Treatment Of High-risk Patients Research Articles

Abstract 19473: Safety and Efficacy of Second Generation Self Expanding Portico® Valve System for the Treatment of Failed Aortic Bioprosthesis: Results From an International Multicenter Valve-in-Valve Registry

Background: Portico valve is a second-generation self-expanding repositionable system with a nitinol stent frame and bovine pericardial leaflets, which is increasingly utilized for transcatheter aortic valve replacement (TAVR) . In this report, we describe the procedural and early clinical results from an international multicenter registry of Portico implantation in patients with degenerated aortic bioprosthesis (Portico ViV). Methodology: Baseline data and outcomes were collected on standard case report forms and by the Valve-in-Valve International Data network from 14 centers across three continents. Procedural endpoints included implantation success and coronary obstruction. Clinical endpoints included death, myocardial infarction (MI), stroke, major bleeding at 30 days as defined by Valve Academic Research consortium II (VARCII). Result: 45 patients undergoing Portico ViV were included in analysis. The mean age was 79± 7 years with STS (mortality) score of 7±4. These procedures had mainly utilized peripheral arterial access (93%), with transesophageal echocardiogram guidance (60%) for treatment of surgical valve label size ≤21, >21-<25, and ≥25mm in 36, 38 and 27% respectively. Four (9%) of the failed surgical bioprostheses were stentless. Successful implantation was achieved in 44 (98%) cases with no malposition events or clinically-evident coronary obstruction. Post implantation valve area was 1.3 ±0.4 cm2, mean gradient of 17.1 ± 7.7 mmHg and ≥ moderate aortic insufficiency was observed in 3 (7%). One death (2%) related to ischemic stroke occurred within 30 days. Major bleeding and vascular complication in 5 (11%) and 1 (2%) respectively. One patient required permanent pacemaker implantation (2%). Conclusion: Results from this international multicenter registry show that Portico offers a safe and effective treatment of failed surgical bioprosthesis with an added advantage of device retrievability, resulting in low incidence of malpositioning and coronary obstruction. Additional studies and comparison with other transcatheter devices should further determine the hemodynamic and clinical performance of this device for selection of optimal treatment of high risk patients with failed surgical bioprostheses

In-hospital resource utilization in surgical and transcatheter aortic valve replacement.

BackgroundLittle is known about preoperative predictors of resource utilization in the treatment of high-risk patients with severe symptomatic aortic valve stenosis. We report results from the prospective, medical-economic “TAVI Calculation of Costs Trial”.MethodsIn-hospital resource utilization was evaluated in 110 elderly patients (age ≥ 75 years) treated either with transfemoral (TF) or transapical (TA) transcatheter aortic valve implantation (TAVI, N = 83), or surgical aortic valve replacement (AVR, N = 27). Overall, 22 patient-specific baseline parameters were tested for within-group prediction of resource use.ResultsBaseline characteristics differed between groups and reflected the non-randomized, real-world allocation of treatment options. Overall procedural times were shortest for TAVI, intensive care unit (ICU) length of stay (LoS) was lowest for AVR. Length of total hospitalization since procedure (THsP) was lowest for TF-TAVI; 13.4 ± 11.4 days as compared to 15.7 ± 10.5 and 21.2 ± 15.4 days for AVR and TA-TAVI, respectively. For TAVI and AVR, EuroScore I remained the main predictor for prolonged THsP (p <0.01). Within the TAVI group, multivariate regression analyses showed that TA-TAVI was associated with a substantial increase in THsP (55 to 61 %, p <0.01). Additionally, preoperative aortic valve area (AVA) was identified as an independent predictor of prolonged THsP in TAVI patients, irrespective of risk scores (p <0.05).ConclusionsOur results demonstrate significant heterogeneity in patients baseline characteristics dependent on treatment and corresponding differences in resource utilization. Prolonged ThsP is not only predicted by risk scores but also by baseline AVA, which might be useful in stratifying TAVI patients.Trial registrationGerman Clinical Trial Register Nr. DRKS00000797

A5118 - Endobarrier as a Pre Bariatric Surgical Intervention in High Risk Patients

A5118 - Endobarrier as a Pre Bariatric Surgical Intervention in High Risk Patients

Venous Thromboembolism Prophylaxis For Esophagectomy: A Survey of Practice Patterns Among Thoracic Surgeons

Current guidelines for gastrointestinal cancer surgical intervention in high-risk patients recommend postoperative venous thromboembolism (VTE) chemical prophylaxis for 4 weeks with low-dose unfractionated heparin or low-molecular-weight heparin, but specific guidelines for esophagectomy are lacking. This survey identified the clinical patterns affecting postesophagectomy VTE chemoprophylaxis use among general thoracic surgeons. General Thoracic Surgery Club members were invited to complete an online survey on VTE prophylaxis to analyze clinical factors affecting their choices. Seventy-seven surgeons (37% membership) responded; of these, 94% (72 of 77) completed fellowships, and 76% (58 of 77) worked at universities. VTE chemoprophylaxis administration varied widely in drug, dosing, and duration, with 30% using suboptimal dosing of unfractionated heparin (every 12 hours). Participants agreed that esophagectomy patients are at high VTE risk, yet 29% (22 of 76) of surgeons delay VTE chemoprophylaxis until postoperative day 1. Only 13% (10 of 77) prescribe postdischarge chemoprophylaxis. Minimally invasive surgeons (>90% of cases) were more likely to prescribe postdischarge prophylaxis (p= 0.007). Epidurals, routinely used by 65% (51 of 78), led to less compliance with recommended dosing. Only 53% (27 of 51) of pain teams allow unfractionated heparin every 8hours, yet 73% (37 of 51) allow suboptimal dosing (every 12 h). Postoperative major complications were identified as a VTE risk factor by only 21% (15 of 72) of surgeons. Most (92% [68 of 74]) would follow esophagectomy-specific guidelines, if developed. Thoracic surgeons agree that VTE chemoprophylaxis is necessary for esophagectomy, yet substantial variability exists in current practice. A noteworthy proportion use suboptimal dosing, and very few choose postdischarge prophylaxis. To improve postesophagectomy morbidity and mortality outcomes, thoracic surgeons are willing to follow evidence-based guidelines for VTE chemoprophylaxis.

Devastating Impact of Fracture Nonunions: The Need for Timely Identification and Intervention for High-Risk Patients: Commentary on an article by Patrick C. Schottel, MD, et al.: "Time Trade-Off as a Measure of Health-Related Quality of Life: Long Bone Nonunions Have a Devastating Impact".

Despite contemporary surgical techniques and novel adjunct therapies, orthopaedic care providers encounter a considerable number of patients with long bone nonunions due to the high-volume nature of musculoskeletal trauma1-3. Although the risk factors and etiology of nonunion may be varied, Schottel et al. demonstrate quite distinctly that the consequences of nonunion are rather harmonized, in that they have a devastating impact on patient quality of life1. In their study titled, “Time Trade-Off as a Measure of Health-Related Quality of Life: Long Bone Nonunions Have a Devastating Impact,” Schottel et al. evaluated more than 800 adult patients with long bone nonunions for their perceived health-related quality of life using the Time Trade-Off approach. On average, patients in this cohort were willing to trade 32% of their remaining …

Transradial percutaneous coronary intervention in high-risk patients

Percutaneous coronary intervention (PCI) is the commonest form of revascularization in patients with coronary heart disease. The benefit of early invasive treatment with PCI in patients presenting with acute coronary syndromes are well accepted. Traditionally, PCI has been performed via the femoral access with significant risks for the development of access site-related bleeding complications. Increased international adoption of the transradial access site for PCI procedures has been shown to reduce such major access site-related bleeding complications and mortality, especially in the high-risk patient groups. We provide a brief overview of the historical perspective on transradial approach and the evidence supporting its use. We then discuss the current data supporting transradial access in high-risk populations and factors that have limited its adoption.

PET response-adapted clinical trials in Hodgkin lymphoma: a comprehensive review

Hodgkin lymphoma (HL) is a highly curable disease, as most HL patients become long-term survivors, with 10-years cure and survival rates after first-line treatment exceeding 80 and 90 %, respectively. Despite these rewarding results, 10–15 % of early stage and 20–25 % of advanced stage patients became chemo-refractory to first-line treatment, and nearly half of them ultimately succumb to their disease. On the other hand, a small but significant fraction of long-term survivors, especially those treated with combined chemoradiation, experience treatment related morbidity and mortality with cardiovascular events and secondary neoplasms arising 5–20 years after the end of therapy. Therefore, an unfulfilled need still exists for a risk-adapted strategy, with a very effective treatment in high-risk patients and a low toxicity regimen in the vast majority of patients who are indeed chemo sensitive. Interim PET scan, performed after few cycles of chemotherapy proved the main predictor of treatment outcome in ABVD-treated patients and superseded the predictive role of traditional prognostic markers. Moreover, simple and reproducible rules for interim PET interpretation agreed among experts have been validated in HL, and are now available for the clinical practice. A number of phase II trials yielded the prof of concept that adapting treatment to interim PET result could ultimately increase long-term disease control in the entire patient population, compared to that obtained with the standard chemotherapy approach. In the present article the results of these pioneer single-centre small trials, as well as the preliminary results of large international prospective trials will be reviewed.

Long noncoding RNAs and neuroblastoma.

Neuroblastoma is a disease that affects infants and despite intense multimodal therapy, high-risk patients have low survival rates (<50%). In recent years long noncoding RNAs (lncRNAs) have become the cutting edge of cancer research with inroads made in understanding their roles in multiple cancer types, including prostate and breast cancers. The roles of lncRNAs in neuroblastoma have just begun to be elucidated. This review summarises where we are with regards to lncRNAs in neuroblastoma. The known mechanistic roles of lncRNAs during neuroblastoma pathogenesis are discussed, as well as the relationship between lncRNA expression and the differentiation capacity of neuroblastoma cells. We speculate about the use of some of these lncRNAs, such as those mapping to the 6p22 hotspot, as biomarkers for neuroblastoma prognosis and treatment. This novel way of thinking about both neuroblastoma and lncRNAs brings a new perspective to the prognosis and treatment of high-risk patients.

Pilot study of modified FOLFOX6 adjuvant chemotherapy for high-risk rectal cancer treated with neoadjuvant chemoradiotherapy

Neoadjuvant chemoradiotherapy (CRT) followed by total mesorectal excision is considered the standard of care for patients with locally advanced adenocarcinoma of the middle/low rectum. The present study evaluated the feasibility of using modified FOLFOX6 regimen as an adjuvant treatment for high-risk patients with locally advanced rectal cancer (LARC) treated with neoadjuvant CRT. Forty patients with LARC (ypT3-4 or N+) treated with neoadjuvant CRT were enrolled at Kyungpook National University Medical Center (Daegu, Korea) between December 2011 and December 2012. All the patients underwent rectal surgery with curative intent 8weeks after the end of the neoadjuvant treatment. Adjuvant chemotherapy using modified FOLFOX6 regimen was then delivered for 3months. The treatments were generally well tolerated. Dose reduction was recorded in 11 of the 40 patients (27.5%). The incidence of febrile neutropenia was 5%, the incidence of grade 3 or 4 asthenia was 10%, and the incidence of grade 3 gastrointestinal adverse events was 5% during treatment. Treatment discontinuation caused by toxic effects or any other reasons was observed in six patients (15%). The reasons for discontinuation were asthenia (n=2, 5%), diarrhea (n=2, 5%), acute renal failure (n=1, 2.5%), and relapse during chemotherapy (n=1, 2.5%). With a median follow-up duration of 18months, six patients (15%) relapsed and one patient (2.5%) died of disease progression. The estimated 3-year disease-free survival and overall survival rates were 84.2 and 97.3%, respectively. Postoperative adjuvant modified FOLFOX6 regimen was found to be feasible for patients with LARC treated with neoadjuvant CRT.

New Trends in Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a chronic idiopathic inflammatory disease of the gastrointestinal (GI) tract. In the past decade a shift in the treatment paradigm of IBD has ensued. The availability of drugs capable of inducing mucosal healing, combined with the recognition that IBD is not an intermittent disease, but rather a progressive one causing bowel damage and disability, led us to a more stringent strategy. Tailored therapy with more aggressive treatment in high-risk patients, treating beyond symptoms, intervening early before damage occurs, optimizing therapeutic regimens, and actively pursuing sustained remission and sustained control of inflammation are strategies that are slowly being incorporated in our clinical practice. Furthermore, new drugs targeting different immunological pathways, such as vedolizumab, have recently been approved and therefore more therapeutic resources for patients failing anti-tumour necrosis factor alpha (anti-TNFα) agents will be available.The future years look promising for IBD. Hopefully the new trends in IBD management, combined with new drugs, will make possible to change the course of disease and provide better therapy and quality of life for patients suffering from this disabling disease.

Transcatheter aortic valve implantation: emerging role in poor left ventricular function severe aortic stenosis?

Surgical aortic valve replacement (AVR) has long been recognized as the gold standard treatment for symptomatic severe aortic stenosis improving symptoms, survival and functional class. Recently, transcatheter aortic valve implantation (TAVI) has also become an established procedure for the treatment of higher risk patients with symptomatic severe aortic stenosis.1 These include the frail, elderly patient with multiple co-morbidities and disabilities. TAVI has been shown to successfully reduce aortic valve gradients to a similar degree as conventional AVR but the incidence of paravalvular aortic regurgitation (AR) is significantly higher.2, 3 Compared to conventional AVR, TAVI has a shorter recovery period, avoids a sternotomy and cardiopulmonary bypass, and has a lower risk of bleeding, acute kidney injury, atrial fibrillation and early mortality, but the risk of vascular complications, pacemaker implantations and cardiac perforations are higher.1, 3 Stroke rates were initially reported to be higher following TAVI compared to conventional AVR but recent studies suggest no difference in stroke rates.3

Synthetic Mesh Repair for Incisional Hernia Treatment in High-risk Patients for Surgical Site Occurrences

Patients with incisional hernias (IH) and risk factors for surgical site occurrences (SSOs) such as defined comorbidities and/or potential contaminations are considered to be treated with bioprosthetics. A retrospective analysis of consecutive patients who had undergone elective IH repair with synthetic mesh materials between 2009 and 2013 was conducted. Only patients who were classified into Grades II and III according to the classification of the Ventral Hernia Working Group (VHWG) were considered for the study. Primary outcome parameter was the incidence of SSO. The relationships among demographics, hernia characteristics, surgical technique, and SSOs were also evaluated. Overall, 108 patients were included (Grade II: 68, Grade III: 40). SSO was identified in 14 patients. Having two or more comorbidities (P = 0.04), an open sublay technique (P = 0.005), duration of operation (P = 0.02), larger hernia defects (P = 0.001), and using larger mesh sizes (P = 0.01) were associated with significantly higher rates of SSO. Affiliation to VHWG Grading II or III showed no impact on SSO occurrence. Synthetic mesh repair both in an "open sublay" and laparoscopic intraperitoneal technique is safe regarding patients with risk factors for SSO. The recommendations of the VHWG must be declined and a modification of the grading system is warranted overlooking a more liberal use of synthetic meshes.

Efficacy of antifungal prophylaxis with oral suspension posaconazole during induction chemotherapy of acute myeloid leukemia.

Severe infectious complications reflect a continuing problem in patients with acute myeloid leukemia (AML). Based on data from a randomized clinical trial demonstrating a reduction of proven and probable invasive fungal disease (IFD), posaconazole has been approved for prophylaxis of fungal infections in AML patients during induction chemotherapy. Nevertheless, recently published observational studies show contradictory results concerning the efficacy of posaconazole in this clinical setting. Furthermore, oral suspension posaconazole is associated with an unpredictable bioavailability that especially depends on nutritional factors or gastric pH value. We retrospectively analyzed the impact of posaconazole prophylaxis in 70 consecutively evaluable AML patients who underwent induction chemotherapy at a tertiary care hospital. The incidence of IFD classified as proven, probable or possible, antifungal therapy including empiric treatment in high-risk patients and tolerability of posaconazole were determined. In addition, important clinical cofactors such as co-treatment with proton pump inhibitors and risk factors for pneumonia were analyzed in this study. We can demonstrate that posaconazole is well tolerated and had to be stopped in only six patients (8.6%). The overall incidence of IFD was 30% including two patients with proven (2.8%), four patients with probable (5.7%) and 15 patients with possible IFD (21.4%). Importantly, 24 out of 49 patients (49.0%) who did not fulfill the criteria of IFD received empiric antifungal therapy. Including patients classified as possible IFD, 39 of 70 patients (55.7%) underwent at least first-line antifungal treatment. Our "real-life" data obtained from 70 AML patients after induction chemotherapy demonstrate the frequent necessity of systemic antifungal treatment despite prophylaxis with oral suspension posaconazole.

Evaluation of the economic impact of the CCP assay in localized prostate cancer.

85 Background: Stratification of localized prostate cancer based on disease aggressiveness remains challenging, resulting in overtreatment of low-risk patients and under treatment of high-risk patients. A biopsy-based, cell cycle progression (CCP) gene expression assay can aid physicians in predicting prostate cancer aggressiveness, leading to more appropriate patient management. This study quantifies the economic impact of the CCP assay on a US commercial health plan. Methods: A fact-based economic model was developed for a hypothetical cohort of prostate cancer patients with localized disease. Patients were followed in the model for 10 years with management and progression assumptions based on published clinical data and interviews with board-certified physicians. Total cost of care was calculated for a reference scenario (current clinical practice) and a test scenario where patient management was altered based on CCP test results. Cost inputs were set for each unit of care that a patient might undergo (diagnostic/surgical/radiotherapy procedures and pharmacological therapy); costs were assigned based on published costs of care. Total cost of care was compared between the two scenarios to determine overall system economic impact. Results: The CCP test reduced costs by $2,850/patient tested over 10 years after accounting for test cost. For a health plan with 10 million members, this would translate to over $16 million in savings with two-thirds of those savings achieved in the first year after testing. The majority of savings came from increased use of active surveillance in AUA low- and intermediate-risk patients. No single model input, when changed within a range of values, caused the model to show that the test was no longer cost saving. Costs of the test scenario were never greater than the reference scenario, resulting in cost savings over the 10 years modeled. Conclusions: Use of the CCP test in a US commercial health plan has the potential to result in cost savings to payers. Savings are due to increased use of active surveillance in low- and intermediate-risk patients with less aggressive disease, but also from reduced progression rates in high-risk patients with more aggressive disease who transition to multi−modality therapy.

Temporal trends and patterns in percutaneous treatment of coronary artery disease in Poland in the years 2005-2011.

According to a recent survey, Poland is one of the leaders of interventional cardiology in Europe in terms of the number of primary percutaneous coronary intervention (PCI) procedures per million inhabitants. To present temporal trends in epidemiology, demographics, treatment, and periprocedural outcome of patients referred for percutaneous coronary angiography and angioplasty in Poland in 2005-2011, based on the Polish National PCI Registry. Patients who underwent percutaneous coronary angiography (ANGIO group) and/or angioplasty (PCI group) were included in the Polish National PCI Registry - a prospective observational registry study in Poland. There were 935,429 patients in the ANGIO group and 501,117 in the PCI group in Poland in 2005-2011. The number of catheterisation labs increased from 75 to 137, angiography procedures rose from 99,195 to 180,935, and PCIs from 50,297 to 99,614. The procedural mortality and stroke rates for the ANGIO group have remained stable whereas for the PCI group procedural mortality has increased over the years. The use of drug eluting stents (DESs) rose from 32.8% to 55.3% in stable angina and the use of a radial approach from 26.8% to 39.1%. Use of modern attributes of interventional cardiology like DES stents, radial approach, and treatment of higher risk patients has increased in Poland in 2005-2011. The adoption of the "Stent for Life" initiative has resulted in an increasing number of percutaneous coronary procedures over the years.

Results of the Chronic Heart Failure Intervention to Improve MEdication Adherence study: A randomized intervention in high-risk patients

BackgroundPoor adherence to evidence-based medications in heart failure (HF) is a major cause of avoidable hospitalizations, disability, and death. To test the feasibility of improving medication adherence, we performed a randomized proof-of-concept study of a self-management intervention in high-risk patients with HF.MethodsPatients with HF who screened positively for poor adherence (<6 Morisky Medication Adherence Scale 8-item) were randomized to either the intervention or attention control group. In the intervention group (n=44), a nurse conducted self-management training prior to discharge that focused on identification of medication goals, facilitation of medication-symptom associations, and use of a symptom-response plan. The attention control group (n=42) received usual care; both groups received follow-up calls at 1 week. However, the content of follow-up calls for the attention control group was unrelated to HF medications or symptoms. General linear mixed models were used to evaluate the magnitude of change in adherence and symptom-related events at 3-, 6-, and 12-month follow-up clinic visits. Efficacy was measured as improved medication adherence using nurse-assessed pill counts at each time point.ResultsPooled over all time points, patients in the intervention group were more likely to be adherent to medications compared with patients in the attention control group (odds ratio [OR] 3.92, t=3.51, p=0.0007).ConclusionsA nurse-delivered, self-care intervention improved medication adherence in patients with advanced HF. Further work is needed to examine whether this intervention can be sustained to improve clinical outcomes.

Post-relapse survival in patients with Ewing sarcoma.

Post-relapse survival (PRS) was evaluated in patients with Ewing sarcoma (EWS) enrolled in chemotherapy protocols based on the use of high-dose chemotherapy with busulfan and melfalan (HDT) as a first-line consolidation treatment in high-risk patients. EWS patients enrolled in ISG/SSG III and IV trials who relapsed after complete remission were included in the analysis. At recurrence, chemotherapy based on high-dose ifosfamide was foreseen, and patients who responded but had not received HDT underwent consolidation therapy with HDT. Data from 107 EWS patients were included in the analysis. Median time to recurrence (RFI) was 18 months, and 45 (42%) patients had multiple sites of recurrence. Patients who had previously been treated with HDT had a significantly (P = 0.02) shorter RFI and were less likely to achieve a second complete remission (CR2). CR2 status was achieved by 42 (39%) patients. Fifty patients received high-dose IFO (20 went to consolidation HDT). The 5-year PRS was 19% (95% CI 11 to 27%). With CR2, the 5-year PRS was 48% (95% CI 31 to 64%). Without CR2, median time to death was six months (range 1-45 months). According to the multivariate analysis, patients younger than 15 years, recurrence to the lung only, and RFI longer than 24 months significantly influenced the probability of PRS. Age, pattern of recurrence, RFI, and response to second-line chemotherapy influence post-relapse survival in patients with recurrent Ewing sarcoma. No survival advantage was observed from chemotherapy consolidation with HDT.

A national survey of defensive medicine among orthopaedic surgeons, trauma surgeons and radiologists in Austria: evaluation of prevalence and context.

Defensive medical practice represents an increasing concern in European countries and is reported to account for rising health care expenditures. Malpractice liability, current jurisdiction and the increasing claim for accountability appear to result in additional diagnostic requests with marginal clinical benefit. Investigations that evaluate the national Austrian prevalence and contextual principles and consequences of defensive medicine are lacking so far. Orthopaedic and trauma surgeons as well as radiologists from public hospitals in Austria were invited to complete a study questionnaire retrieving personal estimation of the quantity of patient contacts and defensive requests in a typical month, subjective judgement of medico-legal climate, evolving defensive trends, working time usage for defensive considerations and prior confrontations with malpractice liability claims. The prevalence of defensive medicine was found to be 97.7%. The average orthopaedic or trauma surgeon requests 19.6 investigations per month for defensive reasons, which represents 28% of all diagnostic examinations. High-quality imaging modalities and short-term admissions yield increasing defensive significance. Participants are confronted with 1.4 liability claims per month. During the treatment of high-risk patients, 81% of doctors request additional diagnostic procedures for defensive considerations. Expenditure of time for defensive practice amounts to 9.2 hours/month in radiology and to 17 and 18% of total working time, respectively, in orthopaedic and trauma surgery. Defensive medical practice represents a serious and common challenge in Austria. Our results indicate the urgent necessity for confrontation with and solution for the increasing effort of self-protection within the health care system.

Value of detection of pentraxins 3 value combined with measurement of vascular lung water index in prognosis of patients with sepsis

To evaluate prognostic value of pentraxin3 ( PTX3 ) content combining with extravascular lung water index ( EVLWI ) in patients with sepsis. A retrospective analysis of complete clinical data of septic patients admitted to Department of Critical Care Medicine of the First Affiliated Hospital of Zhengzhou University from February 2013 to February 2014 was conducted. These patients were divided into two groups, survival group and death group, according to the outcome on the 28th day. Pulse index continuous cardiac output ( PiCCO ) was used to record the levels of EVLWI on the 1st, 2nd and 3rd day of intensive care unit ( ICU ) admission. The plasma level of PTX3 was measured simultaneously by enzyme-linked immunosorbent assay ( ELISA ). At the same time, acute physiology and chronic health evaluation II ( APACHEII) score and sequential organ failure assessment ( SOFA ) were calculated. Correlation analysis between plasma PTX3 and EVLWI values was performed, receiver operating characteristic curve ( ROC ) was drawn, and the prognostic value of each parameter was assessed finally. A total of 74 septic patients were enrolled, with 41 cases in the survival group and 33 cases in the non-survival group. Blood lactate, APACHEII, SOFA scores in the non-survival group were significantly higher than those of the survival group at ICU admission, and the length of ICU stay was significantly shorter than that of the survival group, while differences of the other clinical characteristics between two groups were not statistically significant. The plasma PTX3 level gradually declined with time in both groups, and plasma PTX3 at 1, 2, 3 days after ICU admission in non-survival group were significantly higher than those in survival group [ PTX3 ( μg/L ) at 1 day: 46.3±10.5 vs. 19.4±6.5, t = -13.486, P = 0.000; 2 days: 34.8±10.7 vs. 17.7±8.4, t = -8.284, P = 0.000; 3 days: 23.9±11.2 vs. 15.6±7.9, t = -5.036, P = 0.000 ]. EVLWI gradually declined in survival group, but increased in death group. EVLWI at 1, 2, 3 days after ICU admission in non-survival group were significantly higher than those in survival group [ EVLWI ( mL/kg ) at 1 day: 12.12±4.31 vs. 10.02±2.87, t = -2.502, P = 0.023; 2 days: 13.67±4.95 vs. 9.08±2.89, t = -5.188, P = 0.000; 3 days: 14.51±5.06 vs. 8.09±2.50, t = -7.126, P = 0.000 ]. PTX3 at 1, 2, 3 days after ICU admission showed a significant positive correlation with EVLWI ( r1 = 0.747, r2 = 0.719, r3 = 0.705, all P = 0.000 ). ROC curve analysis showed that the area under the ROC ( AUC ) of PTX3 at 1 day was 0.845±0.045, at the cut-off point of 23.0 μg/L, PTX3 showed a sensitivity of 84.8%, a specificity of 74.1%, a negative predictive value of 85.81%, and a positive predictive value of 72.42%. AUC of EVLWI at 3 days was 0.838±0.048, at the cut-off point of 10.5 mL/kg, EVLWI showed a sensitivity of 83.9%, a specificity of 82.9%, a negative predictive value of 86.45%, and a positive predictive value of 79.79%. Their sensitivities and specificities were found to be better than APACHEII, SOFA score. AUC of PTX3 combined with EVLWI at 1 day was 0.886±0.038. On the 1st day after ICU admission, with combination of the two indicators, cut-off point was found to be 0.312, a sensitivity of 86.8%, a specificity of 85.4%, a negative predictive value of 88.93%, and a positive predictive value of 82.72%. On the 3rd day after ICU admission, AUC of PTX3 combined with EVLWI was 0.856±0.046, and showed a cut-off of 0.471 for the prognosis of sepsis, a sensitivity of 85.8%, a specificity of 85.4%, a negative predictive value of 87.97%, and a positive predictive value of 82.50%. Compared with other single index, a combination of above mentioned two indexes showed a better sensitivity and specificity. PTX3 can serve as a novel prognostic indicator at early stage in septic patients. Combined with EVLWI, it shows important value in predicting prognosis of septic patients, and it also provides guidance in treatment of high-risk patients.

Another hazard to laboratory workers

Needle-stick injuries, unfortunately, are a common occurrence during blood extraction and handling of specimens in the laboratory, which often lead to the contraction of blood-borne viral diseases. Mycobacterium tuberculosis infection also poses a threat to healthcare workers, especially laboratory workers in areas with endemic levels of tuberculosis infections. We present in this report, a case of primary inoculation of tuberculosis of the skin transmitted following a needle-stick injury, which was successfully treated. Reports of such an occurrence are few, and our report further underlines the need to take greater precautions against these accidents. In addition, our case draws attention to the possibility of prophylactic anti-tuberculous treatment in high-risk patients to prevent the progression of an overt illness.