Permanent Placement Research Articles

Timing of Permanent Ventricular Shunt Placement Following External Ventricular Drain Placement in Primary Intracerebral Hemorrhage

Intraventricular hemorrhage requiring ventriculostomy placement is a frequent complication of spontaneous intracerebral hemorrhage. Although a subset of patients will require permanent ventricular shunt placement, little is known about contemporary practices regarding the timing of ventriculostomy and ventricular shunt placement after intracerebral hemorrhage. Using the 2010-2012 National Inpatient Sample, we identified patients with International Classification of Diseases, Ninth Revision codes for intracerebral hemorrhage, excluded secondary causes, and examined procedure dates. Of 35,899 patients with primary intracerebral hemorrhage, 2443 (6.8%) received ventriculostomy, 93% within the first 3 days of admission and 66% within the first day. Permanent shunt placement occurred in 173 (7.1%) patients following ventriculostomy at a median interval of 15 days (interquartile range: 11-20). Among those remaining alive and in hospital at 14, 21, and 28 days, 5%, 11%, and 15%, respectively, underwent shunt placement following ventriculostomy, and 24% of those with multiple ventriculostomy insertions required permanent shunt by 4 weeks of hospitalization. Multiple ventriculostomies, tracheostomy, and black race were associated with longer time to permanent shunt. A wide variation in delay to permanent shunt placement is present, with substantial and increasing prevalence with time in hospital. Better understanding of the risk factors associated with persistent hydrocephalus will help optimize patient selection and timing of treatment.

Clinical Characteristics and Outcomes of Patients with Ischemic and Non-Ischemic Complete Heart Block.

IntroductionThird degree or complete heart block (CHB) is a medical emergency and usually requires permanent pacemaker placement. CHB can be caused by cardiac ischemia or non-ischemic conditions such as infiltrative diseases or fibrosis. The purpose of this study is to identify the baseline clinical characteristics associated with ischemic versus non-ischemic causes of complete heart block and compare their outcomes.Materials and methodsAn institutional review broad approval was granted by the Cleveland Clinic Health System. In our study, 216 patients with CHB presenting to Fairview Hospital between January 2014 and June 2016 were initially identified using the International Classification of Disease (ICD) codes at discharge. Only the patients with a new diagnosis of complete heart block (CHB) were included in the study (total N=62), which led to the exclusion of 154 patients. The patients were characterized into non-ischemic and ischemic groups based on cardiac marker elevation, electrocardiogram changes and/or cardiac catheterization findings. In all the patients, data including the following was collected: demographics such as age, gender, ethnicity and body mass index; pre-existing comorbidities such as hypertension, chronic kidney disease, diabetes mellitus, thyroid disease, previous coronary artery disease, history of cancer; use of nodal blocking agents, electrolyte abnormalities on admission, echocardiographic parameters such as ejection fraction (EF), right ventricular systolic pressure (RVSP), left ventricular end diastolic and systolic volumes (LVEDV and LVESV, respectively). The primary outcome was all-cause mortality and the secondary outcome was pacemaker placement. Categorical variables were analyzed using chi-square and continuous variables using ANOVA.ResultsOut of 62 patients (N=62), 48 had non-ischemic and 14 had ischemic CHB. The mean age was 67 years (95% CI, 60.55-74.73) in the ischemic group and 75 years (95% CI, 71.52-78.80) in the non-ischemic group, p=0.04. Patients with ischemic CHB had a lower mean EF of 49.6% (95% CI, 42.04%-57.23%) compared to 57.42% in non-ischemic CHB patients (95% CI, 53.97%-60.87%), p=0.05. History of coronary artery disease was present in 71.4% (10/14) patients with ischemic CHB compared to 37.5% (18/48) patients with non-ischemic CHB, p=0.02. There was no statistically significant difference between the two groups in terms of gender, diabetes, hypertension, thyroid dysfunction, chronic kidney disease, nodal blocking agents, electrolyte abnormalities or smoking status. For outcomes, 6/48 (12.5%) of patients with non-ischemic CHB had died compared to 3/14 (21.4%) ischemic CHB (p=0.327). Permanent pacemaker was implanted in 45/48 patients (93.75%) of the non-ischemic CHB compared to 6/14 (42.83%) in the ischemic group (p<0.001).ConclusionsPatients with ischemic CHB are younger, and they have a lower ejection fraction but they are less likely to get a pacemaker compared to non-ischemic CHB. Further studies with a bigger sample size are required to understand the long term mortality outcomes of patients with CHB.

Temporary Stent-Assisted Coil Embolization as a Treatment Option for Wide-Neck Aneurysms.

Simple coil embolization is often not a feasible treatment option in wide-neck aneurysms. Stent-assisted coil embolization helps stabilize the coils within the aneurysm. Permanent placement of a stent in an intracranial vessel, however, requires long-term platelet inhibition. Temporary stent-assisted coiling is an alternative technique for the treatment of wide-neck aneurysms. To date, only case reports and small case series have been published. Our purpose was to retrospectively analyze the effectiveness and safety of temporary stent-assisted coiling in a larger cohort. Research was performed for all patients who had undergone endovascular aneurysm treatment in our institution (University Hospital Aachen) between January 2010 and December 2015. During this period, 355 consecutive patients had undergone endovascular aneurysm treatment. We intended to treat 33 (9.2%) of them with temporary stent-assisted coiling, and they were included in this study. Incidental and acutely ruptured aneurysms were included. Sufficient occlusion was achieved in 97.1% of the cases. In 94%, the stent could be fully recovered. Complications occurred in 5 patients (14.7%), whereas in only 1 case was the complication seen as specific to stent-assisted coiling. Temporary stent-assisted coiling is an effective technique for the treatment of wide-neck aneurysms. Safety is comparable with that of stent-assisted coiling and coiling with balloon remodeling.

Disability and mortality after permanent feeding tube placement in patients with acute stroke (P3.107)

Disability and mortality after permanent feeding tube placement in patients with acute stroke (P3.107)

Postoperative atrial fibrillation following cardiac surgery: a persistent complication.

Postoperative atrial fibrillation (POAF) is a common, expensive and potentially morbid complication following cardiac surgery. POAF occurs in around 35% of cardiac surgery cases and has a peak incidence on postoperative day 2. Patients who develop POAF incur on average $10000-$20000 in additional hospital treatment costs, 12-24 h of prolonged ICU time, and an additional 2 to 5 days in the hospital. POAF has been identified as an independent predictor of numerous adverse outcomes, including a 2- to 4-fold increased risk of stroke, reoperation for bleeding, infection, renal or respiratory failure, cardiac arrest, cerebral complications, need for permanent pacemaker placement, and a 2-fold increase in all-cause 30-day and 6-month mortality. The pathogenesis of POAF is incompletely understood but likely involves interplay between pre-existing physiological components and local and systemic inflammation. POAF is associated with numerous risk factors including advanced age, pre-existing conditions that cause cardiac remodelling and certain non-cardiovascular conditions. Clinical management of POAF includes both prophylactic and therapeutic measures, although the efficacy of many interventions remains in question. This review provides a comprehensive and up-to-date summary of the pathogenesis of POAF, outlines current clinical guidelines for POAF prophylaxis and management, and discusses new avenues for further investigation.

Clinical outcome in nonagenarians undergoing transcatheter valve replacement

BackgroundNonagenarians are mostly denied from different therapeutic strategies due to high preoperative risk. We present the results of nonagenarians with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR). MethodsOur retrospective analysis include baseline and procedural data along with clinical outcome. Clinical follow-up was performed in all patients after TAVR. ResultsOut of 689 patients, 33 nonagenarians with a mean age of 90.9±1.4years suffering from severe AS and elevated comorbidity index (logistic EuroSCORE of 16.3±9.6%, STS score 11.1±9.9%) underwent TAVR between September 2009 and July 2016 using self-expanding prosthesis. Baseline transthoracic echocardiography reported a mean aortic valve area (AVA) of 0.64±0.12cm2 with a mean pressure gradient of 56.1±16.1mmHg. Five (16.2%) patients had postprocedural moderate/severe aortic regurgitation. One patient died intraoperally due to ventricular perforation during predilatation, while two patients died within the first 30days, one due to cardiogenic shock and the other due to pneumonia. No patient experienced a myocardial infarction or a stroke, while ten (30.3%) required permanent pacemaker placement. At follow-up (mean 20.3 months, range 1–78 months), all cause and cardiovascular mortality was 24.2% and 15.1%, respectively. Two patients presented heart failure and 12 (40%) had exertional dyspnea. By echo, mean valve area was 1.72±0.12cm2 and mean gradient 11.2±1.4mmHg. Two patients (16.7%) presented moderate aortic regurgitation. ConclusionOur case series demonstrate that even with elevated comorbidity index, clinical endpoints and valve-associated results are relatively favorable in nonagenarians treated with TAVR.

The opioid epidemic

Opioid use disorder is a growing epidemic, with an alarming number of associated deaths. In 2014, in the United States, 18,893 lethal overdoses were related to prescription opioids and 10,574 due to heroin. Despite the growing number of treatment options for substance use disorders, which are chronic, relapsing-remitting conditions, relapse rates remain as high as 91%. In the United States, 7.5 million children reside with at least one patient who abuses drugs or alcohol. Mothers are twice as likely to lose custody of their children. They have higher rates of comorbid abuse and psychopathology and limited social supports. Child service agencies, commonly involved in these scenarios, are often pressured to find permanent placement for children, within an expedited timeframe, inconsistent with the need for sufficient time for recovery and goals of family inclusion and unity. We present the complicated case of a 25-year-old woman with a history of opioid use disorder and depression, who, after being in and out of treatment programs for years, had a lethal overdose. She had a significant family history of addiction and had lost custody of her children. This challenging, but common presentation draws attention to challenges in providing treatment during this opioid epidemic.

A Randomized Controlled Trial of Family Finding: A Relative Search and Engagement Intervention for Youth Lingering in Foster Care.

Youth who have experienced foster care are at risk of negative outcomes in adulthood. The family finding model aims to promote more positive outcomes by finding and engaging relatives of children in foster care in order to provide options for legal and emotional permanency. The present study tested whether family finding, as implemented in North Carolina from 2008 through 2011, improved child welfare outcomes for youth at risk of emancipating foster care without permanency. A randomized controlled trial evaluation was carried out in nine counties in North Carolina. All children eligible for intervention services between 2008 and 2011 underwent random assignment. Effects were tested with an intent-to-treat design. Outcome data were obtained for all subjects from child welfare administrative data. Additional outcome data for a subset of older youth came from in-person interviews. Subjects included 568 children who were in foster care, were 10-17 years old (at time of referral), had no identified permanent placement resource, and had no plan for reunification. The confirmatory outcome was moves to more family-like placements, whether through a step-down in foster care placement or discharge from foster care to legal permanency. No impact on the confirmatory outcome was observed. Findings regarding exploratory impacts are also described; these must be interpreted with caution, given the large number of outcomes compared. The evaluation failed to find evidence that family finding improves the outcomes of older youth at risk of emancipation from foster care.

Perioperative predictors of permanent pacing and long-term dependence following tricuspid valve surgery: a multicentre analysis.

Permanent pacemaker placement (PPM) is often required after valvular surgery and is especially common following tricuspid valve surgery [tricuspid valve repair or replacement (TVR)]. Literature suggests that surgical intervention for isolated tricuspid valve disease is becoming more prevalent. Predictors of PPM dependency following TVR are currently unknown and would be clinically useful from a prognostication standpoint. We conducted a multicentre, retrospective study to assess perioperative factors of TVR that predispose to PPM placement and long-term PPM dependency from 2008 to 2014. Regression analysis was used to determine independent predictors of PPM implantation. A total of 237 patients (age 66 ± 15 years, 29% male) were studied, and the incidence of PPM placement following TVR was 27% (65/237). No significant differences were observed between those who received PPM and those who did not in age (P = 0.092), gender (P = 0.359), and co-morbidities. Regression analysis identified cross-clamp time >60 min (OR 4.1, 95% CI 1.3-12.9, P = 0.015) and concomitant mitral valve surgery (OR 3.8, 95% CI 1.2-12.2, P = 0.026) as independent risk factors for PPM following TVR. Long-term PPM dependency data were only available in 28 patients who received PPM with 14 of these patients developing long-term dependence. The only statistically significant difference noted was an increased frequency of coronary artery disease in the long-term dependent group vs. the non-dependent group (64% vs. 14%, P = 0.018). Cross-clamp time >60 min and concomitant mitral valve surgery were independent predictors of PPM implantation following TVR. Long-term PPM dependency is more prevalent after TVR than other types of valvular surgery.

Long-term outcome of sacral neuromodulation in patients with idiopathic nonobstructive urinary retention: Single-center experience.

Objective:The objective of this study was to determine the safety and efficacy of sacral neuromodulation (SNM) in patients with idiopathic nonobstructive urinary retention.Materials and Methods:We retrospectively reviewed the files of patients who underwent staged neuromodulation for idiopathic nonobstructive urinary retention from 2004 to 2016 at our hospital. Patients who had a 50% improvement in symptoms after 1 week of stage 1 procedure were qualified for permanent device implantation. Patient data were assessed on efficacy and need for intermittent self-catheterization, complications, and operative revision rates.Results:Twenty-seven female patients who underwent SNM therapy were analyzed. The mean age of the patients was 32.5 ± 10.8 years. The mean duration of urinary retention was 3.2 ± 1.7 years. All patients were doing intermittent self-catheterization, but few were able to void <100 ml. Twenty-four (88.8%) of the 27 patients demonstrated a >50% improvement in symptoms and underwent permanent device placement. At a median follow-up of 5.7 ± 3.2 years, 20 (83.3%) of the 24 patients demonstrated sustained improvement rates of >50%. Seventeen (70.83%) of 24 patients could void spontaneously with a mean residual urine of 28.1 ± 24.4 ml (P < 0.001). Three (12.5%) were voiding with significant mean decreasing number of catheterizations from 5.6 ± 2.4 to 1.4 ± 2.1 (P < 0.001). Four (16.6%) had their device explanted. Ten (41.6%) of the 24 patients underwent surgical revision. Most of the adverse events were managed by device reprograming.Conclusion:SNM is a highly effective and safe procedure in this subset of the female population with idiopathic refractory nonobstructive urinary retention.

Efficacy and safety of combined intraventricular fibrinolysis with lumbar drainage for prevention of permanent shunt dependency after intracerebral hemorrhage with severe ventricular involvement: A randomized trial and individual patient data meta-analysis.

Intraventricular hemorrhage (IVH) is a negative prognostic factor in intracerebral hemorrhage (ICH) and is associated with permanent shunt dependency in a substantial proportion of patients post-ICH. IVH treatment by intraventricular fibrinolysis (IVF) was recently linked to reduced mortality rates in the CLEAR III study and IVF represents a safe and effective strategy to hasten clot resolution that may reduce shunt rates. Additionally, promising results from observational studies reported reductions in shunt dependency for a combined treatment approach of IVF plus lumbar drains (LDs). The present randomized, controlled trial investigated efficacy and safety of a combined strategy-IVF plus LD versus IVF alone-on shunt dependency in patients with ICH and severe IVH. This randomized, open-label, parallel-group study included patients aged 18 to 85 years, prehospital modified Rankin Scale ≤3, ICH volume < 60ml, Glasgow Coma Scale of <9, and severe IVH with tamponade of the third and fourth ventricles requiring placement of external ventricular drainage (EVD). Over a 3-year recruitment period, patients were allocated to either standard treatment (control group receiving IVF consisting of 1mg of recombinant human tissue plasminogen activator every 8 hours until clot clearance of third and fourth ventricles) or a combined treatment approach of IVF and-upon clot clearance of third and fourth ventricles-subsequent placement of an LD for drainage of cerebrospinal fluid (CSF; intervention group). The primary endpoint consisted of permanent shunt placement indicated after a total of three unsuccessful EVD clamping attempts or need for CSF drainage longer than 14 days in both groups. Secondary endpoints included IVF- and LD-related safety, such as bleeding or infections, and functional outcome at 90 and 180 days. Conducted endpoint analyses used individual patient data meta-analyses. The study was registered at clinicaltrials.gov (NCT01041950). The trial was stopped upon predefined interim analysis after 30 patients because of significant efficacy of tested intervention. The primary endpoint was analyzed without dropouts and was reached in 43% (7 of 16) of the control group versus 0% (0 of 14) of the intervention group (p = 0.007). Meta-analyses were based on overall 97 patients, 45 patients receiving IVF plus LD versus 42 with IVF only. Meta-analyses on shunt dependency showed an absolute risk reduction of 24% for the intervention (LD, 2.2% [1 of 45] vs no-LD, 26.2% [11 of 42]; odds ratio [OR] = 0.062; confidence interval [CI], 0.011-0.361; p = 0.002). Secondary endpoints did not show significant differences for CSF infections (OR = 0.869;CI, 0.445-1.695; p = 0.680) and functional outcome at 90 days (OR = 0.478; CI, 0.190-1.201; p = 0.116), yet bleeding complications were significantly reduced in favor of the intervention (OR = 0.401; CI, 0.302-0.532; p < 0.001). The present trial and individual patient data meta-analyses provide evidence that, in patients with severe IVH, as compared to IVF alone, a combined approach of IVF plus LD treatment is feasible and safe and significantly reduces rates of permanent shunt dependency for aresorptive hydrocephalus post-ICH. ANN NEUROL 2017;81:93-103.

One-Stage Technique for Rumenal Fistulation in Rams

Rumenal fistula is very essential in nutrition and physiology experimental research studies in sheep. Permanent placement of the cannula without complication is a challenge. This experimental study aimed to provide a detailed description of modified one-stage technique for rumenal fistula in sheep to simplify the surgery, decrease the post-operative complications, and lengthen the functional life of the cannula. As well as reporting the postoperative complications related to the surgery as well as short and long term monitoring. 10 healthy rams were surgically prepared for left side laparotomy in lateral recumbent position. The rumen was grasped, anchored to the subcutaneous tissue, and incised to fit the custom-made cannula. The rumenal wall was sutured directly to the skin after insertion of the cannula, and a metal retainer flange was pushed to secure the cannula in place. No early post-surgical complications. None fistula got a bigger size, and none cannula was rejected, or had to be repositioned. The one-stage technique used in this study to fix a custom-made cannula in its position recommended to experimental research on sheep nutrition and physiology.

Predictive biomarkers for prostate brachytherapy—not there yet

Brachytherapy has been used for the treatment of prostate cancer for nearly 100 years. Low dose rate brachytherapy, the permanent placement of radioactive seeds (e.g., Iodine-125 or Pallidium-103) within the prostate, is an effective treatment for men with clinically localized low-risk prostate cancer. Brachytherapy can also be delivered by temporarily inserting high energy radioactive isotopes (e.g., Iridium-192) into the prostate. This technique is referred to as high dose-rate brachytherapy. The ability of brachytherapy to directly deliver radiation within the prostate while limiting the dose delivered to surrounding normal tissues is a significant advantage of this treatment (1).

Biatrial or Left Atrial Lesion Set for Ablation During Mitral Surgery: Risks and Benefits

Controversy exists when performing surgical atrial fibrillation ablation whether there is an increase in postoperative complications using biatrial (BA) lesions compared with only left atrial (LA) lesions, and some studies indicate similar efficacy. This study compares the clinical outcomes of BA and LA ablation lesions in mitral valve surgery patients. From 2004 through 2014, 2,137 patients had mitral valve surgery with or without other surgeries in a single center. Of those, 836 (39%) had preoperative atrial fibrillation, and of those, 724 (86%) underwent atrial fibrillation ablation surgery; 257 patients had BA lesion sets and 359 had LA lesion sets. Propensity score matching of BA and LA patients was performed. Baseline differences included more postoperative complications in the BA group, specifically, permanent pacemaker placement (13% versus 7%; p= 0.006). Freedom from atrial fibrillation off antiarrhythmic drugs (72% BA versus 75% LA; p= 0.50), postoperative ablation (7% BA versus 5% LA; p= 0.20), stroke (0.11 versus 0.11 per 10 person-years; p= 0.91), and survival were similar between the groups. After matching, patients in the LA group had a higher freedom from postoperative ablation (p= 0.015), but no difference in freedom from atrial fibrillation off antiarrhythmic drugs (79% BA versus 69% LA; p= 0.09), and no difference inpermanent pacemaker placement (10% versus 12%; p= 0.57). Patients undergoing mitral surgery with LA or BA ablation had similar outcomes, survival, and complications. Limiting lesions to the LA is an effective alternative to BA ablation for patients undergoing ablation with concomitant mitral valve surgery.

Is the efficacy of sacral nerve stimulation for faecal incontinence dependent on the number of active electrode poles achieved during permanent lead insertion?

Sacral nerve stimulation (SNS) is effective for faecal incontinence (FI). Little is known about the relationship between the implantation technique and the functional outcome. This study aimed to explore the relationship between the numbers of active electrode poles (AEP) achieved during permanent lead placement and subsequent function, therapeutic amplitude and the need for extra appointments between scheduled follow-up visits. One hundred and eighty-six patients with FI who underwent permanent implantation between May 2009 and March 2015 with a tined (barbed) lead (3093/3080, Medtronic) using the straight stylet were registered on the European two-centre SNS prospective database (SNSPD). Correlation between the number of AEP, function, stimulation amplitude and the need for extra visits was analysed. The numbers of patients having an intra-operative motor response on stimulation of one, two, three and four poles were 18 (9.7%), 75 (40.3%), 61 (32.8%) and 32 (17.2%). The Wexner incontinence score was significantly reduced from 15 (±2.8) at baseline to 9.2 (±4.8) at the latest follow-up after a mean 878±561days (SD; P<0.001). No correlation was found between the number of AEP and the functional outcome (P>0.05). Patients with four-AEP had a reduced therapeutic amplitude up to 289 (±146) days of follow-up (P<0.03). The number of AEP did not influence the need for extra follow-up visits (P<0.223). The functional outcome and number of extra visits after SNS for FI did not depend on the number of AEP achieved. The therapeutic amplitude was reduced during the first postoperative year if four AEP were achieved during lead placement.

Unstable child welfare permanent placements and early adolescent physical and mental health: The roles of adverse childhood experiences and post-traumatic stress

Although researchers have found that child welfare placement disruptions are associated with elevated youth physical and mental health problems, the mechanisms that explain this association have not been previously studied. The present study built on a previous investigation of the physical and behavioral consequences of long-term permanent placement patterns among youth who participated in the Longitudinal Studies of Child Abuse and Neglect (LONGSCAN). The current investigation (n=251) aimed to (a) report the early adolescent living situations of youth with different long-term placement patterns, and (b) to delineate the roles of adverse childhood experiences (ACEs) and post-traumatic stress (PTS) reactions in the association between unstable long-term placement patterns and physical and mental health problems during the transition to adolescence. Information about youth’s living situations, ACEs, and physical and mental health was gathered prospectively from child protective services records and biannual caregiver and youth interviews when youth were 4–14 years old. The majority of youth remained with the same caregiver during early adolescence, but youth with chronically unstable permanent placement patterns continued to experience instability. Path analyses revealed that ACEs mediated the association between unstable placement patterns and elevated mental, but not physical, health problems during late childhood. Additionally, late childhood PTS mediated the association between unstable placement patterns and subsequent escalations in physical and mental health problems during the transition to adolescence. Findings highlight the importance of long-term permanency planning for youth who enter the child welfare system and emphasize the importance of trauma-focused assessment and intervention for these youth.

Making parents pay: The unintended consequences of charging parents for foster care

Most families in the child protective services system also interact with the child support enforcement system. This study exploits a natural experiment in Wisconsin, created by the state's large regional variation in child support referral policy, to estimate a potentially important effect of child support enforcement on the duration of out-of-home foster care placement. The effect we examine is whether requiring parents to pay support to offset the costs of foster care delays children's reunification with a parent or other permanent placement. We find evidence of this unintended effect, which is important not only because longer foster care spells are expensive for taxpayers, but also because extended placements in foster care may have consequences for child well-being. Our results highlight the potential importance of cross-systems analysis and the potential consequences when the policies and fundamental objectives of public systems are inconsistently coordinated. We discuss the implications of our findings for child support and child protective services policy.

Acute Hepatic Failure Associated with Rivaroxaban Administration

A 74-year old male with CAD underwent a coronary artery bypass graft (CABG) and a permanent pacemaker placement (PPM). Two weeks later, he developed a new-onset of non-valvular atrial fibrillation and was started on rivaroxaban 20 mg daily for stroke prophylaxis. He presented 8 days later to the ER with complaints of dizziness, fatigue, epigastric discomfort, and loss of appetite. In the ER, the patient was hemodynamically stable and his home medications were aspirin, atorvastatin, metoprolol and rivaroxaban. He has been on atorvastatin and metoprolol for 5 to 6 years prior to his CABG. At the time of admission, laboratory tests revealed abnormal AST 136 IU/L, ALT 164 IU/L, ALP 78 IU/L and elevated prothrombin time of 35.5s (INR 3.1). These parameters were normal prior to starting rivaroxaban. He denied any use of over-the-counter medications, herbals or supplements. Over the next 2 days there was a dramatic rise in his serum liver enzymes (Graph 1) leading to encephalopathy and multi-organ failure (Graph 2). He was then transferred to the intensive care unit and empirically treated with N-acetyl cysteine (NAC) for probable drug induced liver injury (DILI). He subsequently died on day 8 of hospitalization. An autopsy revealed nutmeg liver (Figure 1), severe centrilobular necrosis of zones 2 and 3 with a rim of viable cells around the periportal area in zone 1 (Figure 2) along with mild steatosis and intra-hepatic cholestasis indicating a possible DILI (Figure 3). DILI is the leading cause of acute liver failure (ALF). Clinically, biochemically and histologically, DILI can mimic nearly all forms of hepatic injury ranging from an asymptomatic elevation of liver enzymes to ALF. There have been reports of hepatitis and/or cholestasis associated with rivaroxaban. Although the exact frequency of Hepatobiliary complications associated with this drug is unclear, the incidence appears to be less than 1%. The CIOMS/RUCAM score for DILI in our patient was 5 suggestive of DILI. To the best of our knowledge, this is the first case of ALF associated with rivaroxaban in the absence of underlying liver disease. The safety of this drug needs to be evaluated in larger cohorts. Discontinuation of the drug, administration of NAC, and supportive care +/- liver transplantation are some of the management options for ALF secondary to DILI.Figure 1Figure 2Figure 3

Three sides to a foster care story: An examination of the lived experiences of young adults, their foster care case record, and the space in between

Between 2000 and 2013, the U.S. foster care caseload decreased while the number of children in adoptive homes doubled. These shifts were a result of federal policies prioritizing the moving of children from state custody into legal permanence (e.g., adoption and guardianship) with the presumption they will live “happily ever after.” This study used a mixed-methods multiphase, iterative process to illuminate the congruencies and incongruencies between the young adults' accounts of their foster care experiences and the legalistic, system-focused view of their experiences. This study highlights the limitations of administrative data as the primary source for evaluating systems, assessing child well-being, and for understanding child welfare outcomes. An important consideration for assessing the success of the child welfare system in finding safe, stable, permanent placements for children involved with the child welfare system is including the perceptions of the young adults with foster care histories. There are often three sides to a foster care story: the lived experiences of the participant, the official case record, and the space in between. This study begins to illuminate this space, through an understanding of the quality and enduring nature of these relationships as reported by young adults who lives were impacted by their foster care histories. Child welfare records indicate a legal permanency status, but the interviews address the enduring nature and quality of the relationships.

P1. A survey of initial patient diagnostic reference levels from selected fluoroscopically guided interventional procedures at Groote Schuur hospital

Introduction Fluoroscopy units must comply with the minimum requirements set up by the Department of Health: Radiation Control, which require a license holder to establish a program to ensure that the radiation dose that a patient receives for diagnostic and interventional procedures is optimised. The approach of optimisation involves several aspects, including quality control, establishment of diagnostic reference levels (DRLs) and conducting dose surveys. Of relevance to this study are the DRLs. The aim of the study is to analyse the initial Dose-Area Product (DAP) records of three fluoroscopically guided procedures performed at Groote Schuur Hospital, to determine a baseline local DRL for each examination and compare the obtained values with reference values from literature. Materials and methods Active tracking of DAP records on the cardiac catheterization laboratories (Cathlabs) began in August 2015. DAP records collected over the period from August 2015 to May 2016 from the two Cathlabs were retrieved and analysed. The third quartile of the DAP distribution for coronary angiography (CA), coronary angiography plus left ventriculography (CA + LV) and permanent pacemaker placement were determined and were set as initial local DRLs. Results In the ten month time period in question, DAP data was recorded for 224 coronary angiographies, 144 coronary angiography plus left ventriculography studies and 90 pacemaker placements. These numbers are adequate to set initial local DRLs. Baseline local DRLs were set as follows: CA: 67 Gy·cm2, CA + LV: 72 Gy·cm2 and pacemaker placement: 10 Gy·cm2. Conclusion DRL values from these selected studies are in line with values reported in literature, but there is definite room for dose optimisation and the enhancement of radiation protection principles.