Kind Of Patients Research Articles

It’s all about the patients: a shift in medical students’ approach to learning during a novel distributed integrated clinical rotation

IntroductionTo ensure that pre-final year medical students at Stellenbosch University were able to resume clinical training during the COVID-19 pandemic, a 12-week integrated rotation was introduced, during which students were distributed across a widespread training platform in two provinces of South Africa, utilizing a range of health care facilities in both rural and urban areas, rather than the central academic hospital (CAH) in which they would have been doing clerkships. Called the Integrated Distributed Engagement to Advance Learning (IDEAL) rotation, this clerkship was based on supervised engagement in healthcare services, focusing on patient-based clinical training, self-regulated learning and student participation as integral members of clinical teams. The success of this emergency intervention has led to its formal incorporation into the medical curriculum. This study aimed to understand the factors that influenced learning among students undertaking the IDEAL rotation at multiple sites on a distributed training platform.MethodsUsing an interpretive paradigm, we sought to conduct focus group interviews with students who completed the first iteration of the IDEAL rotation in the year after they had undertaken it to understand their experiences. All 252 students who were eligible were invited to participate by email on several occasions. Ultimately three focus group discussions and two individual interviews were undertaken, based on volunteers. Using a semi-structured interview guide, these explored student perceptions of their learning and growth through the rotation. Inductive and deductive analysis was carried out to identify themes.FindingsStudent descriptions of their learning experiences coalesced in 6 themes. The rotation was an enabling learning experience, which was more practically focused and assisted students in developing confidence in their clinical skills. It was seen to be a humanizing learning experience with greater opportunities for the development of relationships with patients and families, as well as with health professionals, who made them feel part of the team, so it was also a more collegial learning experience. At the same time, it was a variable learning experience with a lack of standardization on a number of levels and challenges being experienced at particular sites regarding both logistics and the nature of the exposure. Students perceived it to be a very different learning experience from what they had encountered in the CAH in terms of relationships, the kinds of patients and problems they saw, and their active participation. Through this, they also learned more about themselves and their roles, making it a personal learning journey. The findings confirm the importance of the dimensions of person, participation and place for being and becoming a doctor in a clinical environment.ConclusionsStudent learning experiences in the IDEAL rotation emphasize the importance of context, reinforcing the value of a distributed training platform in developing health professionals who are responsive to their environment. They emphasize the vital role of active participation in learning and the centrality of relationships in medical training, helping to develop graduates who are human beings and not only human doings.

Claudin-2: A marker for a better evaluation of histological mucosal healing in inflammatory bowel diseases

BackgroundHistological mucosal healing has become a paramount target goal to achieve in the treatment of inflammatory bowel diseases. However, there is still a lack of agreement on the best way to reach this goal, since numerous histological scores are available worldwide. AimsWe investigated whether claudin-2, a member of claudin family involved in the regulation of intestinal tight junctions, might be useful to assess the presence of active disease in patients with inflammatory bowel diseases. MethodsBiopsies from 123 patients with ulcerative colitis, Crohn's disease, infectious colitides and irritable bowel syndrome patients where tested with immunohistochemistry for claudin-2. ResultsClaudin-2 appeared to be a very sensitive marker of disease activity in inflammatory bowel diseases, but was negative in the other kinds of patients. In addition, immunohistochemistry for claudin-2 showed good reproducibility by different pathologists. ConclusionsShould these findings be confirmed in more numerous cohorts of patients, and especially in those with minimal or focal residual disease activity, this simple assessment could be useful in the routine daily practice to facilitate the task of pathologists and clinicians in the diagnosis and management of patients with inflammatory bowel diseases.

Urgent or Emergent Endovascular Aortic Repair of Infective Aortitis.

Background: Aortitis is a rare inflammation of the aorta. It can be classified as infective, non-infective, or idiopathic. Infective aortitis can debut as an acute aortic syndrome that needs urgent or emergent treatment. Historically, these kinds of patients have been preferably treated by open surgery, with subsequent lack of information about the endovascular repair. The aim of the present study is to report the results of our experience with the urgent or emergent endovascular repair of infective aortitis with acute presentation. Methods: All consecutive urgent or emergent endovascular repairs, performed between January 2019 and January 2024 for the treatment of infective aortitis, were included. The inclusion criteria were clinical, laboratory, and radiological findings recognized as aortitis risk factors. Patients with graft or endograft infection, aortic fistulae, and mycotic aneurysm were excluded. Primary endpoints were technical success and 30-day and follow-up survival. Early and late major adverse events, any changes in lesion morphology over time, and need for re-intervention were also assessed. Results: A total of 15 patients (14 males and 1 female) with a mean age of 74.2 ± 8.3 were included. All the subjects were treated by endovascular means in an urgent or emergent setting because of a rapidly growing aneurysm, symptomatic lesion, or contained or free aortic rupture. The diagnosis of infective aortitis was confirmed postoperatively by positive blood cultures in all the patients. A rapidly growing or symptomatic lesion was noted in all 15 subjects. Among these there were six (40%) contained and two (13%) free aneurysm ruptures. The endovascular techniques performed were as follows: four thoracic-EVAR (TEVAR), three off-the-shelf branched-EVAR (BEVAR), one Chimney-EVAR (Ch-EVAR), six EVAR with bifurcated graft, and one EVAR with straight tube graft. Technical success was achieved in 100% of the patients. Two patients (13%) died within 30 days after the index procedure. No case of early aortic-related mortality was registered. During a mean follow-up of 31.6 ± 23.1 months (range 1-71), no further death or major adverse event was registered among the remaining 13 alive patients. Re-interventions were performed in three cases (20%). Aneurysm's shrinkage > 5 mm or stability was noted in 10 of the 13 patients who survived the early period after repair. Conclusions: Despite the relative reluctance to use an endograft in an infected area, in our experience the endovascular approach resulted to be feasible, safe, and effective in the treatment of infective aortitis with acute presentation, with acceptable peri-operative and mid-term follow-up outcomes. Further studies are needed to confirm our results.

An uncommon orthogeriatric syndrome: a case of Ogilvie’s syndrome

Acute colonic pseudo-obstruction (ACPO), also known as Ogilvie’s syndrome, is an uncommon postoperative complication of major orthopedic surgery that is characterized by massive colonic dilatation and the potential for substantial morbidity and mortality. Most patients who had Ogilvie’s syndrome had risk factors that could be identified preoperatively, such as immobility, elevated comorbidity, and polypharmacy, prefiguring the frail elderly patient. In modern terms, it is considered a typical orthogeriatric syndrome. In these kinds of patients, we need to be vigilant for its development and judicious in the use of epidural anesthesia. We present an ACPO case in an elderly frail patient with a hip fracture, and we review the available literature to outline clinical characteristics and outcomes. Our patient presented numerous risk factors for developing the syndrome in the preoperative period: nonautonomy in basic and daily living activities, polypharmacotherapy, spinal trauma, and hyposodiemia. In this patient, epidural anesthesia was an additional risk factor. The purpose of this case report is to emphasize the presence of this rare syndrome (1.5% of orthogeriatric patients) in orthogeriatric departments and to identify not only pharmacological, traumatic, and electrolytic risk factors but also those that can be identified even through geriatric evaluation to avoid the use of anesthesiologic techniques and drugs that may have an impact on the prognosis of these patients.

Efgartigimod for generalized myasthenia gravis: A multicenter real-world cohort study in China.

Efgartigimod, a neonatal Fc receptor antagonist, facilitates antibody degradation including pathogenic IgGs. The ADAPT study demonstrated the tolerability and efficacy of efgartigimod in the treatment of generalized myasthenia gravis (gMG). However, very limited evidence is available for the Chinese population, and it remains inconclusive about which kind of patients are selected to preferentially receive efgartigimod in real-world settings. This multicenter cohort study included gMG patients treated at 14 neuromuscular reference centers in China. The Myasthenia Gravis Activities of Daily Living (MG-ADL) score, immunosuppressants, and the incidence of treatment-emergent adverse events (TEAEs) were prospectively collected. Of the 1640 gMG admitted between September and December 2023, 61 (3.7%) received efgartigimod for at least one treatment cycle. Among them, 56 cases (92%) were anti-AChR antibody-positive, 4 were anti-MuSK antibody-positive, and 1 was seronegative. Thymoma-associated myasthenia gravis accounted for most cases (44%, 27 out of 61). The principal causes of efgartigimod initiation included MG acute exacerbation (MGAE) (48%, 29 out of 61) and myasthenic crisis (MC) (15%, 9 out of 61). Clinically meaningful improvement was rapidly achieved in 97% (58 out of 61) of patients at 1.3 ± 0.7 weeks. By week 12, the MG-ADL score reduced to 3.8 ± 4.1 (baseline:10.5 ± 5.2) for all participants, while it reduced to 4.0 ± 4.7 for MGAE and 3.8 ± 4.2 for MC, respectively. All but one TMG patient required no additional rescue therapies after efgartigimod initiation. 11.5% (7 out of 61) reported ≥1 TEAEs. This multicenter cohort study demonstrated the efficacy of efgartigimod in rapid control of gMG. Patients with MGAE or MC would benefit from efgartigimod treatment.

Aortic Regurgitation in Bicuspid Aortic Valve: The Role of Multimodality Imaging.

The evaluation of aortic regurgitation (AR) in bicuspid valve (BAV) is still a challenge because of the eccentricity of the jet, which may under/overestimate the regurgitation. The commonly used echocardiography parameters (such as vena contracta, pressure half-time, etc.) may not be useful in this kind of patient. A multimodality approach combining echocardiography, cardiac MRI, cardiac CT, and advanced technologies applied to non-invasive cardiac imaging (e.g., 4D flow and strain imaging) may be useful to better quantify regurgitation and to select patients suitable for valve replacement. This review provides an overview of the most recent insights about cardiovascular imaging tools and their utility in BAV evaluation, focusing on chronic regurgitation. We describe the role of multimodality imaging in both diagnosis and risk assessment of this disease, pointing out the advantages and disadvantages of the imaging techniques, aiming to provide a guide to clinicians and cardiovascular imaging specialists in choosing the best imaging tools to use.

Utilizing Single-Branched Stent in Combination With Fenestration or Chimney for Endovascular Repair of Aortic Arch Lesions With Aberrant Subclavian Artery.

The study was to figure out the feasibility, efficacy, and safety of a single-branched stent graft, namely Castor, in combination with fenestration or chimney in the context of aortic arch lesions presenting with aberrant subclavian artery (ASA) and/or Kommerell's diverticulum (KD). All consecutive patients with aortic arch lesions and ASA and/or KD receiving Castor from June 2018 to June 2023 were investigated. Incorporating 18 patients, the study encompassed 11 cases with KD, 3 cases with dysphagia; 2 cases of right-sided aortic arch with left-sided aberrant left subclavian artery (ALSA), and 16 cases of left-sided aortic arch with right-sided aberrant right subclavian artery (ARSA). The mean operation time was 132±23 minutes. The mean measured proximal aortic diameter was 30.9±1.6 mm, and proximal diameter of Castor stent was 34 (32, 34.5) mm, with oversize of 9.1±1.6%; the mean measured branch diameter was 8.8±0.97 mm, and branch diameter of Castor stent was 10 (8, 10) mm, with oversize of 0.86±0.57 mm. Technical success rate was 100%, and no in-hospital mortality, no stroke, and no endoleak were identified. One (5.6%) case with spinal cord ischemia and one (5.6%) case with poor healing of operative site were identified. During the follow-up period, no aortic-related death or secondary intervention was recorded. The maximal aortic diameter was significantly reduced at the sixth postoperative month (padj=0.031); KD diameter was significantly reduced at the third (padj=0.001) and sixth (padj<0.001) postoperative month. Totally endovascular repair of aortic arch lesions with ASA and KD via Castor stent in combination with fenestration or chimney is feasible, effective, and safe, which can achieve an encouraging medium-term outcome and provide excellent remodeling at the lesions. Single branched stent in combination with fenestration or chimney achieved a sufficient proximal landing zone and provided an encouraging medium-term outcome in this retrospective review of 18 patients receiving endovascular treatment of pathological aortic arch with aberrant subclavian artery and/or Kommerell's diverticulum. The authors suggest this time-saving and efficient technique to establish systematic experience for the treatment in this kind of patients.

Protocolo del dolor abdominal en el paciente con patología cardiovascular

Abdominal pain is a frequent cause of consultation in emergency services. Anamnesis is fundamental, characteristics of abdominal pain usually allows to determine a suspect diagnosis, which is frequently confirmed with the ulterior study. This kind of patients can have cardiovascular causes of abdominal pain, that can be severe. Electrocardiogram and laboratory tests can be obtained in every patient in a quick way, and the first one is essential in the diagnosis of myocardial infarction. Laboratory tests can be useful in the diagnosis of acute mesenteric ischemia or pulmonary thromboembolism, in these diagnosis and in the case of suspiction of aortic aneurysm ruptura is very helpful asking for a computer tomography. But in case the patient has abnormal vital signs and an acute mesenteric ischemia or aortic aneurysm rupture is suspected, an urgent laparomy is indicated, it is diagnostic and it allows to treat the cause.

Ventilator-Associated Pneumonia, Ventilator-Associated Events, and Nosocomial Respiratory Viral Infections on the Leeside of the Pandemic.

The COVID-19 pandemic has had an unprecedented impact on population health and hospital operations. Over 7 million patients have been hospitalized for COVID-19 thus far in the United States alone. Mortality rates for hospitalized patients during the first wave of the pandemic were > 30%, but as we enter the fifth year of the pandemic hospitalizations have fallen and mortality rates for hospitalized patients with COVID-19 have plummeted to 5% or less. These gains reflect lessons learned about how to optimize respiratory support for different kinds of patients, targeted use of therapeutics for patients with different manifestations of COVID-19 including immunosuppressants and antivirals as appropriate, and high levels of population immunity acquired through vaccines and natural infections. At the same time, the pandemic has helped highlight some longstanding sources of harm for hospitalized patients including hospital-acquired pneumonia, ventilator-associated events (VAEs), and hospital-acquired respiratory viral infections. We are, thankfully, on the leeside of the pandemic at present; but the large increases in ventilator-associated pneumonia (VAP), VAEs, bacterial superinfections, and nosocomial respiratory viral infections associated with the pandemic beg the question of how best to prevent these complications moving forward. This paper reviews the burden of hospitalization for COVID-19, the intersection between COVID-19 and both VAP and VAEs, the frequency and impact of hospital-acquired respiratory viral infections, new recommendations on how best to prevent VAP and VAEs, and current insights into effective strategies to prevent nosocomial spread of respiratory viruses.

#2892 The role of physical activity in onco-nephrology; a new weapon in the management of urological malignancies

Abstract Background and Aims New clinical evidence demonstrated that Physical Activity (PA) brings numerous benefits both at the level of Health-RelatedQuality of Life (HRQoL), biological mechanisms and at the psychological level. Indeed, it is well known that cancer treatments results in a series of symptoms and side effects that debilitates the patients with cancer and can be counteracted with physical activity. PA has an effect on several aspects of biological mechanisms: sex hormones, metabolic hormones, inflammation and adiposity, and immune function. Furthermore, strong evidence shows that aerobic or combined (aerobic and endurance) training reduces symptoms of anxiety, depression and fatigue. Combined training also leads to improvements in HRQoL, preventing and improving muscle loss and sarcopenia. This study aims to assess the influence of physical activity on this improved scenario. Method A consecutive cohort of 82 pts was enrolled in the Urological Department at San Raffaele Scientific Institute between 2018-2021. The control group (CT) was composed of 31 patients affected by CKD alone (GFR &amp;lt; 60 ml/min/1.73 m2, K-DIGO 2012 classification) and 51 patients with CKD and a recent history of urological malignancies (within 12 months) represented the case group (CS). Inclusion criteria were: Age (&amp;gt;18 years old), eGFR (&amp;lt;60 ml/min/1.73), Malnutritional Screening Tool (MST&amp;lt;2), Urological Cancer aggressiveness (no metastatic process), Informed consent (signed). Each patient underwent an initial nephrological and nutritional evaluation during which a conventional CKD Mediterranean-like diet with a controlled protein intake (MCPD) (0.6-1 g total protein/kg body weight/die and 30-35 kcal/kg body weight/die) was prescribed together with physical activity recommendation according to The National Kidney Foundation (NKF) for a period of 6 months (±2 months). Physical activity recommendations included some aerobic exercise for 30 min on most days of the week, plus other activities to increase muscle strength (exercises with resistance bands) e/o to improve flexibility (such as stretching) once or twice a week. To assess the influence of physical activity within the collaborative nephrologist-nutritionist approach (NNCA) on enhanced kidney function, the Rapid Assessment of Physical Activity (RAPA) test was administered to each patient. The test consists of two indicators: RAPA 1 will indicate aerobic physical activity levels (from 0=sedentary to 7=physically active), while RAPA 2 will indicate other types of exercises (0=none; 1=strength; 2=flexibility; 3=both). Subsequently, Bioelectrical Impedance Analysis (BIA) was conducted on all participants in the cohort to collect data on Body Cell Mass per height squared (BCM/h2), Phase Angle (PA), Extracellular Mass (ECM)/BCM, and Extracellular to Intracellular water ratio (ECW/ICW). Statistical analysis: Linear regression and Pearson's Chi-Squared test; Data analysis: R programming language and RStudio integrated development environment. Results Table 1 shows the patient's baseline characteristics. Table 2 shows anthropometric indices and parameters at pre- and post-dietary and nephrological intervention. Table 3 underlines the poor condition prevalent in CKD patients with or without oncological history, also confirmed by the low level of usual physical activity detected by the RAPA test at T0. Sure enough, our population was mainly inactive and sedentary. Results show that, after the intervention, our patients became regularly active (RAPA 1 score T0: 2.47; RAPA 1 score T1: 3.17; Delta = + 0.7, p &amp;lt; 0.0001); the same trend was observed for RAPA 2 score (observed increase 14%, p &amp;lt; 0.002). Conclusion Based on these findings, it can be inferred that standard clinical care should incorporate thorough assessment of both nutritional status and PA. The adoption of a MCPD, coupled with exercise training within a collaborative nephrologist-nutritionist approach, emerges as a potential strategy to enhance the HRQoL of this particular kind of patient.

Diabetes Remains the Number One Diagnosis Among Patients Visiting Nephrology Clinic

There is a huge burden of kidney disease overloading the hospitals and nephrology clinics. No clear data exists as to what kind of patients are visiting the outpatient departments. Pakistan is seeing a huge load of diabetics and naturally a significant portion of diabetics ultimately develop diabetic kidney disease. It is important to document such stats so as to make a concrete strategies for preventive medicine. True big data is difficult to obtain due to to the obvious hurdles in manpower and lack of interest of almost all quarters to document the true prevalence of noncommunicable diseases.&#x0D; This study highlights the clinical diagnoses of patients presenting to a private nephrology clinic.

P753 Early perianal abscess recurrence in patients with perianal Crohn's disease on biologic therapy predicts long-term permanent fecal diversion

Abstract Background Generally, it’s difficult to estimate the efficacy of biologics (Bio) for perianal lesions of Crohn’s disease (CD) and lack of evidence. Sometimes, we experience the recurrence of perianal abscess and need to perform re-drainage even after starting 1st Bio. When the 1st bio fails, choosing an accurate 2nd Bio is difficult. The most severe result of this situation is rectal amputation. We wonder if any relationships between recurrence timing and long-term outcomes exist. We reviewed and aimed to know our institute’s perianal CD (pCD) treatment. Methods We retrospectively investigated patients' medical charts with pCD from 1988 to 2022 at Kenseikai Nara Coloproctology Center. We excluded the patients without using Bio or starting Bio after rectal amputation. The cases with missing values are excluded, too. We defined "early" as within two years and compared two cohorts, the early recurrence group (ER) and the no or late recurrence group (non-ER). We use the Kaplan-Meier method for calculating the time to fecal diversion. Results Eighty patients were recruited. The mean current age is 37.5 years old, and the onset of CD is 22.6 years old. The Perianal lesion’s onset is 24.5 years old. The male is 66, and 19 smokers are included. In this part, perianal lesion means only perianal abscess and fistula. Montreal Classification is shown in TABLE1. The Median follow-up duration was 142.5 months. We performed perianal surveillance (PS) for these patients, including EUA, Abscess Drainage, and seton placement, 3.1 times for each person. After the surgical interventions, we treat them with four Bio. After starting Bio, we experienced 33 early recurrences. We observed eight transient stoma creations, nine rectal amputations, and one anorectal cancer. Among them, we calculate the relationships between early recurrence and rectal amputation and find that early recurrence is a risk factor for permanent fecal diversion (HR 6.84 95%CI 1.48-31.7, p=0.0047 FIGURE1). We needed to switch the Bio for 31 patients during the observational period. To know which way of switching is effective for pCD, we calculate the relationships between the practice of switching and any treatment failure. Same class switching and changing MOA are not different for any treatment failure, which means re-abscess drainage and creation of any stoma (HR 0.40 95%CI 0.10-1.57 p=0.19). Conclusion Perianal abscess recurrence as we need to re-incision and drainage within two years after starting Bio treatment are related to permanent fecal diversion. We must pay attention to such kinds of patients, but the types of Bio we change didn’t affect any treatment failure. Further studies are needed in this field.

Evaluation of risk factors for long-term atrial fibrillation development in patients undergoing typical atrial flutter ablation: a multi-center pilot study

Abstract Background/Introduction Atrial flutter (AFL) and atrial fibrillation (AF) are the most commonly detected supraventricular arrhythmia and share similar pathophysiological mechanisms (1). After the successful ablation of AFL, AF frequently occurs in such patients in the long-term follow up (2). As emphasized in some studies, some mechanisms seem to predispose to the development of AF in AFL patients and approximately 20% of such kind of patients have accompanying AFL (3). Purpose We aim to analyze independent risk factors that predict the development of AF in patients who underwent typical AFL ablation. Methods Our study was designed as multi-center, cross-sectional and retrospective. A total of 442 patients who underwent typical AFL ablation at 3 different centers between January 1, 2018 and January 1, 2022 were included retrospectively. The patients after the ablation procedure were divided into those who developed AF and those who did not. The patients were followed up for an average of 12 (4-20) months. In the post-procedure period, atrial arrhythmias were investigated with 24-hour Holter and ECG at 1st month, 6th month, 12th month and at 6-month intervals thereafter. Results AF developed in 206 (46.6%) patients in the long-term follow-up. Age, hypertension (HT), obstructive sleep apnea syndrome (OSAS), previous cerebrovascular accident (CVA), left atrium antero-posterior diameter, severe mitral regurgitation, hemoglobin, blood glucose and HbA1c values were found to be significant in univariable analysis. According to multivariable analysis, HT (p=0.014; HR: 1.483 (1.084 – 2.030)), OSAS (p=0.008; HR: 1.520 (1.117 – 2.068)) and previous CVA (p=0.038; HR: 1.749) (1,031 – 2,968)) were independently associated with the development of AF in AFL patients who underwent ablation procedure. Conclusion In the present study, we found that HT, OSAS and previous CVA were independently correlated with the development of AF in the long-term follow-up of patients who underwent typical AFL ablation. We consider that AFL patients with such risk factors should be followed-up closely following cavo-tricuspid isthmus ablation for the development of AF. Univariable and Multivariable Analyzes Kaplan - Meier Curves

Psychiatric Treatment of Medical Colleagues and Their Families: Potential Risks.

Clinicians treating "very important persons" face potential problems that can negatively impact the quality of care they provide. Mental health professionals face similar pressures, particularly when asked to treat a particular kind of patient who is a very important person: medical colleagues or their family members. The authors present 3 cases that exemplify possible risks associated with the psychiatric treatment of these individuals, including negative effects on the physician-patient relationship, lapses in patient confidentiality, and violations of medical ethics. Preventive and mitigative steps to avoid these pitfalls are discussed. Awareness of these issues when treating fellow physicians or their family members is an important consideration for any mental health clinician.

Efficacy of a Diode Vaginal Laser in the Treatment of the Genitourinary Syndrome of Menopause.

Genitourinary syndrome of menopause (GSM) and vulvovaginal atrophy (VVA) are the most frequent menopause-related clinical entities and are consistently included in the definition of pelvic floor disorders (PFDs). Nonhormonal therapies, such as lubricants and moisturizers, are indicated as first-line treatments, while the "gold standard'' is represented by topical estrogen products; however, in cancer survivors hormonal treatment is not indicated. For this reason, energy-based therapeutic approaches-for instance, through laser technologies-may be employed as alternative options in this kind of patient; however, there are no studies evaluating the efficacy of a pure diode vaginal laser in the treatment of GSM. As a consequence, with our study, we aimed to evaluate outpatient nonablative diode laser treatment in sexually active women, with contraindications, no response, or refusal of local estrogenic therapy. This prospective study included patients with GSM, aged ≥ 18 years old, with contraindications, or refusal of local estrogen therapies. Women were evaluated via the use of their Vaginal Health Index (VHI) scores, which consists of five measures: elasticity, fluid volume, pH, epithelial integrity, and moisture. Moreover, the intensity of VVA symptoms (vaginal burning, vaginal itching, vaginal dryness, dyspareunia, and dysuria) was measured using a 10 cm visual analog scale (VAS), where the left extreme of the scale (score = 0) indicated "absence of symptom" and the right indicated "symptom as bad as it could be" (score = 100). Sexual function was evaluated with the Female Sexual Function Index (FSFI-19) questionnaire. The treatment was performed using a Leonardo Dual diode laser (Biolitec Italia Srl, Milano, Italy). The laser treatment consisted of three sessions, one per month. One month after the third session, the VHI, symptom VAS, and FSFI-19 were re-evaluated. In addition, the Patient Global Impression of Improvement (PGI-I) questionnaire was collected. Our study enrolled a total of 26 consecutive patients. All patients were either in menopause or under treatment with gonadotropin-releasing hormone (GnRH). None of the patients reported adverse effects after laser treatment. In total, 19 (73.1%) patients referred improvements of their symptoms according to PGI-I scores. All domains of the FSFI-19 questionnaire, significantly improved after the diode laser treatment. The mean VHI score increased by 3.2 points, from 12.2 to 15.4 (p < 0.001). Additionally, we documented a significant improvement in symptoms affecting the VAS score, from 69.2 to 43.5 points (p < 0.001). A diode vaginal laser is an effective and easily tolerated ambulatory procedure for vaginal functional restoration in the treatment of GSM and VVA.

Measurement of apixaban concentrations in different human biological fluids by UHPLC-MS/MS. Clinical pharmacokinetic application in a subject with chronic kidney disease and nonvalvular atrial fibrillation on haemodialysis

BackgroundApixaban’s technical sheet does not recommend its use in clinical practice for patients with chronic kidney disease undergoing haemodialysis. However, recent studies indicate that apixaban could be a safe oral anticoagulant in these kinds of patients who do not present valvular atrial fibrillation. We developed and validated ultra–high-performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) procedures for measuring apixaban concentrations in plasma, dialysate liquid, and urine. Material and methodsSimple protein precipitation was implemented to prepare samples. Chromatographic separations were achieved on an Acquity®-UPLC®-BEHTM (2.1x100 mm id, 1.7 µm) reverse-phase C18 column using a water/acetonitrile non-linear gradient containing 0.1 % formic acid at a 0.4 mL/min flow rate. Apixaban and its internal standard (apixaban-d3) were detected by electrospray ionisation mass spectrometry in positive and multiple reaction monitoring modes, using transitions of 460.3 → 199.0/443.2 and 463.3 → 202.0, respectively. ResultsNo significant interferences and carry-overs were observed. Precisions, absolute relative biases, normalised-matrix factors, and normalised recoveries were ≤ 12.2%, ≤8.0%, 94.3–105.1%, and 93.9–105.4%, respectively. Linearity was observed between 5 and 500 μg/L for plasma/dialysate liquid and 5–1000 μg/L for urine. ConclusionsThe validated UHPLC-MS/MS procedures could help support a pharmacokinetic study in non-valvular atrial fibrillation subjects with chronic kidney disease undergoing haemodialysis and apixaban-based anticoagulant therapy.

Pain management in pediatric age. An update.

Differently from the adult patients, in paediatric age it is more difficult to assess and treat efficaciously the pain and often this symptom is undertreated or not treated. In children, a selection of appropriate pain assessment tools should consider the age, the cognitive level, the presence of eventual disability, the type of pain and the situation in which it is occurring. Improved understanding of developmental neurobiology and paediatric analgesic drug pharmacokinetics should facilitate a better management of childhood pain. The objective of this update is to discuss the current practice and the recent advances in pediatric pain management. Using PubMed and the Cochrane Library we conducted an extensive literature analysis on pediatric pain assessment and commonly used analgesic agents in this kind of patients. According to our results, a multimodal analgesic regimen provides a better pain control and a functional outcome in children. Cooperation and communication among the anaesthesiologist, the surgeon and the paediatrician remains essential for successful anaesthesia and pain management in childhood.

Bleeding Disorders and Dental Implants: Review and Clinical Indications.

Bleeding disorders can be divided into three categories: congenital coagulation disorders (CCDs), antiplatelet-induced bleeding disorders (APBDs) and anticoagulant-induced bleeding disorders (ACBDs). Implant placement can be challenging in these kinds of patients. The aim of this study is to provide evidence on implant surgery in patients with bleeding disorders and to generate some practical recommendations for clinicians. Pubmed/MEDLINE, Scopus, Web of Science and Cochrane Library databases were screened. The latest search was performed in July 2022. Case reports, case series, cohort studies, cross-sectional studies, case control studies, reviews, consensus reports, surveys and animal studies were included in the analysis. Seventeen articles on CCDs were found, fourteen on APBDs and twenty-six on ACBDs. Most of these articles were case reports or case series. Patients with CCDs can be treated after the infusion of the missing coagulation factor. Patients with APBDs can be treated without withdrawing the therapy. Patients with ACBDs should be treated depending on the anticoagulative medication. Despite the low level of evidence, dental implants can be safely placed in patients with bleeding disorders. However, careful preoperative evaluation and the adoption of local and post-operative bleeding control measures are mandatory.

Feature Selection Using a Hybrid Approach Depends on Filter and Wrapper Methods for Accurate Breast Cancer Diagnosis

Breast cancer is the biggest cause of mortality in women, outscoring all other malignancies. Diagnosing breast cancer is hard because the disease is complicated, treatment methods change, and there are many different kinds of patients. Information technology and artificial intelligence contribute to improve diagnostic procedures, which are critical for care and treatment as well as reducing and controlling cancer recurrence. The primary part of this research is to develop a new feature selection strategy based on a hybrid approach that combines two methods for selecting features: the filter and the wrapper. In two stages, this method reduces the number of features from 30 to 15 to increase and improve classification accuracy. The suggested method was tested using the Wisconsin Breast Cancer Dataset dataset (WDBC). To enhance the classification of breast cancer tumors, a soft voting classifier was used in this study. The proposed methodology outperforms previous research, achieving 1 for the F1 score, 1 for AUC, 1 for recall, 1 for precision, and 100% for accuracy. Furthermore, 10-fold cross-validation has a 98.2% accuracy rate.

Scoring model with serum albumin and CA19-9 for metastatic pancreatic cancer in second-line treatment: results from the NAPOLEON study.

Patients with metastatic pancreatic cancer refractory to first-line chemotherapy (CTx) have few treatment options. It is unclear what kind of patients could be brought about survival benefit by 2nd-line CTx after refractory to gemcitabine + nab-PTX (GnP) or FOLFIRINOX. This analysis was conducted as part of a multicenter retrospective study of GnP or FOLFIRINOX in patients with metastatic pancreatic cancer. Excluding censored cases, 156 and 77 patients, respectively, received second-line chemotherapy (CTx) and best supportive care (BSC). Using prognostic factors for post-discontinuation survivals (PDSs) at the first-line determination in multivariate analysis, we developed a scoring system to demonstrate the benefit of second-line CTx. The second-line CTx group had a median PDS of 5.2months, whereas the BSC group had a median PDS of 2.7months (hazard ratio 0.42; 95% confidence interval [CI] 0.31-0.57; p < 0.01). According to the Cox regression model, serum albumin levels below 3.5g/dL, and CA19-9 levels above 1000 U/mL were independent prognostic factors (p < 0.01). Serum albumin (≥ and < 3.5g/dL allotted to scores 0 and 1) and CA19-9 (< and ≥ 1000 U/mL allotted to scores 0 and 1) at first-line determination were used to develop the scoring system. The PDSs of patients with scores of 0 and 1 were significantly better than those of the BSC group; however, there was no significant difference between the PDSs of patients with score 2 and the BSC group. The survival advantage of second-line CTx, was observed in patients with scores of 0 and 1 but not in those with score 2.