Einfluss erweiterter Allokationsprogramme und Organ- und Empfängerqualitätsmerkmale auf die Kostenentstehung bei der Nierentransplantation

Hintergrund. Die terminale Niereninsuffizienz (TNI) hat einen großen Einfluss auf Gesundheitskosten. Die Nierentransplantation ist die kostengünstigste Therapie der TNI. Ein zunehmender Organmangel und stetig wachsende Empfänger-Wartelisten schränken den Zugang zur Nierentransplantation ein und werden mit der Ausweitung von Spenderpools um marginale Organe begegnet. Die Auswirkungen dieser Erweiterungsprogramme auf Gesundheitsausgaben werden kontrovers diskutiert. Ziel dieser Studie war es, die entstehenden Kosten bei Nierentransplantationen mit marginalen Organen (engl. expanded criteria donor, ECD) zu untersuchen und unabhängige Risikofaktoren für erhöhte transplantationsbedingte Kosten zu ermitteln. Methoden. Retrospektive explorative Analyse von Krankenhauskosten und Kostenvergütungsdaten von Nierentransplantationen, die zwischen 2012 und 2016 an der Chirurgischen Klinik der Charité – Universitätsmedizin Berlin durchgeführt wurden. Ergebnisse. Insgesamt wurden 174 Nierentransplantationen untersucht. Darunter waren 92 (52,9%) ECD-Organtransplantationen. Die ECD-Gruppe umfasste zudem 43 (24,7%) "old-for-old" Transplantationen. Die medianen Gesundheitskosten betrugen 19.570 € (IQR 18.735-27.405 €) in der Gruppe der Standardkriterien-Spender gegenüber 25.478 € (IQR 19.957-29.634 €) in der ECD-Gruppe (+30%; p=0,076). "Old-for-old" Transplantationen wiesen die höchsten Gesundheitsausgaben auf (26.702 € [19.570-33.940 €]). Unabhängig von der Allokationsgruppe zeigten sich die transplantationbedingten Kosten bei adipösen (+6.221€; p=0,009) und älteren Empfängern (+6.717€; p=0,019), beim Vorliegen einer warmen Ischämiezeit von über 30 Minuten (+3.212€; p=0,009), beim Auftreten einer verzögerten Transplantatfunktion oder chirurgischer Komplikationen (+8.976€ und +10.624€; beide p<0,001) signifikant erhöht. Fazit. Transplantationen von ECD-Organen sind mit zusätzlichen Kosten verbunden. Dies gilt insbesondere bei älteren und adipösen Empfängern. Unabhängig von der Allokationsgruppe, scheinen eine kritische Patientenauswahl, die Behandlung von Adipositas vor der Nierentransplantation und die Einhaltung einer kurzen warmen Ischämiezeit entscheidend, um erhöhte Kosten bei der Nierentransplantation zu vermeiden.End-stage renal disease (ESRD) has a major impact on health care costs. Kidney transplantation is the most cost-effective therapy of ESRD. Donor organ shortage and growing waiting lists have led to expansions of donor pools. However, expansions of donor pools have a controversial impact on healthcare expenditures. The aim of this study was to investigate the emerging costs of expanded criteria donor kidney transplantations and to identify independent risk factors for increased transplant-related costs. Methods. We performed a retrospective explorative analysis of hospital costs and reimbursements of patients who underwent a kidney transplantation between 2012 and 2016 in a German university hospital (Department of Surgery, Charité – Universitätsmedizin Berlin). Results. We examined a total of 174 KTs, including 92 (52.9%) ECD organ transplantations. The ECD group comprised 43 (24.7%) 'old-for-old' transplantations. Median healthcare costs were 19,570 € (IQR 18,735-27,405 €) in the standard criteria donor (SCD) group vs 25,478 € (IQR 19,957-29,634 €) in the ECD group (+30%; p=0.076). ‘Old-for-old’ transplantations showed the highest healthcare expenditures (26,702 € [19,570-33,940 €]). Irrespective of the allocation group, transplant-related costs increased significantly in obese (+6,221€; p=0.009) and elderly recipients (+6,717 €; p=0.019), in warm ischemia time exceeding 30 minutes (+3,212 €; p=0.009) and in kidneys with delayed graft function or surgical complications (+8,976 € and +10,624 €; both p<0.001). Conclusion. The usage of ECD kidney organs is associated with incremental costs, especially when transplanted into elderly and obese recipients. Regardless of the allocation group a critical patient selection, treatment of obesity before KT and keeping warm ischemia times short seem crucial elements of a cost-effective KT

The influence of gender on mortality in patients after thoracic endovascular aortic repair

Objectives: The aim of this study was to determine if gender affects mortality in patients after thoracic endovascular aortic repair (TEVAR). Methods: We retrospectively analyzed 286 consecutive patients undergoing TEVAR at our institution during a 12-year period (female 29%, median age 69 years). Chronic health conditions, risk factors, as well as early and long-term outcome were assessed. Follow-up data were available in all patients. Results: For female gender, 1-year survival and 5-year survival was 84% and 56% versus 83% and 60% for male gender. No significant gender influence was observed (odds ratio (OR) 0.96, 95% confidence interval (CI) 0.59-1.56). Furthermore, no significant gender influence could be observed according to the individual indication - atherosclerotic aneurysms (OR 0.78 95%CI 0.41-1.47), acute type B dissections (OR 0.78 95%CI 0.21-2.83), penetrating atherosclerotic ulcers/intramural hematoma (OR 1.48 95%CI 0.53-4.19), and traumatic aortic lesions (OR 1.48 95%CI 0.53-4.19). Age (OR 3.6 95%CI 1.24-10.45) and chronic obstructive pulmonary disease (COPD; OR 3.09 95%CI 0.98-9.73) were independent predictors of mortality in females. Conclusions: Gender does not affect mortality in patients after TEVAR irrespective of the underlying indication, atherosclerotic aneurysms, acute type B dissections, penetrating ulcers/intramural hematoma, and traumatic aortic lesions. Classical risk factors such as age and the presence of COPD at the time of TEVAR remain the most important risk factors in female

Perioperative Pleural Drainage in Liver Transplantation: A Retrospective Analysis from a High-Volume Liver Transplant Center

BACKGROUND Pleural effusions represent a common complication after liver transplantation (LT) and chest drain (CD) placement is frequently necessary. MATERIAL AND METHODS In this retrospective cohort study, adult LT recipients between 2009 and 2016 were analyzed for pleural effusion formation and its treatment within the first 10 postoperative days. The aim of the study was to compare different settings of CD placement with regard to intervention-related complications. RESULTS Overall, 597 patients met the inclusion criteria, of which 361 patients (60.5%) received at least 1 CD within the study period. Patients with a MELD >25 were more frequently affected (75.7% versus 56.0%, P<0.001). Typically, CDs were placed in the intensive care unit (ICU) (66.8%) or in the operating room (14.1% during LT, 11.5% in the context of reoperations). In total, 97.0% of the patients received a right-sided CD, presumably caused by local irritations. Approximately one-third (35.4%) of ICU-patients required pre-interventional optimization of coagulation. Of the 361 patients receiving a CD, 15 patients (4.2%) suffered a post-interventional hemorrhage and 6 patients (1.4%) had a pneumothorax requiring further treatment. Less complications were observed when the CD was performed in the operating room compared to the ICU: 1 out 127 patients (0.8%) versus 20 out of 332 patients (6.0%); P=0.016. CONCLUSIONS CD placement occurring in the operating room was associated with fewer complications in contrast to placement occurring in the ICU. Planned CD placement in the course of surgery might be favorable in high-risk patients

The influence of bicuspid aortic valves on the dynamic pressure distribution in the ascending aorta: a porcine ex vivo model †

OBJECTIVES The aim of the study was to simulate the effect of different bicuspid aortic valve configurations on the dynamic pressure distribution in the ascending aorta. METHODS Aortic specimens were harvested from adult domestic pigs. In Group 1, bicuspidalization was created by a running suture between the left and the right coronary leaflets (n = 6) and in Group 2 by a running suture between the left and the non-coronary leaflets (n = 6). Eleven tricuspid specimens served as controls. Two intraluminal pressure catheters were positioned at the concavity and the convexity of the ascending aorta. The specimens were connected to a mock circulation (heart rate: 60 bpm, target pressure: 95 mmHg). A comparison of the different conditions was also done in a numerical simulation. RESULTS At a distal mean aortic pressure of 94 ± 10 mmHg, a mean flow rate of 5.2 ± 0.3 l/min was achieved. The difference of maximal dynamic pressure values (which occurred in systole) between locations at the convexity and the concavity was 7.8 ± 2.9 mmHg for the bicuspid and 1.0 ± 0.9 mmHg for the tricuspid specimens (P < 0.001). The numerical simulation revealed an even higher pressure difference between convexity and concavity for bicuspid formation. CONCLUSIONS In this hydrodynamic mock circulation model, we were able to demonstrate that bicuspid aortic valves are associated with significant pressure differences in different locations within the ascending aorta compared with tricuspid aortic valves. These altered pressure distributions and flow patterns may further add to the understanding of aneurismal development in patients with bicuspid aortic valves and might serve to anticipate adverse aortic events due to a better knowledge of the underlying mechanism

Literature-based considerations regarding organizing and performing cardiac surgery against the backdrop of the coronavirus pandemic

Background: The ongoing coronavirus disease 2019 (Covid-19) pandemic presents challenges for surgeons of all disciplines, including cardiologists. The volume of cardiac surgery cases has to comply with the mandatory constraints of healthcare capacities. The treatment of Covid-19-positive patients must also be considered. Unfortunately, no scientific evidence is available on this issue. Therefore, this study aimed to offer some consensus-based considerations, derived from available scientific papers, regarding the organization and performance of cardiac surgery against the backdrop of the Covid-19 pandemic. Methods Key recommendations were extracted from recent literature concerning cardiac surgery. RESULTS: Reducing elective cardiac procedures should be based on frequent clinical assessment of patients on the waiting list (every one or two weeks) and the current local status of the Covid-19 pandemic. Screening tests at admission for every patient are broadly recommended. Where appropriate, alternative treatment methods can be considered, including percutaneous techniques and minimally invasive surgery, if performed by experienced cardiac surgery teams. Conclusions There is little evidence on the strategies to organize cardiac surgery in the Covid-19 pandemic. Most authors agree on reducing elective operations based on patients' clinical condition and the status of the Covid-19 pandemic. Admission screenings and the use of percutaneous or minimally invasive approaches should be preferred to reduce in-hospital stays

Effect on false-lumen status of a combined vascular and endovascular approach for the treatment of acute type A aortic dissection

OBJECTIVE The aim of the study is to evaluate midterm results with regard to false-lumen status of a combined vascular and endovascular approach for the treatment of acute type A aortic dissection. METHODS We performed ascending/hemiarch replacement during hypothermic circulatory arrest with additional open implantation of the Djumbodis Dissection System (non-self-expanding bare metal stent) to readapt the dissected layers in the arch and the proximal descending aorta in a consecutive series of 15 patients (mean age 61 years, 20% female) suffering from acute type A aortic dissections. The primary end point was the status of the false lumen at the level of the stent. RESULTS We observed three in-hospital deaths (20%). Complete thrombosis of the false lumen was observed in one patient (8%). In 25% of patients, partial thrombosis of the false lumen was observed. The remaining patients had continuing antegrade perfusion. Surgical conversion during a mean follow-up of 37 months was required in two patients (16%) due to continuing enlargement of the distal arch and the proximal descending aorta. No late deaths were observed. CONCLUSION Additional implantation of the Djumbodis Dissection System to readapt the dissected layers in the arch and the proximal descending aorta does not seem to have additive value as an adjunct to standard ascending/hemiarch replacement with regard to closure of the false lumen in the arch and the proximal descending aorta. The most limiting factor seems to be the non-self-expanding capability of the devic

The Burden Of Diarrhea: A Survey Of The Caregivers’ Opinions And Perceptions Of Workload In The Intensive Care Unit

In the literature, the prevalence of diarrhea in the Intensive Care Unit (ICU) has been reported to be 3.3-78%. The problem is significant to patients and also increases workload burden for ICU staff. Unfortunately, research on this topic is very limited; we found one single study on the impact that diarrhea has on nursing staff workload. Therefore, we conducted a retrospective chart review to describe the prevalence and impact of diarrhea in our organization. For the purposes of this study, we equated diarrhea with type 7 stools as defined in the Bristol Stool Form Scale. In January of 2018, we developed a bowel management guideline and rolled out the associated protocol in a multifaceted implementation process which included a variety of educational strategies. Toward promoting the use of the tool in practice, we sought to assess staff perceptions of the resources and time needed to manage diarrhea and bowel function with a survey that was administered to ICU staff in a 600 bed, level one trauma center. The purpose of this poster is to describe the findings from a survey to assess perceptions of workload after the implementation of the new bowel management guidelines

Neurocardiac risk stratification 6 hours after resuscitation from cardiac arrest

Introduction: • An increasing number of patients are resuscitated from out-ofhospital cardiac arrest. Triage to optimal treatment pathways could improve and increase the efficacy of post-resuscition care. • Despite great variability in etiology, duration, and patterns of injury from cardiac arrest, post-resuscitation treatment guidelines emphasize standard treatments. We hypothesize that by categorizing competing risks very early after resuscitation, it may be possible to improve the efficacy and efficiency of care. • When measured very early after resuscitation, suppression ratio (SR, the percentage of suppressed EEG), correlates with severity of brain injury and the likelihood of poor neurological outcome. • The CREST score2 is a validated model to predict circulatoryetiology death (CED) based on: Coronary artery disease, initial nonshockable Rhythm, Ejection fraction25 minutes

Validation of a new prognostic model to predict short and medium-term survival in patients with liver cirrhosis

Background: MELD score and MELD score derivates are used to objectify and grade the risk of liver-related death in patients with liver cirrhosis. We recently proposed a new predictive model that combines serum creatinine levels and maximum liver function capacity (LiMAx®), namely the CreLiMAx risk score. In this validation study we have aimed to reproduce its diagnostic accuracy in patients with end-stage liver disease. Methods: Liver function of 113 patients with liver cirrhosis was prospectively investigated. Primary end-point of the study was liver-related death within 12 months of follow-up. Results: Alcoholic liver disease was the main cause of liver disease (n = 51; 45%). Within 12 months of follow-up 11 patients (9.7%) underwent liver transplantation and 17 (15.1%) died (13 deaths were related to liver disease, two not). Measures of diagnostic accuracy were comparable for MELD, MELD-Na and the CreLiMAx risk score as to power in predicting short and medium-term mortality risk in the overall cohort: AUROCS for liver related risk of death were for MELD [6 months 0.89 (95% CI 0.80–0.98) p < 0.001; 12 months 0.89 (95% CI 0.81–0.96) p < 0.001]; MELD-Na [6 months 0.93 (95% CI 0.85–1.00) p < 0.001 and 12 months 0.89 (95% CI 0.80–0.98) p < 0.001]; CPS 6 months 0.91 (95% CI 0.85–0.97) p < 0.01 and 12 months 0.88 (95% CI 0.80–0.96) p < 0.001] and CreLiMAx score [6 months 0.80 (95% CI 0.67–0.96) p < 0.01 and 12 months 0.79 (95% CI 0.64–0.94) p = 0.001]. In a subgroup analysis of patients with Child-Pugh Class B cirrhosis, the CreLiMAx risk score remained the only parameter significantly differing in non-survivors and survivors. Furthermore, in these patients the proposed score had a good predictive performance. Conclusion: The CreLiMAx risk score appears to be a competitive and valid tool for estimating not only short- but also medium-term survival of patients with end-stage liver disease. Particularly in patients with Child-Pugh Class B cirrhosis the new score showed a good ability to identify patients not at risk of death

Prevalence and management of driveline infections in mechanical circulatory support - a single center analysis

Background: Driveline infections in continuous-flow left ventricular assist devices (cf-LVAD) remain the most common adverse event. This single-center retrospective study investigated the risk factors, prevalence and management of driveline infections. :Methods Patients treated after cf-LVAD implantation from December 2014 to January 2020 were enrolled. Baseline data were collected and potential risk factors were elaborated. The multi-modal treatment was based on antibiotic therapy, daily wound care, surgical driveline reposition, and heart transplantation. Time of infection development, freedom of reinfection, freedom of heart transplantation, and death in the follow-up time were investigated. Results: Of 75 observed patients, 26 (34.7%) developed a driveline infection. The mean time from implantation to infection diagnosis was 463 (+/- 399; range, 35-1400) days. The most common pathogen was Staphylococcus aureus (n = 15, 60%). First-line therapy was based on antibiotics, with a primary success rate of 27%. The majority of patients (n = 19; 73.1%) were treated with surgical reposition after initial antibiotic therapy. During the follow-up time of 569 (+/- 506; range 32-2093) days, the reinfection freedom after surgical transposition was 57.9%. Heart transplantation was performed in eight patients due to resistant infection. The overall mortality for driveline infection was 11.5%. Conclusions: Driveline infections are frequent in patients with implanted cf-LVAD, and treatment does not efficiently avoid reinfection, leading to moderate mortality rates. Only about a quarter of the infected patients were cured with antibiotics alone. Surgical driveline reposition is a reasonable treatment option and does not preclude subsequent heart transplantation due to limited reinfection freedom