Category Archives: Original Research

Understanding the Difficulties in Diagnosing Neonatal Sepsis: Assessing the Role of Sepsis Biomarkers

Nicoleta Lungu1, Ana-Maria-Cristina Jura2, Daniela-Eugenia Popescu1, Florin George Horhat3, Aniko Maria Manea1, Marioara Boia1

1 Department of Obstetrics and Gynecology, “Victor Babes” University of Medicine and Pharmacy, Timișoara, Romania
2 University of Medicine and Pharmacy Victor Babes Timisoara, Timisoara, Romania
3 Multidisciplinary Research Center on Antimicrobial Resistance (MULTI-REZ), Microbiology Department, “Victor Babes” University of Medicine and Pharmacy, Timișoara, Romania

DOI: 10.2478/jccm-2024-0039

Background. Neonatal sepsis is a serious condition with high rates of morbidity and mortality, caused by the rapid growth of microorganisms that trigger a systemic reaction. Symptoms can range from mild to severe presentations. The causative microorganism is usually transmitted from mothers, especially from the urogenital tract, or can originate from the community or hospital.
Methods. Our retrospective study assessed 121 newborns, including both preterm and term infants, divided into three groups within the first 28 days of life: early-onset sepsis (35), late-onset sepsis (39), and a control group (47). Blood samples and cultures were obtained upon admission or at the onset of sepsis (at 24 and 72 hours). The study aimed to evaluate the limitations of commonly used biomarkers and new markers such as lactate dehydrogenase and ferritin in more accurately diagnosing neonatal sepsis.
Results. Our study revealed a significant difference between the initial and final measures of lactate dehydrogenase (LDH) and ferritin in the early-onset sepsis (EOS) and late-onset sepsis (LOS) groups.
Conclusion. Ferritin and LDH may serve as potential markers associated with systemic response and sepsis in cases of both early and late-onset sepsis. Monitoring these biomarkers can aid in the timely detection and management of sepsis, potentially improving patient outcomes.

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Outcomes of Patients Transferred to Tertiary Center by Life-Saving System in Saudi Arabia. A Propensity Score Matching Observational Study

Mohammed Soliman1, Hanan Alenzi1, Rehab Alfenaikh1, Ahmed Aletreby2, Malak Alenzi1, Hend Alenzi1, Jennifer Gano1, Rana Alrashed1, Yasmeen Altaymani3, Mohammed Al-Odat1, Waleed Aletreby1

1 King Saud Medical City, Riyadh, Ar Riyad, Saudi Arabia
2 Faculty of Medicine, Alexandria University, Alexandria, Egypt
3 Imam Abdulrahman Alfaisal Hospital, Riyad, Saudi Arabia

DOI: 10.2478/jccm-2024-0038

Background: Inter-hospital transfer is intended to provide access to centralized special care for critically ill patients, when resources in their hospitals are not available. However, an empirical gap exists in available evidence, as outcomes of transferred patients to higher centers are inconsistent.
Method: Single center propensity score matching retrospective observational study. Life-Saving transfers during 2023 were matched to direct admissions to the ICU. Hospital mortality, ICU length of stay, and costs of both groups were compared.
Results: During the study period, 328 Life-Saving transfers were matched to 656 direct admissions. Propensity score matching eliminated all imbalances between groups. Hospital mortality was not different between groups, there were 114 (34.8%) hospital mortalities of Life-Saving transfers, while there were 216 (32.9%) hospital mortalities of direct admissions, with a percent difference of 1.9% (95% CI: -4.5%, 8.4%); p value = 0.6, this result persisted in the sensitivity analysis. There were no differences in mortality risks for all the studied subgroups except pediatric patients. ICU length of stay of direct admissions and Life-Saving transfers were 10 ± 13.1 and 11.6 ± 12.4 days respectively, mean difference was statistically significant (-1.6 [95% CI: -3.2, 0.1]; p = 0.005). Life-Saving transfers entailed significantly higher costs per admission by 28,200 thousand SAR (95% CI: 26,400 – 30,000; p < 0.001).
Conclusion: Our study shows no difference in hospital mortality between Life-Saving transfers and direct admissions to ICU, however, Life-Saving transfers had a longer ICU length of stay, and higher costs per admission.

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Role of Quetiapine in the Prevention of ICU Delirium in Elderly Patients at a High Risk

Walid Y. Kamel1, Heba Y. Kamel2, Ibrahim M. Elsherif1

1 Department of Anesthesia, Intensive Care and Pain Management, Ain Shams University, Abbasiya, Cairo, Egypt
2 Geriatrics and Gerontology department, Faculty of Medicine, Ain Shams University, Abbasiya, Cairo, Egypt

DOI: 10.2478/jccm-2024-0032

Background: The aim of the present study was to denote the effectiveness of Quetiapine as additive to preventive bundle of delirium in elderly patients with multiple risks for delirium.
Patients and methods: The study was performed on 90 elderly patients over 60 years. The patients were divided into Group Q (Quetiapine) and Group C (No Quetiapine). Delirium was assessed using Intensive Care Delirium Screening Checklist (ICDSC) and the Confusion Assessment Method for the ICU (CAM-ICU).
Results: The incidence of delirium was significantly higher in group C. The severity of delirium was higher among group C; however, it was not statistically significant. The dominant type of delirium was hypoactive in group Q whereas hyperactive in group C. The interrater reliability between CAM-ICU-7 and ICDSE showed a kappa 0.98 denoting excellent correlation between the two scores. Somnolence was the most common side effect of Quetiapine (25%) followed by dry mouth (18%).
Conclusions: Prophylactic low dose of Quetiapine in elderly population in the preventive bundle could reduce the incidence of delirium with a low incidence of a major side effect, as well as CAM-ICU-7 is as effective as ICDSC in monitoring and early diagnosis of delirium.

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Outcome and Determining Characteristics of ICU Patients with Acute Kidney Injury in a Low-Income Country, a Multicenter Experience

Abubakar Ballah1, Jika Mohammed2, Gyadale Abdulhamid Njidda2, Halima Bidemi Yahaya3, Nwokorie Mabong Rosemary4, Ibrahim Naziru2, Adamu Yusuf Baffah2, Hassan Ali Maina5, Hajara Galadima2, Abdullahi Maryam Mohammed6, Franklin Andibanbang7, Adam Ibrahim Abdullahi8

1 Abubakar Tafawa Balewa University, Bauchi, Nigeria
2 Federal Medical Centre Gombe, Gombe, Nigeria
3 Airdale NHS Foundation Trust, Steeton, England
4 Nile University of Nigeria, Abuja, Nigeria
5 Modibbo Adama University of Technology, Yola, Nigeria
6 Aminu Kano Teaching Hospital, Kano, Nigeria
7 Saudi Arabia Ministry of Health, Fayfa, Saudi Arabia
8 Bauchi State University Gadau, Bauchi, Nigeria

DOI: 10.2478/jccm-2024-0037

Background: Acute kidney injury (AKI) is a disease that affects millions of people globally making it a major public health concern. It is defined as an abrupt decrease in kidney function that occurs within ours affecting both the structure and functionality of the kidneys.
The outcome of AKI and the determinants in Nigeria are largely unknown. This study aimed to describe the determining factors of the outcome of AKI patients admitted into the ICU of three tertiary health institutions in Northeast Nigeria.
Methods: The study is a prospective multicentered observational study of the patients admitted into the ICU in three tertiary health institutions from January 2022 to December 2023. KDIGO criteria was used to define AKI. The outcome of the study was to determine survivors among the patients admitted into the ICU with AKI or developed AKI while in ICU and also the determinants of mortality. A chi-square test was done to determine the association between the dependent variable (patient outcome) and the independent variables. To determine the predictors of patient outcomes, a regression analysis was done. The sociodemographic data of the patients admitted during these periods were studied in addition to Acute Physiology and Chronic Health Evaluation (APACHE) II, Kidney Disease: Improving Global Outcomes (KDIGO), Average length of stay in the ICU, Admitting/referring ward (Obstetrics, Gynae, Medical, Surgical or Emergency unit), Ability to afford care (out of pocket payment, social welfare or through Health insurance Scheme, Co-morbidity (presence or absence of comorbidity), Interventions done while in ICU (use of vasopressors and inotropes, mechanical ventilation (MV) support and renal replacement therapy (RRT) and outcome (discharge to the wards or mortality).
Results: Of 1494 patient records screened, 464 met the inclusion criteria. The overall incidence of AKI was 57%. About 53% were females, the mean age was 42.2 years, and 81% of the patients had a normal BMI (18.5 – 24.9). About 40% of the patients had APACHE II scores ≥ 29%. More than three-quarters (79.5%) of the patients paid for their health care expenditure out-of-pocket. Most patients (72%) were from the Medical and Gynae/Ward. Mortality was highest (54.2%) among patients who were brought into the ICU from the Medical ward. Most patients admitted were KDIGO I (44.3%) followed by KDIGO II (35.1%). Among the patients, 61.2% present with one or more comorbidity. Mortality was higher (50%) among those with comorbidity compared to 13.6% among those without comorbidity. Mortality was lowest among patients who stayed in the ICU between 8-14 days compared to those who stayed > 2 weeks. Most of the patients (72%) were from the Medical and Gynae/Ward. Mortality was highest (54.2%) among patients who were brought into the ICU from the Medical ward followed by those brought in from the Obstetric and Gynecological ward (20.4%). An association was found between the intervention received in the ICU and the outcome, which was found to be statistically significant (p < 0.001). A regression analysis was done to determine the predictors of patients’ outcomes admitted in the ICU. The results showed that APACHE II score greater than 10 (p-value < 0.001), presence of comorbidities (p = 0.031) and intervention which included a combination of Vasopressors, mechanical ventilation and RRT (p < 0.01) are the predictors of patients’ outcome. The regression model is valid (X2 = 469.894, df = 24, p < 0.001) and it fits the sample as shown by the Hosmer and Lemeshow test (X2 = 7.749, p = 0.45, df = 8,). It also shows that the predictors account for 92% of patients’ outcomes (Nagelkerke R2 = 0.92).
Conclusions: Our study revealed that the presence of comorbidity, high APACHE II score, and the need for interventional supports including both mechanical ventilatory and ionotropic, were found to be strong mortality predictors in patients with AKI.

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The Role of Feedback Training on Early Postoperative Recovery and Anxiety Scores in an Ambulatory Surgical Unit: A Secular Trend Study

Alexander Dukhan1, Teymur Yusupov1, Naama Kabra1, Tiberiu Ezri1,2, Mona Boaz3

1 Ambulatory Surgery Unit, Anesthesiology, Kaplan Medical Center, Rehovot, Israel
2 Tel Aviv University, Israel| Kaplan Medical Center
3 Ariel University, School of Health Sciences, Ariel, Israel

DOI: 10.2478/jccm-2024-0036

Background: We used a ten-item postoperative quality of recovery score (QoR-10) to assess the perioperative quality of care in an in-hospital ambulatory surgical unit.
Methods: In Phase 1 of this secular trend study (n=300 patients, 3-months duration), we collected QoR-10 scores and potential confounders, including type of anesthesia and surgery; co-morbidities; and anesthesia components of the Amsterdam scale-measured anxiety scores. Phase 2 was the one-month performance feedback learning phase in which modifiable variables identified in Phase 1 were translated to actionable steps, reinforcing the already existing routine of our department’s clinical practices, including pain, shivering and anxiety. The anesthesiology team was instructed and reminded of these steps using performance feedback methods. In Phase 3 (n=300 patients, 3-month duration) we evaluated the efficacy of this performance feedback instruction. QoR-10 scores were compared between Phase 1 and Phase 3.
Results: Phase 1 identified three modifiable variables as targets for improvement: postoperative shivering; percentage of patients with numerical rating pain scale (NRS)<4; and preoperative anxiety from anesthesia scores. Compared to Phase 1, significantly fewer Phase 3 patients had severe shivering (2.3% vs. 7.3%, p = 0.023), and a greater percentage had NRS < 4 points (79% vs. 49.7%, p <0.001). The percentage of patients with a high anxiety score did not differ between phases. A direct association between anxiety score and QoR-10 score was not detected. The QoR-10 score (median (IQR)) was significantly higher in Phase 3 than Phase 1: 50 (49-50) vs. 49(49-50), p<0.001. In a multivariable logistic regression analysis, odds for a QoR-10 score of 49-50 were 1.92 higher in Phase 3 than Phase 1.
Conclusion: Considering the study limitations, team feedback education contributed to improvement of the QoR-10 score, reduced the proportion of patients with severe shivering and increased the percentage of patients with low pain scores.

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Understanding the Correlation between Blood Profile and the Duration of Hospitalization in Pediatric Bronchopneumonia Patients: A Cross-Sectional Original Article

Dessika Listiarini1, Dev Desai2, Yanuar Wahyu Hidayat1, Kevin Alvaro Handoko3

1 Dr. Soeselo General Hospital, Slawi, Central Java, Indonesia
2 Smt. NHL Municipal Medical College, Ahmedabad, Gujarat, India
3 Bhakti Rahayu Tabanan Hospital, Tabanan, Bali, Indonesia

DOI: 10.2478/jccm-2024-0031

Introduction: Pediatric bronchopneumonia is a prevalent life-threatening disease, particularly in developing countries. Affordable and accessible blood biomarkers are needed to predict disease severity which can be based on the Duration of Hospitalization (DOH).
Aim of the Study: To assess the significance and correlation between differential blood profiles, especially the Neutrophil-Lymphocyte Ratio (NLR), and the DOH in bronchopneumonia children.
Material and Methods: A record-based study was conducted at a secondary care hospital in Indonesia. After due ethical permission, following inclusion and exclusion criteria, 284 children with confirmed diagnoses of bronchopneumonia were included in the study. Blood cell counts and ratios were assessed with the DOH as the main criterion of severity. Mann-Whitney test and correlation coefficient were used to draw an analysis.
Results: Study samples were grouped into DOH of ≤ 4 days and > 4 days, focusing on NLR values, neutrophils, lymphocytes, and leukocytes. The NLR median was higher (3.98) in patients hospitalized over 4 days (P<0.0001). Lymphocyte medians were significantly higher in the opposite group (P<0.0001). Thrombocyte medians were similar in both groups (P=0.44481). The overall NLR and DOH were weakly positively correlated, with a moderate positive correlation in total neutrophils and DOH, and a moderate negative correlation in total lymphocytes and DOH. The correlation between the DOH ≤ 4 days group with each biomarker was stronger, except for leukocyte and thrombocyte. Analysis of the longer DOH group did not yield enough correlation across all blood counts.
Conclusions: Admission levels of leukocyte count, neutrophil, lymphocyte, and NLR significantly correlate with the DOH, with NLR predicting severity and positively correlated with the DOH.

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Rate of Sodium Correction and Osmotic Demyelination Syndrome in Severe Hyponatremia: A Meta-Analysis

Xin Ya See1, Yu-Cheng Chang2, Chun-Yu Peng2, Shih-Syuan Wang3, Kuan-Yu Chi4, Cho-Hung Chiang5, Cho-Han Chiang6

1 Unity Hospital, Rochester Regional Health, Rochester, NY, USA
2 Danbury Hospital, Danbury, CT, USA
3 SUNY Downstate Medical Center, Brooklyn, NY, USA
4 Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
5 National Taiwan University Hospital, Taipei, Taiwan
6 Mount Auburn Hospital, Harvard Medical School, Cambridge, MA, USA

DOI: 10.2478/jccm-2024-0030

Introduction: Current guidelines recommend limiting the rate of correction in patients with severe hyponatremia to avoid severe neurologic complications such as osmotic demyelination syndrome (ODS). However, published data have been conflicting. We aimed to evaluate the association between rapid sodium correction and ODS in patients with severe hyponatremia.
Materials and methods: We searched PubMed, Embase, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials from inception to November 2023. The primary outcome was ODS and the secondary outcomes were in-hospital mortality and length of hospital stay.
Results: We identified 7 cohort studies involving 6,032 adult patients with severe hyponatremia. Twenty-nine patients developed ODS, resulting in an incidence rate of 0.48%. Seventeen patients (61%) had a rapid correction of serum sodium in the first or any 24-hour period of admission. Compared with a limited rate of sodium correction, a rapid rate of sodium correction was associated with an increased risk of ODS (RR, 3.91 [95% CI, 1.17 to 13.04]; I2 = 44.47%; p = 0.03). However, a rapid rate of sodium correction reduced the risk of in-hospital mortality by approximately 50% (RR, 0.51 [95% CI, 0.39 to 0.66]; I2 = 0.11%; p < 0.001) and the length of stay by 1.3 days (Mean difference, -1.32 [95% CI, -2.54 to -0.10]; I2 = 71.47%; p = 0.03).
Conclusions: Rapid correction of serum sodium may increase the risk of ODS among patients hospitalized with severe hyponatremia. However, ODS may occur in patients regardless of the rate of serum sodium correction.

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A Comparative Analysis of the Effects of Haloperidol and Dexmedetomidine on QTc Interval Prolongation during Delirium Treatment in Intensive Care Units

Ali Haspolat1, Fuat Polat2, Ali Şefik Köprülü3

1 Kolan International Hospital, İstanbul, Turkey
2 Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
3 Yeni Yuzyil University, İstanbul, Turkey

DOI: 10.2478/jccm-2024-0027

Background: Haloperidol and dexmedetomidine are used to treat delirium in the intensive care unit (ICU). The effects of these drugs on the corrected QT (QTc) interval have not been compared before. It was aimed to compare the effects of haloperidol and dexmedetomidine treatment on QTc intervals in patients who developed delirium during ICU follow-up.
Method: The study is single-center, randomized, and prospective. Half of the patients diagnosed with delirium in the ICU were treated with haloperidol and the other half with dexmedetomidine. The QTc interval was measured in the treatment groups before and after drug treatment. The study’s primary endpoints were maximal QT and QTc interval changes after drug administration.
Results: 90 patients were included in the study, the mean age was 75.2±12.9 years, and half were women. The mean time to delirium was 142+173.8 hours, and 53.3% of the patients died during their ICU follow-up. The most common reason for hospitalization in the ICU was sepsis (%37.8.). There was no significant change in QT and QTc interval after dexmedetomidine treatment (QT: 360.5±81.7, 352.0±67.0, p= 0.491; QTc: 409.4±63.1, 409.8±49.7, p=0.974). There was a significant increase in both QT and QTc interval after haloperidol treatment (QT: 363.2±51.1, 384.6±59.2, p=0.028; QTc: 409.4±50.9, 427.3±45.9, p=0.020).
Conclusions: Based on the results obtained from the study, it can be concluded that the administration of haloperidol was associated with a significant increase in QT and QTc interval. In contrast, the administration of dexmedetomidine did not cause a significant change in QT and QTc interval.

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Development of a Machine Learning-Based Model for Predicting the Incidence of Peripheral Intravenous Catheter-Associated Phlebitis

Hideto Yasuda1,2,3,4, Claire M. Rickard3, 4, 5, Olivier Mimoz6,7,8, Nicole Marsh3,4,5, Jessica A Schults3,4,5, Bertrand Drugeon6,7, Masahiro Kashiura1, Yuki Kishihara1, Yutaro Shinzato1, Midori Koike1, Takashi Moriya1, Yuki Kotani9, Natsuki Kondo10, Kosuke Sekine11, Nobuaki Shime12, Keita Morikane13, Takayuki Abe14,15

1 Department of Emergency and Critical Care Medicine, Jichi Medical University Saimata Medical Center, Saitama, Japan
2 Department of Clinical Research Education and Training Unit, Keio University Hospital Clinical and Translational Research Center (CTR), Tokyo, Japan
3 School of Nursing, Midwifery and Social Work, UQ Centre for Clinical Research, The University of Queensland, QLD, Australia
4 School of Nursing and Midwifery; Alliance for Vascular Access Teaching and Research, Griffith University, Nathan, QLD, Australia
5 Herston Infectious Diseases Institute; Nursing and Midwifery Research Centre, Royal Brisbane and Women’s Hospital, Metro North Health, Herston, QLD, Australia
6 CHU de Poitiers, Emergency Department and prehospital care, Poitiers, France
7 University of Poitiers, INSERM U1070, Pharmacology of antimicrobial agents and antibiotics resistance (PHAR2), Poitiers, France
8 University of Poitiers, Faculty of Medicine and Pharmacy, Poitiers, France
9 Department of Intensive Care Medicine, Kameda Medical Center, Chiba, Japan
10 Department of Emergency Medicine, Koga Community Hospital, Shizuoka, Japan
11 Department of Medical Engineer, Kameda Medical Center, Chiba, Japan
12 Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
13 Division of Clinical Laboratory and Infection Control, Yamagata University Hospital, Yamagata, Japan
14 Biostatistics, Clinical and Translational Research Center, Keio University School of Medicine, Tokyo, Japan
15 School of Data Science, Kyoto Women’s University, Kyoto, Japan

DOI: 10.2478/jccm-2024-0028

Introduction: Early and accurate identification of high-risk patients with peripheral intravascular catheter (PIVC)-related phlebitis is vital to prevent medical device-related complications.
Aim of the study: This study aimed to develop and validate a machine learning-based model for predicting the incidence of PIVC-related phlebitis in critically ill patients.
Materials and methods: Four machine learning models were created using data from patients ≥ 18 years with a newly inserted PIVC during intensive care unit admission. Models were developed and validated using a 7:3 split. Random survival forest (RSF) was used to create predictive models for time-to-event outcomes. Logistic regression with least absolute reduction and selection operator (LASSO), random forest (RF), and gradient boosting decision tree were used to develop predictive models that treat outcome as a binary variable. Cox proportional hazards (COX) and logistic regression (LR) were used as comparators for time-to-event and binary outcomes, respectively.
Results: The final cohort had 3429 PIVCs, which were divided into the development cohort (2400 PIVCs) and validation cohort (1029 PIVCs). The c-statistic (95% confidence interval) of the models in the validation cohort for discrimination were as follows: RSF, 0.689 (0.627–0.750); LASSO, 0.664 (0.610–0.717); RF, 0.699 (0.645–0.753); gradient boosting tree, 0.699 (0.647–0.750); COX, 0.516 (0.454–0.578); and LR, 0.633 (0.575–0.691). No significant difference was observed among the c-statistic of the four models for binary outcome. However, RSF had a higher c-statistic than COX. The important predictive factors in RSF included inserted site, catheter material, age, and nicardipine, whereas those in RF included catheter dwell duration, nicardipine, and age.
Conclusions: The RSF model for the survival time analysis of phlebitis occurrence showed relatively high prediction performance compared with the COX model. No significant differences in prediction performance were observed among the models with phlebitis occurrence as the binary outcome.

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Evaluation of the Efficiency of the Newly Developed Needle in Emergency Room: A Single-Center Observational Study

Yuki Kishihara, Hideto Yasuda, Masahiro Kashiura, Takatoshi Oishi, Yutaro Shinzato, Takashi Moriya

Jichi Ika University Saitama Medical Center, Saitama-shi, Saitama Japan

DOI: 10.2478/jccm-2024-0025

Aim of the study: Peripheral intravascular catheter (PIVC) insertion is frequently performed in the emergency room (ER) and many failures of initial PIVC insertion occur. To reduce the failures, new needles were developed. This study aimed to investigate whether the use of the newly developed needle reduced the failure of initial PIVC insertion in the ER compared with the use of the existing needle.
Material and methods: This single-centre, prospective observational study was conducted in Japan between April 1, 2022, and February 2, 2023. We included consecutive patients who visited our hospital by ambulance as a secondary emergency on a weekday during the day shift (from 8:00 AM to 5:00 PM). The practitioners for PIVC insertion and assessors were independent. The primary and secondary outcomes were the failure of initial PIVC insertion and number of procedures, respectively. We defined the difficulty of titrating, leakage, and hematoma within 30 s after insertion as failures. To evaluate the association between the outcomes and the use of newly developed needles, we performed multivariate logistic regression and multiple regression analyses by adjusting for covariates.
Results: In total, 522 patients without missing data were analysed, and 81 (15.5%) patients showed failure of initial PIVC insertion. The median number of procedures (interquartile range) was 1 (1–1). Multivariate logistic regression analysis revealed no significant association between the use of newly developed PIVCs and the failure of initial PIVC insertion (odds ratio, 0.79; 95% confidence interval, [0.48–1.31]; p = 0.36). Moreover, multiple regression analysis revealed no significant association between the use of newly developed PIVCs and the number of procedures (regression coefficient, -0.0042; 95% confidence interval, [-0.065–0.056]; p = 0.89).
Conclusions: Our study did not show a difference between the two types of needles with respect to the failure of initial PIVC insertion and the number of procedures.

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