Accepted Article This by is protectedarticle reserved. Allrights copyright. doi: 10.1111/acem.13401 lead to differences between this version and the throughbeen the copyediting, pagination typesetting, which process, may and proofreading hasThis article been accepted publicationfor andundergone peerfull but review not has Emergency Medicine, Doha, Qatar 8. Michael Levine MD ENVENOMATED PATIENTS. ASSESSING THE EFFECT OF A MEDICAL TOXICOLOGIST IN THE CARE OF RATTLESNAKE Contribution :Original type Article statistical analysis. analysis. statistical manuscr and design study with assisted Thomas Dr. Drs. Spyres and LoVecchioassisted with study design,data abstraction, and manuscript preparation preparation manuscript and abstraction data with assisted Quann and Lapoint, Wolk, Vohra, Offerman, Drs. and takes responsibility for the study in its entirety. preparation, manuscript with assisted abstraction, data performed study, the conceived Levine Dr. contribution: Author Disclosures: are There no financial, litigational,orother conflicts of interest to disclose 7. Department of Emergency Medicine, Medicine, Emergency of Department 7. 6. Scottsdale Healthcare. Scottsdale, AZ Medicine Emergency of Department 5. CA Linda, Loma Center. Medical Linda Loma Medicine. Emergency of Department 4. UCSF Medicine, ofEmergency 3.Department Sacramento, CA division Medicine, Emergency of Department 2. California, Los Angeles CA of Division Medicine, Emergency of Department 1. Quan DO Weill Cornell College of Medicine in Qatar and Hamad Medical Corporation, Department of of Department Corporation, Medical Hamad and Qatar in Medicine of College Cornell Weill 6 , Meghan SpyresMD 1 , Steve Offerman MD Offerman , Steve 1 , Frank LoVecchio DO LoVecchio , Frank

. Kaiser San Diego. San Diego, CA Maricopa Medical Center.Maricopa Phoenix, AZ 2 , Rais Vohra MD Vohra , Rais Fresno Medical Center. Fresno, CA CA Fresno, Center. Medical Fresno of Medical Toxicology. Kaiser South Sacramento. Sacramento. South Kaiser Toxicology. Medical of Medical Toxicology. University of Southern Southern of University Toxicology. Medical ipt preparation. Dr. Thomas performed all of the the of all performed Thomas Dr. preparation. ipt Version of Record. Please Version as this cite of Record. article 7 , Stephen H. Thomas MD, MPH 3 , Brian Wolk MD 4 , JeffLapoint DO 8

5 , Dan Accepted Article This by is protectedarticle reserved. Allrights copyright. for snakebite annually in the United States. in the for annually snakebite treated patients 9,000 nearly with problem, health an important remains envenomation Rattlesnake INTRODUCTION involvement medical ofa toxicologist. direct without those to compared stay of length reduced asignificant have toxicologist a medical statistically significant change in readmission rates. Conclusion: Rattlesnake patientsbite treated by [59.1-79.9] vs. 48.1 [41.4-54.8] hours). This reduced length of staywas not associated with any medical toxicologywas service associated with asignificant reduction inthe length of stay (69.5 characteristics and post-MTS pre-MTS the between (post-MTS). Results: total A subjects of 300 were included pre-MTS; (169 131 post MTS). Baseline toxicology or (pre-MTS) service theyears two in creationthe after toxicologyof medical a service Patients were included were in they years admitted establishment if two before the the medical of a Methods: The authors conducted retrospective a st study evaluateto is theof impact medical a toxicology on serviceoflength the patients. of such stay cases managedare without the involvement of medical a toxicologist. primary The objective thisof be complex.Despitethes these envenomationscan proble animportant is envenomation Rattlesnake ABSTRACT Corresponding author mail id:[email protected] ENVENOMATED PATIENTS. ASSESSING THE IMPACT OF AMEDICAL TOXICOLOGIST INTHE CARE OF RATTLESNAKE involves intensive evaluation and reassessment. In addition, specific post discharge instructions and are associated with significant morbidity and cost. management The of such envenomations ideally 1 Although mortality low, is envenomations rattlesnake

m in the United States, and the management ofmanagement the United and the States, in m udy at six centers in California and Arizona. group were very similar. The creation of a a creation of The similar. group very were e complexities, however, the majority such of however, complexities,e the

Accepted Article This by is protectedarticle reserved. Allrights copyright. re-evaluations are recommended. centers assisted healthcare facilities management the in than of more snakebites. 3500 is associated with reduced length of stay (LOS), and possibly reduced healthcarecosts. involvement atoxicologi of envenomated patients. The of bedside the at care direct provide toxicologist medical service, admitting or consulting a as the poison information specialists remotely managing patients.these Additionally,when available toxicologists,physicians with specialized training excluded. Definitive confirmation of the snake was not required. In addition, if, upon reviewing the the reviewing upon if, addition, In required. not was snake the of confirmation Definitive excluded. of ICD-9 codes. (E905.0) Bites due known to non-venomous snakesking pet (e.g. snake) were or a(pre-MTS) toxicology (post-MTS) after service was created. Patientswere identified via . search if presented a after knownthey suspected or rattlesnake envenomationyears two before in the th at groups toxicology independent five by provided were Consults envenomation. the to related issues the managed and consultant a as antivenom for orders write did toxicologist the centers, the of one but all In privileges. consulting formal between 2011-2015. of At these centers,each the toxicologist consultant, aserves as has and service toxicology amedical established centers these of Each hospital. non-teaching community one and hospital non-teaching university-affiliated one hospitals, teaching community two hospitals, following rattlesnake envenomation. centers These include two university-affiliated teaching California in centers medical different six at evaluated patients of study retrospective is a This study METHODS envenomations. objectiveof study evaluate this onto the is of patientsLOS impact MTS with the of a rattlesnake providingcare, direct patient patientsprovidesin with rattlesnake envenomations. primary The unclear, however,what role a medical toxicology se 1 In 2015, poison information specialistspoison at US control in envenomations, frequently provide guidance to to guidance provide frequently envenomations, in rvicewhich (MTS), in medical a toxicologist is e six hospitals. Eligible patients were included included were patients Eligible hospitals. six e st in the care of poisoned patients in general general in patients poisoned of care in the st

3-6 2 Medical It is is It Accepted Article This by is protectedarticle reserved. Allrights copyright. antibiotics, blood products, and incidence of surgical intervention was abstracted. Lastly, length of of length Lastly, abstracted. was intervention surgical of incidence and products, blood antibiotics, an with Treatment were recorded. center control (prothrombin time, platelets, and fibrinogen), incidence of bleeding, and involvement of poisona studies laboratory final and nadir, initial, LOS, patient’s The medications. anticoagulant or antiplatelet of use and history, medical past bite, the of location MTS), of initiation post or age, included record medical the from abstracted data data collection,were dataentered into an SpreadsheetExcel (Microsoft, Redmond, Baseline WA). After hypothesis. study the to blinded were Theinvestigators each site. at uniform was abstraction br received a Each reviewer each institution. pre-desi a on collected were Data Data abstraction stay. hospital patient’s the during any point Poison controlconsidered was toinvolved be discussion if with poison controlwas documented at site. bite the from oozing local beyond bleeding any as defined was Bleeding apart. hours each six ofantivenom, doses three orderfor scheduled a as defined was therapy Maintenance hospital. the from discharge until emergency department the to presentation from hours in calculated was LOS definitions Study centers. medical participating the of each at board review institutional the by approved was study The consulted. not was toxicology if even included, was period, MTS post was excluded. This was study performed as an intent to analysis, treat such each patientthat in the snake, a dueto not clearly was bite record, the gned data abstraction sheet by one member of the study team at at team study the of member byone sheet abstraction data gned ief training on data onief training data abstraction toensure the but simply coded based on ICD-9 code, the record record the code, ICD-9 on based coded simply but tivenom, non-steroidal anti-inflammatory drugs, drugs, anti-inflammatory non-steroidal tivenom, sex, year of admission, study time period (pre

Accepted Article This by is protectedarticle reserved. Allrights copyright. below five) wereused categorical for variables. continuous variables, andchi-square analysis and Fisher’s exact testing (when anyvalue cell fell regression modeling. Kruskal-Wallis nonparametricmethods were utilized for initial analysis of iden were any differences whether to as decisions inform to order in groups, MTS and pre-MTS period’s study the between acuity or complexity Univariate analysis was utilized toassess whether there were apparentchanges patientin methods. exact binomial using calculated were which (CIs) intervals confidence 95% with reported were Proportions (IQR). range interquartile and median using tendency central for analyzed were testing, Shapiro-Wilk by non-normal be to found were which of all data, Continuous model. before/after a in analyzed and pooled was centers medical six these from The data Data analysis complications. related snakebite for readmission and bleeding and intervention, surgical of incidence drugs, anti-inflammatory non-steroidal and antibiotics, products, blood of administration values, laboratory nadir and maximum used, antivenom vials LO hospital was study this in outcome The primary measures Outcome related to the snakebite were recorded. stay, administration of rattlesnake-specific discharge instructions, and readmissioncomplications for tified that prompted a need for multivariate need for a prompted tified that S. Additional outcomes evaluated included total total included evaluated outcomes Additional S.

Accepted Article status, anticoagulation therapy, and known liver disease. Additional information used to assess assess to used information Additional disease. liver known and therapy, anticoagulation status, and MTS groups included patient demographics and medical history, information regarding diabetes pre-MTS the between similar were characteristics patient whether determine to assessed Variables group MTS on clustered periods, post-MTS and pre- the between CI) 95% (with difference median Stata’s calculations, conservative provide order to In groups. two the of medians the between difference results were compared using Wilcoxon rank-sum testing, toassess the null hypothesis ofzero This by is protectedarticle reserved. Allrights copyright. services, two approaches were taken. First, the LOS for the pre- and post-MTS periods were were periods post-MTS and pre- the for LOS the First, taken. were approaches two services, MTS the of each for periods post-MTS and pre- the in differences median the assess to In order pre- and post-MTS periods’ LOS data were tabulated. The overall pre- pre- The overall tabulated. were data LOS periods’ post-MTS pre- and of group overall the Next, hospitals). 6 covered services (5 groups MTS 5 the of foreach tabulated underestimate the significance of any MTS effect on LOS. on effect MTS any of significance the underestimate would anything if and medians) for CIs 95% (for boostrapping as such oftechniques use (the Wallis testing first. Then, only non-parametric the if An to treat). calculate needed number to used latter the inverse the of relative of The measures weremeasures calculated. When significant differences were a priori t test) to accuratelytest) effect magnitude.estimate the This approach conservative, it is as avoids cendif cendif decision was made to analyze the primary endpoint (LOS) with non-parametric Kruskal- non-parametric with (LOS) endpoint primary the analyze to made was decision procedure was used, in order to provide a provide to order in used, was procedure identified in univariate testing, epidemiological univariate identified standard in p risk were the risk ratio and risk difference (with (with risk difference and theriskratio were risk was significant,with parametric techniques robust calculation of the (Hodges-Lehmann) (Hodges-Lehmann) the of calculation robust 7-9

vs. vs. post-MTS period LOS Accepted Article This by is protectedarticle reserved. Allrights copyright. the post-MTS compared thepre-MTS to groupwas hours 21.4 (95% 8.2-34.5 hours).CI Overall, 69.5 [59.1-79.9] hours; p=0.014) in non-parametric analysis. The reduction inLOS associated with LOS was significantly shorter for post-MTS as compared to cases pre-MTS (48.1[41.4-54.8] hoursvs. LOS. and status MTS between association possible a assess priori with accordance in analysis, univariate in findings negative these upon Based I. table See groups. respectively).no difference was Similarly, there Shock on presentationwasuncommon vs(2.4% 2.3%in pre-MTS the and post-MTS groups, groups. two the between parameters baseline the in observed differences nosignificant were There years. (22-55.5) 44 was age range) (interquartile The median (15.3%). extremity lower non-foot and (20%), foot (60.3%), hand the to were bites of the majority in (76%) 99 cases inthe postMTS group. Overall, accounted males (76%) for 228 of all subjects. The toxicologist was involvedcases in 0of the cohort,in the pre MTS whereas a toxicologistwas involved There were 169patients in thepre-MTS cohort, andpatients 131 in the post-MTS cohort. A stung by non crotalidae and thus were excluded. Thus, finalthe population included 300patients. A total of 302patients were identified. Upon review of the records,patients two were bitten or RESULTS location). other or extremity, non-foot hand or non- foot, hand, to as (categorized location bite and treatment, first in vials antivenom of number parameters, laboratory coagulation initial the included presentation ED index-visit at acuity patient methods planning, was nothere requirementproceed to with multivariate analysis in to order in initial hematologic parameters between the two

a Accepted Article This by is protectedarticle reserved. Allrights copyright. is such that it seems unlikely explainable by unmeasured variables. The implementation of the MTS MTS the of implementation The variables. unmeasured by explainable unlikely seems it that such is presence MTS a with associated reduction LOS the of magnitude the Furthermore, such. evidence of no find we confounding, residual of possibility the eliminate not does parameters assessed all presentation differed significantly. apparentWhile the similarity two of the groups with respect to initial to respect with groups two the between assessed parameters or medical laboratory, demographic, the of None groups. two the between characteristics baseline in difference da theavailable was study retrospective, While the with similar ratesof antivenom administration and readmission rates. stay, of length decreased with associated was MTS a of development the demonstrated study This DISCUSSION the post group MTS (p=0.718). Seetable II complete for outcome results. Twenty-one patients (12.4%) group of the re-admitted pre-MTS comparedwere with in 18(13.9%) risk ratio 1.8; 1.0-3.4). 95% There CI were no fatalities ineither group. Antibiotics,however, were administered more group theoften in MTS pre (18.3%vs. 10.0%; p=0.04; still low inboth group (31.5%vs. 17.8%; 95% CI3.42-24%) albeit group, pre-MTS the with compared group MTS post the in higher somewhat was of antivenom dosing maintenance of use the However, p0.09) post-MTS; vials (6-20) 12 and pre-MTS vials (6-16) 10.8%, respectively; p=0.554). was no There difference in the total vials antivenom administered (10 vs. (13% groups andpost-MTS pre-MTS the both in low was assistance control poison documented ta suggest little, if any clinically important important clinically any if little, suggest ta

Accepted Article This by is protectedarticle reserved. Allrights copyright. Antibiotics are not routinely indicated for crotaline bites in North America. in North bites crotaline for indicated routinely arenot Antibiotics management. in practice change result of national a hospitals. in different years different at occurred MTS was associatedreduction with a in antibiotic vs. therapy (18% 10%) of care. of care. of medical a toxicologistthe rattlesnake care of in patienta is bite associated with improved quality involvement the that made be can argument an rates, re-admission increasing not while antibiotics) (e.g. treatments unnecessary in reduction a and stay of length the in reduction a is Given there obtained on each group, thepatient post in MTS results would the likelybe magnified.further group were admittedhospitalist toa and the toxicolo typicallynot follow patient the as an outpatient. this study, In several patients post in MTS the group, the as toxicologistswere following patientsthe as out patients, whereas a hospitalistwould MTS post the in higher be would rate readmission the that case a imagine could one However, MTS. vs post pre the in different be significantly would this unlikely is it site, study of the outside a hospital to presented patient the if bemissed would readmissions that possible is it While rates. readmission Importantly, reduction the in length of stay associated was MTS with a associated with similar contributorcost-effectiveness tothe of instituting in MTS hospitals such studyas the centers. amajor as investigated be could lines these along reductions LOS Such hours). 21 (over LOS shorter significant. The MTS groupstatus on univariate analysis was associatedwith nearly afull day’s cases than cases. pre-MTS the difference The was clinically, administratively, statisticallyand The most important the that was finding a priori primary endpoint, LOS, was shorter for the MTS MTS the for shorter was LOS, endpoint, primary Thus, it is unlikely that the decreased LOS was the the was LOS decreased the that unlikely is it Thus, gist was not consulted. Thus, if consults were consults if Thus, consulted. not was gist

10 Implementation of a Accepted Article This by is protectedarticle reserved. Allrights copyright. savings. cost of benefit added the with toxicology admitting was service associatedwithdecreased length of stay and decreased morbidity mortality their for admittingcomparison service in the Premier to database. The authors found their percent and stay, of length cost, the of comparison a severity-weighted performed colleagues and Curry aMTS. to benefit potential have demonstrated that studies previous to similar is study This most. it period needed usein whothe MTS lead patients increasedgreater thepost to in of level expertise the because was discrepancy apparent this Perhaps, not. was it LOS, increased an with associated be to antivenom maintenance of use increased expect would one While 32%). vs. (18% uncommon The use of maintenance therapy was greater MTSpost in group, the remained relatively still but value., of may be study prospective a such observation, and hospitalizations over influence more exert pressures healthcare As increased patients. to orcost perform analysisof acosts MTS the overall a associated with rattlesnake envenomated orintended designed not was study the group, MTS the in patients for stay of length the in decrease patient would associated be withsignificant a cost savings. While there was a statistically significant patient by toxicologist a was associatedcostwith savings a $1000 of than patient.more per poisoned ofa care study, one in However, etc. patients, of volume the toxicologists, of number The exact cost savings are difficultdetermine, to and dependent onmultiple variables, including the admitted with acetaminophen toxicity before and after the service was created. was service the after and before toxicity acetaminophen with admitted service at university-affiliated their teachinghospit assumed,but known not definitively, that the involvement toxicologist of a rattlesnake in a bite 3 Vhora and colleagues established a medical toxicology toxicology a medical established colleagues and Vhora al, and examined the length of stay patientsin

5 The authors found found authors The 3 It is is It Accepted Article in a retrospective inreview. retrospective a likely reduced,not if eliminated abstractor bias, th abstracted data the in choices these feel we not), or procedure surgical documented (e.g. variables dichotomous and etc.) fibrinogen, hospital; a in hours of number (e.g. variables continuous used primarily study the because However, record. medical the in data of the completeness and quality by the limited are conclusions any consequently, and nature retrospective its by limited is study This LIMITATIONS toxicologist. or the readmissioncompared rate topatients treated without the involvement direct of a stay of length the in reduction a with associated be would patient envenomated an in involvement variability administrationin of antivenom,was not known,it prior thisto study, a if toxicologist’s patient, on MTS this envenomated the examine effect of a is patients. firstto the ofBecause This by is protectedarticle reserved. Allrights copyright. conclusions. our on impact asignificant has this feel not do we groups), post-MTS pre- and the the relatively low involvement in both groups (36 total cases which were distributed evenly between given limitation, potential a is this While involvement. center control poison for control did not We stay. the toxicology service resultedin wascreatedmajor a at metropolitan teaching hospitalin Australia. The authors found creation of service toxicology a after and before period month 12 the in stay of length the examined colleagues a significant decreased length of stay after amedica 6 While other studies have examined the effect of theeffect examined Whileother studieshave 11

increased number of patients treated while reducing the length of of length the reducing while treated patients of number increased ereby minimizing some of the limitations inherent inherent limitations of the some minimizing ereby l toxicology servicecreated. was Lastly, Lee and a toxicologist care an the overdoseof in

Accepted Article 11:65-72. 2015; Toxicol. J Med diagnoses. poisoning-related with discharged inpatients among mortality and cost, of stay,

This by is protectedarticle reserved. Allrights copyright. 33 (NPDS): System Data Poison national Centers’ Control Poison Association American of of the 2015Annual report et. al. Brooks DE, DA, 2.JB, MowrySpyker Emergency Medicine. 2011; 11:2 Unitedcrotaline results States: in snakebite the of management the for algorithm treatment Unified al. et. W, Banner AM, Ruha EJ, Lavonas 1. REFERENCES: stay, without corresponding a increase in amouthe The implementation medical a of toxicology servic service and intangible benefits associated with the MTS (e.g. teaching or “curb-side” consultations). “curb-side” or teaching (e.g. MTS the with associated benefits intangible and service recommendations presence and at bedside the of the toxicologist, or thatthere theis a just fact involvement orno involvement toxicologist. of a impossible Itis toknow benefit the is the actual decision was made toanalyze these patients based andon MTS than postpre MTS, rather There severalwere patients the post in period werenot that by toxicologist. seen a An 3. 54:924-1109 CONCLUSION CurryBrooks SC, DE, Skolnik AB, et. al. Effect of a medical toxicologyadmitting service on length of an evidence-informed evidence-informed of an e wasassociatede witha nt of antivenom administered or re-admission re-admission or administered of antivenom nt

rd Annual report.Clin Toxicol. 2016; consensus workshop. BMC reduction in length of a priori

. Accepted Article of stay of poisoned patients and saves hospital bed days. Emerg Med Australas. 2017; 7: Epub (DOI: (DOI: 7: Epub 2017; Australas. Med Emerg days. bed hospital saves and patients poisoned of of stay This by is protectedarticle reserved. Allrights copyright. 7 (Eds.). NS Harris T, Cushing P, Auerbach Medicine. Wilderness Auerbach’s In Mexico. 10. Norris RL, Bush SP, Cardwell MD. Bites by venomous reptiles in Canada,United the States, and 5:35. 2005; Methodol. Res Med BMC data. distributed non-normally 9. Vickers Parametric AJ. versus non-parametric statistics in theanalysisof randomizedwith trials example. Acad Emerg 2010; Med. 17:1113-21 stay of length the tests: statistical nonparametric versus Parametric JD. Shuur DJ, Pallin M, Qualls 8. “difficult” distributions. Acad Emerg 2005;12:360-5. Med. 7. Haukoos JS,Lewis RJ. Advanced statistics: bootstrapping confidence intervals for statisticswith hospital. Emerg 2011;Med. 13:37-42. teaching metropolitan a on service atoxicology of Impact al. G, et. Braitberg JF, Kerr V, Lee 6. 12:9 2016; Toxicol. J Med center. medical academic asingle on stay of on length service consultation toxicology a of Effect poisoning: Acetaminophen M. Levine R, Vohra J, Chang 5. 10.1111/1742-6723.12755) 4. Elsevier. Philadelphia. 2017; 729-60 Isoardi KZ, Armitage MC, Harris K, et. al. Establishing a dedicated toxicology unit reduces length length reduces unit toxicology dedicated a Establishing al. et. K, Harris MC, Armitage KZ, Isoardi

th Edition. Edition. Accepted Article This by is protectedarticle reserved. Allrights copyright. .831 (4-6) 6 6(4-6) .554 7(5.4% of * 130) 14(10.8% of * 130) .411 * Initial vials of therapy (median, IQR) presentation (1.8% 3 of 169) 22(13.0% of 169) on or shock bleeding Diffuse (22-57) 47 IQR) Lab values(median, Poison Control Center call 43(22-55) Pre-bite aspirin therapy History diabetes of locationBite Male Age median (IQR) used. Parameter Pre-MTS Pre-MTS Parameter TABLE I: research: What methods? are the Ann Emerg Med. 1996; 27:305-8. 11. Gilbert LowensteinEH, SR, Koziol-McLainChart J, et.al.reviews inemergency medicine Datawere missing for one patient gr inMTS the N % 11(75 f19 7(41 f11 .485 97(74.1% of 131) (77.5% 131 of 169) (%) pe xrmt nthn) 30)6(.% (4.6%) 6 (3.0%) 5 Upper extremity (not hand) oe xrmt ntfo) 6(54)2 1.% 20(15.3%) (15.4%) 26 Lower extremity (not foot) N nta rtrmi ie 1. 1.-26 22(061.) .282 12.2(10.6-13.4) 11.5(10.7-12.6) Initial prothrombin time %o 0) .499 of 300) (% nta irngnlvl 7 2737 7 2535 .773 274 (235-325) 274 (227-327) Initial fibrinogen level nta ltltcut 0 1121 0 1729 .505 200 (157-249) 204 (171-251) Initial platelet count N % 0(.%o 6)8(.%o 3) .932 8(6.2% of 130)* 10(5.9% of 169) (%) Other 0 (0%) 2 2 0 Other (1.5%) (0%) ad 0 6.%o 6)7 5.%o 3) 76(58.0% of 131) (62.1% 105 of 169) Hand ot 3 1.% 7(06) 27(20.6%) (19.5%) 33 Foot 24 f19 23 f10 1.00 of * 130) 3(2.3% 4 (2.4% of 169) N oupforparameter. this A denominator of 130was = 169 = 169

Post-MTS N = 131

.085 p

Accepted Article This by is protectedarticle reserved. Allrights copyright. 18(13.9%) 21(12.4%) (2.3%) 3 (0.8%) 1 1(0.6%) ** Readmission assessment 5(3.0%) lab follow-up for given Instructions administered therapy medical Other Blood-product administration Surgical intervention (IQR) Laboratorymedian parameters; (IQR) median Antivenom therapy; mean) Length of stay (mean, 95% CI for

Parameter Pre-MTS Pre-MTS Parameter MTS groups. and pre-MTS in outcomes the and Table II: Therapy s fmitnneteayrgmn 0(78 f19 1(15 f10 .005 41(31.5% of 130) (17.8% of 169) 30 Use of maintenance-therapy regimen Denominatorof patients, 130 rather 131patientsthan Non-steroidal anti-inflammatory anti-inflammatory Non-steroidal aiu rtrmi ie 1 1-34 22(11) .881 12.2 (11-14) 12 (11-13.4) Maximumprothrombin time nrvnu niitc 3 1.% 13(10.0%) 31(18.3%) Intravenous antibiotics ltltcutndr 7 1721 7 1926 .749 (139-206) 170 (137-211) 171 Platelet count nadir irngnndr 5 2926 4 2727 .976 248 (217-287) 253(209-296) Fibrinogen nadir oa il 0(-6 2(-0 .090 12(6-20) 10(6-16) Total vials drugs drugs 95(917.)4. 4.-48 .002 (41.4-54.8) 48.1 (59.1-79.9) 69.5 3 8.% 116 (89.2%) 138 (81.7%) 4 (2.4%) 0 (0%) 0 4 (2.4%) N = 169 =

Post-MTS N = 131 ** ** ** .135 ** **

.321 .238 **

.044 .718 .069 p