6-3.9 wRVUs; low, ≤1.5 wRVUs). Total and tiered generalist versus subspecialist workforce composition was assessed. Results Just 25 unique services comprised more than 75% of invasive procedures performed by radiologists. Of radiologists who performed procedures, 57.5% were generalists, 15.8% were interventionalists, and 26.8% were other subspecialists. Of the radiologists who performed low-, mid-, and high-complexity procedures, generalists accounted for 46.3%, 30.9%, and 23.1%, respectively; interventionalists accounted for 35.4%, 30.9%, and 75.2%, respectively; and other subspecialists accounted for 18.3%, 14.6%, and 1.7%, respectively. Generalists were the dominant providers of six of the top 10 low-complexity and seven of the top 10 midcomplexity procedures. Interventionalists were the dominant providers of all top 10 high-complexity procedures. Nationally, over twice as many U.S. counties had local access to generalists (869 counties) for invasive procedures versus interventionalists (347 counties) or other subspecialists (380 counties). Conclusion Among radiologists, generalists perform far more procedures in more geographic locations and are more likely to serve patients with less complex service needs than are interventionalists or other subspecialists. Practices and professional societies must remain vigilant to ensure that the subspecialty evolution in radiology does not exacerbate patient access disparities. © RSNA, 2018 Online supplemental material is available for this article.

Tu1429 SAFETY AND EFFICACY OF ENDOTHERAPY IN PANCREAS DIVISUM IN PATIENTS WITH ACUTE RECURRENT PANCREATITIS

Pancreas divisum is a common anatomical variant encountered in approximately in about 5-14% of general population. In recurrent acute pancreatitis (RAP), endoscopic treatment of divisum has shown variable success rates. ERCP for endoscopic therapy in PD patient is considered a high complexity procedure (ASGE grade 3). Objective: To evaluate efficacy and safety of endoscopic therapy in patients with RAP due to pancreas divisum. All patients with confirmed RAP and pancreas divisum who underwent endoscopic therapy from April 2009 to November 2016 were included in the study. Patient demographics, disease specifics and procedural data were abstracted from the medical records. Technical success of endoscopic therapy was defined as successful minor papilla cannulation with successful completion of the intended therapeutic intervention. Clinical success was defined as the absence of pancreatitis from the last ERCP to the last clinical contact. Patients with clinical success were compared with patients who did not respond to endoscopic therapy using unpaired t-test and chi-square test. Complication rates were calculated. Patients with and without post-ERCP Pancreatitis (PEP) were compared using univariate and multivariate analysis. A total of 174 ERCPs were performed in 82 patients with pancreas divisum. Technical success was achieved in 90% (n-74) of cases. Clinical success was achieved in 63% (n – 38) of cases over an average follow up of 16 months (range – 3-84 months). 17% (n – 14) were lost to follow up. There was no difference in patient or procedure-related factors between responders and non-responders (Table-1). 9 (5.2%) patients developed PEP. Out of this, 2 patients had severe but self-limiting PEP (1.14%). 3 patients developed post sphincterotomy bleeding. Opioid users had higher odds of PEP. Indomethacin did not impact the risk of PEP (Table-2). No mortality was observed. PEP occurred in 3.2% of those who received Indomethacin and in 6.2% of those prior to routine administration of Indomethacin administration (P=0.4). Endoscopic therapy appears to be safe and effective in patients with pancreas divisum with confirmed recurrent acute pancreatitis. Particularly in the setting of Indomethacin and pancreatic duct stenting, the rate of PEP was very low. Sustained clinical success was found in approximately 3 of 5 patients managed with endoscopic intervention.Tabled 1Table: 1 – Comparison between clinical responders and non-respondersClinical RespondersN = 38Non-respondersN=22P valueAge (average in years)46.3 +/- 20.344 +/- 20.10.64Gender (M:F)1.031.10.91RaceCaucasian - 22Caucasian - 130.81African American - 14African American - 7Hispanic - 2Hispanic - 1Divisum - Complete: Partial1.92.50.6Smoking history (%)30.247.60.16Alcohol intake (%)30.228.60.86Opioid use (%)37.333.70.72# Stent exchange2.3 +/- 1.61.9 +/- 1.70.24Final stent size (Fr)6.3+/- 1.65.9 +/- 1.30.31Final stent length (cm)8.5 +/- 2.47.6+/- 2.20.14Stent configurationPigtail - 27Pigtail - 130.4Straight - 26Straight - 8 Open table in a new tab Tabled 1Table – 2: Comparison between PEP and non-PEP group.PEP (N=9)No PEP (control) (N=165)P ValueAge (Mean in years)38 +/- 1646 +/- 170.21Gender (%Male)88%52%0.06RaceCaucasian - 6African American - 3Caucasian - 102African American - 54Hispanic - 6Asian - 31Indomethacin use (%)22360.41Smoking history (%)44350.56Alcohol use (%)22340.45Opioid use (%)89340.008Native papilla (%)44340.5Divisum anatomy (Complete: partial)3.52.50.19Average procedure time (minutes)64.2 +/- 1762.04 +/- 270.76Trainee involvement (%)35420.5 Open table in a new tab

Cytoreductive Surgery and Intraperitoneal Hyperthermic Chemotherapy (HIPEC) by Minimally Invasive Approach, an Initial Experience.

The cytoreductive surgery (CRS) associated with hyperthermic intraperitoneal chemotherapy (HIPEC) has become the standard treatment in patients with carcinomatosis peritoneal from different origins. The use of a minimally invasive approach for this high complex procedure might be an alternative that provides them less morbidity and faster recovery with similar oncologic outcomes. We describe the initial experience of CRS and HIPEC done via the laparoscopic route in patients with minimal peritoneal metastases in our Unit from March 2016 to January 2018. A total of eight patients were operated by this minimally invasive approach. The different diagnoses were low-grade pseudomyxoma peritonei (2), benign multicystic mesothelioma (2), primary epithelial ovarian carcinomatosis (2) and locally advanced colon carcinoma T4 (2). The median age was 54 (20-62) years, the median PCI was 3 (2-4), the median operative time was 287min (240-360), complete cytoreduction CC0 was achieved in all the patients, and no major morbidity was observed. The median length of stay was 4.75days (4-5). After a median follow-up of 9.5months, no relapse has been observed. The results suggest that this minimally invasive approach for CRS and HIPEC is feasible and safe in a highly selected group of patients with peritoneal surface malignancies.

Abstract 180: Some Like it Hot; Radiation Safety in the Catheterization Lab

Objective: Ionizing radiation is an unseen and often unappreciated safety concern for patients and cath lab staff. Radiation exposure has both deterministic and stochastic effects, with patient risk estimated by peak Skin Dose and Air kerma Area product. In our lab exposure guidelines have been set for radiation safety (fluoro time < 60 min, 4,000 mGray and 20,000 cGray cm 2 ). A prior audit of practice 2011-2013 found that 17.1% (758/4,439) of patients undergoing interventional procedures exceeded these limits. Safer radiation practices were implemented including: intra procedure operator feedback, decrease in cine frame rate and run length, promote mapping and less angled views. However changing patient characteristics (increased obesity, prior CABG) and an increase in structural procedures warrant reexamination of practice. Procedure: The frequency of guideline excessive radiation exposure for cardiac cath lab patients was tracked over a 12 month period from 11/2016-11/2017. The frequency of radiation exposure exceeding our guidelines was tracked overall and by operator (16), and by specific intervention. Results: Over the one year period 10.2% of interventions [174/1,702] received excessive skin or total body radiation. Rates exceeding guidelines by operator ranged from 4% to 26% with operators performing structural or peripheral procedures having the highest patient radiation exposures. Structural procedures resulted in exposures as high as 123 min fluoro time, TAD of 226,385 cGray cm2, 11,129 mGray skin dose [patient had post procedure skin damage]. Factors associated with high radiation exposures included: increasing obesity, prior surgical revascularization, coronary anomalies, multivessel procedure or high complexity procedure, difficulties in imaging requiring highly angled or multiple views, procedural complications. Interventions associated with limiting exposure included: limiting fellow participation, decrease in frame rate, interim stills with limited cine runs. The default settings of X-Ray equipment have been modified to encourage safe and appropriate use of radiation in the cardiac catheterization lab (however, physician overide of settings is still possible). Conclusions: The changes made in imaging equipment and procedures 5 years ago have been largely sustained and have resulted in less frequent radiation outliers. Patient factors (e.g. obesity, prior CABG) complex and multivessel interventions, structural and vascular procedures are potentially frequently associated with excess radiation. Changing default settings and implementing radiation safety practices, including staging where appropriate, can significantly decrease radiation exposure to patients and staff. Cumulative and target organ specific patient doses of radiation should be tracked and more readily accessible in the patient’s medical record.

ORBDA: An openEHR benchmark dataset for performance assessment of electronic health record servers.

The openEHR specifications are designed to support implementation of flexible and interoperable Electronic Health Record (EHR) systems. Despite the increasing number of solutions based on the openEHR specifications, it is difficult to find publicly available healthcare datasets in the openEHR format that can be used to test, compare and validate different data persistence mechanisms for openEHR. To foster research on openEHR servers, we present the openEHR Benchmark Dataset, ORBDA, a very large healthcare benchmark dataset encoded using the openEHR formalism. To construct ORBDA, we extracted and cleaned a de-identified dataset from the Brazilian National Healthcare System (SUS) containing hospitalisation and high complexity procedures information and formalised it using a set of openEHR archetypes and templates. Then, we implemented a tool to enrich the raw relational data and convert it into the openEHR model using the openEHR Java reference model library. The ORBDA dataset is available in composition, versioned composition and EHR openEHR representations in XML and JSON formats. In total, the dataset contains more than 150 million composition records. We describe the dataset and provide means to access it. Additionally, we demonstrate the usage of ORBDA for evaluating inserting throughput and query latency performances of some NoSQL database management systems. We believe that ORBDA is a valuable asset for assessing storage models for openEHR-based information systems during the software engineering process. It may also be a suitable component in future standardised benchmarking of available openEHR storage platforms.

Intelligent Interruption Management System to Enhance Safety and Performance in Complex Surgical and Robotic Procedures.

Procedural flow disruptions secondary to interruptions play a key role in error occurrence during complex medical procedures, mainly because they increase mental workload among team members, negatively impacting team performance and patient safety. Since certain types of interruptions are unavoidable, and consequently the need for multitasking is inherent to complex procedural care, this field can benefit from an intelligent system capable of identifying in which moment flow interference is appropriate without generating disruptions. In the present study we describe a novel approach for the identification of tasks imposing low cognitive load and tasks that demand high cognitive effort during real-life cardiac surgeries. We used heart rate variability analysis as an objective measure of cognitive load, capturing data in a real-time and unobtrusive manner from multiple team members (surgeon, anesthesiologist and perfusionist) simultaneously. Using audio-video recordings, behavioral coding and a hierarchical surgical process model, we integrated multiple data sources to create an interactive surgical dashboard, enabling the identification of specific steps, substeps and tasks that impose low cognitive load. An interruption management system can use these low demand situations to guide the surgical team in terms of the appropriateness of flow interruptions. The described approach also enables us to detect cognitive load fluctuations over time, under specific conditions (e.g. emergencies) or in situations that are prone to errors. An in-depth understanding of the relationship between cognitive overload states, task demands, and error occurrence will drive the development of cognitive supporting systems that recognize and mitigate errors efficiently and proactively during high complex procedures.

PD54 Associated Factors Renal Graft Loss Using Real-World Evidence In Brazil

Introduction:Renal transplantation is considered a cost-effective treatment compared to dialysis and represents a significant percentage of public health resources. Post-transplant treatment requires the use of three immunosuppressive drugs. The immunosuppressive regimens consists of a corticosteroid, a calcineurin inhibitor (cyclosporine or tacrolimus) and an antiproliferative agent (azathioprine or mycophenolate) and also by sirolimus or everolimus. In Brazil, the Unified Health System (as known as Sistema Único de Saúde - SUS) is responsible for 95 percent of all kidney transplants performed, as well as ensuring access to immunosuppressive drugs. Therefore, there is a huge and growing economic impact caused by the distribution of these drugs in SUS. We evaluated the factors associated with kidney graft loss in patients who received deceased donor organ and used maintenance immunosuppressive regimens in SUS, in fifteen years.Methods:We analyzed a nationwide cohort of kidney transplant recipients from January 2000 to December 2015 developed through deterministic-probabilistic linkage of SUS administrative databases: Hospital Information System (SIH/SUS); Subsystem for High Complexity Procedures (SIA/SUS) and the Mortality Information System (SIM). Graft loss was defined as death or dialysis for more than three months. All regimens included corticosteroid. We used Cox proportional hazards model to evaluate the factors associated with progression to graft loss.Results:In total, 18,333 patients were included; 58.5 percent used tracolimus+mycophenolate, 11.7 percent cyclosporine+mycophenolate, 8.9 percent tacrolimus+azathyoprine, 5.5 percent cyclosporine+azathyoprine and 15.4 percent received other immunosuppressive regimens (sirolimus+mycophenolate, everolimus+mycophenolate, tacrolimus, mycophenolate, cyclosporine, azathyoprine) . Most patients were male with a median age of 46 years. A higher risk of graft loss was associated with the use of tracolimus+mycophenolate (HR = 1.069; 95% CI, 0.999–1.146), sirolimus+mycophenolate (HR1.395;95% CI, 1 .150–1.692), tracolimus (monotherapy) (1.468;1.239–1.739); mycophenolate (monotherapy) (1.297;1.126–1.493), male gender (1.144; 1.072–1.221), an additional year of age (1.010; 1.007–1.013), a median dialysis period greater than 38 months (1.266; 1.182–1.356), a diagnosis of diabetes (1.211; 1.071–1.367) and a diagnosis of arterial hypertension (1.209; 1.134–1.288) (HR=1.468;95% CI,1.239 −1.739); mycophenolate (monotherapy) (HR = 1.297; 95% CI, 1.126–1.493), male gender (HR = 1.144; 95% CI 1.072–1.221), an additional year of age (HR = 1.010; 95% CI, 1.007–1.013), a median dialysis period greater than 38 months (HR = 1.266; 95% CI, 1.182–1.356), a diagnosis of diabetes (HR = 1.211; 95% CI, 1.071–1.367) and a diagnosis of arterial hypertension (HR = 1.209; 95% CI, 1.134–1.288)as the primary cause of chronic kidney disease.Conclusions:In Brazil, the use of regimens mycophenolate, tacrolimus, tacrolimus+mycophenolate was associated a higher risk of graft loss, among other factors. The choice of drug therapy is one of the few factors that influence survival amenable to direct action by health professionals. Therefore, the results of this study are important and should be disseminated aiming to better outcomes for kidney transplant patients.

Cirurgia abdominal de alta complexidade: classificação e escolha dos equipamentos pela equipe multiprofissional

Introdução: Os procedimentos de alta complexidade são caracterizados pelo uso da alta tecnologia. A classificação e a escolha dos equipamentossão um desafio para os profissionais envolvidos. Objetivo: Comparar a classificação das cirurgias abdominais de alta complexidade e a escolhados equipamentos pela equipe multiprofissional entre duas instituições hospitalares. Método: Pesquisa descritiva, quantitativa, transversal e comparativa,com questionários estruturados sobre a opinião dos cirurgiões, anestesiologistas e enfermeiros. Resultado: A classificação dos procedimentos ésemelhante quando levados em conta equipamentos (P<1,0) e estrutura física (P=0,172) diferenciados. Discussão: A classificação dos procedimentosmais complexos tem concordância entre os profissionais comparado à legislação, mesmo não englobando o porte anestésico, tipo de procedimentoe condições clínicas na sua classificação; a escolha dos equipamentos é do profissional que os utiliza, incluindo amplas salas de operações, sendo acirurgia robótica dispensável aos cirurgiões. Conclusão: Há diferenças entre instituições de saúde em relação à escolha, à disponibilidade de equipamentose aos tipos de cirurgias abdominais.

PCN49 - Real World Data on Multiple Myeloma Treatment Patterns: First and Second-Line Treatment in the Brazilian Public Health System

Multiple Myeloma (MM) is a bone marrow-based plasma cell neoplasm; data regarding current treatment patterns in Brazil are scarce. Brazilian Public Healthcare System (SUS) defines two procedures for first (1L) and second-line (2L) treatment for MM and reimburses it through High Complexity Procedures Authorization (APAC) System. The objective of this analysis was to analyze 1L and 2L treatment patterns in MM reimbursed during 2012-2016 by SUS and compare them to current Brazilian treatment guideline (PCDT). All APACs for procedures 03.04.03.018-0 (1L) and 03.04.03.019-8 (2L) during 2012-2016 considering the International Classification of Disease Code (ICD-10) C90.0 were extracted from the ambulatory care information system (SIA/SUS) from the Brazilian Health Information System. A key for decoding all chemotherapy inputs was developed by two health professionals and validated by one oncologist and fuzzy matching method was applied. Patient characteristics and treatments were assessed using summary statistics. Overall, 118,177 (1L) and 58,044 (2L) APACs were obtained, corresponding to 11,594 (1L) and 5,569 (2L) patients. Mean number of APACs per patient were 10.43±8.99 (1L) and 10.19±8.93 (2L). After Jan-2012, 8,947 patients in 1L and 3,486 in 2L were diagnosed with MM. Median time from first to last APAC was 7 months for 1L (IQR:2-13) and 6 months for 2L (IQR:2-13). Among patients in 1L, 48.6% were men; overall median age was 64 years (IQR:57-72). Drugs from 90.1% (1L) and 87.5% (2L) APACs could be decoded. Most used drug combinations reported for 1L-treatment were cyclophosphamide monotherapy (8.6%), cyclophosphamide+dexamethasone+thalidomide (7.7%) and melphalane+prednisone (4.9%); for 2L-treatment, cyclophosphamide monotherapy (9.7%), bortezomibe (6.3%) cyclophosphamide+dexamethasone+thalidomide (5.2%) were the most frequent. The most reported drug was a monotherapy not included in the PCDT recommendations, all other frequent combinations were coherent with the current PCDT. The results found are limited by the uncertainty in data input in the database.

COMPREHENSIVE ANALYSIS ON SEEPAGE AND STRUCTURAL STABILITY OF EARTH-ROCK DAM: A CASE STUDY OF XIQUANYAN DAM IN CHINA

Earth-rock dam is commonly used in the high-dam engineering around the world. It has been widely accepted that the analysis on structural and seepage stability plays a very important role, and it is necessary to take into account while designing the earth-rock dam. In performing the analysis of structural and seepage stability, many remarkable methods are available at current stage. However, there are still some important issues remaining unsolved, including: (1) Finite element methods (FEMs) is a means of solutions to analysis seepage process, but it is often a difficult task to determine the so-called seepage coefficient, because the common-used water injection test is limited in the practical work due to the high cost and complex procedure. (2) It has long been discussed that the key parameters for structural stability analysis show a significant spatial and temporal variations. It may be partly explained by the inhomogeneous dam-filling during construction work and the developing seepage process. The consequence is that one constant value of the parameter cannot represent the above variations. In this context, we solve the above issues and introduce the solution with a practical earth-rock dam project. For determining the seepage coefficient, the data from the piezo metric tube is used to calculate the potential value, based on which the seepage coefficient can be back-analysed. Then the seepage field, as well as the seepage stability are numerically analysed using the FEM-based SEEP/W program. As to the structural safety, we take into account the spatial and temporal variations of the key parameters, and incorporate the Monte-Carlo simulation method into the commonly used M-P method to calculate the frequency distribution of the obtained structural safety factor. In this way, the structural and seepage safety can be well analysed. This study is also beneficial to provide a mature method and a theoretical insight into the earth-rock dam design. The earth-rock dam of Xiquanyan Reservoir near Harbin city in China is also selected as case study to illustrate the described method.

PCN41 - Incidence Rates Of Patients Starting Treatment For Chronic Lymphocytic Leukemia In The Brazilian Public Health Care System: A Retrospective Epidemiologic Study Based On Datasus

Chronic lymphocytic leukemia (CLL) is the most common type of leukemia in adults. In the US, the numbers of new cases and deaths represent 4.5/100,000 and 1.4/100,000 per year, respectively (SEERS database). In Brazil, epidemiologic data for CLL are very scarce. The aim of this study was to assess characteristics and to describe incidence rates (IR) for frontline and relapsed/refractory CLL treatment in the Brazilian public health system. A retrospective longitudinal analysis was performed based on Government administrative claims database (Datasus). Eligibility criteria were patients with CLL (ICD code C911) who received treatment from January-2011 to December-2014. IR were calculated by the ratio (number of CLL patients starting treatment)/(total population according to national statistics – IBGE and ANS), categorized by year and based on the following variables: gender, age group and 5 territorial regions. Parametric tests were used to compare different IR across the groups. 86,488 APACs (Authorization for High Complexity Procedures) met eligibility criteria, representing 8,633 patients. The population cohort (57.5% male) comprised patients with an average (±SD) age of 67.5±11.8yrs and 77% were 60yrs of age or over (30.7% 60-69yrs; 31.4% 70-79yrs). There was no statistically significant difference in global IR from 2011 to 2014 (average: 0.75/100,000 per year). Ages over 60yrs had the highest IR: 3.68/100,000 for 60-69yrs, 7.60/100,000 for 70-79yrs and 8.76/100,000 over 80yrs. The average of global IR was 1.38x higher for males (0.872/100,000) compared to females (0.632/100,000) (p<0.001). South region had the highest IR (1.19/100,000), followed by Southeast (0.94/100,000) and Center-west (0.61/100,000). Management of CLL patients is undergoing recent advances with the emergence of BTK inhibitors such as ibrutinib. Epidemiologic studies represent a powerful tool to better comprehend biology of disease and guide clinical decisions. This study showed characteristics of CLL treatment and indicated asymmetry in the Brazilian public healthcare system by age, gender, and geographical region.

Predicting the Burden of Revision Knee Arthroplasty: Simulation of a 20-Year Horizon

ObjectivesTo estimate future utilization scenarios for knee arthroplasty (KA) revision in the Spanish National Health System in the short- and long-term and their impact on primary KA utilization. MethodsA discrete-event simulation model was built to represent KA utilization for 20 years (2012–2031) in the Spanish National Health System. Data on KA utilization from 1997 to 2011 were obtained from the minimum data set. Three scenarios of future utilization of primary KA (1, fixed number since 2011; 2, fixed age- and sex-adjusted rates since 2011; and 3, projection using a linear regression model) were combined with two prosthesis survival functions (W [worse survival], from a study including primary KA from 1995 to 2000; and B [better survival], from the Catalan Registry of Arthroplasty, including primary KA from 2005 to 2013). The simulation results were analyzed in the short-term (2015) and the long-term (2030). ResultsVariations in the number of revisions depended on both the primary utilization rate and the survival function applied, ranging from increases of 8.3% to 31.6% in the short- term and from 38.3% to 176.9% in the long-term, corresponding to scenarios 1-B and 3-W, respectively. The prediction of increases in overall surgeries ranged from 0.1% to 22.3% in the short-term and from 3.7% to 98.2% in the long-term. ConclusionsProjections of the burden of KA provide a quantitative basis for future policy decisions on the concentration of high-complexity procedures, the number of orthopedic surgeons required to perform these procedures, and the resources needed.

Impact of Residents on Surgical Outcomes in High-Complexity Procedures

There are different views on the effects of resident involvement on surgical outcomes. We hypothesized that resident participation in surgical care does not appreciably alter outcomes. We analyzed an American College of Surgeons NSQIP subset of inpatients having procedures with high complexity, including 4 surgical specialties (general surgery, cardiothoracic surgery, neurosurgery, and vascular surgery) with the highest mean work relative value units. We evaluated surgical outcomes in patients having procedures performed by the attending surgeon alone, or by the attending surgeon with assistance from at least one surgical resident (PGY1 to PGY≥6). Outcomes measures included operative mortality, composite morbidity, and failure to rescue (FTR). Propensity-score matching minimized the effects of nonrandom assignment of residents to procedures. In 266,411 patients, unmatched comparisons showed significantly higher operative mortality and composite morbidity rates, but decreased FTR, in operations performed with resident involvement. After propensity-score matching, there were small but significant resident-related increases in composite morbidity, but significant improvement in FTR. Senior-level resident involvement translated into improved outcomes, especially in cardiothoracic surgery procedures where >63.6% of procedures had PGY≥6 resident involvement. Resident involvement attenuated the significant worsening of operative mortality and FTR associated with multiple serious complications in individual patients. Measures of resource use increased modestly with resident involvement. We found substantial improvement in FTR with resident involvement, both in unmatched and propensity-matched comparisons. Senior-level resident participation seemed to attenuate, and even improve, surgical outcomes, despite slightly increased resource use. These results provide some reassurance about teaching paradigms.

Surgical strategies for restoring liver arterial perfusion in pancreatic resections.

Hepatic perfusion failure represents an important risk factor for severe complications and death after pancreatic resections. Arterial reconstruction could be required during pancreatic surgery because of tumor infiltration, benign strictures, or as a consequence of accidental arterial injury during dissection. All these situations can be faced with a certain frequency in high-volume pancreatic centers, where surgeons must be aware of the different alternatives to deal with these intricate scenarios. We herein describe the preoperative surgical planning as well as different surgical strategies for the restoration of arterial perfusion of the liver in pancreatic resections. A thorough preoperative evaluation is essential for planning pancreatic surgery and preparing the surgeon and patient for potentially high complex procedures. The various therapeutic alternatives presented in this technical report might represent a good solution for selected patients with no other potentially curative option than surgery.

Predischarge Transthoracic Echocardiography after Surgery for Congenital Heart Disease: A Routine withaReason?

Predischarge (pre-d/c) transthoracic echocardiography (TTE) is routine after surgery for congenital heart disease, but how it affects clinical care is unknown. The aim of this study was to test the hypothesis that pre-d/c TTE frequently reveals findings associated with short-term clinical course through a systematic review of findings on pre-d/c TTE and clinical events that followed. Clinical outcomes of mortality, hospitalization, catheterization, and surgery at 1year were examined for pediatric patients undergoing pre-d/c TTE between June 2010 and June 2012. Using logistic regression, a multivariate model was generated associating clinical, pre-d/c transthoracic echocardiographic, and demographic variables with unplanned postdischarge cardiac events (UCEs) within 1 year. Of 462 patients who underwent pre-d/c TTE, there were 265 male patients (57%) and 197 female patients (43%); the median age was 0.8years (range, 0-33years). Two hundred thirty-seven patients (51%) had findings (valve regurgitation, hemodynamic obstruction, ventricular dysfunction, unintended shunt, or pericardial effusion) on pre-d/c TTE, 57 of which were of more than mild severity. Agreement between pre-d/c TTE and postoperative transesophageal echocardiographic findings was only fair to moderate (κ= 0.27-0.43). Sixty-four patients (14%) had UCEs. Univariate analysis revealed that UCE were more frequent in patients with diagnoses and surgical procedures of high complexity. After accounting for these confounding nonechocardiographic variables, pre-d/c transthoracic echocardiographic findings, specifically valve regurgitation of more than mild severity, and ventricular dysfunction and obstructions of any severity were independently associated with UCEs (odds ratios, 1.90, 1.99, and 1.85, respectively). Findings on pre-d/c TTE are frequent, commonly discordant with postoperative transesophageal echocardiographic results, and associated with adverse clinical events after surgery for congenital heart disease. These data would strongly support the practice of pre-d/c TTE after surgery for congenital heart disease.

Name segmentation using hidden Markov models and its application in record linkage.

This study aimed to evaluate the use of hidden Markov models (HMM) for the segmentation of person names and its influence on record linkage. A HMM was applied to the segmentation of patient's and mother's names in the databases of the Mortality Information System (SIM), Information Subsystem for High Complexity Procedures (APAC), and Hospital Information System (AIH). A sample of 200 patients from each database was segmented via HMM, and the results were compared to those from segmentation by the authors. The APAC-SIM and APAC-AIH databases were linked using three different segmentation strategies, one of which used HMM. Conformity of segmentation via HMM varied from 90.5% to 92.5%. The different segmentation strategies yielded similar results in the record linkage process. This study suggests that segmentation of Brazilian names via HMM is no more effective than traditional segmentation approaches in the linkage process.

Research on a New Radar Antenna Pattern Measurement Method

. The traditional radar antenna pattern measurement has high cost and complex procedures. With the flexibility and low cost of small rotor UAV, we propose a new radar antenna pattern measurement based on UAV platform. In the following we will analyze the traditional radar antenna pattern measurement techniques and its shortcomings. Then we suggest a solution based on UAV and expound the key technologies. At the end we analyze the difficulties and errors that may occur in engineering practices, which provides basis for the next project implementation.

Dialysis for end stage renal disease financed through the Brazilian National Health System, 2000 to 2012.

BackgroundChronic kidney disease has become a public health problem worldwide. Its terminal stage requires renal replacement therapy – dialysis or transplantation – for the maintenance of life, resulting in high economic and social costs. Though the number of patients with end-stage renal disease treated by dialysis in Brazil is among the highest in the world, current estimates of incidence and prevalence are imprecise. Our aim is to describe incidence and prevalence trends and the epidemiologic profile of end-stage renal disease patients receiving publically-financed dialysis in Brazil between 2000 and 2012.MethodsWe internally linked records of the High Complexity Procedure Authorization/Renal Replacement Therapy (APAC/TRS) system so as to permit analyses of incidence and prevalence of dialysis over the period 2000-2012. We characterized temporal variations in the incidence and prevalence using Joinpoint regression.ResultsOver the period, 280,667 patients received publically-financed dialysis, 57.2% of these being male. The underlying disease causes listed were hypertension (20.8%), diabetes (12.0%) and glomerulonephritis (7.7%); for 42.3%, no specific cause was recorded. Hemodialysis was the therapeutic modality in 90.1%. Over this period, prevalence increased 47%, rising 3.6% (95% CI 3.2% - 4.0%)/year. Incidence increased 20%, or 1.8% (1.1% – 2.5%)/year. Incidence increased in both sexes, in all regions of the country and particularly in older age groups.ConclusionsIncidence and prevalence of end-stage renal disease receiving publically-financed dialysis treatment has increased notably. The linkage approach developed will permit continuous future monitoring of these indicators.