Invasive Therapeutic Procedures Research Articles

Age-Stratified Propofol Dosage for Pediatric Procedural Sedation and Analgesia.

Procedural sedation and analgesia (PSA) for diagnostic and minimally invasive therapeutic procedures has become common practice in children of all ages. Based on our clinical experience, we suspected an inverse relation between age and dosage. However, a schedule for age-stratified propofol induction and maintenance dosage for PSA was not available and could be helpful to many anesthesiologists as a reference. We performed a retrospective cohort study of children who received procedural sedation at the Wilhelmina Children's Hospital (WKZ), a tertiary pediatric hospital part of the University Medical Center Utrecht (UMCU), between June 2007 and December 2020. We studied whether the induction (mg·kg -1 ) and maintenance (mg·kg -1 ·h -1 ) dosage is age-dependent using linear regression models. A total of 6438 pediatric procedures were retrieved from Anesthesia Information Management Systems (AIMS). A total of 5567 records were available for induction dose analysis and 5420 records for analysis of the maintenance dose. After adjustment for sex, American Society of Anesthesiologists (ASA) physical status classification, opioid administration, and diagnostic or interventional, we obtained a coefficient of -0.11 (95% confidence interval [CI], -0.12 to -0.11) for age (years) from a multivariable linear regression model for propofol induction dosage (mg·kg -1 ) and a coefficient of -0.36 (95% CI, -0.39 to -0.34) for age (years) for propofol maintenance dosage. We found a noteworthy inverse age-effect on propofol dosage for both induction and maintenance of pediatric procedural sedation. Furthermore, our study revealed that remarkably higher propofol sedation doses were needed for infants and toddlers than previously expected and reported.

Evaluation of Intraligamentous and Intraosseous Computer-Controlled Anesthetic Delivery Systems in Pediatric Dentistry: A Randomized Controlled Trial.

Computer-controlled local anesthetic delivery systems (CDS) represent one of the resources that have progressed the most in recent years, but their efficacy and applicability in pediatric dentistry is still the subject of certain controversies. This randomized, controlled, split-mouth clinical trial assessed two CDS in children (n = 100) with deep caries in the temporary dentition that required invasive therapeutic procedures, using inferior alveolar nerve block as the gold standard. Half of the patients (n = 50) underwent the intraligamentary technique (Wand STA®) on one side of the mouth and conventional inferior alveolar nerve block on the contralateral side, while the other half (n = 50) underwent the intraosseous technique (QuickSleeper®) on one side of the mouth and conventional inferior alveolar nerve block on the contralateral side. The following were considered covariates: age, sex, type of dental procedure and the applied local anesthesia system. The outcome variables were the pain caused by the anesthesia injection, the physical reaction during the anesthesia injection, the need for anesthetic reinforcement, pain during the therapeutic procedure, the overall behavior during the visit, the postoperative morbidity and, lastly, the patient's preference. In conclusion, we confirmed the efficacy of intraligamentary and intraosseous techniques administered using a CDS for conducting invasive dental treatments in children, their advantages compared with inferior alveolar nerve block in terms of less pain generated by the anesthesia injection and less postoperative morbidity, as well as the pediatric patients' preference for CDS versus conventional techniques.

Specialist Palliative Care Consultations in COVID-19 Patients in the ICU-A Retrospective Analysis of Patient Characteristics and Symptoms at a German University Hospital.

COVID-19 patients who may require invasive therapeutic procedures such as extracorporeal membrane oxygenation (ECMO) have high symptom burden and in-hospital mortality. In addition, awake patients on ECMO are new in the intensive care unit (ICU) setting. Inpatient specialist palliative care (sPC) provides support such as symptom control on a physical, psychosocial and spiritual level. The field of sPC in COVID-19 patients is still new and important to investigate. We aim to analyze sPC of COVID-19 patients in the ICU with regard to patient characteristics and symptoms from a palliative care perspective. We conducted a retrospective analysis (03/2020–04/2021) and identified 51 ICU patients receiving sPC. The statistical analysis included descriptive statistics and comparisons of symptoms. The first sPC contact of patients (mean age 69.5 years, 62.7% male) was around 14 days after COVID-19 confirmation, and 43% were treated with ECMO therapy. The baseline symptom burden was high with a focus on weakness (100%), tiredness (98%), dyspnea (96%) and family burden (92%). The symptom intensity significantly decreased during the time period of sPC and COVID-19 treatment (t(99) = 3.119, p = 0.003, d = 0.437). These results help intensivists and sPC clinicians to identify symptoms and the need for sPC in COVID-19 patients. However, studies with prospective and controlled designs need to follow.

IATROGENIC PNEUMOTHORAX

Iatrogenic (a subtype of traumatic) pneumothorax commonly occurs as a complication of transthoracic puncture biopsy (TTPB), central venous catheterization (especially the subclavian vein), thoracocentesis, positive pressure mechanical ventilation (PPMV), transbronchial (TBB) and pleural biopsy. The incidence has recently been increasing due to the increasing use of invasive diagnostic and therapeutic procedures. The aim of this reseacrh is to present the results and the efficiency in the care of iatrogenic pneumothorax in the pneumophtisiologist practice in general hospital. Material and methods: the analysis includes 290 hospital histories (mainly from the Pulmonology Department, in a much smaller number from other Internal Medicine or Surgery Department at the GOB “September 8”) for a 4-year period (January 2018 - December 2021) with final discharge diagnoses: pleural effusion, pyothorax, lung cancer, pulmonary infiltration, pleural mesothelioma and metastatic pleural fluid - ICD codes: J90, J91, J86.9, C34, C45.0 and C78.2. All underwent an invasive diagnostic or therapeutic procedure. The diagnosis of pneumothorax included a radiological examination (PA-posteroanterior proection and LL -profile chest X-ray). Results: from 290 diagnostic-therapeutic procedures, immediately and up to 24 hours after the intervention, a total of 24 (8.3%) pneumothoraxes were recorded, namely: 15 (27%) out of 54 after TTPB, 3 (4.8%) of 62 after TBB and 3 (2%) of 124 after thoracocenthesis and percutaneous biopsyes of the parietal pleura. In 2 (4%) of 49 cases after lavage of the pleural space, partial pneumothorax was recorded, 1 complete hematopneumothorax after catheterization of the subclavian vein. Thoracic drainage was performed in 12 (50%) (initially in 9, and in 3 after 24 hours due to progression of incomplete lung collapse). Of the remaining 12 patients, the pneumothorax was treated with exufflation in 4, and in 8 conservatively (with a procedure of forced expiration and respiratory exercises). No case requiring a surgical approach has been registered. Conclusion: a condition for successful care of iatrogenic pneumothorax is compliance with standards in the application of diagnostic procedures in pulmonology and related areas, careful observation and efficient application of modern attitudes in care of complications from invasive-interventional diagnostic-therapeutic procedures.

Retrospective observational study on safety of sedation for colonoscopies in ASA I and II patients performed by a nurse and under the supervision of anesthesiology.

Out of operating room sedation with propofol by non-anaesthesiologists (Non Anaesthesiologist Administration of Propofol: NAAP) is a growing practice. This is due to the increase in minimally invasive diagnostic and therapeutic procedures requiring sedation, and the difficulty of anaesthesiology services to respond adequately to this demand. The main objective of this study is to assess the safety of a programme of nurse sedationist-administered target controlled infusion (TCI) of propofol in colonoscopies supervised by anaesthesiologists. Over a period of 6 months, all ASA I and II patients who required colonoscopy and met the inclusion criteria were included in the study. A total of 381 colonoscopies were performed. Episodes of desaturation, hypo- or hypertension, bradycardia or tachyarrhythmia and the need for anaesthesiology assistance during sedation were analysed. After the procedure, patient satisfaction was assessed on a scale of 1-5, and pain was assessed on a numerical verbal scale of 1-5. A small percentage (5%) of patients presented oxygen saturation of less than 90%, without requiring mask ventilation; 7.35% presented hypotension, 3.94% presented bradycardia, and the supervising anaesthesiologist was called in 22% of cases. Patient satisfaction at the end of the procedure was 4.27 out of 5. Sedation during colonoscopy in ASA I and II patients following an agreed protocol can be safely administered by nurse sedationists under the supervision of an anaesthesiologist.

Therapeutic lumbar puncture and lumbar drainage: which is more effective for the management of intracranial hypertension in HIV patients with cryptococcal meningitis? Results of a prospective non-randomized interventional study in China

Objective This study aimed to evaluate the effectiveness of therapeutic lumbar drainage (LD) compared to therapeutic lumbar puncture (LP) for the management of intracranial hypertension (ICH) among HIV-positive patients with cryptococcal meningitis (CM). Methods The study was a multicenter prospective non-randomized interventional clinical trial. One hundred and sixteen HIV-associated CM patients were identified who presented with ICH (≥250 mmH2O). The LP group comprised 76 cases, while the LD group consisted of 40 cases. We compared mortality, intracranial pressure (ICP) normalization rate, and clinical symptom remission at 10 weeks, between the two groups. Results The cumulative mortality at week 10 was 22.4% in the LP group and 20% in the LD group (p = .927), without any significant difference in mortality between the two groups. Improvement after treatment at 2-weeks, ICP normalization, and headache reversal event occurrence in the two groups showed no significant difference (p > .05). The incidence of CSF Cryptococcus clearance at two weeks in the LD group was significantly higher than in the LP group (p < .05). The frequency of invasive lumbar therapeutic procedures in the LP group during the first week was higher than that of the LD group (p < .05). Localized infection at the puncture site occurred more frequently in the LD group than in the LP group (p < .05). Conclusion For HIV-positive CM patients with an elevated ICP, LD and LP are comparably effective and safe options to normalize ICP. LP increases the frequency of invasive lumbar therapeutic procedures but does not incur more risk of infection events at the puncture site, while LD may accelerate CSF Cryptococcus clearance but may induce more frequent localized infection. Trial registration This study was registered as one of 12 trials under a general project at the Chinese Clinical Trial Registry (ChiCTR1900021195).

Palliative care and interventional radiology for older adults during the COVID-19 pandemic

Given the limitations imposed by the COVID-19 pandemic vis-à-vis limited and inaccessible healthcare services, the poor health conditions of older patients become even more exacerbated. Due to their underlying comorbidities and higher risk of developing peri and post-operative complications, older patients may be poor anesthetic candidates and are usually denied surgical treatments [1]. Hence, frontline minimally invasive therapeutic procedures that are alternatives or may serve as adjuncts to traditional surgical treatments are becoming all the more critical in the curative or palliative management of older, frail patients with multiple comorbidities.

Polymer-Based Materials and their Applications in Image-Guided Cancer Therapy.

Advances in nanotechnology have enabled the combination of disease diagnosis and therapy into a single nano package that has tremendous potential for the development of new theranostic strategies. The variety of polymer-based materials has grown exponentially over the past several decades. Such materials have great potential as carriers in disease detection imaging and image monitoring and in systems for the precise delivery of drugs to specific target sites. In the present article, we review recent key developments in the synthesis of polymer- based materials for various medical applications and their clinical trials. There is a growing range of multi-faceted, polymer-based materials with various functions. These functions include carriers for image contrast agents, drug delivery systems, and real-time image-guided systems for noninvasive or minimally invasive therapeutic procedures for cancer therapy.

Estudio observacional retrospectivo sobre la seguridad de la sedación para colonoscopias en pacientes ASA I y II realizada por enfermería y tutelada por anestesiología

IntroductionOut of operating room sedation with propofol by non-anaesthesiologists (Non Anaesthesiologist Administration of Propofol) is a growing practice. This is due to the increase in minimally invasive diagnostic and therapeutic procedures requiring sedation, and the difficulty of anaesthesiology services to respond adequately to this demand. ObjectiveThe main objective of this study is to assess the safety of a programme of nurse sedationist-administered target controlled infusion of propofol in colonoscopies supervised by anaesthesiologists. Material and methodsOver a period of 6 months, all ASA I and II patients who required colonoscopy and met the inclusion criteria were included in the study. A total of 381 colonoscopies were performed. Episodes of desaturation, hypo- or hypertension, bradycardia or tachyarrhythmia and the need for anaesthesiology assistance during sedation were analysed. After the procedure, patient satisfaction was assessed on a scale of 1 to 5, and pain was assessed on a numerical verbal scale of 1 to 5. ResultsA small percentage (5%) of patients presented oxygen saturation of less than 90%, without requiring mask ventilation; 7.35% presented hypotension, 3.94% presented bradycardia, and the supervising anaesthesiologist was called in 22% of cases. Patient satisfaction at the end of the procedure was 4.27 out of 5. ConclusionSedation during colonoscopy in ASA I and II patients following an agreed protocol can be safely administered by nurse sedationists under the supervision of an anaesthesiologist.

New trends in advanced parkinson disease stage therapy

The aim of the study was to point out the contribution of new invasive therapeutic procedures in the treatment of advanced stages of Parkinson’s disease (PD) in comparison with classical oral pharmacotherapy. Data originated from a group of 43 patients with PD, 39% (17) with classic treatment, 23% (10) with intestinal gel of methyl ester levodopa (Duodopa), 19% (8) of patients were using subcutaneous delivery of apomorphine (APO) and the same quantity of patients had undergone deep brain stimulation (DBS). Majority of patients had advanced stages of PD, stage 4, by standards of Hoehn and Yahr scale (Hoehn and Yahr, 1967). Research observed improvement in majority of patients with novel treatments. A positive effect was also noted in the reduced need for oral therapy, where there was a significant decrease in all new therapies. Benefits were observed in the amount of antiparkinsonic drugs taken per os, where we observed reduction in all new therapies. A positive effect of the new therapeutic approaches in reducing “off” periods in patients has also been noted. In the case of Duodopa and DBS, the ”off” period was shortened up to 50% and in the apomorphine pump up to 40%. Patients also reported reduction of some symptoms like rigidity, tremor and bradykinesis while dyskinesis still remains suba challenge. On the basis of the obtained results, it can be concluded that new therapeutic procedures for PCh will make it possible to manage symptoms typical of advanced stages of the disease, which without these procedures would lead to disability, which is the main reason for their indication. However, in early stages, well responding patients or in slow progressing disease oral antiparkinsonics are remaining as golden standard of treatment. This is not just due to good response but also because these classic drug formulations are significantly less expensive. In Slovakia, novel treatments are accessible through healthcare insurance only after secondary revision by insurance company doctors.

Indications, Efficacy, Safety and Complications of Retrograde Intrarenal Surgery

Kidney stones are one of the most prevalent disorders associated with significant morbidity. Initially the renal stones were treated with open surgery but with the advancements in technology shift towards the minimally invasive therapeutic procedures is observed. Recent technological advances in the field of urology have led to more prevalent use of retrograde intrarenal surgery for the treatment of urolithiasis. The introduction of new laser systems and advanced flexible ureteroscopy with a small ureteroscope have contributed to increase in indications for intrarenal surgery to include not only larger kidney stones &gt; 2 cm, but also urothelial carcinoma of the upper urinary tract, urethra, and idiopathic renal haematuria. Retrograde intrarenal surgery is one of the most safe and effective minimally invasive technique which due to its positive outcomes and less rate of complications has gained much popularity in the field of urology with the passage of time. The purpose of this research is to review the available information about the indications, efficacy, safety and complications of retrograde intrarenal surgery. Retrograde intrarenal renal surgery is indicated in various cases including lower calyx stones and stones greater than 2 cm among many others. Evidence from the literature suggests retrograde intrarenal surgery as quite a safe and effective method with high success rate and minimum and minor complications being reported. In future more randomized trial studies on retrograde intrarenal surgery can however significantly contribute to literature and benefit clinical practice also

Sn(IV) porphyrin-biotin decorated nitrogen doped graphene quantum dots nanohybrids for photodynamic therapy

Photodynamic therapy (PDT) is a minimally invasive therapeutic procedure for cancer treatment. This study focuses on the synthesis, photophysicochemical properties, and PDT activity of Sn (IV) porphyrin (2), when linked to biotin decorated nitrogen doped graphene quantum dots (B-NGQDs). The porphyrin complex 2 was conjugated through an ester bond to B-NGQDs to form 2-B-NGQDs. Singlet oxygen quantum yield increased for 2 when linked to B-NGQDs to form 2-B-NQGDs. The dark toxicity and photodynamic therapy studies were conducted for 2, NGQDs and their conjugates using MCF-7 breast cancer cells. The cell viability for dark toxicity of all the compounds was above 90%, and 2-B-NGQDs showed high PDT activity at a concentration of 40 µg/mL with cell viability of 22%.

Abstract 14284: "Weeding" Out Wellens' Syndrome

Introduction: Wellens’ syndrome, most often associated with proximal left anterior descending coronary artery stenosis, is considered highly specific for impending myocardial infarction (MI). Its diagnosis relies on symmetric biphasic or deeply inverted T waves in leads V1-V4, normal precordial R wave progression and normal to slightly elevated cardiac markers. Pseudo-Wellens’ syndrome presents similarly, but in the absence of coronary artery disease (CAD). We present a challenging case of a patient with history of excessive recreational cannabis use and incidental electrocardiogram (ECG) findings concerning for Wellens’ syndrome who ultimately was diagnosed with Pseudo-Wellens’ syndrome. With familiarity of cannabis associated Pseudo-Wellens’ syndrome, unnecessary invasive diagnostic and therapeutic procedures were avoided. Case: A 20 year old male without significant past medical history presented for evaluation of vomiting and abdominal pain of 2 days duration. In view of his daily cannabis use, he was diagnosed with cannabis hyperemesis syndrome. An ECG to measure QTc prior to administration of ondansetron demonstrated ST elevation in lead V2. A repeat ECG showed T-wave inversions in leads V2-4. Troponin levels were negative. The patient denied chest pain or shortness of breath. An echocardiogram showed normal cardiac wall motion and an estimated ejection fraction of 55-60%. The diagnosis of Pseudo-Wellens’ syndrome secondary to cannabis use was made and the patient was subsequently discharged home following extensive cannabis cessation counseling. Discussion: The definitive treatment of Wellens’ Syndrome relies on cardiac catheterization even in patients without cardiac history or risk factors for CAD. This immediate intervention is required to halt the evolution of MI and is crucial for a positive outcome. In contrast, Pseudo-Wellens’ syndrome occurs in the absence of CAD and has been reported in younger, healthy patients in association with illicit drug use. In the era of increased legalized marijuana use, it is imperative that health care providers are familiar with cannabis induced Pseudo-Wellens’ syndrome as to avoid the potential for inappropriate invasive diagnostic modalities in otherwise healthy individuals.

Clinical anatomy of the spatial structure of the right ventricular outflow tract.

The right ventricular outflow tract (RVOT) is located above the supraventricular crest and reaches the level of the pulmonary valve. Detailed knowledge of the RVOT spatial structure and its morphology is extremely important for cardiac invasive therapeutic procedures. To examine the spatial structure of the RVOT using virtual models of the right ventricle (RV) interior obtained post mortem. The study was carried out using 40 adult hearts from both sexes fixed in formalin. Donors had a negative history of cardiovascular diseases. Silicone models of the interior of the RV were made and then subjected to a digital modelling procedure using the photogrammetry technique. For each 3D model of the RV, the RVOT was extracted and measurements were performed. Statistical analysis demonstrated that the dimensions of the transverse (p < 0.001) and sagittal (p = 0.002) axis at the level of the upper and lower border of the RVOT differed significantly. There was also a significant difference between the right and left height of the RVOT (p = 0.009). A clear correlation was found between the volume of the RVOT and the volume of the entire RV (r = 0.718, p < 0.001). The obtained 3D models of the RVOT can help standardize the data related to RVOT architecture. Furthermore, they can extend knowledge about the RVOT in the field of cardiology and improve the procedures in cardiac surgery.

Association Between COVID-19 Diagnosis and In-Hospital Mortality in Patients Hospitalized With ST-Segment Elevation Myocardial Infarction

There has been limited research on patients with ST-segment elevation myocardial infarction (STEMI) and COVID-19. To compare characteristics, treatment, and outcomes of patients with STEMI with vs without COVID-19 infection. Retrospective cohort study of consecutive adult patients admitted between January 2019 and December 2020 (end of follow-up in January 2021) with out-of-hospital or in-hospital STEMI at 509 US centers in the Vizient Clinical Database (N = 80 449). Active COVID-19 infection present during the same encounter. The primary outcome was in-hospital mortality. Patients were propensity matched on the likelihood of COVID-19 diagnosis. In the main analysis, patients with COVID-19 were compared with those without COVID-19 during the previous calendar year. The out-of-hospital STEMI group included 76 434 patients (551 with COVID-19 vs 2755 without COVID-19 after matching) from 370 centers (64.1% aged 51-74 years; 70.3% men). The in-hospital STEMI group included 4015 patients (252 with COVID-19 vs 756 without COVID-19 after matching) from 353 centers (58.3% aged 51-74 years; 60.7% men). In patients with out-of-hospital STEMI, there was no significant difference in the likelihood of undergoing primary percutaneous coronary intervention by COVID-19 status; patients with in-hospital STEMI and COVID-19 were significantly less likely to undergo invasive diagnostic or therapeutic coronary procedures than those without COVID-19. Among patients with out-of-hospital STEMI and COVID-19 vs out-of-hospital STEMI without COVID-19, the rates of in-hospital mortality were 15.2% vs 11.2% (absolute difference, 4.1% [95% CI, 1.1%-7.0%]; P = .007). Among patients with in-hospital STEMI and COVID-19 vs in-hospital STEMI without COVID-19, the rates of in-hospital mortality were 78.5% vs 46.1% (absolute difference, 32.4% [95% CI, 29.0%-35.9%]; P < .001). Among patients with out-of-hospital or in-hospital STEMI, a concomitant diagnosis of COVID-19 was significantly associated with higher rates of in-hospital mortality compared with patients without a diagnosis of COVID-19 from the past year. Further research is required to understand the potential mechanisms underlying this association.

A Review of Immunocryosurgery and a Practical Guide to Its Applications.

Immunocryosurgery is a minimally invasive combinational therapeutic procedure that has been designed, developed, and evaluated in the Dermatology Department of the University of Ioannina from 2004. In a fixed time protocol, this approach combines immune stimulatory therapy with imiquimod and cryosurgery, i.e., cryosurgery is applied during continuous imiquimod treatment. Laboratory findings in tissue and blood level credit the efficacy to the synergy of imiquimod and cryosurgery. The synergy has been established through clinical trials and the excellent feasibility and efficacy demonstrated in clinical practice. Immunocryosurgery has extensive proof of excellent efficacy, comparable to surgery, in the treatment of basal cell carcinoma. It has also been evaluated in cases of Bowen’s disease, keratoacanthoma, Merkel cell carcinoma, lentigo maligna, and cutaneous squamous cell carcinoma with or without the addition of adjuvants. The aims of this review are to detail the immunocryosurgery protocol with the addition of daily practice clinical tips, compile data on the mechanism of action of immunocryosurgery, and delineate indications and possible future applications. Most of the available data originate from the treatment of BCC, of all histological types and localizations, and the principles reported mainly reflect on evidence related to the treatment of this common skin cancer.

Three-year mortality after acute myocardial infarction in patients with different diabetic status.

The prevalence of diabetes mellitus (DM) in patients with myocardial infarction (MI) is estimated at about 25%. Short- and long-term prognosis is worse in patients with DM and hyperglycemia compared with nondiabetics. Our aim was to analyze the impact of DM and transient hyperglycemia on in-hospital complications and long-term outcomes in patients with MI. We evaluated a prospective cohort of 58 394 patients with MI in the Polish Registry of Acute Coronary Syndromes (PL-ACS) in terms of in-hospital complications and 30-day, 12-month, and 36-month outcomes between 2009 and 2012. Patients with type 1 DM (T1DM) and type 2 DM (T2DM) underwent invasive diagnostic and therapeutic procedures less frequently than those without diabetes, transient hyperglycemia, and new-onset DM (P <⁠0.001). T2DM was associated with a significantly higher risk of MI complicated by cardiogenic shock. The rates of pulmonary edema in the transient hyperglycemia group and the DM group were 2-fold higher than in the nondiabetic group (P <⁠0.001). T1DM and T2DM were associated with a significantly higher risk of death. Unadjusted 3-year all-cause death rates in patients with T1DM, T2DM, transient hyperglycemia, new-onset diabetes and those without diabetes were 26.8%, 25.6%, 18.5%, 17.9%, and 16.2%, respectively. Hazard ratios (95% CI) adjusted for age, sex, clinical characteristics, and revascularization were 1.49 (1.12–2.00), 1.20 (1.14–1.27), 0.94 (0.67–1.31), and 0.66 (0.34–1.28), respectively. T1DM and T2DM are associated with elevated in-hospital and long-term mortality rates after MI. Diabetics and patients with transient hyperglycemia are more likely to develop significant in-hospital complications compared with nondiabetics. No significant differences regarding acute mechanical complications were noted between populations.

Unindicated cervical cancer screening in adolescent females within a large healthcare system in the United States

Current consensus recommendations are to not initiate cervical cancer screening for immunocompetent adolescent females before 21 years of age. This is in part because of the very low rate of 0.8 per 100,000 new cervical cancer cases diagnosed among women aged between 20 to 24 years. Timely human papillomavirus vaccination further decreases the incidence of cervical cancer to 4 cases per 100,000 persons by the age of 28 years. Screening before 21 years of age has demonstrated no clear benefit in cancer risk reduction or outcomes. In addition, unindicated screening among adolescents can lead to patient harm and increasing costs to the healthcare system. It is important to assess the rates of overutilization of cervical cancer screening and to identify areas where improvements have occurred and where further opportunities exist. This study aimed to assess the trends over time and the practice and provider factors associated with unindicated cervical cancer screening tests in adolescent females within the largest healthcare system in the state. Cross-sectional data from patients aged 13 to 20 years who underwent cervical cancer screening between January 1, 2012, and December 31, 2018, across a large multihospital health system were reviewed. All cervical cancer screening results were included. The incidence rate of unindicated screening was analyzed over 6-month intervals using the Poisson regression analysis. The study included data from 118 providers and 794 women. Among the 900 screening results, most (90%) were unindicated: 87% with unindicated cytology testing alone and 14% with unindicated human papillomavirus testing. Screening tests were collected from patients aged 13 to 20 years, many of whom had multiple unindicated cytology tests, with 25 patients having ≥3 tests before the age of 21 years. Most results of cytology testing were negative for intraepithelial lesion or malignancy (77%). Moreover, 52 invasive diagnostic or therapeutic procedures (49 colposcopies and 3 conizations) were performed, of which 45 (87%) followed an unindicated screening test. Between 2012 and 2018, the incidence rate of unindicated cytology decreased by 33% (12.6 to 8.5 unindicated cytology per 1000 encounters). The incidence rate of unindicated screening was lower in the academic setting than in the community setting (incidence rate ratio, 0.43; P<.01). Even with decreases in the overall rates of unindicated screening throughout the study period, there were still 58 unindicated screening tests performed in the final year of this study. Despite substantial reductions in unindicated screening for women aged <21 years, there remained areas for improvement. Our data reflected practices of guideline nonadherence up to 7 years after the 2012 guideline. Now, with a new series of changes to the guidelines, which may be even more challenging for patients and providers, it is more important than ever to utilize evidence-based strategies to improve guideline dissemination and adherence.

Sunitinib with photoirradiation-mediated reactive oxygen species generation induces apoptosis of renal cell carcinoma cells

BackgroundPhotodynamic therapy is a clinically approved, minimally invasive,therapeutic procedure used for the treatment of several cancers. In recent years, sunitinib, one of the tyrosine kinase inhibitors, has also attracted attention as a novel photosensitizer. However, there is currently no data available on the combined cytotoxic effects of sunitinib and photoirradiation on renal cell carcinoma including how the treatment induced cellular toxicity. MethodsIn the present study, we used sunitinib as a photosensitizer and evaluated the effects of sunitinib and photodynamic therapy treatment on renal cancer cell lines, including the induction of cell death. ResultsOur study showed that treatment with sunitinib and photoirradiation at 8 mW/cm2 for 30 min resulted in the production intracellular reactive oxygen species (ROS), which is indicated by the increase in mRNA expression levels of PAI-1, NF-κβ, and Caspase-3. An increase in rate of apoptotic reaction and increase in the expression level of apoptotic marker were also observed when cells undergo treatment with sunitinib and photoirradiation. ConclusionsOur findings suggest that combining photodynamic therapy with sunitinib represents a minimally invasive therapeutic procedure with cancer selectivity for renal cell carcinoma.

Informed consent of palliative patients to participate in quality of life research

Informed consent as a procedure is mandatory in cases of patient participation in clinical trials of pharmaceuticals, preparation for surgical interventions, diagnostic and therapeutic invasive procedures, and even in surveys (questionnaires) on health issues according to the legislation of most countries of the world. The practice of obtaining informed consent in Ukraine is widespread and well-studied in cases of preparing palliative patients for operations, hospitalizations, invasive procedures, but there is a certain lack of information on obtaining informed consent when studying quality of life. In our research, we used the method of systematic analysis and the bibliosemantic method, with references to scientific and legal sources. As a result of the study, it was determined that informed consent is an important part of the legal regulation of medical care and social security in Ukraine and the world. We researched the issue of legal capacity, identified separate issues of confidentiality, compliance with the requirements of Ukrainian legislation regarding the observance of individual rights of patients that could potentially be violated during the study of the quality of life, collecting and processing answers to questionnaire, signing informed consent. The text of the informed consent can be modified for the purposes of the scientific study, but without violating the procedure of informing the patient (or his legal representative) about the goals and possible inconveniences of the study. The text of the informed consent must be signed by the patient (in his own hand) and the attending physician. If the patient cannot write independently, but understands the essence of the text of the informed consent and the questions of the questionnaire and gives clear and unambiguous answers to them, the questionnaire and the informed consent can be signed only by the attending physician. Keywords: medical deontology, medical ethics, medical law, palliative and hospice care.