Risky Patients Research Articles

Reducing Emergency Department Crowding Using Health Analytics Methods: Designing AnEvidence Based Decision Algorithm

Abstract OBJECTIVE: The main objective of this study is to utilize health analytics methods in designing an evidence based decision algorithm to support healthcare professionals in identifying and safely diverting less risky emergency patients to ambulatory care settings or referring them to other hospitals in order to reduce emergency department crowding. METHODS: The study used retrospective analysis methods. Data were retrieved from the hospital data warehouse system including a total of 13,750 emergency encounters conducted over the first six months of 2014. Descriptive analytics were used to explore different variables and test for any relationships between these variables and admission probability of the patient to determine which variables could be used to build the suggested decision algorithm model. RESULTS: Three variables; acuity level, mode of arrival and age group were identified as the most influential factors on future admission status of emergency patients and were recommended as indicators for designing the decision algorithm. DISCUSSION: Based on the analysis and the suggested decision algorithm, 30% of emergency patients had a 0.2% admission rate; these were suggested to be diverted to urgent outpatient appointments within 24 hours. About 20% of patients can be safely referred to other hospitals, according to the conditions set in the decision algorithm while the remaining 50% of patients should continue their emergency treatment. CONCLUSION: Health analytics can support designing evidence based tools to guide the process of performance improvement, in our study reducing emergency department crowding at King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia.

Pneumocytis jiroveci Infection Developed in Aplastic Anemia Patients Under Prophylaxis

Pneumocystis jiroveci (PJ) is an opportunistic pathogen that can cause infection in immunocompromised patients, primarily in patients with AIDS (Acquired Immune deficiency syndrome). It is quite rare in healthy induviduals. It causes interstitial pneumonia, severe hypoxemia and may demonstrate a fulminant course. Trimethoprim- sulfamethoxazole (TMP-SMX) prophylaxis is recommended for risky patients. In this article, we present a patient with the diagnosis of aplastic anemia who developed pneumocystis jiroveji pneumonia (PJP) and scheduled for haploidentical bone marrow transplantation (BMT) from mother. The patient was under TMP-SMX prophylaxis for a long time and had no history of hospitalization except for the need for transfusion. He was admitted to the emergency department with sudden onset of respiratory distress, and during follow- up period he required mechanical ventilation due to hypoxia and rapid clinical deterioration. Bronchoalveolar fluid samples obtained showed the presence of Pneumocystis jirovecii. Clinical improvement was achieved with mechanical ventilation and supportive treatment. Colonization under antibiotic prophylaxis suggests that effectiveness of prophylaxis does not always prevent colonization. 

Effects of combined epidural analgesia with total intravenous anesthesia on risky patients underwent major abdominal surgery.

The aim of this study is to investigate the effects of combined epidural analgesia with total intravenous anaesthesia and only total intravenous anaesthesia on the different clinical parameters. Sixty high risk patients undergoing a major abdominal surgical procedure were included in this prospective, double blind, randomized study. Induction of anaesthesia was performed with IV remifentanil 0.5µg/kg and propofol titrated to achieve bispectral index score between 40 and 50. after intubation; in Group E, 0.1% bupivacaine and 2 µg/mL fentanyl were administered by an infusion rate at 0.15 ml/kg/h via the epidural catheter and Group C received epidural normal saline as same infusion rate. In group E, intraoperative MAP values were significantly lower than those in group C (p<0.05). Time of extubation, time of eye opening with audible warning and time of verbal response was significantly lower in group E than those in group C. Total anaesthetic drug consumption was significantly higher in group C than those in group E (p<0.05). Based on lower requirements for propofol and remifentanil as well as the favourable effects on clinical parameters; we conclude that bispectral index score guided combined epidural with total intravenous anaesthesia is superior to solely total intravenous anaesthesia in this type of surgery.

Reoperation for post-hepatectomy hemorrhage: increased risk of mortality

Reoperation for post-hepatectomy hemorrhage (PHH) represents an important complication in patients undergoing liver resection. Yet, few studies have reported its presentation and patient outcomes of this event. Among the 2,086 patients who underwent elective hepatectomy from 2000 to 2009 in our HPB unit, the perioperative data of 12 (0.6 %) patients who underwent re-laparotomy for PHH were retrospectively analyzed. The diagnosis of PHH was established in all cases by the presence of blood in the drain. The mean interval time between the end of liver resection and the diagnosis of bleeding and reoperation were 17 h (1-43) and 38 h (1-93), respectively. The causes of bleeding were the hepatic vein branch (n = 4), liver cut surface (n = 3), and a hepatic artery branch (n = 2). In three cases, no bleeding spot was identified. Postoperative death occurred in 3 patients (25 %) between 15 and 18 days after re-laparotomy. These 3 patients were all cirrhotic; 2 underwent early re-laparotomy (≤6 h) and 1 underwent re-laparotomy 24 h after the first recognition of active bleeding. Reoperation for PHH remains an important morbid event after liver resection. Death in patients with this complication is considerably high. It is diagnosed mainly on the aspect of the abdominal drain, justifying its use in risky patients.

Epidural Anesthesia in a Patient with High Cardiac Risk

Cardiac morbidity is the most common cause postoperative of mortality furthermore anesthesia technics are associated with cardiac morbidity and mortality. A 48-year-old male, 90 kg, ASA physical status IV patient underwent femoropopliteal bypass under epidural anesthesia. Comorbidities included atrial fibrillation, dilated cardiomyopathy and 20% left ventricular ejection fraction. Epidural anesthesia was established with bupivacaine and fentanyl at L3-L4 intervertebral space. Hemodynamic stability and pain relief were established during and after the surgery. We consider that epidural anesthesia is preferable as an alternative regarding the risks of spinal anesthesia and general anesthesia for high cardiac risky patients.

P160 Prevalence of IBD among celiacs in our celiac centre

years 1995 and 2011. Each patient was questioned by clinical, labarotory and imaging examinations and finally pathology records for the existence of PSC and any hepatopancreatobiliary tumor and NET. Results: 59 UC patients with IPAA had full records for further evaluations. All of the patients, except one, had normal serum ast, alt, alp, and ggt levels and abdominal ultrasound examination before the operation. We found 4 patients with PSC. Only one was diagnosed before the operation (44 years old). The rest, 3 patients, were diagnosed after the IPAA operation. Interestingly, approximately 12 months later, these patients developed either liver enzyme abnormalities or pruritis and further examination showed PSC. In one (31 years-old, female), mrcp was normal at the beginning, psc was then diagnosed by liver biopsy. 24 months following the IPAA, MRCP and ERCP showed dominant stricture, no cholangiocancer during the follow-up. The other one (35 years old) developed serum alp/ggt abnormalities, then MRCP showed PSC. The last case had UC complicated with rectum cancer, operated and 1 year later (53 years old) developed enzyme abnormalities and psc with dominant stricture diagnosed by both MRCP and ERCP. Only 2 pateints were dead due to complications of IPAA operation during the follow-up. We also evaluated whether hepatopancreatobiliary cancers and NET was increased in this study. Nobody developed HCC, cholangio or gallblader and pancreas cancer or NET. In addition to the case above mentioned, we found 3 patients with colon cancer on the pathologic examination. According to the our IBD registration, of the 2200 patients with IBD in our IBD center, 41 patients (1.6%) had PSC and DS was diagnosed in 34%. Conclusions: Our results showed that the prevalence of PSC was increased by the existence of proctocolectomy-IPAA procedure in patients with UC, in a short period like 12 months. Of the 3 patients developed PSC after the operation, 2 had dominant stricture that was developed in a short period like 24 months. This experience suggests that proctocolectomyIPAA procedure can be formed in UC patients after the careful monitoring for the hepatobiliary conditions, even by liver biopsy in risky patients.

Clinical features of three avian influenza H7N9 virus-infected patients in Shanghai

IntroductionSince February 2013, a novel reassortant H7N9 virus associated with human deaths, but no apparent outbreaks in poultry and wild birds has emerged in eastern China.ObjectivesThe potential reemergence of H7N9 during next year's influenza season demand a further understanding of this important disease.MethodsBetween March 1 and April 30, 2013, we obtained and analyzed clinical, epidemiologic and radiologic features, and virologic data from three laboratory‐confirmed patients of A H7N9 infection admitted in Shanghai Ruijin Hospital.ResultsAll patients were middle to old aged (mean age 62 years) and overweight (mean body mass index 31) patients. Two patients were exposed to poultry directly or indirectly in food market. They presented with fever and rapidly progressive pneumonia that did not respond to antibiotics. Time between onset of symptoms and onset of respiratory failure (days) were 7–11 days. Two patients presented secondary invasive bacterial infections. All patients died on day 7 to day 86 after the onset of symptoms.ConclusionsCross species poultry‐to‐person transmission of this new reassortant avian influenza H7N9 virus can result in severe and fatal respiratory disease like acute respiratory distress syndrome (ARDS) in humans. Reduplicate chest imaging examination is suggested for risky patients with fever and dyspnea. Secondary invasive bacterial infections and pneumothorax can cause severe and fatal consequence. Old age, obesity and presence of comorbidity may be associated with increased mortality. Pulmonary fibrosis can be seen at late stage of the disease.

Consensus on control of risky nonvariceal upper gastrointestinal bleeding in Taiwan with National Health Insurance.

Background and Aims. To compose upper gastrointestinal bleeding (UGIB) consensus from a nationwide scale to improve the control of UGIB, especially for the high-risk comorbidity group. Methods. The steering committee defined the consensus scope to cover preendoscopy, endoscopy, postendoscopy, and overview from Taiwan National Health Insurance Research Database (NHIRD) assessments for UGIB. The expert group comprised thirty-two Taiwan experts of UGIB to conduct the consensus conference by a modified Delphi process through two separate iterations to modify the draft statements and to vote anonymously to reach consensus with an agreement ≥80% for each statement and to set the recommendation grade. Results. The consensus included 17 statements to highlight that patients with comorbidities, including liver cirrhosis, end-stage renal disease, probable chronic obstructive pulmonary disease, and diabetes, are at high risk of peptic ulcer bleeding and rebleeding. Special considerations are recommended for such risky patients, including raising hematocrit to 30% in uremia or acute myocardial infarction, aggressive acid secretory control in high Rockall scores, monitoring delayed rebleeding in uremia or cirrhosis, considering cycloxygenase-2 inhibitors plus PPI for pain control, and early resumption of antiplatelets plus PPI in coronary artery disease or stroke. Conclusions. The consensus comprises recommendations to improve care of UGIB, especially for high-risk comorbidities.

EPA-0344 – Psychodynamic group psychotherapy: a proposition for a new method

in psychodynamic group psychotherapy it is used to divide patients in different groups with direct access and/or after preliminary individual sessions. Since 2003 our research group started a new method. Aim of this study was to assess the value of this new methodology. we use: psychodynamic approach, 10–14 patients, open access for pathology, age, sex, starting and ending. Therapy begins with individual sessions. Therapy deals with symptoms, intra-psychic conflicts, and private issues. Meanwhile psychiatrist develops relational capacity of the patient, allowing him to enter group therapy. We continue, at the same time, with individual and group therapy, for a time different for each case. Then therapy continues in the group only, until its ends. The duration of the three steps is variable, but the total amount of time of the therapeutic approach is reduced by half in 10 years. Efficiency of this method is divided in three points. 1) Advantages for the single patient in the group: improvement of patient privacy; decrease of transferal resistance, acting-out and drop-out; economic advantages. 2) Advantages for group dynamics: decrease of aggressive behavior and interpersonal conflicts, improving of climate group; attenuation of hierarchal levels among patients, manipulation, fabrication, selfpity, narcissism. 3) Advantages for psychiatrist: continuous monitoring of the new patient or ‘difficult’ or risky patients with decrease of countertrasfert issues. This methodology is an effective alternative to the usual group therapy. It allows a thorough and solid approach to the patient, offering a larger possibility of patient recovery.

Is combined myocardial performance index and tricuspid annular plane systolic excursion a better predictive estimator than each of them alone in patients with inferior ST-elevation myocardial infarction?

We aimed to assess the combined estimator of left ventricular (LV) myocardial performance index (MPI) and tricuspid annular plane systolic excursion (TAPSE) as a pooled independent predictive factor for hospital mortality and one-year mortality and re-hospitalization in patients with primary LV inferior ST segment elevation myocardial infarction (STEMI). We prospectively studied 221 consecutive patients (189 males, 32 females; mean age 58.2±4.5; range 38 to 72 years) with primary LV inferior STEMI. Standard echocardiography and Doppler myocardial imaging were used within 24 hours of onset of myocardial infarction to measure LV MPI and TAPSE. Based on LV MPI and TAPSE values, all subjects were categorized into two groups: Group 1 with LV MPI ≥0.55 and TAPSE ≤14 mm (n=78) and Group 2 with the remaining patients (n=143). Patients were followed up for the endpoints of hospital mortality, one-year mortality and one-year re-hospitalization. Hospital mortality (17.9% vs. 6.3%, adjusted odds ratio [OR(adj)] 3.26, p<0.01) one-year mortality (39.1% vs. 14.2%, OR(adj) 3.88, p<0.001) and one-year re-hospitalization rates (50.0% vs. 18.7%, OR(adj) 4.36, p<0.001) were significantly higher in Group 1 than in Group 2. Compared with OR for LV MPI ≥0.55 vs. LV MPI <0.55 or TAPSE ≤14 mm vs. TAPSE >14 mm alone, the pooled parameter of LV MPI ≥0.55 and TAPSE ≤14 mm was shown to be the better predictive estimator, with higher OR and lower significance p-values. In primary LV inferior STEMI patients, combined LV MPI ≥0.55 and TAPSE ≤14 mm was seen to be a more valuable prognostic estimator than LV MPI ≥0.55 or TAPSE ≤14 mm alone for stratifying risky patients.

Frontline Intensive Chemotherapy Brings Survival Benefit In Young, Risky Patients With Follicular Lymphoma: Pair-Matched Analysis From The Czech Lymphoma Study Group (CLSG) Database

BackgroundFollicular lymphoma (FL) is a disease with very heterogeneous course ranging from the indolent forms to rapidly progressive cases with poor outcome. Optimal therapy in FL patients with high tumor burden is immunochemotherapy (R-CHOP is the most frequent regimen used), followed by maintenance treatment. Data from randomized prospective studies (PRIMA) showed poorer outcome in those with high risk disease in terms of lower CR rate, higher risk of relapse and lower efficacy of maintenance therapy. Data comparing up-front intensive approach in younger fit patients and R-CHOP are limited. AimTo analyze long term results of intensive treatment protocol (R-sequential chemotherapy) in comparison with age, FLIPI and maintenance delivery matched (R-CHOP) controls. MethodsHere we analyzed data of 48 prospectively enrolled FL patients who were treated by sequential (R-SQ) chemotherapy with or without up-front autologous stem cell transplant (ASCT) as a part of stratified risk adapted treatment in one institution. For R-SQ regimen were indicated patients<65 years with INT-FLIPI (with at least 2 additional risk factors: bulk and/or elevated B2M>3mg/L and/or thymidine kinase>15 IU/L) or HIGH-FLIPI patients (irrespective of additional risk factors). R-SQ protocol consists of alternating three cycles of etoposide-doxorubicine regimen (PACEBO), one methotrexate-ifosfamide regimen (IVAM), and one cycle of high dose cytarabine regimen (HAM). Remission was consolidated with 6th cycle of chemotherapy (PACEBO) in INT-FLIPI patients (n=22, 46%) or with ASCT with BEAM-200 conditioning (n=26, 54%) in HIGH-FLIPI patients. Maintenance immunotherapy was applied for historical reasons in 24 patients (50%). Controls were randomly selected from the Czech Lymphoma Study Group (CLSG) database from 626 cases with confirmed FL grade I to IIIa, treated with R-CHOP. Pair matching was performed on 1:3 basis, controls were matched by age, FLIPI and rituximab maintenance application. In the end, we analyzed intensive SQ-group (n=44) and standard control R-CHOP-group (n=144). Maintenance therapy was delivered to 24 patients (50%) in R-SQ group and to 72 patients (50%) in R-CHOP-group (P=1.00). ResultsMedian age of SQ-group was 47.6 years compared to 48.7 years in R-CHOP (P=0.44), FLIPI index was equally distributed: INT-FLIPI (43% vs 43%), HIGH-FLIPI (57% vs 57%, P=1.00). Treatment response quality was higher in SQ-group than in R-CHOP-group: CR/CRu 93.8% vs 70%, PR 6.2% vs 23% and SD/PD 0% vs 8% respectively (P=0.01). During the follow-up, (median 3.5 and 6.1 years in R-CHOP and SQ-group respectively, P<0.01) 10 patients (20.8%) relapsed or progressed in the R-SQ-group, and 41 (29%) in the R-CHOP-group (P=0.01). Only two of 48 patients (4.2%) died in the R-SQ-group, whereas twelve (8.7%) died in the R-CHOP-group (P=0.03). Five-year progression-free survival (PFS) was superior in the R-SQ-group with 78.5% (95% CI 0.66-0.91) survival compared to 53.8% (95% CI 0.43-0.65, P=0.005, HR=0.37) in the R-CHOP-group. Five-year overall survival (OS) was 100% in the R-SQ-group and 91.9% (95% CI 0.86-0.97, P=0.027, HR=0.18) in the R-CHOP group. When analyzing patients who received maintenance therapy, we found no difference in OS (P=0.13), but there was still significant difference in 5-year PFS in favor of the R-SQ-arm (88.4% and 58.2%, P=0.034). ConclusionsIn risky FL patients, intensive front-line therapy brings about 24% advantage in CR rate, about 25% higher 5-year PFS (reduces risk of relapse/progression by 62%) and about 10% advantage in 5-year OS (reduces risk of death by 82%). Maintenance immunotherapy application overshadows OS but not PFS advantage of intensive chemotherapy. Finally, in younger physically fit risky patients, more intensive induction regimen leads to superior disease control a remission duration compared to standard R-CHOP. AcknowledgmentSupported by grants: LF-2013-004, IGA NT12193-5/2011 and PRVOUK-27/LF1/1. We would like to thank to all referring physicians: Jan Pirnos (Ceske Budejovice), Katerina Kubackova (FN Motol), Lucie Barsova (Liberec), Petr Kessler (Pelhrimov), Jitka Jakesova (Pribram), Milan Lysy (Usti n. Labem), Jindra Ciberova (Znojmo), Dagmar Adamova (Opava), Milan Matuska (Ostrava), Martin Brejcha (Novy Jicin). [Display omitted] Disclosures:Trneny:Roche: Honoraria, Research Funding.

Türkiye’den Bildirilen Zigomikoz Olgularının Havuz Analiz Yöntemi ile Değerlendirilmesi

Zygomycosis is a rapidly-progressive invasive fungal disease with high mortality rates. Mucor, Rhizopus, Rhizomucor and Absidia species classified in Mucorales order, are the main causative agents of zygomycosis. Uncontrolled diabetes, hematologic malignancies, long term corticosteroid use and immunosuppressive therapies are the main predisposing factors for mucormycosis. In this study, we aimed to evaluate the mucormycosis cases from Turkey published in national and international databases in the last 17 years by means of age, gender, co-morbidities, signs and symptoms, diagnostic methods, therapeutic modalities, and mortality rate by pooling analysis. In our study, two national (http://uvt.ulakbim.gov.tr, http://www.turkmedline.net) and two international (www.ncbi.nlm.nih.gov, http://apps.webofknowledge.com) databases were used. A total of 64 manuscript (34 from national and 30 from international databases) published between 1995 and 2012, which were eligible for the study criteria and accessible as full text were included in the study. A total of 151 mucormycosis patients (71 female, 80 male; mean age: 45.4 ± 21.4 years) from these studies, with definitive diagnosis of invasive fungal infections according to the criteria of European Organization for Research and Treatment of Cancer (EORTC) have been evaluated. Of 151 patients 91 (60%) were diagnosed as rhinocerebral, 42 (%27.8) were sinoorbital, 7 (4.6%) were pulmonary, 6 (3.9%) were disseminated, 3 (1.9%) were skin, and 2 (1.3%) were gastrointestinal mycormycosis. The most common symptoms and signs were; swelling of eye and face (n= 95, 63%), fever (n= 72, 48%), nasal obstruction (n= 60, 40%), headache (n= 58, 38%) and opthtalmoplegia (n= 48, 32%). The most common co-morbidity was diabetes (49%) followed by hematological malignancies (39.7%). Mycological cultures were performed for 82 patients, and fungal growth were detected in the clinical specimens of 51 cases. The distribution of strains isolated in culture were as follows: Mucor spp. (n= 19, 37.2%), Rhizopus spp. (n= 13, 25.5%), Zygomycetes (n= 9, 17.6%), Rhizopus oryzae (n= 4, 7.8%), Rhizopus spp. + yeast (n= 3, 5.9%), Rhizomucor spp. (n= 2, 3.9%) and Rhizosporium spp. (n= 1, 1.9%). In 133 patients, histopathological investigation and in 126 patients radiological examinations were performed for diagnosis. Both surgical debridement and antifungal therapy were employed in 115 patients. Four patients had received only surgical debridement and 30 only antifungal therapies. Classical amphotericin B (AMP-B) therapy for 77 cases, liposomal AMP-B for 60 cases, liposomal AMP-B + posaconazole for six cases and lipid complex AMP-B for two cases have been started as antifungal therapies. Total mortality rate was detected as 54.3% (82/151). In conclusion, despite new diagnostic tools and therapeutic agents, mortality rates in mucormycosis are still very high. For the management, mucormycosis should be considered early in risky patients, and surgical debridement together with effective antifungal therapy should be applied as soon as possible.

Frequency and Risk Factors for the Colonization and Infections of Vancomycin Resistant Enterococci (VRE) and Clinical Outcome in Pediatric Hematology/Oncology Patients

VRE is one of the most important nosocomial pathogens in immunocompromised patients, so good practice in antibiotic usage, isolation precautions and VRE surveillance studies are very important. VRE by itself is not a cause of serious infection, but together with the risk factors, morbidity and mortality might be higher. Surveillance studies including rectal sample cultures for risky patients to decrease VRE spread should be recommended.

Quality: A Process or an Outcome? It’s not what you may think…

Quality: A Process or an Outcome? It’s not what you may think…

The Incidence of Heparin-Induced Thrombocytopenia (HIT) After Prophylactic Heparin Exposure in Pediatric Intensive Care and Congenital Cardiology Patients: A Single Center, Prospective and Phase-IV Study: Turkish Experience

AbstractAbstract 4365Heparin is the standard therapy for the prevention and the treatment of venous thromboembolism in children. Heparin-induced thrombocytopenia (HIT) is a well-known serious adverse effect related with heparin therapy or prophylaxis. HIT affects up to %5 of patients treated with unfractionated heparin (UFH). However, prospective studies are so rare in children for technical and ethical reasons.Aim of this study was to determine the incidence of HIT in UFH-exposed children for prohylaxis. Patients who used treatment doses of UFH were excluded. Only ICU and cardiology patients were included. We performed a prospective single center phase-IV study in Ege University Children’s Hospital after approved by Ethics Commitee and Ministry of Health. Children who exposed to UFH for any time were eligible for study. Study group consists of intensive care (ICU) patients (n=28) and congenital heart disorders who will undergo catheter operation (n=25). Mean age was 52 mo (range:1–204). Thirty of patients were female and others were male. All ICU patients used diluted UFH for flushing to maintain patency of central lines. All cardiology cases received only one bolus dose of UFH (50 IU/kg) for prophylaxis. In all patients (n=53) blood samples were collected for platelet counts (CELL DYN 3700 counter, Abbott), anti-Heparin/PF4 antibody (ELISA)(Asserachrom HPIA-Ig G, Diagnostica Stago) and heparin-induced platelet agregation tests (APACT-4004, Tokra) prior to and after 10 days (median) (range: 7–15) of first UFH exposure.After 2 years of observation, we have not found any single patient diagnosed as HIT by clinical findings and confirmed by laboratory analysis. Significant dropping (>50%) of platelet count was observed in only 4 ICU patients. Only one patient had below <150.000/mm3. However, ELISA and agregation tests were negative for these patients. Reasons for thrombocytopenia were evaluated as underlying medical conditions (trauma, pneumonia and sepsis) not for HIT. In only one ICU case, ELISA test was found border-line positive (O.D: 1.374)(positive controls: 1.35±0.34). However, no thrombocytopenia and no activation in agregation related heparin studies were found. This result was evaluated as false-positivity for ELISA. However, mean OD values for ELISA test was found significantly elevated after heparin exposure (before heparin: 0.119±0.061 versus after heparin: 0.258±0.262)(Wilcoxon test; p<0.0001). Elevated heparin-induced agregation response (more than >20% after heparin exposure) was found only in three cardiology patients (diagnosed as ASD, VSD and PDA). However, there was no thrombocytopenia and ELISA seropositivity in these patients. This hyperactivity was evaluated as “non-specific” heparin-induced agregation.In literature, infants with congenital heart disease or children requiring admission to ICU are particularly at risk of venous thromboembolism and likely to be exposed to heparins for prevention and treatment. However, in this single center phase-IV study, we have not found prospectively any HIT patients among 53 risky patients. Reasons may be prophylaxis versus treatment doses, short exposure time versus long-term exposures and medical versus surgical interventions and lower count of patients for low incidence. However significant ELISA activity after heparin exposure was noted as interesting finding. This point might supported for mild heparin activity in patient group who has lower immunogenicity of heparin. Disclosures:No relevant conflicts of interest to declare.

1335 Efficacy of Prophylactic Fluconazole in Reducing Candidemia in High Risk NICU And PICU Patients

BackgroundCandidal infection is a common cause of morbidity and mortality in neonatal intensive care unit (NICU) and pediatric intensive care unit(PICU) pateints, especially those with risk factors.ObjectivesTo determine the prevalence...

Screening and brief intervention delivered simultaneously in multiple settings: it is cost-effective, but can it influence community-level outcomes?

A 20-community randomized controlled trial, the Alcohol Action in Rural Communities (AARC) project, provided the opportunity to examine the cost-effectiveness of screening and brief intervention (SBI) delivered simultaneously in general practice (GP), pharmacy, and emergency department (ED) settings and the community level impact of the SBI on problem drinking. For the GP- and pharmacy-delivered SBI, decision models and scenario analysis assessed outcomes and costs in the 10 experimental communities of the trial. For the ED-delivered SBI, a randomized controlled trial design was used to examine the cost-effectiveness of mailed personalized feedback. For both the GP- and pharmacy-delivered SBI, the most cost-effective outcome was to increase screening alone: GPs and pharmacies screening all patients achieved an incremental cost-effectiveness ratio (ICER) of AUD $197 and AUD $29, respectively, per risky drinker who reduced drinking. The ED-based SBI resulted in a reduction of 2.6 fewer drinks per week at an average cost of $5.55 per patient and an ICER of $2.13 per one standard drink reduction in average weekly consumption. In addition to cost-effectiveness, the AARC community approach provided the opportunity to analyze the effect of SBI on community level outcomes. Currently, 19% of risky drinkers in a community visit a GP and reduce their drinking, which would increase to 36% if all patients got SBI. Similarly, 23% of risky drinkers in a community visit a pharmacy and reduce their drinking, which would increase to 34% if they all got SBI. Although our results confirm SBI is cost-effective, the impact at the community level is unclear: if all GPs and pharmacists delivered SBI to all their risky drinking patients, only 34-36% would reduce their drinking. A trial that assessed the impact of SBI delivered in multiple settings simultaneously on community level indicators of alcohol harm would move the field toward demonstrating the cost benefit, as well as cost-effectiveness, of SBI.

Editorial Comment: Aortic stenosis in octogenarians and other high-risk groups: what can surgical valve replacement offer?

The paper published in this issue of the Journal by Molstad et al. [1] from Feiring, Norway, deals with the long-term survival after aortic valve replacement (AVR) in octogenarians and high-risk subgroups. A total of 1525 patients were submitted to AVR in their institution over a period of approximately 11 years. Included were 361 patients (24%) older than 80 years of age (mean 83.1 ± 2.4 years). The main aim of the study was to assess survival, and the accuracy of the outcome analysis is guaranteed by the Norwegian National Registry, assuring a complete follow-up. This comes at the time when there is great enthusiasm around for percutaneous aortic valve implantation (TAVI), which some now call, in my view inappropriately, transcatheter aortic valve replacement (TAVR). This novel technique was initially implemented specifically for use in patients to whom conventional AVR was denied because it was either not possible or considered too high risk. This issue was triggered by the initial reports derived from the Euro Heart Survey, conducted one decade ago, which showed that approximately one third of the patients with severe symptomatic aortic valve stenosis were never offered surgery [2]. Since then, this subgroup of patients have been given an opportunity for treatment of a pathology that cannot be treated by medical means alone, with a well-known natural history of up to 50% mortality within 1 year in patients with severe symptoms. Some studies have shown early TAVI results to be at least similar to those obtained with AVR. These preliminary results have had the effect of potentiating the implantation rate and in the last few years over thirty thousand patients have received the percutaneous valves in Europe, in an unprecedented surge of a new technique, massively driven by a multi-million dollar industry. In 2011, TAVI constituted 30.5% of all interventions in patients with aortic stenosis in Germany, where 40% of the TAVI performed in Europe is done [3]. It is evident that this intervention has an important role to play in the future and there are already studies under way involving younger and less risky patients. However, the majority, if not all, of the comparative studies thus conducted are based on risk-predicting models, such as the original EuroSCORE, which are now overwhelmingly recognized to overpredict risk, especially mortality. The new EuroSCORE II was launched very recently, and has not yet been widely used. Strangely, very few of these comparative studies used the Society of Thoracic Surgeons (STS) risk score, recognized as being more accurate to predict surgical mortality. It is here that the current study by Molstad and colleagues becomes important. Not so much because of the number of patients included, as much larger series have been published, but because of the results reported. Importantly, the patients in the cohort were treated during the same period of use of the percutaneous valves, but with a mean follow-up of almost 5 years, which is important when referring to over 80-year olds. And this study includes all comers, comprising 58% of patients with associated coronary diseases requiring coronary artery bypass grafting. The logistic EuroSCORE of the latter group was 15.2 and 17.5% of the patients had an EuroSCORE over 20. Short-term (30-day) mortality was 2.2% in the whole population and 3.9% in the over 80-year group. Five-year survival was 83.1% for the whole population and 68.1% for the over 80-year old group where the median survival time was 7.3 years, which parallels the mean expected survival time for the general Norwegian population matched for age and gender in the octogenarian group (7.4 years). Other authors have recently reported equally good results with AVR in the elderly. El Bardissi and associates from Boston reported operative mortality of 3% and 1-, 5-, and 10-year survival of 91, 77 and 56%, respectively, in 249 octogenarians (mean age: 84 years; EuroSCORE: 11) undergoing AVR during this modern era, ‘who might otherwise have been considered candidates for TAVI’ [4]. And even more recently, Langanay et al. reported on 1193 AVR in octogenarians, with a mortality of 5.5% for isolated valve procedures [5]. Of interest, by comparison, 1-year survival after TAVI was 76.1% in the SOURCE Registry and 69% in the PARTNER trial, although both studies concluded that the survival was similar to surgical AVR in the populations studied. These results, and not those predicted by the most popular risk scores, should constitute the benchmark for both TAVI and AVR. Our Journal still receives reports of series of AVR with mortality figures approximating two digits, which should no longer be considered acceptable. Not even the usual presence of some of the risk factors so far identified should constitute a justification for higher mortality. Unequivocally, AVR in the elderly patient with

Czech TAVI Registry—rationale and design

Aortic stenosis is the most common type of valve disease in the adults. Until recently its treatment was an exclusive domain of cardiac surgery. At the same time the aortic valve replacement (SAVR) was not indicated in about 1/3 of the patients, though the prognosis of conservatively treated patients is very unfavourable with one-year mortality rate of 50%. These facts were the main reasons for starting a new interventional era of the aortic valve disease therapy in 2002 and from 2007 two types of valves fixed in stents have been commercially available.In the early phase the transcatheter aortic valve implantation (TAVI) was used just in patients with contraindication to SAVR or with high perioperative risk after surgery. Before applying this therapy to less risky patients some problems have to be solved: 1. clinical impact of the relatively high rate of paravalvular leaks and 2. long-term function of the implanted valve in follow-up exceeding 5years.In the Czech Republic the first TAVI was performed in Prague, IKEM in December 2008. During a short period of time the TAVI programme was initiated also in other complex cardiovascular centres in Hradec Kralove, Brno, Prague—FN Kralovske Vinohrady and Trinec. Including the later starting centres (Usti n. Labem, Olomouc, Ceske Budejovice and other three centres in Prague—Nemocnice na Homolce, FN Motol and VFN) there is a total of 11 centres providing the TAVI at present. All centres except one (FN Motol) are part of the Czech TAVI Registry that was developed with the support of the Czech Society of Cardiology and started on 1 September, 2010. In general and more theoretically there are two parts of the Registry: 1. “Retrospective” including all the TAVI procedures from the beginning of the TAVI programme in the Czech Republic that was terminated on June 30, 2011 and 2. “Prospective” that has been following. Institute of Biostatistics and Analyses of Masaryk University takes care of the online and anonymized database.The results of the national Czech TAVI Registry should help to answer the clinical relevant questions mentioned above.

Laparoscopic and laparotomic approaches for endometrial cancer treatment: a comprehensive review

Endometrial cancer (EC) is the most common gynecological malignancy in the developed world, particularly among postmenopausal women. Endoscopic surgery is gaining more popularity among surgeons as a safe and feasible option for treatment of endometrial carcinoma, providing the possibility of adequate lymph node excision. A comprehensive review. The advantages of laparoscopy prevail over laparotomy and authors report lower peri-operative complication rates, less blood loss, lower transfusion rates, and shorter hospital stay, as well as a better quality of life (QoL) after laparoscopic surgery, in contrast to conventional abdominal surgery. This was confirmed by a meta-analysis of four randomized controlled studies. This is also true for obese risky patients to whom laparotomies carry indolent side effects. In addition, with more training and experience this procedure would be even more feasible and safer. Because of the increasing importance of economic efficiency in health care, the endoscopic approach will continue to play a more important role in the future treatment of EC providing a better treatment option for the coming patients. As a promising therapeutical option, it should be offered to all patients with an early-stage EC.