Multidisciplinary Procedure Research Articles

Seismic vulnerability assessment of Venetian façades and artistic assets: Historical Digital Twin approach

The seismic vulnerability assessment of monumental façades and of their valuable artistic assets, along with considerations for protection and valorisation, requires the development of an integrated, multidisciplinary procedure able to enhance the accessibility, promotion and management of cultural heritage as well as to effectively model and simulate the structural performances of each artistic element. The multi-step methodology presented in this paper starting from an advanced survey and an appropriate tridimensional (3D) restitution, leads to the development of an Historical Digital Twin useful to create a detailed finite element model able to carry out structural simulations of both the historic façade and the artistic assets. To illustrate this methodology, the paper delves into a real case study involving a typical Venetian monumental façade, focusing on the seismic vulnerability assessment of two statues located at different levels. Emphasis is given to the importance of the 3D models to support vulnerability analysis, and to evaluate the seismic action at the points of the façade where the statues are placed. To this aim different methods are used and compared, showing on the one hand a strong dependence of the amplification of the seismic acceleration on earthquake frequency content and on the other hand the precautions to take using design-oriented predictive formulations.

1046 A Multi-Specialty Approach to the Management of CBD Stones: Utilising a High-Power Holmium Laser to Perform Laser Lithotripsy of a Complex Common Bile Duct Stone

Abstract Laser Lithotripsy is a therapeutic technique commonly used for the treatment of urological stones. This report presents the case of a patient with a common bile duct (CBD) stone refractory to traditional management approaches including ERCP, internal and external drains. A plan was made for the patient to undergo laser lithotripsy of their CBD stone in a multi-disciplinary procedure. A high-power Holmium laser, operated by a Urology Consultant, was used to perform percutaneous fragmentation of the CBD stone. An Interventional Radiologist was also scrubbed to assist with access. The Upper GI Surgeon had also been involved in the planning of the case and was on standby should there be a need to proceed to further surgical intervention at this time. Intra-operatively, good progress was made in reducing the size of the stone, however due to the stone’s composition complete fragmentation could not be achieved. There is a current plan to bring the patient back for a further attempt and complete fragmentation. Whilst this approach has been described in the literature and is likely to become more common in practice, it is a newly emerging approach for the trust and presents some important considerations for future practice. This case demonstrates the value of transferable skills and multi-specialty approaches to the management of surgical pathologies which fail standard treatment strategies. It also highlights the power of innovation in surgery to continue to find new ways to treat common and important pathologies.

Hybrid Epicardial Ventricular Ablation for Arrhythmogenic Right Ventricular Cardiomyopathy

Arrhythmogenic right ventricular cardiomyopathy (ARVC) causes progressive fibro-fatty infiltration of the right ventricle (RV) and is associated with ventricular arrhythmias (VA). The disease progresses from the subepicardium to subendocardium; thus. epicardial ablation improves outcome in patients with recurrent VA. When percutaneous epicardial ablation is unsuccessful, a surgical approach may be required. Limited data are available for minimally invasive hybrid surgical-catheter techniques. Case: A 28-year-old man with ARVC presented with recurrent VA refractory to medical therapy following COVID-19 infection and underwent endocardial ablation with attempted epicardial ablation. He had nine or more different inducible VA morphologies at this study. Epicardial access was unsuccessful due to adhesions. Minimally invasive surgical access for epicardial ablation was scheduled as a multidisciplinary procedure in the electrophysiology suite. A left thoracoscopic approach provided intrapericardial access. Surgical ports were used to facilitate catheter placement and mapping. Relevant clinical arrhythmias were targeted, and substrate modification was performed. The patient was discharged the following morning. No subjective symptoms or implanted-device defibrillation has been required post procedure. Combined surgical and catheter-based approaches for ARVC ablation are safe and feasible. Multidisciplinary team collaboration is key for case planning and success.

Update on imaging in Code Stroke

“Code Stroke” is a multidisciplinary procedure designed to detect acute ischemic strokes and transfer patients for early reperfusion.Selecting these patients requires multimodal imaging with either CT or MRI. 1) Conventional studies without contrast material are obligatory to detect bleeding. Applying the ASPECTS scale, these studies can also identify and quantify areas of early infarction. 2) In candidates for mechanical thrombectomy, angiographic studies are necessary to identify stenoses and obstructions and to evaluate the collateral circulation. 3) Patients with known onset between 6 and 24h or with unknown onset require perfusion studies to distinguish between infracted tissue and recoverable ischemic tissue.Semi-automatic software facilitates diagnosis, but radiologists must interpret its output.

Ocular Brachytherapy (Interventional Radiotherapy): Preserving the Vision

Uveal melanoma represents the most common intraocular neoplasia among adults. Brachytherapy (interventional radiotherapy; IRT) has a great advantage, when compared with enucleation, both in terms of organ and function sparing. The Collaborative Ocular Melanoma Study introduced into clinical practice a standardised procedure that allowed the equivalence of IRT with enucleation in terms of overall survival to be demonstrated. IRT is carried out by placing a plaque in direct contact with the sclera under the uveal melanoma. Several radioactive sources may be used, including 106-ruthenium, 125-iodine, 103-palladium and 90-strontium. It is a multidisciplinary procedure requiring the collaboration of interventional radiation oncologists and ophthalmologists in the operating theatre and medical physicists for an accurate treatment time calculation. It also relies on ultrasound imaging to identify the lesion and verifiy the correct plaque placement. An emerging tool of paramount importance could be the use of artificial intelligence and predictive models to identify those patients at higher risk of developing late side-effects and therefore who may deserve preventive and supportive therapies.

수학 예비교사가 국어, 과학, 윤리 예비교사와 함께 설계한 융복합 수업의 특징 탐색

This study was conducted with the purpose of analyzing the cases of convergence classes of pre-service teachers and providing information for conducting convergence classes in the secondary school. Mathematics pre-service teachers participated in a 4-week convergence class design and demonstration program with teachers of Korean language, Science, and Ethics to develop 51 convergence class cases, and I analyzed the characteristics of convergence classes in terms of class purpose, motivation context, convergence procedure, and student agency. The characteristics of each dimension were different depending on the subject integrated with mathematics. For example, convergence classes with the Korean language use a lot of statistics, and interdisciplinary procedures, and student-led classes are designed, and convergence classes with Science utilize a variety of mathematical knowledge, but multidisciplinary procedures are used and teacher-led classes are designed. Based on these results, the role of mathematics according to the purpose of the convergence class was presented, context, procedure, and student agency should be considered in designing convergence classes, considerations for convergence with Korean language, Science, and Ethics, and implications for convergence education and pre-service teacher education.

Actualización del código ictus en urgencias

“Code Stroke” is a multidisciplinary procedure designed to detect acute ischemic strokes and transfer patients for early reperfusion. Selecting these patients requires multimodal imaging with either CT or MRI. 1) Conventional studies without contrast material are obligatory to detect bleeding. Applying the ASPECTS scale, these studies can also identify and quantify areas of early infarction. 2) In candidates for mechanical thrombectomy, angiographic studies are necessary to identify stenoses and obstructions and to evaluate the collateral circulation. 3) Patients with known onset between 6 and 24hours or with unknown onset require perfusion studies to distinguish between infracted tissue and recoverable ischemic tissue. Semi-automatic software facilitates diagnosis, but radiologists must interpret its output.

498. MINIMALLY INVASIVE ESOPHAGECTOMY FOR PATIENTS WITH ESOPHAGEAL CANCER AND A HISTORY OF LIVER TRANSPLANTATION: A LITERATURE REVIEW AND CASE SERIES

Abstract The survival after liver transplantation is continually improving. With evidence of an increased risk of de-novo malignancies after liver transplantation, it is urgent to improve the treatment of an esophageal cancer in patients with a history of liver transplantation. With this study we wanted to show a case series of totally minimally invasive Esophagectomy for patients with a history of liver transplantation, as well as an literature review. We performed a systematic literature review according to the PRISMA guidance to identify the documented cases of an operative procedure in patients with a history of liver transplantation. Baseline characteristics, tumor stages as well as operative and postoperative management is compared with the case series of 2 cases operated minimally invasive in our center. Seven studies were identified, with a total of 15 patients who underwent esophagectomy after liver transplantation. In 67% of the cases, including our two patients, alcohol associated liver cirrhosis was the indication for the liver transplantation. All reported cases proceed an open surgical approach for the Esophagectomy, except for 1 case with an open abdominal approach and a thoracoscopic chest procedure. The two cases in our center underwent a totally minimally invasive esophagectomy. The mean length of stay in the hospital was 21.5 days, compared to 8 and 14 days in our presented cases. The importance of an optimal treatment of esophageal cancer after liver transplantation is evident. With this case series we showed that it is technically feasible to proceed a total minimally invasive Esophagectomy for patients with a history of liver transplantation in a curative intention. For a successful and radical treatment of malignancies after liver transplantation a multidisciplinary procedure is necessary.

Vascular injury during cholecystectomy: A multicenter critical analysis behind the drama

BackgroundThe management of a vascular injury during cholecystectomy is still very complicated, especially in centers not specialized in complex hepatobiliary surgery. MethodsThis was a multi-institutional retrospective study in patients with vascular injuries during cholecystectomy from 18 centers in 4 countries. The aim of the study was to analyze the management of vascular injuries focusing on referral, time to perform the repair, and different treatments options outcomes. ResultsA total of 104 patients were included. Twenty-nine patients underwent vascular repair (27.9%), 13 (12.5%) liver resection, and 1 liver transplant as a first treatment. Eighty-four (80.4%) vascular and biliary injuries occurred in nonspecialized centers and 45 (53.6%) were immediately transferred. Intraoperative diagnosed injuries were rare in referred patients (18% vs 84%, P = .001). The patients managed at the hospital where the injury occurred had a higher number of reoperations (64% vs 20%, P ˂ .001). The need for vascular reconstruction was associated with higher mortality (P = .04). Two of the 4 patients transplanted died. ConclusionVascular lesions during cholecystectomy are a potentially life-threatening complication. Management of referral to specialized centers to perform multiple complex multidisciplinary procedures should be mandatory. Late vascular repair has not shown to be associated with worse results.

Using Spatial Context and Demographic Analysis to Assess Surface Permeability in Philadelphia

Surface permeability significantly impacts the urban environment. Specifically, impermeable surfaces result in runoff, which in turn causes flooding and pollution. Left unchecked, impermeable surfaces can lead to hazardous conditions for unlucky city residents. These concerns are prominent in Philadelphia, and in response the municipal government has launched an ambitious plan to increase permeability by installing green infrastructure. This paper explores how spatial and demographic research can be combined to provide a holistic assessment of surface permeability across one of America’s largest cities. First, 2020 satellite imagery, provided by the USGS, was used to classify permeable and impermeable surfaces over the entire city. Next, demographic data from the 2014-2018 American Community Survey – household income, rent, and home value, all by census block group – were individually merged with the surface permeability classification to generate three overlays (e.g., surface permeability correlated with household income). Upon quantitative and qualitative examination of these overlays, it was found that impermeable surfaces are unevenly distributed and inequitably concentrated in Philadelphia’s less-affluent communities. Overall, the methodology used in this research demonstrates a multi-disciplinary and reproducible procedure for joint environmental-demographic research. Additionally, the conclusions reached offer location-specific insights that can help inform Philadelphia’s future green infrastructure investments and runoff mitigation strategies.

A rectal duplication cyst with rectovaginal fistula: A case report

Alimentary tract duplications (ATD's) are rare congenital anatomical abnormalities. They have an incidence of 1 in 4500 live births and can occur anywhere throughout the digestive tract from the oropharynx to the anus. ATD's occurs most commonly in the midgut (56%), less commonly in the foregut (33%) and even more rare in the hind gut (11%). Rectal duplications are the least common among other alimentary tract duplications, forming only 4% of them. Typically, they are cystic masses, slightly more common in males and they can present in the newborns period or any time later in childhood and even adulthood. We describe a case of an adolescent female presenting with long standing constipation since birth associated with painful defecation and offensive stool odor, abdominal pain and distention. She recently noticed stool in the vagina at the time of defecation. Patient was admitted to our medical center for further investigations and underwent colonoscopy. The study showed two pouches in the rectum, one with blind end and ulcer with suspected fistula opening, and the other lumen continues to the cecum. Abdomen and pelvic CT with rectal contrast was also done, showing a huge recto-sigmoid duplication cyst compressing the native rectum. Evidence of contrast in the vagina was also seen. Decision for surgery was then made. The procedure commenced laparoscopically, showing a huge duplication cyst starting at the distal part of sigmoid and extending downward distally to the rectum. Severe adhesions and edema was also encountered (frozen pelvis) which forced us to convert to open surgery. It was not possible therefore, to perform complete excision of the cyst without risking to damage the rectum and surrounding structures, which will increase the morbidity significantly in our case. Moreover, the fistula was not seen from this approach, as it was very low. We eventually performed a near total cystectomy with the sigmoid attached to it, joined the common wall of the remaining of the cyst and the native rectosigmoid using endo-GIA staplers. We decided to exteriorize the proximal colon as end colostomy. Subsequently, the fistula was taken down trans -vaginally by the gynecology team as a second procedure . A third procedure was performed 6 months later, a laparotomy was performed, the colostomy was taken down and primary anastomosis was performed. No immediate postoperative complications were seen and the patient was discharged in good general condition. This is a unique case as it is a case of a huge rectosigmoidal duplication cyst that was discovered in a female at an adolescent age, causing severe adhesions and chronic inflammations in the pelvis which led to a rectovaginal fistula and made complete resection impossible without converting the surgery into a major surgery with risk of morbidity and long term sequela. As the condition is considered benign, the medical literature is usually against performing a major surgery that can be harmful to the patient like a very low anterior resection to excise the duplication cyst as it is acceptable to perform partial excision with unification the two lumens together which was performed in our case. This case is an example of multistage and multidisciplinary procedure to treat a rare duplication cyst anomaly.

Hydraulic Safety Evaluation and Dynamic Investigations of Baghetto Bridge in Italy

The present study deals with the structural safety evaluation of a 50-year-old river bridge, called Baghetto Bridge, located in north Italy on the Adda River. Generally speaking, hydraulic processes are the main cause of bridge failure. Scour and hydrodynamic loads have been largely studied by the hydraulic engineering community; however, in practice, integration with structural analysis is often missing. The aim of this research is to provide a multidisciplinary procedure based on hydraulic and dynamic investigations devoted to the structural verification and monitoring of river bridges with traditional mechanical bearings. The deck–river interaction is addressed, studying the influence of debris accumulation on the bridge and performing structural verification of the bearing supports. The actions exerted on the bridge deck by the river current were estimated following the recommendations of the Italian code and making some further assumptions. In addition, dynamic investigations and FE modelling were performed. The results show (1) a relatively fast procedure that can be applied by practitioners to perform structural verification of river bridges with traditional mechanical bearings, and (2) an investigation method to evaluate temperature–frequency correlation as a reference for future inspections.

Sourcing of chalkstone used in medieval buildings in the Eastern Duchy of Normandy (10th−14th centuries) through geological and geochemistry analyses

AbstractThe provenance of medieval building stones links historic constructions with their quarrying areas, thereby revealing medieval trade routes and the spatial organization of past societies. In northern France, the Duchy of Normandy played a significant role in the medieval history of Europe, situated at the centre of the disputes between the English and French kingdoms. However, the historical documentation from this period is scarce, particularly in terms of the quarrying industry. Our study aims to define the quarrying areas and their diffusion zones and map the territorial organization of Eastern Normandy during the 10th–14th centuries. A multidisciplinary procedure using archaeological, geological and geochemical techniques was designed to establish the provenance of Normandy Chalkstone. First, we obtained a representative assembly of building stones by the selection and strategic sampling of 22 buildings. Second, we determined areas of chalk bedrock from a geological map rendered through GIS and sampled chalkstones from natural outcrops and quarries. In total, 118 samples from buildings, quarries and natural outcrops were characterized via optical microscopy and geochemical analyses for major, minor and trace elements (XRF, ICP‐MS and ICP‐OES), as well as for 87Sr/86Sr isotope ratios (MC‐ICP‐MS). The application in situ of pXRF analysis allows for the identification of Normandy Chalkstone sources preserved in archaeological sites. The results indicate that all chalkstones came from five local varieties of Normandy Chalkstone and one of Shelly Limestone imported from nearby regions. The suitability of chalkstone as construction material was evaluated in situ using a sclerometer, which revealed that the singular and local geological features of the chalkstone make it suitable for walling. Our study demonstrates the development of a prominent and relatively continued quarrying industry over the 10th to 14th centuries in Eastern Normandy. The main quarrying areas were constituted of three chalkstone diffusion zones that run coevally with smaller and apparently sporadic quarries. The chalkstone diffusion was strongly related to the occurrence of singular and local geological resources and the stone transport system, which favoured the use of effective fluvial and maritime navigation for transport over 50 km from the quarrying areas.

Post-trauma complex orthodontic approach: the impact of psychological issues of bullying on treatment decision.

ABSTRACTObjective: This article aims to discuss the multidisciplinary approach required in the treatment of cases of impaction and ankylosis of permanent teeth, associated with a history of trauma, considering the psychological state of the child and family when faced with a traumatic case of bullying, by reporting the complex treatment of a central incisor needing to be orthodontically moved across the midline. Conclusion: This clinical case was a major challenge, which included complex multidisciplinary procedures. Results and stability after 26 months of retention indicated successful orthodontic space closure of two maxillary teeth, without the use of implants or prostheses, in an adolescent patient who had a history of dental trauma, alveolar bone loss, and an uncertain initial prognosis.

Sestrinske intervencije kod bolesnika nakon biopsije pluća

Introduction: Lung biopsy is a relatively frequent multidisciplinary procedure that is accompanied by a certain percentage of morbidity and mortality. The incidence of complications in a performed lung biopsy depends ona number of factors. In order to prevent and diagnose complications after the biopsy, it is necessary for a patient to be continuously monitored by a nurse. Objective: To consider the importance of nursing interventions in patients after lung biopsy. Respondents and method: The study involved 50 patients, hospitalized at the pulmonology department of the clinic for pulmonology of the Military Medical Academy in Belgrade, who underwent a lung biopsy. A specially created questionnaire for patients consisting of 15 questions was used as an instrument. Results: The largest percentage of surveyed patients is men, aged 50 to 69, who have finished high school and live in the countryside. One-fifth of the subjects had a chest drain inserted after a lung biopsy. The obtained results indicate that in the field of health care, after the lung biopsy, the most important thing is to monitor vital functions, place patients in a certain position and monitor the symptoms and signs of possible complications. Conclusion: Based on the conducted research, we came to the conclusion that nursing interventions in the patient after lung biopsy are of great importance. Adequate patient care results in quicker recovery of the patients and fewer complications.

One-step diagnosis strategy together with multidisciplinary telematics referral perform an effective approach for identifying and treating patients with active Hepatitis C infection

Introduction and objectivesImplementation of a one-step strategy for diagnosis of active Hepatitis C virus (HCV) infection would encourage the early diagnosis and reduce the time to access antiviral treatments. The aim of this study was to evaluate the impact of a HCV one-step diagnosis compared to the traditional two-step protocol in terms of the time required for patients to be seen by specialists and the time taken to start antiviral treatment. Material and methodsA comparative study was carried out to assess two diagnostic algorithms (one-step and two-step) for active HCV infection. Serological markers were quantified using the same serum sample to determine both anti-HCV antibodies (HCV-Ab) and HCV core antigen (HCV-cAg) by Architect i2000 SR kit. In this period, a multidisciplinary procedure was started for telematics referral of viremic patients. ResultsOne-step approach reduced the time required for patient HCV diagnosis, referral to a specialist, access to treatment, and eliminated the loss of patients to follow-up. Significant differences were observed between one-step and two-step diagnosis methods in the time required for patients to be seen by a specialist (18 days [Interquartile range (IQR) = 14–42] versus 107 days [IQR = 62–148]) and for the initiation of treatment (54 days [IQR = 43–75] versus 200 days [IQR = 116–388]), mainly for patients with advanced fibrosis (35 days [IQR = 116–388] versus 126 days [IQR = 152–366]). ConclusionsUse of HCV-cAg has proven to be a useful tool for screening patients with active hepatitis C. The development of a multidisciplinary protocol for the communication of results improved the efficiency of the care process.

Application of Spatial Multi-Criteria Analysis (SMCA) to assess rockfall hazard and plan mitigation strategies along long infrastructures

Long infrastructures often cross areas with a high probability of landslides, causing eventually serious problems to the serviceability and compromising safety. The identification and prediction of hazardous zones are difficult, especially for what concerning rockfalls, as they can occur quickly and suddenly. In order to assess rockfall hazard, detailed data such as slope geometry, geotechnical and geomechanical properties of materials, drainage system pattern, etc. are needed. Even though thematic datasets are available and easily downloadable for the majority of the Italian territory, their scale is not adequate and ad-hoc input data must be gathered. An original multi-disciplinary procedure (GEO4) has been developed by the authors based on a mobile mapping system (ARCHITA) integrated with Airborne Lidar and ILI (In-Line Inspections), geomatics, geological models, geotechnical-geomechanical characterization and geomorphometric approach. A Spatial Multi-Criteria Analysis (SMCA) is then used to create a composed and spatially distributed index of landslide hazard based on normalized values of triggering factors. Such index is used to identify and classify the morphological unstable element along the infrastructure, supporting decision-makers in defining the most appropriate mitigation measures and planning their implementation in a clearer, more repeatable and more objective orientated-way. The presented method has been successfully applied so far to hundreds of km of railway lines in Italy.

Feasibility and outcomes of cytoreductive surgery and HIPEC for peritoneal surface malignancies in low- and middle-income countries: a single-center experience of 232 cases

BackgroundCytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has recently emerged as a viable management option for peritoneal surface malignancy (PSM). CRS and HIPEC is a complex, multidisciplinary and resource-intensive surgical procedure. It has a steep learning curve and is associated with significant morbidity and mortality. The expertise is mostly limited to few dedicated high-volume centers located in developed countries. We present a single institutional experience of 232 cases of CRS and HIPEC performed at a tertiary care cancer center in a low- and middle-income country (LMIC).MethodsA multidisciplinary PSM program was initiated in 2015 at a high-volume public-sector tertiary care cancer center in North India catering largely to patients belonging to low- and middle-income groups. Perioperative protocols were developed, and a prospective structured database was created to capture data. All patients undergoing CRS and HIPEC between January 2015 and December 2020 were identified, and the data was retrospectively analyzed for clinical spectrum, surgical details, and perioperative morbidity and mortality.ResultsTwo hundred and thirty-two patients underwent CRS and HIPEC during the study period. Epithelial ovarian carcinoma (56.5%) was the most common malignancy treated, followed by pseudomyxoma peritonei (18.5%), colorectal carcinoma (13.4%), and malignant mesothelioma (5.6%). Optimal CRS could be achieved in 94.4% of patients. Cisplatin and mitomycin were the most common drugs used for HIPEC. A total of 28.0% of patients had morbidity including deep vein thrombosis, subacute intestinal obstruction, sepsis, burst abdomen, lymphocele, urinoma, acute renal failure, and enterocutaneous fistula. The overall treatment-related mortality was 3.5%.ConclusionsResults of the current study indicate that it is feasible to establish a successful CRS and HIPEC program for PSM in government-funded hospitals in LMIC facing resource constraints. The most common indication for CRS and HIPEC were carcinoma of the ovary followed by pseudomyxoma peritonei and colorectal carcinoma. Overall morbidity and mortality in the current series are comparable to global standards, reported from high-income countries. A protocol-based multidisciplinary team approach, optimal patient selection, and surgical expertise can help achieve optimal outcomes in government-funded hospitals in LMIC.

Continuous Deep Sedation Until Death: First National Survey in France after the 2016 Law Promulgating It

ContextThe French parliament passed a groundbreaking law in 2016, opening a right for patients to access continuous and deep sedation until death (CDS) at the end of life, under conditions. Parliamentarians’ goal was to consolidate patients’ rights whilst avoiding legislating on medical aid in dying. ObjectivesTo conduct a first national retrospective survey on CDS to evaluate the number of CDS requested, proposed and performed in 2017 and to elicit qualitative data from physicians on the practice and on the terms used by patients to refer to CDS. MethodsEarly 2018, an online survey was sent to all French hospitals, nursing homes, hospital at homes services and general practitioners (GPs). Descriptive statistics and qualitative inductive content analysis were used to analyze the data and comments of respondents. ResultsThe qualitative data show that respondents generally approve the law on CDS as it sets a legal framework; nonetheless, there is a persistent controversy about CDS vs. euthanasia for some physicians in all settings. GPs reported limited access to midazolam and the difficulty in organizing multidisciplinary procedures as major constraints. In hospital settings in particular, differentiating CDS from other sedation practices is uneasy. All physicians reported patients use multiple elements of language to request CDS. ConclusionAfter the law was passed in France, CDS were requested, proposed and performed in all medical settings, in nursing homes, at home. The qualitative data presented here show the relevance of exploring physicians’ reflexive stances on this practice in different settings and within the context of a patient-physician relationship marked by a new patient's right. The study highlights the wide range of elements of language used by patients at the end of life, as understood by respondent physicians to mean a request for CDS and underscores the polymorphous meaning of CDS.

Comparison of Coated and Immobilized Chiral Stationary Phases Based on Amylose tris-[(S)-α-Methylbenzylcarbamate] for the HPLC Enantiomer Separation of α-Lipoic Acid and Its Reduced Form.

The couple of chiral sulfur compounds α-lipoic acid (ALA)/α-dihydrolipoic acid (DHALA) has attracted considerable attention in recent years owing to its remarkable anti-inflammatory and antioxidant properties. It is well known that the chirality of the C6 plays a key role in determining the biological activity of ALA. The natural occurring (R)-ALA enantiomer is an essential cofactor for key oxidative metabolism enzyme complexes and, after oral administration of the racemic mixture, it shows higher plasma concentration than (S)-ALA. Differently, the in vivo enantioselective action difference between the enantiomers of DHALA has not yet been studied. This lacking is perhaps due to the unavailability of analytical methods capable of determining the enantiomeric composition of biological samples during pharmacokinetic and pharmacodynamic events. In the present work, the direct and baseline enantioresolution of both chiral acids by HPLC on two amylose-derived chiral stationary phases is presented. The proposed chiral enantioselective protocol, therefore, does not require pre- or on-column derivatization. The performance of the coated Chiralpak AS-H CSP and the new immobilized Chiralpak IH-3 CSP, which have the same chiral selector amylose tris-[(S)-α-methylbenzylcarbamate], were compared using conventional normal-phase mobile phases containing ethanol or 2-propanol as alcoholic solvents and a fixed percentage of trifluoroacetic acid. Nonconventional eluents containing dichloromethane, ethyl acetate, and 2-methyltetrahydrofuran as organic cosolvents were applied in the separation of the enantiomers of two carboxylic acids on the immobilized Chiralpak IH-3 CSP. The effect of the column temperature was carefully evaluated in order to improve enantioselectivity. Adequate amounts of enantiomers were isolated by an analytical-size Chiralpak IH-3 column and submitted to chiroptical measurements. The absolute configuration assignment of the isolated enantiomers was determined by a multidisciplinary procedure based on the comparison of the experimental and calculated chiroptical properties.