Management Of Patients Research Articles

Oxaliplatin triggered hypersensitivity reactions in colorectal cancer patients: Case report

Colorectal cancer stands as a significant global health concern, encompassing adenocarcinoma of both the colon and rectum. Recognized risk factors include advancing age and medical history of inflammatory bowel conditions like Crohn's disease or ulcerative colitis. Oxaliplatin, a platinum-based chemotherapy agent, serves as the frontline treatment for colorectal cancer due to its cytotoxic effects on cancerous cells. However, its use is not without complications, as hypersensitivity reactions can occur, posing challenges in patient management. This case report discusses two instances where patients undergoing chemotherapy for colorectal cancer developed grade two hypersensitivity reactions following oxaliplatin administration, the Naranjo probability scale was used to analyze the causation of the adverse drug reactions (ADRs), and a score of 6 was obtained, indicating oxaliplatin as a probable cause of the hypersensitivity reactions. In both cases, treatment was promptly halted upon manifestation of symptoms, and patients were administered intravenous steroids along with anti-histamines. This intervention resulted in significant improvement in the patients' conditions. Both genders are equally susceptible to such reactions, emphasizing the need for gender-neutral awareness and precautionary measures among medical practitioners. This case report serves as a reminder of the potential adverse effects associated with oxaliplatin therapy in colorectal cancer patients. Heightened awareness among healthcare professionals regarding the risk of hypersensitivity reactions is imperative to ensure timely detection and appropriate management, thereby optimizing patient outcomes. Consequently, while giving oxaliplatin to cancer patients, healthcare professionals need to use extreme caution.

Necessity for a global patient co-owned cloud (GPOC)

BackgroundThe use of Cloud-based storage of personal health records has increased globally. The GPOC Series introduces the concept of a Global Patient co-Owned Cloud (GPOC) of personal health records. Here, we present the GPOC Series’ international survey on the necessity of a GPOC.MethodsOnline global survey with invitations sent to health ministries and major organisations. It received answers from health ministries and affiliated advisors of all 193 United Nations (UN) member states, 2 UN observer states (Holy See & Palestine) and 1 de facto UN non-member state (Taiwan) and from 18 major international organisations. The survey examined a dozen aspects encompassing demographics, privacy, sharing, movability, co-ownership, research, company usage, regulation and the necessity of a GPOC.ResultsThe GPOC Survey elicited responses from 267 individuals from 214 entities, including all UN member states, and major international organisations. Twelve domains were identified, covering demographics, correctness, privacy, commercial use, medical and non-medical research, co-ownership, data sharing, record movement, ownership centralisation, patient rights, environmental concerns, and foundation creation. Results show high agreement on most issues, including support for co-ownership (89%) and movement of personal health records (84%). Disagreement was prominent regarding centralised ownership by the state (64%) and data sharing without consent (85%). Additionally, respondents expressed interest in a neutral, decentralised foundation for regulation (73%) and the environmental sustainability of electronic health records (84%).ConclusionsA Global Patient co-Owned Cloud (GPOC) of personal health records could significantly enhance patient independence and involvement in health management, supported by the near consensus agreement across various domains identified in our survey. This consensus underscores the potential of GPOC to democratise healthcare and align with UN Sustainable Development Goals (SDGs). The survey results demonstrate strong support for GPOC’s role in promoting evidence-based patient management, reducing information silos, and fostering ethical data sharing. Moreover, the overwhelming agreement on key principles of co-ownership, data sharing, and environmental sustainability highlights the global inclination for a decentralised, patient-controlled PHR platform. This platform stands to empower patients worldwide, advance precision medicine, and contribute to the global development and dissemination of artificial intelligence in healthcare.

Clinical performance of a new lateral flow immunoassay for xylazine detection.

Xylazine is a potent sedative used in veterinary medicine. Recently, recreational drugs such as fentanyl havebeen found to contain xylazine, increasing the risk of respiratory depression and death. Despite a similar presentation to opioid overdose, patients who ingest xylazine donot respond to treatment with Narcan. Therefore, rapid detection of xylazine could improve patient management and prevent adverse outcomes. We evaluated the XYL500 one-step xylazine drug of abuse test for its ability to detect xylazine in 152 urine samples from patients on chronic opioid therapy for pain management or in treatment for substance use disorder. Results were compared to LC-MS/MS as the reference method. Precision, cross-reactivity, interference and stability studies were performed. Pooled patient samples were consistently negative or positive when tested five times on the same day and over three days of testing. The diagnostic sensitivity, specificity and accuracy of the XYL500 assay were 74, 98, and 82 % respectively, as compared with LC-MS/MS. XYL500 detected 77 of the 104 LC-MS/MS positive samples identified in our initial evaluation, including some that contained low levels of xylazine (n=8), <10 ng/mL. Minimal cross-reactivity with other opioid analgesics and commonly encountered drugs was seen with only one false positive result. Interferences by common urine contaminants were negligible. Specimens were stable up to 160 days refrigerated and up to 80 days at room temperature. XYL500 allows for rapid detection of xylazine, illustrating its utility in monitoring patients who ingested recreational drugs containing the additive, xylazine, and its potential to improve patient management.

Delayed onset Spontaneous Hyphema after OMNI® Surgical System

Minimally invasive glaucoma surgery (MIGS) offers options for glaucoma treatment that have generally improved safety profiles compared with filtering surgery. MIGS vary in design and procedure, but all angle-based MIGS function by bypassing or removing aqueous humor outflow resistance at the level of the trabecular meshwork. This can lower intraocular pressure but also remove the blood-aqueous barrier. Most studies of MIGS report on relatively short-term safety, but awareness of potential long-term complications is critical for optimal patient management. This case report describes a patient with recurrent and refractory delayed onset spontaneous hyphema after OMNI procedure. To the best of our knowledge, this is the first case report describing this complication of the OMNI surgical system.

Etiology of nosocomial infections and antibiotic resistance (level of antibiotic resistance) of identified pathogens in patients with traumatic chest injuries

Background. Chest injuries and wounds are common during armed conflicts, with frequent nosocomial infections and mortality up to 35-45% [1-4]. Infectious complications associated with multidrug-resistant microorganisms are an urgent issue in the management of patients with trauma. Aim. To conduct a retrospective review of the main causative agents of infectious complications in patients with traumatic chest injuries and evaluate antibiotic resistance of isolated pathogens. Materials and methods. Samples for microbiological examination were obtained from 160 patients with chest trauma and nosocomial complications. The samples included sputum, pleural fluid, bronchial washings obtained by fiberoptic bronchoscopy, and tracheal secretions. Antibacterial susceptibility tests were performed, and the antibiotic resistance mechanisms in isolated microorganisms were determined. Results. Gram-negative pathogens accounted for 93% of cases. The following organisms prevailed: Klebsiella pneumoniae – 42%, Acinetobacter baumannii – 28%, Pseudomonas aeruginosa – 18%, Escherichia coli – 9%. Of note, 91.4% of K. pneumoniae strains produced extended-spectrum β-lactamases and carbapenemases. The percentage of multidrug-resistant and pandrug-resistant strains was 48.2% and 52%, respectively. Conclusion. The data obtained indicate a wide spread of gram-negative microorganisms and their multiple resistance in patients with traumatic breast injuries complicated by nosocomial infection.

Exploring the Factors Associated with Sleep Concerns and Perceived Need for Treatment among Patients with Sleep Disorders

ABSTRACT Objectives This study aimed to investigate the factors affecting patient perceptions of sleep concerns and the need for treatment to understand and enable effective management. Methods This cross-sectional study analyzed data collected between November 2018 and October 2022 at the sleep clinic of a tertiary hospital. Adults aged > 19 years who completed sleep questionnaires and polysomnography (PSG) were included. Logistic regression models were used to assess the associations between demographic, clinical, and social factors, sleep questionnaire responses, and PSG data with self-reported sleep concerns (n = 3,457) and perceived need for treatment(n = 3,135). Results Insomnia-related symptoms affect both sleep concerns and need for treatment, and sleep maintenance is the most influential factor in both sleep concerns (odds ratio[OR] = 19.74, 95% confidence interval[CI] 6.17–63.20) and need for treatment (OR = 3.84, 95% CI 2.19–6.73). Young age (OR = 2.66, 95% CI 1.38–5.12), employment status, and daily life dysfunction were determinants of treatment readiness. None of the PSG parameters showed an independent association with sleep concerns or need for treatment. Conclusions Sleep maintenance problems had the most profound effect on sleep concerns and the need for treatment. Social needs are key factors in seeking treatment. A discrepancy has been noted between the effects of subjective and objective factors on sleep concerns and the need for treatment; therefore, patient management should pay attention to subjective sleep complaints.

Comprehensive anaesthesia management strategies for orthognathic surgical procedure.

Orthognathic surgery is commonly performed to correct malocclusion and facial asymmetry, typically in young and healthy patients. However, it's crucial to recognize that facial deformities can also be features of various syndromes, complicating the surgical and anesthetic management. This review examines the key factors influencing anaesthesia management in orthognathic surgery patients. The perioperative care process was analyzed, focusing on the surgical procedure, airway management, and anaesthesia techniques. Additional factors considered include bleeding control, postoperative nausea and vomiting (PONV), antibiotic prophylaxis, analgesia, and deep venous thrombosis (DVT) prevention. The review highlighted the critical role of comprehensive anaesthesia management in determining the outcomes of orthognathic surgery. Proper airway management, effective bleeding control, and the prevention of PONV and DVT were identified as significant factors in optimizing patient recovery. The use of protocols and a multidisciplinary approach were emphasized as essential in minimizing complications and improving postoperative outcomes. Comprehensive and carefully planned anesthesia management is vital for the success of orthognathic surgery. Employing a multidisciplinary approach and adhering to established protocols can enhance patient outcomes and expedite recovery, especially in cases involving complex syndromic patients.

Is there an association between periodontal disease and infertility? A systematic review.

Today, idiopathic infertility is becoming more frequent, affecting more than 186 million people in the world. The presence of comorbidities makes patient management complex, requiring individualized infertility treatment. Periodontal diseases could contribute negatively to the management of infertility, increasing inflammation, oxidative stress and insulin resistance, and contributing negatively to the development and progression of comorbidities associated with these two entities. The aim of this systematic review is to explore whether there is an association between periodontal diseases and male and female infertility and deepen into the possible mechanisms underlying this association. The studies analyzed in this research included a total of 4871 patients (732 men and 4139 women), were original studies with high quality, mostly with a control group. Authors who have investigated idiopathic infertility suggest that infertility is associated with diseases that present low-grade chronic inflammation, oxidative stress and insulin resistance (such as obesity, type 2 diabetes and polycystic ovary syndrome), which are in turn related to periodontal diseases. A higher prevalence of periodontal disease was found in patients with infertility compared with controls. Periodontal diseases could initially be mediated by a local and systemic proinflammatory environment, which favors a pro-oxidant state, leading to oxidative stress and, finally, irreversible destruction of the periodontal tissue. Insulin resistance, oxidative stress and inflammation are present in the pathologies associated with an increase in the prevalence and severity of periodontal diseases (such as obesity, type 2 diabetes and polycystic ovary syndrome). Therefore, IR, low-grade chronic inflammation and the oxidative stress could be the pathophysiological mechanisms linking idiopathic infertility and periodontal diseases. Studies suggest an association between infertility and periodontitis. Future researches are necessary to find causality factors. Studying the patient in a global and multidisciplinary way could help in the management and treatment of idiopathic infertility.

Plasma Cell-free DNA Metagenomic Next-Generation Sequencing in Immunocompromised Children

Abstract Background Plasma cell-free DNA metagenomic next-generation sequencing (mNGS) is a novel diagnostic tool for infectious diseases [1]. Data suggests that plasma mNGS may be useful in immunocompromised adults, changing management in up to 60% of the patients [2]. A prospective study evaluating utility of plasma mNGS for pneumonia in immunocompromised adults concluded that mNGS provided an additive diagnostic value of 12.1% [3]. A similar study in adults with febrile neutropenia reported a sensitivity and specificity of 85 and 100%, respectively [4]. However, there is limited data evaluating the utility of mNGS in immunocompromised children. Methods We retrospectively reviewed all pediatric immunocompromised patients who had plasma mNGS testing performed from December 2018 to July 2023 at St. Jude Children’s Research Hospital. Electronic medical records were reviewed to extract relevant clinical data and microbiologic data including results of mNGS, contemporaneous cultures, and related antimicrobial treatment. Descriptive statistics are presented as frequencies and medians (interquartile range, IQR). Comparisons were performed using Fisher’s exact test or Wilcoxon rank-sum test, as appropriate, using R version 3.6.3. Results A total of 18 immunocompromised children underwent plasma mNGS testing. Acute lymphoblastic leukemia was the most common malignancy (33.3%), followed by acute myeloid leukemia (22.2%). Two patients (11.1%) had undergone hematopoietic cell transplant, both allogeneic. At the time of testing, 16 patients (88.9%) had fever and 10 (55.6%) had an absolute neutrophil count of &amp;lt;500/mm3. All except one were on antimicrobial therapy at the time of testing, with a median duration of 8 days (IQR=12.25). Only 9 (50%) patients had a positive mNGS result. A positive mNGS resulted in broadening or extending antibiotics course in 4 patients (22.2%); negative mNGS results did not lead to changes in management in any of the cases. There were no significant differences in age, sex, days of fever, neutropenia, gastrointestinal (GI) symptoms, and days of fever before testing between those with positive versus negative results. However, a higher frequency of GI symptoms at the time of testing among those with positive results was observed. Clinical characteristics and impact on management in patients with positive and negative results are summarized in Table 1. Conclusion Plasma mNGS had a limited impact on the management of immunocompromised children at our institution. Negative results did not lead to de-escalation of therapy, and positive results led to additional exposure to antibiotics. Further research is needed to determine the role of mNGS in this population, and the interpretation of positive testing in the setting of gastrointestinal disease.

A Scoping Review of Patient Health-Related Quality of Life Following Surgery or Molecular Testing for Individuals with Indeterminate Thyroid Nodules

Background: Molecular testing can reduce the need for diagnostic thyroidectomy in cytologically indeterminate thyroid nodules. However, the health-related quality of life in patients managed with molecular testing is not well studied. Objective: The objective of this scoping review was to identify and analyze the health-related quality of life outcomes in patients with indeterminate thyroid nodules who are expected to undergo or have undergone surgery or molecular testing. Methods: A comprehensive search was conducted on PubMed, Scopus, PsychINFO, and Embase to identify relevant studies. The search terms included “thyroid neoplasms” or “thyroid nodule” and “molecular testing” or “surgery” and “quality of life”. The included articles were analyzed for their main study objective, study design, participant characteristics, and main results. Results: Eight studies were included in this scoping review. Four evaluated the quality-adjusted life years for patients with indeterminate thyroid nodules. Three of these studies found that molecular testing slightly improved quality-adjusted life years compared to surgery, while one study found no difference. Two studies assessed surgical health-related quality of life outcomes and reported that patients with indeterminate thyroid nodules who were expected to undergo surgery favored surgical procedures, while those who underwent surgery experienced impaired health-related quality of life. Two studies evaluated molecular testing in patients with indeterminate thyroid nodules and found that the final molecular test result significantly impacted health-related quality of life outcomes. Patients with suspicious/positive molecular test results had worse symptoms of goiter, anxiety, and depression, while those with benign results had preserved health-related quality of life scores. Patients with benign results from molecular testing experience better health-related quality of life within the first year compared to those with benign surgical outcomes. Conclusions: This scoping review highlights the importance of considering health-related quality of life outcomes in the management of patients with indeterminate thyroid nodules. Benign molecular testing results yield better quality of life than benign surgical outcomes within the first year, suggesting molecular testing as a preferable option. Further research comparing the impact of surgery and molecular testing on health-related quality of life is needed to improve shared decision-making and patient outcomes.

Examining Physicians’ Approaches to Treating Relatives in Primary Health Care Centers: Insights from a Qualitative Study

Introduction: Family medicine physicians take care of a diverse population of patients with a variety of acute and chronic diseases. These patients include family, friends, and acquaintances who may ask for direct medical care or help in accessing healthcare products and services within or outside of officially approved procedures. This is ethically challenging due to an ambiguous medical code of ethics, but it is commonly accepted as normal behavior by society. The aim of this study was to explore family medicine physicians’ perspectives regarding the benefits, difficulties, and ethics of responding to medical care requests and/or favors from family, relatives, friends, and acquaintances and to make recommendations. Methods: The study sample consisted of junior and senior family medicine physicians working in primary healthcare centers affiliated with the Ministry of Health in Saudi Arabia. In-depth semi-structured interviews were conducted to collect data. Using social exchange theory, this qualitative study explores how family medicine physicians perceive and handle requests for medical favors from family members and others. Results: Semi-structured interviews were conducted with 19 family medicine physicians (six focus groups) with clinical experience ranging from 3 to 20 years. The data analysis identified three themes: perceived benefits and costs of cultural and social connectedness, shortcomings in patient management and healthcare systems, and recommendations to address challenges between physicians and patients who are relatives. Discussion and Conclusions: This study shows that treating others outside of normal access to healthcare services presents several ethical, moral, and professional challenges. Therefore, policy adaptation requires understanding this intricate dilemma and improving laws, system regulations, and guidelines for physicians and community members to improve access to care, reduce system abuse, empower providers, and enhance community awareness and compliance.

Korean Guidelines for the Management and Antibiotic Therapy in Adult Patients with Hospital-Acquired Pneumonia.

Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are correlated with high morbidity and mortality rates. Guidelines that consider local epidemiologic data are fundamental for identifying optimal treatment strategies. However, Korea has no HAP/VAP guidelines. This study was conducted by a committee of nine experts from the Korean Academy of Tuberculosis and Respiratory Diseases Respiratory Infection Study Group using the results of Korean HAP/VAP epidemiologic studies. Eleven key questions for HAP/VAP diagnosis and treatment were addressed. The Convergence of Opinion on Suggestions and Evidence (CORE) process was used to derive suggestions, and evidence levels and recommendation grades were in accordance with the Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology. Suggestions were made for the 11 key questions pertinent to diagnosis, biomarkers, antibiotics, and treatment strategies for adult patients with HAP/VAP. Using the CORE process and GRADE methodology, the committee generated a series of recommendations for HAP/VAP diagnosis and treatment in the Korean context.

Diverticulitis Management in Complex Medical Contexts

AbstractDiverticulitis is a prevalent medical issue, particularly among elderly individuals in the Western world. Management is nuanced and is influenced by both disease presentation and patient factors, especially those that affect risk of septic and surgical complications. This paper reviews existing literature to explore the incidence, presentation, and management of diverticulitis in complex medical contexts—immunocompromised populations, specifically highlighting those undergoing chemotherapy, HIV/AIDS patients, transplant recipients, and individuals with autoimmune and connective tissue diseases. Not surprisingly, management of diverticulitis in these complex patient populations is associated with increased morbidity. However, even taking into consideration the risk of septic and surgical complications, more recent data and treatment recommendations suggest that both nonoperative and operative management strategies may be appropriate based on individual patient presentations, mirroring the treatment paradigm of immunocompetent patients. In addition, in discussing operative management of complex medical patients, immunosuppression alone should not be considered a contraindication to primary anastomosis. Overall, there are limited existing data on diverticulitis in immunocompromised populations and, especially, patients with autoimmune and connective tissue disorders. Further research is warranted to better understand the impact of these chronic diseases on diverticulitis severity and to best inform evidence-based practices in this complex clinical scenario.

Frequency, Clinical Characteristics, and Management of Snakebite Patients Admitted at the Envenomation Treatment Center of the Applied Biology Research Institute of Guinea

The aim of this study was to describe the frequency, clinical signs, management, and outcomes of snakebite patients admitted to the envenomation treatment center of the Institut de Recherche en Biologie Appliquée de Guinée (IRBAG). This was a retrospective review combining aggregated annual statistics (2011–2015) and routine data (from January to October 2021) from the IRBAG treatment center. There were 1345 (57.2%) snakebite victims out of a total of 2352 consultations at the center during the study period. Males (67.7%), persons aged ≥45 years (29%) and ≤14 years (27.7%), farmers/housewives (44.5%), workers (23.9%), and those residing in the Kindia Prefecture (53.5%) were the most commonly affected. The majority of victims (84.5%) were admitted three hours after snakebite, with bites mainly occurring in rural areas (86.5%) and during the rainy season (83.2%). Pain (100%), edema (76.8%), and bleeding (65.2%) were the most common clinical presentations. Almost all victims received antivenom serum (98%), antibiotics (87.7%), and analgesics or anti-inflammatory drugs (88.4%). Six out of the one hundred and fifty-five patients died. Snakebites are a frequent public health problem in rural Guinea. The majority of victims seek medical attention too late. There is an urgent need to include snakebite in the country’s list of priority NTDs in order to promote access to antivenom serum.

How I Treat Older Patients with Ph/BCR-ABL-Negative Acute Lymphoblastic Leukemia.

Despite advancements in new treatments, management of older patients with acute lymphoblastic leukaemia (ALL) remains an unmet medical need. With increasing age, ALL patients have a significantly lower CR rate, higher early mortality and relapse rate, and poorer survival compared to younger patients. This is attributed to a higher prevalence of adverse prognostic factors among older individuals and reduced tolerance to chemotherapy. Progress has been made in tailoring moderately intensive chemotherapy protocols for Ph/BCR-ABL (Ph) negative ALL in older patients, and recent phase II studies have explored integrating immunotherapy into initial treatment with very promising results. However, establishing new standard regimens for this age group remains and improving general management strategy is a pending task.

Prevention of perioperative venous thromboembolic complications using pneumatic compression cuffs in oral cancer patients in maxillofacial surgery

ObjectivesVenous thromboembolism (VTE) is still considered to be a significant medical issue. Physical measures to prevent perioperative venous thrombosis include early mobilization and intermittent pneumatic compression (IPC). The aim of this study was to evaluate whether IPC can reduce the incidence of postoperative thromboembolic events in patients with oral squamous cell carcinoma (OSCC) undergoing maxillofacial surgery.Materials and methodsBetween March 2020 and May 2021, 75 patients with OSCC who did not receive perioperative prophylaxis using IPC were retrospectively examined to determine the occurrence of postoperative thromboembolism. Accordingly, 79 patients who received perioperative thrombosis prophylaxis using an IPC system as part of surgical tumor therapy from May 2021 to September 2023 were included in the study. The primary outcome measure was the occurrence of postoperative thromboembolism.ResultsIn the control group without IPC, thromboembolic events were observed in five out of 75 patients during postoperative hospitalization. In the intervention group, no thromboembolic occurrences were identified among the 79 patients studied (p = 0.02). The mean Caprini score in the control group was 7.72, whereas in the intervention group it averaged 8.30 (p = 0.027).ConclusionsThe implementation of IPC-devices as supplementary perioperative thrombosis prophylaxis resulted in a notable decrease in postoperative venous thromboembolism (Number Needed to Treat = 15), which is why implementation of the system as a regular part of the clinical routine for perioperative management of OSCC patients can be considered a sensible approach.Clinical relevanceThe use of IPC enhances patient outcomes and may lead to improved postoperative care protocols in this high-risk patient population.

ERN eUROGEN Guidelines on the Management of Anorectal Malformations Part I: Diagnostics.

Anorectal malformations (ARMs) are rare congenital anomalies that involve the anus, rectum, and oftentimes the genitourinary tract. The management of ARM patients is complex, and many controversies exist. To address this issue, the European Reference Network eUROGEN for rare and complex urogenital conditions aimed to develop comprehensive guidelines for the management of ARM. The Dutch Quality Standard for ARM served as the basis for the development of guidelines applicable on a European level. Literature was searched in Medline, Embase, and Cochrane. The ADAPTE method was utilized to incorporate the newest available evidence. A panel of 15 experts from 7 European countries assessed currency, acceptability, and applicability of recommendations. Recommendations from the Dutch Quality Standard were adapted, adopted, or rejected, and recommendations were formed considering current evidence and/or expert consensus. Prenatal and neonatal diagnostic workup as well as postsurgical follow-up of anorectal, genitourinary tract, and neurologic system were reviewed. Seven new studies were identified. The panel adapted 13 recommendations, adopted 7, and developed 8 de novo. The availability of high-quality evidence was limited, and most recommendations were based on retrospective studies, case series, or expert opinion. Patients with ARM and their families require highly specialized and comprehensive care from the prenatal period to adulthood. This guideline provides recommendations for a comprehensive diagnostic workup of children with ARM throughout their life that is applicable on a European level.

Pharmacodynamics of Rivaroxaban and Dabigatran in Adults with Diffuse Large B-Cell Lymphoma Receiving R-CHOP Immunochemotherapy

Background/Objectives: Rivaroxaban and dabigatran are commonly used for thromboembolic disease management in active cancer patients. However, limited research explores the impact of concurrent chemotherapy on the pharmacodynamics of direct oral anticoagulants (DOAC). The aim of our study was to evaluate the impact of combined chemotherapy with rivaroxaban and dabigatran on the pharmacodynamics in patients with diffuse large B-cell lymphoma (DLBCL).; Methods: This was a prospective, pharmacodynamic study. Eligible subjects were ≥18 years old, diagnosed with DLBCL and initiating R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) immunochemotherapy. The enrolled adults received either rivaroxaban (10 mg once daily) or dabigatran etixalate (110 mg twice daily). Plasma anti-factor Xa (FXa) in participants on rivaroxaban and diluted thrombin time (dTT) in participants on dabigatran were assessed over the dosing interval before and after R-CHOP administration. Pharmacodynamic parameters of rivaroxaban and dabigatran were determined using a non-compartmental analysis.; Results: Twenty-six adults participated, with twelve in the rivaroxaban group and fourteen in the dabigatran group. The mean age was 59 ± 14.4 years. In the rivaroxaban group, the AUEC of FXa inhibition showed no significant change after R-CHOP (mean difference 3.8 ng·h/mL, 95% confidence interval (CI) −155.4 to 163.0, p = 0.96). Similarly, in the dabigatran group, the AUEC of dTT remained unchanged post R-CHOP (mean difference 54.41 ng·h/mL, 95% CI −99.09 to 207.9 ng/mL, p = 0.46). However, the median time-to-peak dTT was significantly faster with R-CHOP (3 h, [min–max, 1.5–8] compared to without it (4 h, [min–max, 3–8], p = 0.04); Conclusions: Concurrent R-CHOP chemotherapy did not significantly impact FXa inhibition by rivaroxaban or dTT by dabigatran. The time-to-peak dTT was faster when dabigatran was administered with R-CHOP.

Symptomatic Nonstenotic Carotids: A Topical Review.

Historically, the management of carotid artery disease has primarily focused on the degree of stenosis as the main indicator for assessing stroke etiology, risk, and need for intervention. However, accumulating evidence suggests that structural and biological features within the arterial wall, such as intraplaque hemorrhage, may have superior diagnostic, prognostic, and therapeutic values. Under current guidelines, unless an atheroma results in ≥50% stenosis, it is not considered the cause of a cerebrovascular event. This results in extensive and often unproductive diagnostic workup, prescription of ineffective medical therapy, and preclusion of patients from receiving revascularization procedures that have been shown to prevent recurrent cerebrovascular events in cases of ≥50% stenosis. A subset of embolic strokes of undetermined source, which account for up to 25% of all ischemic cerebrovascular events, are thought to be due to thromboembolic phenomena from undiagnosed plaque disruptions in nonstenotic arteries (<50% stenosis). Recently, it has been proposed to reclassify this subgroup of patients as symptomatic nonstenotic carotid if the carotid plaque ipsilateral to the cerebrovascular event presents with high-risk features including intraplaque hemorrhage, lipid-rich necrotic core, thinning/rupture of the fibrous cap, and ulceration. In this review, we first provide a historical overview of the chain of events and circumstances that resulted in the present management of carotid artery disease. Second, we embed the contemporary biomarkers of plaque vulnerability in a modern mechanistic paradigm of carotid plaque disruption and thromboembolization. Third, we review the clinically available imaging tools to detect these biomarkers, and how their use has started to shed light on the prevalence and natural history of this underdiagnosed condition. Fourth, we review recent clinical studies employing a contemporary definition of symptomatic nonstenotic carotid and discuss targeted treatments for this condition. Finally, we make a case to generate the much-needed high-level evidence to align the clinical management of patients with symptomatic nonstenotic carotid with a contemporary understanding of plaque disruption and thromboembolization.

Removable partial dentures: Part 1.

The provision of removable partial dentures (RPDs) is an important skill for practitioners and it can often be challenging to make a successful prosthesis which the patient finds satisfactory. This three-part series has been designed to provide an overview of the clinical management of patients requiring RPDs. This first part provides a refresher of the aspects of the history and examination that are relevant to RPDs. We describe some key principles that are relevant to challenging denture cases. This will help the reader begin the treatment planning process and understand some of the factors which influence the prognosis of dentures.