Journal articles on the topic 'Ictus minor'

BackgroundThe recent literature pertaining to delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage has downplayed the role of angiographic vasospasm. However, it is our hypothesis that angiographic vasospasm has a significant pathophysiological role in this disease. We undertook an observational radiographic study of patients who presented in a delayed manner (>72 h from ictus) with evidence of severe angiographic vasospasm on initial angiography in order to describe an apparent association between vasospasm and infarct location.MethodsThis was a retrospective study of consecutive patients treated at our unit. Initial, subsequent, and follow-up cross-sectional imaging with CT or MRI was analyzed in conjunction with initial angiography. Sites of angiographic narrowing, angiographic hypoperfusion, and subsequent sites of infarction were assessed.ResultsThirteen patients (6 women, 7 men) of mean age 49 years were assessed. Mean time to presentation was 6 days. All had severe angiographic vasospasm. Nine of the 13 patients suffered infarction; the infarcts in seven of the nine patients were large. There was correlation between sites of angiographic narrowing and infarction in all cases and eight of the nine cases showed angiographic hypoperfusion in a location corresponding to eventual infarct location.ConclusionsSevere angiographic vasospasm may be linked to infarction in patients who present late. These infarcts are mostly large despite maximal treatment. We question the notion that proximal vasospasm has a minor role in delayed ischemia.

Most studies in literature about the occurrence of the so-called vascular epilepsy suggest that this complication is an episodic and relatively rare event mostly due to clinical conditions related to haemorrhagic ictus while chronic vascular disease (multifocal vascular encephalopathy, vasculopathy with lacunar infarcts or minor stroke and ischemic strokes) is not usually considered as risk factors for the onset of secondary epilepsy. Furthermore, the epilepsy of the elderly is often ascribed to the atrophy of the brain tissues linked to both age and chronic hypoxia induced by Atherosclerosis (ATS) or a complication of pharmacological therapies in the elderly (anticholinesterases, neuroleptics, anticoagulants). In fact, in our clinical and practical experience in the district outpatients clinic and home care center, numerous clinical cases have been subject to diagnosis and treatment of late epilepsy following an ischemic stroke. In this study we had thepurpose to describe our experience of occurrence of epileptic complications in patients with morewide Cerebrovascular Disease (CVD) patterns. We studied a group of 15 patients (8 Male and 7 Female) affected by CVD and by recent recently onset epilepsy. Our study found that Cerebrovascular disease CVD constitutes a significant risk factor for secondary epilepsy in the groups with elder age even though younger subjects can be involved after being affected by relevant cerebrovascular events. In opposition to the opinion assumed in common clinical practice an important part of these causal events are ischemic and non-haemorrhagic as previously known.

Lo sviluppo delle moderne tecniche di immagini non invasive ha determinato un notevole progresso nelle conoscenze del recupero funzionale dopo ictus, potenzialmente di grande utilità per la messa a punto di programmi terapeutici e riabilitativi. Diversi meccanismi sono stati proposti, quali l'attivazione di vie derivanti dalle aree corticali motorie omolaterali al lato paretico, il reclutamento di aree corticali adiacenti alla lesione, il rinforzo di circuiti neuronali preesistenti, lo stabilirsi di nuove connessioni a livello sinaptico. Considerati i dati contraddittori della letteratura, abbiamo effettuato un studio mediante Risonanza Magnetica funzionale (fMRI) con lo scopo di definire meglio il ruolo delle proiezioni omolaterali e i fenomeni di riorganizzazione plastica post-ictale delle aree corticali motoria primaria (M1), premotoria laterale (PML) e supplementare motoria (SMA). Sono stati studiati 14 pazienti con pregresso ictus ischemico sottocorticale in buon recupero funzionale, 7 con emiparesi destra e 7 con emiparesi sinistra, ad una distanza mediana di 61 giorni dall'evento ischemico. I risultati hanno evidenziato durante il movimento della mano paretica un'attivazione bilaterale della M1 ed in misura minore delle PML e SMA, mentre si è registrata un'attivazione controlaterale più selettiva durante il movimento della mano sana. I dati sembrerebbero dimostrare che una maggiore attivazione delle aree motorie corticali omolaterali alla lesione sia un importante meccanismo di compenso al danno funzionale conseguente ad ictus non solo nella fase postacuta ma anche nella fase di stabilizzazione.

The Belgian Euthanasia Act of 2002 (The Act), amended in 2014 to include the Minor Act (The Minor Act), has drawn international criticisms for its liberal laws and practices regarding Euthanasia. This research study is a response to media allegations that the liberal laws on euthanasia has encouraged doctors to adopt a paternalistic approach towards their patients by terminating their lives without their explicit consent, i.e. engaging in involuntary Euthanasia. Although in theory, only voluntary euthanasia (explicit patient request and therefore consent) is permitted in Belgium, the media allegations implied that in practice, involuntary euthanasia (no explicit patient request and therefore no consent) is practiced, especially in the Intensive Care Units (ICUs) in Belgium. One major criticism is that because of its liberal laws, Belgian doctors are killing patients without their non-explicit consent. Specifically, it is alleged that Intensivists are shortening lives or hastening the deaths of their patients without their non-explicit consent in the ICUs in the Wallonia Region in Belgium. This research study conducted an empirical-qualitative study to discover if these media allegations were true or false, by interviewing heads of ICUs in five major hospitals in the Wallonia region in Belgium. The research discovered that the media allegations are true, but they are also false. The media allegations are true because shortening life or hastening the death is sometimes practiced in the ICUs without the patient’s non-explicit consent. The media allegations are false because consent is not available due to the patient’s critical condition, and not because it was not asked for. In other words, what is practiced in the ICUs is non-voluntary euthanasia or where patient is unable to request or consent to euthanasia.

Conflicts are an integral part of people’s lives, regardless of their age. This aspect of life evokes many negative connotations. Nevertheless, the advantages of confl icts are now often exposed, providing that they are solved in a constructive way. The adolescent period is a stage of life that undoubtedly favours the frequency and intensity of diffi cult interpersonal situations. Therefore, the researchers decided to analyse which confl ict resolution styles are favoured by youth. The research was conducted in a group of one hundred and twentytwo secondary school students, half of whom were minors. A diagnostic opinion poll was applied. To be precise, it was the Confl ict Mode Instrument of Thomas and Kilmann. From the data obtained it stems that the minors, in comparison to the youth who are not under the supervision of a probation offi cer, are less likely to give up their own needs and interests on behalf of their partner in confl ict. However, equally often, people from the comparison groups solve confl icts by competing, looking for a compromise, using escaping mechanisms as well as cooperating with the confl ict partner. This means that it is worth applying negotiation and mediation as a preventative measure to prevent the escalation of the symptoms of social maladjustment.

Increased frequency of methicillin-resistantStaphylococcus aureus(MRSA) in hospitalized patients requires rapid and reliable characterization of isolates for control of MRSA spread in hospitals. This study evaluated polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) as a molecular typing technique for MRSA strains on the basis of protein A (spa) and coagulase (coa) gene polymorphisms to verify their ability in assessing the relatedness of isolates. Seventy-five MRSA isolates, from different ICUs of Alexandria University Main Hospital, were characterized using antibiotyping and PCR-RFLP analysis ofcoaandspagenes. Thirty-two antibiotypes were identified.coagene PCR generated 3 types and 10 subtypes of band patterns.HaeIIIrestriction digestion of amplifiedcoagene products produced 5 major banding patterns and 12 subtypes.spagene PCR products generated 4 major and 11 minor types, and theirHaeIIrestriction digestion showed 5 major and 12 minor banding patterns. The combinedcoaandspaRFLP patterns generated 22 combined R types. Typing usingcoaPCR and PCR-RFLP had the same discriminatory index (DI) value (0.64), which was comparable to that of bothspaPCR and PCR-RFLP techniques (0.68). The combined grouping increased the DI value to 0.836. The current study revealed that testing for multiple gene polymorphisms is more useful for local epidemiologic purposes.

Introduction: During the one-year CCFP-EM program, residents rotate through different teaching sites. The purpose of this project is to investigate differences in procedural skills acquisition between these sites, which will help identify the effectiveness of each setting for teaching procedural skills amongst EM trainees. Methods: Over a two year period, residents enrolled in a CCFP-EM residency training program were asked to log their procedures and the sites where they were performed. The cumulative data was analyzed to show the number and types of procedures performed at each site. Results: A total of 477 procedures were logged over two years, with 198 procedures performed at urban tertiary emergency departments (EDs), 116 at community EDs, 87 at intensive care units (ICUs), 37 at urgent care centre, 24 in clinics, and 15 at other settings. Overall, 48 point of care ultrasounds, 75 vascular access procedures, 99 reduction/casting, 48 lumbar punctures, 29 procedural sedations, 125 minor surgical procedures, and 32 other procedures were performed. The majority of procedures were performed at the tertiary care urban ED, followed closely by community ED setting. The only exception was vascular access, which was performed most commonly in ICU settings. Conclusion: Our urban tertiary care ED setting provided the most learning opportunity for procedural skill acquisition, suggesting that having maximized time allocated in this setting is essential for EM learners to acquire procedural skills. One exception is that EM learners gain more vascular access training in ICUs.

The AIMS-ICU project is a national study set up to develop, introduce and evaluate an anonymous voluntary incident reporting system for intensive care. ICU staff members reported events which could have reduced, or did reduce, the safety margin for the patient. Seven ICUs contributed 536 reports, which identified 610 incidents involving the airway (20%), procedures (23%), drugs (28%), patient environment (21%), and ICU management (9%). Incidents were detected most frequently by rechecking the patient or the equipment, or by prior experience. No ill effects or only minor ones were experienced by most patients (short-term 76%, long-term 92%) as a result of the incident. Multiple contributing factors were identified, 33% system-based and 66% human factor-based. Incident monitoring promises to be a useful technique for improving patient safety in the ICU, when sufficient data have been collected to allow analysis of sets of incidents in defined “clinical situations”.

This article analyses the way in which the digital divide affects Roma/Gitano minors. This ethnic group is a paradigmatic case among socially underprivileged groups in Spain; excluded from industrial society, they appear to be facing a similar situation in the post-industrial era. We, therefore, sought to explore the digital experiences of minors from this group in order to study social and digital exclusion/inclusion among them. The research strategy took a comprehensive approach, covering both offline and online behaviour. We focused on the results of fieldwork undertaken in Spain during 2017. In all, interviews were conducted with 17 adolescents (aged 11 to 18) as well as with several social workers who were providing support to the minors. Given that the use of technology has become a prerequisite for the welfare of children and for the development of their rights, the issue tends to centre on three main areas, commonly known as the three Ps: provision, participation, and protection. As such, the analysis of inequality was based on these areas. The findings presented in this article illustrate that the use of ICTs can contribute to empowering Roma/Gitano adolescents to improve the position they occupy as a group in the social structure.

BACKGROUND: Intrahospital transportation of critically ill patients can contribute to patients' morbidity and mortality. OBJECTIVE: To determine adverse outcomes associated with intrahospital transportation of critically ill patients by a specially trained nursing transport team. METHODS: Monitoring and intervention data were collected for 237 instances of transportation of patients between a hospital's ICUs and radiology suites. These results were compared with the results of national studies on complication rates associated with intrahospital transportation of patients. RESULTS: The patients moved by the specially trained transport team has a 15.5% overall complication rate, with 10.2% minor, 2.5% moderate (compensated for with medications), and 2.8% severe complications that did not respond to intervention. No medications of therapies were delayed, and only 2 patients (0.8%) had decompensation that required the examinations to be aborted. Reported national complication rates for intrahospital transportation of patients are as high as 75%; the complications include adverse events such as delayed administration of medications, significant changes in vital signs, dislodgment of artificial airways and i.v. catheters, and cardiopulmonary arrest. CONCLUSION: Use of a specially trained ICU transport team can substantially reduce the rate of adverse outcomes generated by the transportation of critically ill patients for specialized radiological procedures.

In the past decade there has been a dramatic increase in the incidence of life-threatening Candida infections in patients in intensive care units (ICUs). Once considered a minor pathogen, Candida is now among the most commonly cultured pathogens in the ICU. This phenomenon is in part attributable to greater numbers of immunocompromised patients being hospitalized and the more frequent use of surgery, instrumentation, and broadspectrum antibiotics. Serious Candida infections can present as generalized sepsis, as focal involvement of virtually any organ, or as part of the syndrome of multiple system organ failure. Once established, these infections can be difficult to detect until their late stages and consequently are responsible for significant morbidity and mortality in ICU patients. For treatment to be successful it must be instituted promptly and, on occasion, empirically. As a result, new diagnostic techniques, treatments, and prophylactic strategies to minimize the occurrence of Candida infections are the subjects of ongoing research. This article is intended to provide practitioners with an understanding of why serious Candida infections are increasing, as well as information on pathogenesis, diagnosis, treatment, and some measures that can be taken to prevent such infections in critically ill patients.

BackgroundTo improve care it is necessary to feed back experiences of those receiving care. Of patients admitted to intensive care units (ICUs), approximately one-quarter die, and few survivors recollect their experiences, so family members have a vital role. The most widely validated tool to seek their views is the Family Satisfaction in the Intensive Care Unit questionnaire (FS-ICU).ObjectivesTo test face and content validity and comprehensibility of the FS-ICU (phase 1). To establish internal consistency, construct validity and reliability of the FS-ICU; to describe family satisfaction and explore how it varies by family member, patient, unit/hospital and other contextual factors and by country; and to model approaches to sampling for future use in quality improvement (phase 2).DesignMixed methods: qualitative study (phase 1) and cohort study (phase 2).SettingNHS ICUs (n = 2, phase 1;n = 20, phase 2).ParticipantsHealth-care professionals, ex-patients, family members of ICU patients (n = 41, phase 1). Family members of ICU patients (n = 12,303, phase 2).InterventionsNone.Main outcome measuresKey themes regarding each item of the 24-item FS-ICU (FS-ICU-24) (phase 1). Overall family satisfaction and domain scores of the FS-ICU-24 (phase 2).ResultsIn phase 1, face validity, content validity and comprehensibility were good. Adaptation to the UK required only minor edits. In phase 2, one to four family members were recruited for 60.6% of 10,530 patients (staying in ICU for 24 hours or more). Of 12,303 family members, 7173 (58.3%) completed the questionnaire. Psychometric assessment of the questionnaire established high internal consistency and criterion validity. Exploratory factor analysis indicated new domains:satisfaction with care,satisfaction with informationandsatisfaction with the decision-making process. All scores were high with skewed distributions towards more positive scores. For family members of ICU survivors, factors associated with increased/decreased satisfaction were age, ethnicity, relationship to patient, and visit frequency, and patient factors were acute severity of illness and invasive ventilation. For family members of ICU non-survivors, average satisfaction was higher but no family member factors were associated with increased/decreased satisfaction; patient factors were age, acute severity of illness and duration of stay. Neither ICU/hospital factors nor seasonality were associated. Funnel plots confirmed significant variation in family satisfaction across ICUs. Adjusting for family member and patient characteristics reduced variation, resulting in fewer ICUs identified as potential outliers. Simulations suggested that family satisfaction surveys using short recruitment windows can produce relatively unbiased estimates of average family satisfaction.ConclusionsThe Family-Reported Experiences Evaluation study has provided a UK-adapted, psychometrically valid questionnaire for overall family satisfaction and three domains. The large sample size allowed for robust multilevel multivariable modelling of factors associated with family satisfaction to inform important adjustment of any future evaluation.LimitationsResponses to three free-text questions indicate the questionnaire may not be sensitive to all aspects of family satisfaction.Future workReservations remain about the current questionnaire. While formal analysis of the free-text questions did not form part of this proposal, brief analysis suggested considerable scope for improvement of the FS-ICU-24.Study registrationCurrent Controlled Trials ISRCTN47363549.Funding detailsThe National Institute for Health Research Health Services and Delivery Research programme.

Professional Stress and Health among Critical Care Nurses in SerbiaThe aim of this study was to identify and analyse professional stressors, evaluate the level of stress in nurses in Intensive Care Units (ICU), and assess the correlation between the perception of stress and psychological and somatic symptoms or diseases shown by nurses. The research, designed as a cross-sectional study, was carried out in the Intensive Care Units (ICU), in health centres in Serbia. The sample population encompassed 1000 nurses. Expanded Nursing Stress Scale (ENSS) was used as the research instrument. ENSS revealed a valid metric characteristic within our sample population. Nurses from ICUs rated situations involving physical and psychological working environments as the most stressful ones, whereas situations related to social working environment were described as less stressful; however, the differences in the perception of stressfulness of these environments were minor. Socio-demographic determinants of the participants (age, marital status and education level) significantly affected the perception of stress at work. Significant differences in the perception of stressfulness of particular stress factors were observed among nurses with respect to psychological and somatic symptoms (such as headache, insomnia, fatigue, despair, lower back pain, mood swings etc.) and certain diseases (such as hypertension, myocardial infarction, stroke, diabetes mellitus etc). In view of permanent escalation of professional stressors, creating a supportive working environment is essential for positive health outcomes, prevention of job-related diseases and better protection of already ill nurses.

Increasing psychological resistance to manipulative influence and preventing the involvement of minors in illegal activities with the help of information and communication technologies (ICTs) are important tasks of the State. The article analyzes some psychological mechanisms that contribute to manipulation on the Internet, including the effects of normative influence, conformity, perceived interpersonal similarity, cascades of available information, emotional contagion, hemophilicity, false memories, and multiple sources. The authors analyze the main strategies for promoting false and misleading information: artificial polarization, managing false accounts on behalf of public opinion leaders, creating emotional messages, using conspiracy theories, trolling aimed at provoking harassment of users on the network, defaming and delegitimizing opponents.
 Attention is also drawn to ways to counteract destructive information and psychological impact, which include not only ways to improve the legislative apparatus and the use of software and technical solutions, but also to increase the level of psychological stability of citizens, conducting preventive and preventive measures aimed at forming ideas about information threats, their types, methods of identification and protection, group norms and values. The author points out the need to develop and implement special psychological trainings and games created in the form of computer programs, mobile applications and online simulators in the socio-cultural and educational environment.

Background The authors conducted a patient-based survey of practices to fully describe the assessment and the management of pain and sedation of a large cohort of mechanically ventilated patients during their first week of intensive care unit (ICU) stay. Methods A total of 1,381 adult patients were included in a prospective, observational study in 44 ICUs in France. Pain and sedation assessment, analgesic and sedative use, and analgesic management during procedural pain were collected on days 2, 4, and 6 of the ICU stay. Results The observed rates of assessment on day 2 for sedation (43%) and analgesia (42%) were significantly smaller than that of use of sedatives (72%) and opioids (90%), also noted on days 4 and 6. The use of protocols/guidelines for sedation/analgesia in the ICU reduced the proportion of patients who were treated, although not evaluated. A large proportion of assessed patients were in a deep state of sedation (40-50%). Minor changes in the dosages of the main prescribed agents for sedation (midazolam, propofol) and analgesia (sufentanil, fentanyl, morphine, remifentanil) were found across 6 days of the patient's ICU stay. Procedural pain was specifically managed for less than 25% of patients; during those procedures, the proportion of patients with pain significantly increased from the baseline pain evaluation. Conclusions Excessively deep states of sedation and a lack of analgesia during painful procedures must be prevented. To facilitate systematic pain and sedation assessment and to adjust daily drug dosages accordingly, it seems crucial to promote educational programs and elaboration of protocols/guidelines in the ICU.

Background: This study is based on the tragic firework accident, with the highest death toll in India, that occurred in Puttingal Devi Temple, Kollam District, Kerala, at 3.30 am on 10/04/2016. Around 1500 people were injured. On the spot death toll was 109 and 12 others died in hospitals later. 1039 were treated as OP case and 410 as inpatients in various secondary and tertiary care hospitals in Kollam and Thiruvananthapuram with the help of the team of experts from AIIMS, Delhi. The aim was to study the clinical profile of inpatients admitted with trauma and/or burns following the incident and to formulate a Medical action- plan of in such eventualities.Methods: The present study is descriptive in nature with study setting in secondary and tertiary care hospitals in Kollam and Thiruvananthapuram districts. The study subjects were all the inpatient victims of the firework tragedy. The study method used analysis of relevant patient details collected from hospitals records. Results: 410 inpatients of various hospitals were analysed. Majority of the victims were males. (95.6%) Major age group affected is 20-50 years (66.1%). 79.5% of patients were treated in wards and 20.5% in various ICUs. 54.4% in secondary care centres and 45.6% in tertiary care centres. 78.2% of patients had traumatic injuries alone, 19.8% had trauma and burn injuries and 2% had burn injuries alone. 37.3% had major injuries, 21.5% had multiple fractures and 39.1% had minor injuries. 29% of patients had to undergo various surgeries. Hospital stay -76.4% of patients <2 weeks, 16.6% 2-4 weeks and 7.1% more than 30 days. Outcome: 70.7% were completely cured, 21.5% had temporary disability, 4.9% developed permanent disability. Mortality was 2.9%.Conclusions: Dedicated team work and inter-disciplinary care at Secondary and tertiary care centres of Kollam and Trivandrum districts with the timely help of medical team from Delhi has brought down the mortality rate to 2.9% in a major firework disaster with 1500 victims, which is comparable with the international standards.

The integration of medical signal processing capabilities and advanced sensors into Internet of Things (IoT) devices plays a key role in providing comfort and convenience to human lives. As the number of patients is increasing gradually, providing healthcare facilities to each patient, particularly to the patients located in remote regions, not only has become challenging but also results in several issues, such as: (i) increase in workload on paramedics, (ii) wastage of time, and (iii) accommodation of patients. Therefore, the design of smart healthcare systems has become an important area of research to overcome these above-mentioned issues. Several healthcare applications have been designed using wireless sensor networks (WSNs), cloud computing, and fog computing. Most of the e-healthcare applications are designed using the cloud computing paradigm. Cloud-based architecture introduces high latency while processing huge amounts of data, thus restricting the large-scale implementation of latency-sensitive e-healthcare applications. Fog computing architecture offers processing and storage resources near to the edge of the network, thus, designing e-healthcare applications using the fog computing paradigm is of interest to meet the low latency requirement of such applications. Patients that are minors or are in intensive care units (ICUs) are unable to self-report their pain conditions. The remote healthcare monitoring applications deploy IoT devices with bio-sensors capable of sensing surface electromyogram (sEMG) and electrocardiogram (ECG) signals to monitor the pain condition of such patients. In this article, fog computing architecture is proposed for deploying a remote pain monitoring system. The key motivation for adopting the fog paradigm in our proposed approach is to reduce latency and network consumption. To validate the effectiveness of the proposed approach in minimizing delay and network utilization, simulations were carried out in iFogSim and the results were compared with the cloud-based systems. The results of the simulations carried out in this research indicate that a reduction in both latency and network consumption can be achieved by adopting the proposed approach for implementing a remote pain monitoring system.

Child victims of trafficking are recognized as particularly vulnerable victims, who require additional protection and support and a more rigorous legal framework. The regional anti-trafficking instruments 1 explicitly enforce the importance of protecting child trafficking victims, requiring Member States to ‘appoint a guardian or a representative for a child victim of trafficking in human beings from the moment the child is identified by the authorities’. 2 The problem of child trafficking and exploitation has received increased attention in England and Wales in recent years, with record number of minors referred to the National Referral Mechanism in 2016. Running parallel to this are the apparent failings of the domestic social care system to safeguard not only trafficked children but also those who are seeking asylum or unaccompanied. Over a quarter of officially identified trafficked children were found to have gone missing between 2014 and 2015. 3 Across the United Kingdom when transposing the European Union (EU) legal framework, the Government maintained that existing provisions by local authorities under their statutory child protection obligations, including social workers and independent reviewing officers, fulfilled the guardian requirements in the Directive. The Modern Slavery Act 2015 has placed significant emphasis on reforming the approach to the protection for child trafficking victims, culminating in the introduction a specific statutory provision establishing Independent Child Trafficking Advocates (ICTAs). 4 Such a scheme is the first guardian of its kind, designed specifically for child trafficking victims in Europe. Taking into account the recent evaluation of pilot schemes, 5 and the slight variation in approach taken in the devolved jurisdictions of the United Kingdom, 6 this article will consider the extent to which the protection of child trafficking victims under the jurisdiction of the Modern Slavery Act 2015 is sufficient to fulfil the legal positive obligations imposed by EU Law. This article will demonstrate that as it stands the Modern Slavery Act 2015 fulfils the obligations of the EU Trafficking Directive in relation to the protection of child trafficking victims. However, its fully effective enforcement requires further efforts in policy to ensure that these legal obligations are implemented in practice.

Abstract Myelodysplastic syndromes (MDS) constitute a heterogeneous group of hematopoietic stem cell disorders, characterized by ineffective hematopoiesis resulting in cytopenias and a variable risk to develop acute myeloid leukemia. Discrimination between MDS and non-clonal causes of cytopenia is regularly based on cytomorphology (CM) and conventional cytogenetics (CCG) and can be challenging in case of minor morphologic dysplastic features or if karyotypic abnormalities are lacking. In these cases an integrated multi-diagnostic approach is warranted. The aim of this prospective study was to investigate the role of flow cytometry (FC) compared to other diagnostic tools in MDS. We evaluated bone marrow samples of 316 patients with unexplained cytopenias, who were routinely analyzed by CM and FC combined with CCG, i.e. karyotyping or interphase fluorescence in situ hybridization (iFISH) when karyotyping failed. CM as gold standard classified 82 patients as MDS and 114 patients as non-clonal diseases while in 120 patients the diagnosis was indeterminate. Four patients were classified as normal. CCG analysis was normal in 192 patients, abnormal in 58 patients (MDS-associated abnormalities in 28), and not performed in 66 patients because there was no indication based on the CM result. Additional iFISH analysis in 4 patients where CCG failed, showed no abnormalities. FC analysis, performed according to European LeukemiaNet guidelines (Van de Loosdrecht et al., Haematologica 2009 and Leukemia 2012), disclosed MDS in 90 patients, showed signs of dysmyelopoiesis in 74 patients, and no signs of MDS in 141 patients (Van de Loosdrecht et al., J. Natl Compr Canc Net 2013). FC as diagnostic tool in MDS reached a sensitivity of 83% and a specificity of 77%; the positive predictive value of FC was 78% and the negative predictive value was 83%, when compared to outcome of the multi-diagnostic approach in which CM was leading. Focusing on the patient population with indeterminable CM (N=120), CCG analysis identified 1 patient with a chronic lymphatic leukemia associated abnormality and 5 patients with typical MDS abnormalities (Schanz et al., JCO 2012). The latter were also recognized by FC. In the remaining 114 CM-inconclusive cases, where CCG did not add to the diagnosis (note: ∼60% of MDS patients have normal karyotypes) FC identified 11 patients with a typical MDS profile, 28 patients with dysmyelopoiesis and 69 patients without any signs of dysmyelopoiesis. Based on the negative predictive value of FC (83%, as described above), we postulate that most of these 69 inconclusive cytopenic cases are no MDS. These cases might be classified as idiopathic cytopenia of unknown significance (ICUS), in the absence of other causes. In summary, this prospective single center study analyzed the integrated diagnostic work-up of patients with unexplained cytopenias. We demonstrated that FC is instrumental in discriminating clonal and non-clonal causes of cytopenia by excluding underlying MDS when validated standard diagnostic tools such as CM and CCG are not informative. Disclosures: No relevant conflicts of interest to declare.

Statement of the problem. There are a lot of works in the national musicology focusing on the study of vocal chamber music for voice and piano by Ukrainian composers of the 20th century. Researchers cover quite a wide range of issues regarding vocal pieces and touch upon the problems of cyclocreation, dramaturgy, features of musical and linguistic means, etc. However, they rarely pay attention to translation, though there are many vocal opuses, in which composers use foreign poetry. In this case, the specifi c choice of the translated sample helps to determine the principles of the composer’s approach to the embodiment of the poetic text, especially in comparison with other works based on the same sources. Hence separate songs from D. Klebanov’s vocal cycle on the poems of H. Heine did not become an exception, thereby confi rming the relevance of the proposed topic. The purpose of the article is to determine specifi c features of the embodiment of H. Heine’s poetry translations in the vocal cycle of D. Klebanov on the basis of two romances – “In a grove, on a wild path”, “My love, lay your hand on my heart”, as compared to the works of other composers of the twentieth century . To achieve the research objectives the following methods were used: historical, structural-functional, genre-style and comparative. Results. Under consideration are peculiarities of the embodiment of H. Heine’s poetry translations in the vocal cycle of D. Klebanov, one of the founders of Kharkiv composition school. For this work the author took eight verses from the fi rst two cycles of the “Book of Songs” by the German poet. They were based on the motives of love poems with vivid images of nature; sometimes the poems are full of sadness, a sense of loneliness. When D. Klebanov was choosing certain samples from different poetic cycles, he tried to stick to the plot of the “Book of Songs”, since he ordered the poems in the same way they were written in the collection. Another indicator of the composer’s relation to Heiner’s texts is the choice of poetic works which are given in the cycle in Ukrainian and Russian languages. The composer’s individual vision of Heine’s lyric poetry is clearly seen when compared to the vocal works of other composers of the twentieth century, M. Medtner and E. Denisov, written on the same poetic texts. In cross-romances, similar musical-linguistic means are used, including the metrical principle of vocalization of the poetic text, homophonic-harmonic structure, harmony of classical-romantic type. However, each of the composers renders the fi gurative and semantic implications of the poems in their own way. M. Medtner builds his romance “My love, lay your hand on my heart” according to the crescendo principle. Beginning with a quieter dynamics, the composer gradually increases the volume of the sound, which at the end leads to a general climax that moves from the point of the golden section. D. Klebanov chose a different way – to reinforce the dramatism of the poem. This was possible thanks to various musical and linguistic means: a strict, intense melody in the bass doubled in the sixth with a chromatic motion and semiquavers at the end of each bar in the last line of the fi rst stanza, designation Meno mosso, chromaticized vocal melody. The composers’ choice of poetic translations depends on the place and role of the romance in the general structure of the cycle. The eight-part composition of D. Klebanov is based on the wave principle of the plot development. The original four romances pave the way to the fi rst climax – unrequited love in the fi rst romance (“Every morning I awake and ask”), painful memories in the second one (“In a grove, on a wild path”), a tragic image in the third one (“My love, lay your hand on my heart “), and an attempt to overcome the pain in the fourth romance (“First I was afraid of darkness”). Further on, the development is based on contrast: the image of death in the fi fth romance (“Your lovely face, so fair and dear”), a subtle feeling of love in the sixth one (“Oh, let me plunge my heart”), worries because of the marriage of a loved one to another guy in the seventh romance (“I hear the fl ute and the fi ddle”) and disappointment in her spiritual values in the last one (“The violets blue”). Such a location of the third romance justifi es the choice of translation, where the colours are thickening and the content becomes even darker. Such kind of a fi gurative and semantic plot resembles the tradition of a romantic vocal cycle, in which the emotional state of the lyrical character, his emotional collisions сome to the fore. In this perspective, “ 3 Poems of H. Heine” by D. Medtner demonstrate another relationship between the romances of the cycle. All of them have feelings of sorrow, despair circle, a no-go. At the same time, distancing from the immediate events is felt, as if it is a look at someone else’s life, which is evidenced by the storytelling from the third person in the second and third romances. Therefore, the fi rst romance, based on the poem “My love, lay your hand on my heart”, is a kind of “preface” to the cycle, which involves some personal detachment. This leads to the selection of softened content in the translated version of the poem. The second romance, “In a grove, on a wild path”, has a similar function in the vocal cycle of D. Klebanov as it became the preparation for the climax of the third one. The semantic line of his poem is based on two storylines: the external one is the “theme of the journey” that is refl ected in the image of nature, and the internal one is the “theme of sadness”, which focuses on the feelings of the lyrical hero. The composer here, like Анна in the third romance, deepens the line of inner experiences. This became possible thanks to the Tranquillo tempo, fl at minor tonality, massive discordant accompaniment chords, variable measure, melody of the recitative-oratorial type. H. Heine’s poem, presented in the work of D. Klebanov, became the basis of the fi fth romance of E. Denisov’s vocal opus. Like the Ukrainian master, E. Denisov builds his cycle in the spirit of the romantic tradition, but in revealing the fi gurative structure of the poem he goes a different way. He makes a clear distinction between two fi gurativesemantic lines. This is refl ected in the form of a romance that has the features of binarity and variability, the embodiment of the metro-rhythmic structure of the verse based on two opposing principles - metric and cantilena, as well as other means of musical expression. Thus, choosing the same poem by H. Heine, D. Klebanov and E. Denisov represent their own vision of its content. Conclusions The comparative analysis of the embodiment of Heine’s texts by D. Klebanov and other composers of the twentieth century helps to highlight the individual approach of the Ukrainian artist. Despite the fact that the composer chooses similar means of musical expression, he fi nds his own way of refl ecting the semantics of the poetic source. In the above mentioned romances – “In a grove, on a wild path” and “My love, lay your hand on my heart” – the author focuses on the inner confl icts of the lyrical hero, his experiences. Attention paid to the sensory side of the poems also determined the selected translations, since the rejection of translators from the original results in a certain deformation of its meaning and fi gurative structure, which infl uences the musical embodiment of the poetic source.

Introduction: Rebleed after resumption of anticoagulation following intracranial hemorrhage (ICH) remains a substantial concern, but little data is available describing the occurrence of such events. Methods: Prospectively collected data from 2008-2011 was reviewed in patients with intraparencymal (IPH), subdural (SDH), and subarachnoid (SAH) hemorrhage. Patients with anticoagulant use prior to ictus were identified, as were patients started on full anticoagulation during hospitalization. In hospital rates of ischemic events, major and minor hemorrhages were collected. Univariate analyses were performed using either Fisher’s exact or Mann-Whitney U tests. Results: 387 total ICH patients were identified, including 132 (34.1%) SAH, 134 (34.6%) SDH, and 121 (31.3%) IPH. At time of ictus, 67 (17.3%) were anticoagulated and underwent reversal of coagulopathy. Of these 67 patients, ischemic complications including myocardial infarction (MI), pulmonary embolism (PE), and deep vein thrombosis (DVT) occurred in 8 (11.9%) during hospitalization. 6 of 67 (9.0%) patients resumed full anticoagulation at a median of 14.5 days from ictus. 14 additional patients were started on full anticoagulation de novo at a median of 12 days from ictus. Significant indications for anticoagulation after ICH included: 4 (20%) history of valvular heart disease, 7 (35%) DVT, 1 (5%) PE, 7 (35%) arrhythmia, and 1 (5%) coronary artery disease. Of the 20 patients fully anticoagulated after ICH, 2 (10%) experienced a major hemorrhagic complication. 1 new ICH occurred 36 days from ictus on the day anticoagulation was restarted, and 1 SDH expansion occurred 56 days from ictus and 47 days from resuming anticoagulation. 1 patient experienced a minor hemorrhagic complication (retroperitoneal hematoma). Conclusions: Ischemic complications occurred in 11.9% of ICH patients who underwent coagulopathy reversal. It remains unclear if coagulopathy reversal or delay to resuming anticoagulation is the cause of ischemic events. Initiation of anticoagulation after a median of 14 days from ictus was associated with major hemorrhage in 10% of patients. Reversal of anticoagulation and initiation of anticoagulation after a median of 14 days is associated with an acceptable risk profile.

AbstractObjectivesFor a long time, the therapeutic drug monitoring of anti-infectives (ATDM) was recommended only to avoid the toxic side effects of overdosing. During the last decade, however, this attitude has undergone a significant change. Insufficient antibiotic therapy may promote the occurrence of drug resistance; therefore, the “one-dose-fits-all” principle can no longer be classified as up to date. Patients in intensive care units (ICU), in particular, can benefit from individualized antibiotic therapies.MethodsPresented here is a rapid and sufficient LC-MS/MS based assay for the analysis of eight antibiotics (ampicillin, cefepime, cefotaxime, ceftazidime, cefuroxime, linezolid, meropenem, and piperacillin) applicated by continuous infusion and voriconazole. In addition a dose adjustment procedure for individualized antibiotic therapy has been established.ResultsThe suggested dose adjustments following the initial dosing of 121 patient samples from ICUs, were evaluated over a period of three months. Only a minor percentage of the serum levels were found to be within the target range while overdosing was often observed for β-lactam antibiotics, and linezolid tended to be often underused. The results demonstrate an appreciable potential for β-lactam savings while enabling optimal therapy.ConclusionsThe presented monitoring method provides high specificity and is very robust against various interferences. A fast and straightforward method, the developed routine ensures rapid turnaround time. Its application has been well received by participating ICUs and has led to an expanding number of hospital wards participating in ATDM.

Abstract Background Antimicrobial resistance (AMR) compromises the treatment of patients with serious infections in intensive care units (ICUs), and intensive care physicians are increasingly facing patients with bacterial infections with limited or no adequate therapeutic options. A survey was conducted to assess the intensive care physicians’ perception of the AMR situation in the European Union/European Economic Area (EU/EEA). Methods Between May and July 2017, physicians working in European ICUs were invited to complete an online questionnaire hosted by the European Society of Intensive Care Medicine. The survey included 20 questions on hospital and ICU characteristics, frequency of infections with multidrug-resistant (MDR) bacteria and relevance of AMR in the respondent’s ICU, management of antimicrobial treatment as well as the use of last-line antibiotics in the six months preceding the survey. For the analysis of regional differences, EU/EEA countries were grouped into the four sub-regions of Eastern, Northern, Southern and Western Europe. Results Overall, 1062 responses from four European sub-regions were analysed. Infections with MDR bacteria in their ICU were rated as a major problem by 257 (24.2%), moderate problem by 360 (33.9%) and minor problem by 391 (36.8%) respondents. Third-generation cephalosporin-resistant Enterobacteriaceae were the most frequently encountered MDR bacteria followed by, in order of decreasing frequency, meticillin-resistant Staphylococcus aureus, carbapenem-resistant Enterobacteriaceae, carbapenem-resistant Pseudomonas aeruginosa and vancomycin-resistant enterococci. Perception of the relevance of the AMR problem and the frequency of specific MDR bacteria varied by European sub-region. Bacteria resistant to all or almost all available antibiotics were encountered by 132 (12.4%) respondents. Many physicians reported not having access to specific last-line antibiotics. Conclusions The percentage of European ICU physicians perceiving AMR as a substantial problem in their ICU is high with variation by sub-region in line with epidemiological studies. The reports of bacteria resistant to almost all available antibiotics and the limited availability of last-line antibiotics in ICUs in the EU/EEA are of concern.

Abstract Background Bleeding and ischemic complications are the main cause of morbidity and mortality in critically ill cardiogenic shock patients, supported by short-term percutaneous mechanical circulatory support (pMCS) devices. Hence, finding the optimal antithrombotic regimen is challenging. Bleeding not only occurs because of heparin and antiplatelet therapy (both required in the prevention of pump and acute stent thrombosis) but also because of device- and disease related coagulopathy. To prevent clotting-related device failure, most centers target full therapeutic heparin anticoagulation levels in left ventricular (LV) Impella™ supported patients in analogy with Veno-Arterial Extracorporeal Membrane Oxygenation. We aimed to investigate the safety (related to bleeding and thrombotic complications) of targeting low-dose versus therapeutic heparin levels in left Impella™-supported cardiogenic shock patients on dual antiplatelet therapy (DAPT). Methods In this hypothesis generating pilot study, we investigated 114 patients supported for at least two days by LV Impella™ mechanical support due to cardiogenic shock at three tertiary ICUs, highly specialized in mechanical support. Low-dose heparin (aPTT 40–60s or anti-Xa 0.2–0.3) was compared to standard of care (aPTT 60–80s or anti-Xa 0.3–0.5). Major adverse cardio- and cerebrovascular events (MACCE; composite of death, myocardial infarction, stroke/transient ischemic attack) and BARC bleeding (bleeding academic research consortium classification) during 30 day follow-up were assessed. Inverse probability of treatment weighting (IPTW) analysis was calculated with age, gender, arterial hypertension, diabetes mellitus, smoking, chronic kidney disease, previous stroke, previous myocardial infarction, previous coronary arterial bypass grafting, hypercholesterolemia and DAPT as matching variables. COX regression analysis was conducted to test for robustness. Results IPTW revealed 52 patients in the low-dose heparin group and 62 patients in the therapeutic group. Mean age of patients after IPTW was 62±16 years in the intermediate and 62±13 years in the therapeutic group (p=0.99). 25% and 42.2% were male (p=0.92). Overall bleeding events and major (BARC3b) bleeding events were higher in the therapeutic heparin group (overall bleeding: Hazard ratio [HR]=2.58, 95% confidence interval [CI] 1.2–5.5; p=0.015; BARC 3b: HR=4.4, 95% CI 1.4–13.6, p=0.009). Minor bleeding (BARC3a) as well as MACCE and its single components (ischemic events) did not differ between both groups. These findings were robust in the COX regression analysis. Conclusion In this pilot analysis, low-dose heparin in 114 LV Impella™ cardiogenic shock patients was associated with less bleeding without increased ischemic events, adjusted for DAPT. Reducing the target heparin levels in critically ill patients supported by LV Impella™ might improve the outcome of this precarious group. These findings need to be validated in randomized clinical trials. Funding Acknowledgement Type of funding source: None