Protocol For Management Of Patients Research Articles

Consensus Recommendations for the Reconstitution and Aesthetic Use of Poly-D,L-Lactic Acid Microspheres.

Poly-D,L-lactic acid (PDLLA) microspheres, marketed globally as Aesthefill® (Regen Biotech, Seoul, South Korea), are recognized for their biocompatible and biostimulatory properties, positioning them as a preferred option in aesthetic medicine. This article presents consensus recommendations from Brazilian experts on the reconstitution and clinical application of PDLLA for facial and non-facial treatments. Developed using a modified Delphi method with contributions from leading dermatologists and plastic surgeons, the consensus outlines protocols for reconstitution, injection techniques, and patient management. Key recommendations include reconstitution with 7-8 mL of sterile water for injection, the addition of lidocaine to improve patient comfort, and a preference for targeting the superficial subcutaneous layer. Dosing guidelines are specifically tailored to each treatment area and the desired degree of correction, underscoring the importance of personalized treatment plans. Maintenance treatments are advised at biennial intervals or at shorter intervals for patients exhibiting accelerated collagen degradation. The consensus also highlights the need for proper training and patient screening to minimize adverse effects, such as nodules and granulomas. This comprehensive guide aims to standardize the use of PDLLA, prioritizing patient safety and optimizing outcomes. While clinical trials evaluating PDLLA's aesthetic indications remain limited, these evidence-based guidelines bridge the gap by offering practical protocols grounded in clinical expertise. Further research is encouraged to validate these recommendations and explore new applications for PDLLA in aesthetic medicine.

HPB SO52 - Ambulatory Management of Acute Pancreatitis (A-MAP) – Novel approach: A Pilot study

Abstract Background Acute pancreatitis (AP) is a very common problem, and its incidence is increasing over time. NICE guidelines, describes incidence of AP in UK is around 56 cases / 100000 population. Majority of AP cases are self-limiting, whereas only 15% of patients develop serious complications, with an overall mortality of 5%. Traditionally, Patients with AP managed as inpatients with much pressure on NHS resources. As we now have better understanding of AP, pain becomes the main concern in management of AP, as most of cases are self-limiting. The aim is to set a protocol for outpatient management of patients with mild AP. Method All patient diagnosed with mild acute pancreatitis according to revised Atlanta criteria (2012), aged 18 – 85, living within 1 hour from the hospital, and being attended by a responsible adult at home are eligible to be included in the study. The management plan includes; pain control, antiemetic, PPIs, oral intake (fluids & low fat diet). A phone call next day of presentation. Patient review on the second day and tenth day following the presentation. All patient provided with Information leaflet with all warning symptoms and contact details in case of worsening symptoms. Results Over the period between March 2023 and April 2024, 18 patients (8 Males) with median age 47.5 (IQR 19) included in this prospective study. Ten patients have gallstones/biliary sludge, seven patients known to have alcoholic pancreatitis, & one patient where no cause could identified. All patients managed as outpatients as the protocol, except one female patient who lost follow up on day 2, as she reported no symptoms. Out of the 10 patients who have gallstones/ sludge; six patients had laparoscopic cholecystectomy and one patient had laparoscopic cholecystectomy with bile duct exploration within two weeks from their index presentation (70%). Conclusion This pilot study shows the feasibility of this novel approach of ambulatory management of patients presented with mild acute pancreatitis, with compliance to NICE guidelines by offering patients laparoscopic cholecystectomy within two weeks from presentation in cases of biliary pancreatitis. There is a need for a wider study possibly multicentre with the option of subgroup analysis by the cause of pancreatitis, frequency of presentation, and presence of element of chronic pancreatitis.

Laboratory analysis of 124 chronic lymphocytic leukemia cases: Single center study

Abstract BACKGROUND: Chronic lymphocytic leukemia (CLL) is a disease characterized by an uncontrolled proliferation of malfunctioning mature B-lymphocytes. It represents a variable range of clinical presentation and prognoses. Understanding the demographic and cellular characteristics of CLL patients can aid in better disease management and treatment outcomes. OBJECTIVES: To identifying hematological parameters and patterns and potential markers that could assist in better diagnosis and of CLL in the local population. PATIENTS, MATERIALS AND METHODS: A retrospective analysis of 124 cases of newly diagnosed CLL was conducted. Data were collected from reports over 2 years (April 2022-April2024), including demographics, Hb levels, WBC counts, platelet counts and expression of CD markers (5, 19, 20, 23, 200, FMC7, LAIR1 and others) using flow cytometry on peripheral blood specimens. Based on FC findings, patients were categorized into two groups for better assessment; definite diagnosis CLL and possible diagnosis CLL; then further subdivided into poor prognosis CLL and good prognosis CLL. RESULTS: Male patients represented 59.5% of cases and females were 40.5% with a median age of 61 years at diagnosis. The mean Hb level was 109 ± 2 g/L, the mean WBC count was 58.0 ± 25.0 × 109/L, and the mean platelet count was 190 ± 40 × 109/L. CD5 was positive in 97.6% of cases, with CD23 in 96%. CONCLUSION: This study provides an overview of the demographic and cellular marker characteristics of CLL patients in FC unit. The findings underscore the heterogeneity of CLL immunophenotype and the importance of detailed characterization in improving patient management protocols; however, further research is warranted to correlate these findings with other parameters of disease burden and prognosis to optimize the therapeutic approaches for CLL patients.

Retrospective Assessment of Post-Transurethral Resection of the Prostate Complications in Benign Prostatic Hyperplasia Patients: Impact of Acute Urinary Retention.

Background Benign prostatic hyperplasia (BPH) is the most common urological condition affecting older men, leading to lower urinary tract symptoms (LUTS) and complications such as acute urinary retention (AUR), which can significantly impact quality of life. This study aims at comparing the postoperative outcomes and complication rates of monopolar transurethral resection of the prostate (TURP) in BPH patients with and without AUR. By examining the differences in postoperative outcomes, the study seeks to highlight the impact of AUR on complications such as UTIs, prolonged catheterization, and extended hospital stays, and assess the potential clinical implications for improving treatment strategies in these patients. Methodology An observational retrospective study was conducted at a tertiary care hospital in central India, over a period of two years. The study included 150 men aged 45 to 70 years with LUTS due to BPH, and participants were equally divided between two groups: Group A (AUR positive) and Group B (AUR negative). Wide-ranging assessments were performed on all patients, including history, physical examination, digital rectal examination, ultrasound, and post-void residual (PVR) urine assessment. Postoperative outcomes and complications were determined, and statistical analyses were conducted using Student's t-test with a level of significance of p < 0.05. Results The findings of the study indicated that patients in Group A, who experienced AUR, had significantly higher postoperative complications compared to Group B, who did not have AUR. Specifically, the mean complication rate was 60% in Group A compared to 30% in Group B. Common complications included urinary tract infections and prolonged hospital stays. In terms of urodynamic parameters, Group A exhibited a significantly lower maximum flow rate (Qmax) at 7.5 mL/s compared to 9.8 mL/s in Group B (p < 0.01). The average PVRvolume was also notably higher in Group A at 150.4 mL, compared to 90.2 mL in Group B (p < 0.01). These differences highlight the impact of AUR on surgical outcomes. Conclusion The findings of this study highlight the increased risks of complications associated with AUR in patients undergoing monopolar TURP. These results underscore the need for careful patient selection and management strategies to optimize outcomes. Future research should focus on expanding the sample size and incorporating multicenter data to enhance the generalizability of the results. Additionally, further investigation into long-term outcomes and the effectiveness of different management protocols for patients with AUR will be essential for improving the quality of care in the management of BPH.

A personalized approach to the treatment of chronic tension-type headache: quality of life of patients

Objective: to evaluate the quality of life in a personalized approach to the treatment of chronic tension-type headache (CTTH) in comparison with a standard treatment protocol.Material and methods. The study involved 61 patients with CTTH. Patients were randomly divided into two groups. The first (main) group consisted of patients (n=30) who received a personalized approach with a psychotherapist contributing to the treatment. The comparison group consisted of patients (n=31) who were treated according to a standard protocol with counselling and observation by a neurologist. Pain intensity was assessed using the visual analogue pain scale (VAS). The SF-36 questionnaire was used to assess quality of life. Differences between the groups were analyzed by assessing individual changes in eight different domains of the SF-36 questionnaire for each patient.Results. In the main group, parameters characterizing the physical (pain intensity) and emotional experience of the pain (mental health, social functioning, life activity; p&lt;0.05) decreased after 6 months of treatment when a personalized approach to the treatment of CTTH was applied, compared to the control group (with a standard patient management protocol).Conclusion. The personalized approach showed an improvement of the quality of life of patients with CTTH compared with the standard protocol, allowing us to recommend it for a wider application in clinical practice.

Reintroduction of excluded food triggers as a crucial step in managing patients with food allergies

Introduction. Despite active research into the mechanisms of food allergies (FA), the main approach to managing patients with this condition remains the complete exclusion of causative allergens from the diet for a certain period. At the same time, the question of timely reintroduction of excluded food triggers into the diet is frequently raised, which is important both for maintaining oral tolerance and reducing the negative effects of long-term elimination diets, such as nutritional and eating behavior disorders, as well as financial burdens on families. However, clear recommendations on the reintroduction of previously excluded foods have not existed until recently. Regarding cow’s milk protein allergy (CMPA), such recommendations were provided in 2023 in the consensus document of the World Allergy Organization (WAO) — DRACMA.Aim. The aim of this review is to present current approaches to the reintroduction of food allergens into the diets of patients with food allergies and to evaluate various reintroduction protocols, including those used for cow’s milk protein allergy (CMPA).Material and methods. This review provides a concise summary of current approaches to reintroducing food allergens into the diet, covering both IgE-mediated and non-IgE-mediated forms of food allergy. The advantages of different patient management protocols are discussed, with special attention given to CMPA as one of the most common manifestations of FA in children.Results. An analysis of modern approaches has demonstrated that modern recommendations regarding the reintroduction of allergens, including those presented in the document of the World Allergological Organization — DRACMA for allergy to cow’s milk proteins, allow for a more personalized and safe approach to the reintroduction of allergens, which helps reduce risks and maintain food tolerance.Conclusions. The introduction of new guidelines for the reintroduction of food allergens is an important step in managing patients with food allergies. These recommendations provide a more personalized approach to treating food-allergic patients, including those with cow’s milk protein allergy, reducing the risks associated with reintroducing allergens into the diet. They also help to mitigate the negative effects of elimination diets and maintain oral tolerance in patients, which is particularly important for children with FA.

Best Patient Care Practices for Administering PSMA-Targeted Radiopharmaceutical Therapy.

Optimal patient management protocols for metastatic castration-resistant prostate cancer (mCRPC) are poorly defined and even further complexified with new therapy approvals, such as radiopharmaceuticals. The prostate-specific membrane antigen (PSMA)-targeted agent 177Lu vipivotide tetraxetan ([177Lu]Lu-PSMA-617), approved after the phase III VISION study, presents physicians with additional aspects of patient management, including specific adverse event (AE) monitoring and management, as well as radiation safety. Drawing on our experience as VISION study investigators, here we provide guidance on best practices for delivering PSMA-targeted radiopharmaceutical therapy (RPT) to patients with mCRPC. After a comprehensive review of published evidence and guidelines on RPT management in prostate cancer, we identified educational gaps in managing the radiation safety and AEs associated with [177Lu]Lu-PSMA-617. Our results showed that providing sufficient education on AEs (e.g., fatigue and dry mouth) and radiation safety principles is key to effective delivery and management of patient expectations. Patient counseling by health care professionals, across disciplines, is a cornerstone of optimal patient management during PSMA-targeted RPT. Multidisciplinary collaboration is crucial, and physicians must adhere to radiation safety protocols and counsel patients on radiation safety considerations. Treatment with [177Lu]Lu-PSMA-617 is generally well tolerated; however, additional interventions may be required, such as dosing modification, medications, or transfusions. Urinary incontinence can be challenging in the context of radiation safety. Multidisciplinary collaboration between medical oncologists and nuclear medicine teams ensures that patients are monitored and managed safely and efficiently. In clinical practice, the benefit-to-risk ratio should always be evaluated on a case-by-case basis.

A-152 Enhancing PNH Diagnosis with Multicolor Flow Cytometry Immunophenotyping Protocol in a Medical Center in Taiwan

Abstract Background Paroxysmal Nocturnal Hemoglobinuria (PNH) is a rare hematopoietic stem cell disorder resulting from mutations in the X-linked PIG-A gene, leading to an inability to produce GPI-anchored proteins on RBCs and WBCs. PNH presents in three variants: classic (hemolytic), associated with specified bone marrow disorders, and subclinical. Flow cytometric analysis stands as the gold standard for PNH detection, crucial in diagnosis, monitoring, and clinical management. Recognizing potential variations in PNH testing among labs, it is essential to establish a precise and consistent protocol for accurate diagnosis and patient management. This report aims to demonstrate the effectiveness of a PNH immunophenotyping protocol adhering to ICCS/ESCCA PNH consensus guidelines. Methods A total of 501 samples were analyzed from Jan 1st, 2021 to Dec 31st, 2023. All the acquisitions were accomplished by a 3-laser and 10-PMT Navios EX (Beckman Coulter) flow cytometry. A typical combination of anti-CD235a-FITC (clone KC16) and anti-CD59-PE (clone MEM43) antibodies were adopted to identify the PNH clone size in the RBC tube. To achieve higher sensitivities in PNH granulocyte and PNH monocyte detection, a single tube, 6-color mixture of FLAER, monoclonal antibodies including CD14-APC, CD24-PE, CD33-APC-H7, CD15-PacB, and CD45-KrO, to immunostaining simultaneously was developed. An unstained control was run after the full-stained tube to determine the position of threshold for positivity, and to exam the potential carryover into the test sample. Results RBC and granulocyte assays can detect PNH phenotypes at the 0.009% level or higher with more than 50,000 cells of gated cells acquired, while the monocyte assay can detect at &amp;gt;=0.069% with at least 20,000 cells acquired. Analysis was conducted on five hundred and one patients to investigate potential PNH clones in their blood cells. Among them, 45 patients were identified as having classic PNH, while PNH clones were not detected in 168 cases, constituting 33.5% of total cases. Minor PNH clone (&amp;lt;1.0%) in single cell lineage were observed in 144 cases, making up 28.7% of all cases. Minor PNH clones found in more than one cell lineages were found in 155 cases (30.9% of 501). Additionally, minor PNH clones were identified across RBCs, granulocytes, and monocytes, with percentages of 32.9%, 23.8%, and 43.9%, respectively of all patients. Notably, monocyte clones exceeded granulocyte clones in 23.0% of cases with WBC PNH clones, irrespective of clone sizes. Furthermore, we investigated seven patients exhibiting persistent minor PNH clones in 2 to 3 cell lineages. Among them, five had aplastic anemia or myelodysplastic syndromes, while one underwent evaluation for young stroke and one was investigated for venous thromboembolism. Conclusions Flow cytometry labs aim not only to identify classic PNH patients but also to consistently detect minor or small clones in individuals with bone marrow disorders or subclinical conditions. Our findings are compatible with international reports, underscoring the importance of routinely examining patients with minor clones. Such assays serve as essential tools for ongoing monitoring, facilitating PNH diagnosis and management by physicians.

Role of empirical antitubercular therapy for chronic mastitis—A prospective study

Objectives Chronic mastitis (CM) is an uncommon inflammatory condition of the breast, clinically mimicking malignancy with variable etiological factors. It often recurs, causing cosmetic disfigurement and hampering the quality of life of affected females. Limited literature reveals underlying bacterial infection as causative agents in a few cases, while the majority belong to idiopathic entities. CM can be seen as two histological types—chronic granulomatous mastitis (CGM) and chronic nonspecific inflammatory infiltrates (NGM). Etiological and ethnic variations exist globally, and there is lack of information from India. Understanding this entity is important for undertaking etiology-based therapy and preventing unnecessary mismanagement. Materials and Methods We evaluated the demographic, imaging profile and management protocol of CM patients presenting to a tertiary care center in India. Clinically suspected CM patients were prospectively evaluated by mammography and ultrasound (USG). USG-guided biopsy was performed for histopathological and microbiological analysis and treatment was administered accordingly. Response assessment was conducted at six months through USG and clinical evaluation. Results Out of the 53 clinically suspected CM patients, 48 biopsy-proven CM patients were enrolled (five breast carcinoma cases were excluded). All 48 patients were females, with a mean age of 36 ± 9 years. The most common symptom was a unilateral painful lump with skin discoloration. The etiology was idiopathic in 58.3% of cases, tuberculosis in 29%, and bacterial in 4%. Mammography revealed focal asymmetry, architectural distortion, and trabecular thickening. USG showed tracking fluid collections, microlobulated hypoechoic masses, and skin thickening. Etiology-based treatment was administered, and all patients showed 90–100% resolution between four and six months. Conclusion Mammography and USG are important for raising the suspicion while histopathology and microbiological analysis are mandatory for accurate treatment of CM. In India, idiopathic and tubercular etiology of CM is encountered and patients respond well to therapy.

Formulation of the Best Practice Evidence-Based Nutrition Management Protocol for Nasopharyngeal Carcinoma Patients Undergoing Chemoradiotherapy

To formulate a nutrition management protocol and processes for nasopharyngeal carcinoma patients undergoing chemoradiotherapy. A nutrition management protocol and the process for nasopharyngeal carcinoma patients undergoing chemoradiotherapy were formulated on the basis of literature review and the Delphi expert consensus method. Literature analysis and two rounds of Delphi expert consultations via correspondence were conducted. The final protocol subsequently derived included 7 first-level items and 36 second-level items. The first-level items included the establishment of a nutrition management team, nutritional risk screening and nutritional status assessment, health education, the timing and method of nutritional treatment, energy and nutrient supply, nutritional monitoring, and follow-up after discharge. After summarizing the best evidence for the nutritional management protocol and classifying the evidence by different grades, the construction process of the nutrition management team and the nutrition management processes for the pre-cancer treatment period, the tumor treatment period, and the post-discharge follow-up period were formulated. The nutritional management protocol and the relevant processes for nasopharyngeal carcinoma patients undergoing chemoradiotherapy formulated in this study demonstrate a certain level of scientific validity and reliability and can be further tested and applied in clinical practice.

Diagnostic Musculoskeletal Ultrasound for Medial Collateral Ligament Injuries: Applications in Rehabilitation.

Medial collateral ligament (MCL) injuries are prevalent in sports and other physical activities and constitute a significant cause of knee pain and dysfunction. Traditional diagnostic modalities such as magnetic resonance imaging (MRI) are often utilized for their detailed visualization capabilities. However, musculoskeletal ultrasound (MSK-US) has emerged as a pivotal diagnostic tool in the evaluation of MCL injuries due to its non-invasive nature, cost-effectiveness, and dynamic imaging capabilities. This article reviews the utility and advantages of MSK-US in diagnosing MCL injuries, with a specific focus on its implications for rehabilitation providers. We discuss the technical aspects of ultrasound (US) imaging, including the sonographic appearance of MCL injuries across various grades, and compare its diagnostic accuracy with other imaging modalities such as MRI. Additionally, the role of US in monitoring the healing process and guiding rehabilitation strategies is explored. This review emphasizes the practical application of MSK-US in clinical settings, offering rehabilitation providers a comprehensive understanding of how US can be integrated into patient management protocols to enhance outcomes in patients with MCL injuries.

Implementing Massive Parallel Sequencing into Biliary Samples Obtained through Endoscopic Retrograde Cholangiopancreatography for Diagnosing Malignant Bile Duct Strictures.

Despite advancements in radiologic, laboratory, and pathological evaluations, differentiating between benign and malignant bile duct strictures remains a diagnostic challenge. Recent developments in massive parallel sequencing (MPS) have introduced new opportunities for early cancer detection and management, but these techniques have not yet been rigorously applied to biliary samples. We prospectively evaluated the Oncomine Comprehensive Assay (OCA) and the Oncomine Pan-Cancer Cell-Free Assay (OPCCFA) using biliary brush cytology and bile fluid obtained via endoscopic retrograde cholangiopancreatography from patients with bile duct strictures. The diagnostic performance of MPS testing was assessed and compared to the pathological findings of biliary brush cytology and primary tissue. Mutations in TP53, BRAF, CTNNB1, SMAD4, and K-/N-RAS identified in biliary brush cytology samples were also detected in the corresponding bile fluid samples from patients with extrahepatic cholangiocarcinoma. These mutations were also identified in the bile fluid samples, but with variant allele frequencies lower than those in the corresponding biliary brush cytology samples. In control patients diagnosed with gallstones, neither the biliary brush cytology samples nor the bile fluid samples showed any pathogenic mutations classified as tier 1 or 2. Our study represents a prospective investigation into the role of MPS-based molecular testing in evaluating bile duct strictures. MPS-based molecular testing shows promise in identifying actionable genomic alterations, potentially enabling the stratification of patients for targeted chemotherapeutic treatments. Future research should focus on integrating OCA and OPCCFA testing, as well as similar MPS-based assays, into existing surveillance and management protocols for patients with bile duct strictures.

Impression fracture of the lateral condyle of tibial plateau complicated by acute peri-implant infection: a case report

Introduction. Deep infection after open osteosynthesis of tibial plateau fractures occurs in 9.9%. This rate is significantly higher than in surgical treatment of closed injuries of other localizations. Many authors consider it necessary to improve management protocols for patients with complex plateau fractures in order to minimize or prevent the development of infectious complications. Aims of the study: 1) to discuss the treatment tactics of a patient with an intraarticular fracture of the tibial plateau after osteosynthesis complicated by the development of early deep surgical site infection (SSI), using clinical case as an example; 2) to carry out the analysis of medical care defects. Case description. A 71-year-old patient with compromised somatic status underwent osteosynthesis with a buttress plate and allogeneic bone grafting of the metaphyseal defect on the 12th day after injury. In 7 days after the occurrence of signs of infection, a revision surgery was performed. Later, a number of consecutive revisions were performed due to recurrences of the infectious process. The complex of measures against SSI included the use of vacuum drainage systems and antibacterial spacers. As a result, the wounds had healed. Two years after the injury, the patient had a good functional result. Conclusion. The presented clinical case has shown that even if the treatment tactic for early peri-implant infection is chosen correctly, there are several defects in our routine practice. First of all, inaccurate sampling of material for bacteriological study and inadequate duration of antibacterial therapy are to be mentioned. To successfully treat infectious complications of osteosynthesis, a team of like-minded specialists including traumatologists as well as physicians, microbiologists and clinical pharmacologists is needed. Undoubtedly, surgical treatment of fractures might develop into infectious complications. Their diagnosis and treatment are often accompanied by a number of various mistakes. The most important points are early radical revision of the postoperative wound, etiotropic antibacterial therapy, maintaining stability of fixation after primary osteosynthesis. If these standards are complied with, the outcome of surgical treatment might be satisfying even with such a severe complication as peri-implant infection. At the same time, we are planning further researches aimed at improving algorithms and tactics for surgical treatment of infectious complications, reducing surgery trauma level and upgrading quality of primary osteosynthesis.

The heart of it: dental care and cardiothoracic surgery.

Both dental and cardiovascular disease are prevalent in the general population, have common risk factors and may be closely associated.Following cardiothoracic surgery, patients may be higher risk for developing infective endocarditis (IE) than the general population. Before cardiothoracic interventions, it is common practice for a dental assessment to be carried out and any necessary dental treatment provided. This aims to reduce the risk of IE arising from dental sources and avoid dental pain or infection during the peri- and post-operative period. There is little guidance on which treatments should be performed and when.Many patients with cardiac disease may have dental treatment provided safely in primary care. However, there is often a need to consider additional factors, including bleeding risk, condition stability or medication interactions. Dental teams must have an awareness of the implications of cardiac disease and provide reasonable adjustments to care provision where necessary, ensuring patient safety.This article proposes a protocol for dental management of patients awaiting cardiothoracic surgery and explores important considerations for dental care in this patient group.

Artificial intelligence-based quantification of COVID-19 pneumonia burden using chest CT

AbstractDuring the coronavirus disease 2019 (COVID-19) pandemic, artificial intelligence (AI) based software on chest computed tomography (CT) imaging has proven to have a valuable role in accelerating diagnosis and screening. The proposed AI-based tools proved to be rapid and reproducible techniques to guide patient management and treatment protocols. Although no specific guidelines exist, CT-imaging and clinical features are used for patient staging. To shed light on the role of AI techniques that have been developed in fighting COVID-19, in this review, studies investigating the usage of commonly used AI models on chest CT imaging for disease quantification and prognostication are collected.

Unraveling the Dual Role of Voriconazole as an Antifungal Agent and Precursor to Squamous Cell Carcinoma

Voriconazole, a potent triazole antifungal medication, is extensively used to treat serious fungal infections in immunocompromised patients. Despite its efficacy, recent findings suggest a potential link between long-term voriconazole therapy and the development of squamous cell carcinoma (SCC). This review examines the dual role of voriconazole, emphasizing both its therapeutic benefits and carcinogenic risks. The pharmacodynamics of voriconazole involve the inhibition of ergosterol synthesis, crucial to fungal cell integrity. However, its metabolites, such as voriconazole-N-oxide, have been implicated in phototoxic reactions that lead to DNA damage and tumor formation. This is particularly significant in patients with prolonged drug exposure, such as organ transplant recipients, where increased SCC incidence has been observed. Clinical evidence and molecular studies suggest that voriconazole may disrupt key cellular pathways like the Hedgehog pathway, affecting epidermal differentiation and increasing cancer risk. Given these concerns, the necessity for careful therapeutic monitoring and patient education about potential risks is discussed. Alternative antifungal therapies and protective measures against phototoxic effects are also recommended as strategies to mitigate SCC risk. Future research should focus on understanding the mechanisms of voriconazole-induced carcinogenesis and refining patient management protocols. This review highlights the need for a balanced approach to voriconazole therapy, weighing its antifungal benefits against the risks of adverse dermatological outcomes.

Gestion des patients avec protéine C réactive élevée après chirurgie colorectale élective : étude pilote sur une attitude diagnostique et thérapeutique proactive (GESPACE)

Study objective. To evaluate the feasibility and benefit of a diagnostic and therapeutic algorithm for management of patients presenting with a high C-reactive protein (CRP) level after colorectal surgery.Patients and methods. Prospective study including patients with CRP > 125 mg/L at the 4th postoperative day following elective colorectal surgery. The protocol involved CT-scan of which the results were to orient subsequent management: antibiotics, radiological drainage, endoscopy or surgical redo. Success (primary endpoint) consisted in the proportion of patients with total duration of hospitalization fewer than 15 days. Secondary endpoints were: applicability of the protocol in real-life conditions, number of stomas created, duration of hospitalization in an intensive care unit.Results. One hundred and six (106) patients were included: 51 patients (48%) presented with postoperative complications, of which 21 (41%) were severe. No death occurred. Among the included patients, 68% had a hospital stay < 15 days. Major deviations from the management algorithm occurred in 38% of cases. Early endoscopy was not applicable. There was no significant difference with regard to the secondary endpoints according to whether or not the protocol was strictly observed.Conclusion. It is necessary to define a protocol for management of patients presenting with high CRP levels after colorectal surgery, the objective being to reduce the impact of complications and to avoid excessive lengthening of hospital stay. The protocol begins with CT-scan, which is to orient subsequent management.

Dedicated anticoagulation management protocols in fragility femoral fracture care – a source of significant variance and limited effectiveness in improving time to surgery: The hip and femoral fracture anticoagulation surgical timing evaluation (HASTE) study

IntroductionApproximately 20 % of femoral fragility fracture patients take anticoagulants, typically warfarin or Direct Oral AntiCoagulant (DOAC). These can impact timing of surgery affecting patient survival. Due to several possible approaches and numerous factors to consider in the preoperative workup of anticoagulated patients, potential for variations in clinical practice exist. Some hospitals employ dedicated anticoagulation management protocols to address this issue, and to improve time to surgery. This study aimed to determine the proportion of hospitals with such protocols, compare protocol guidance between hospitals, and evaluate the effectiveness of protocols in facilitating prompt surgery. MethodsData was prospectively collected through a collaborative, multicentre approach involving hospitals across the UK. Femoral fragility fracture patients aged ≥60 years and admitted to hospital between 1st May to 31st July 2023 were included. Information from dedicated anticoagulation management protocols were collated on several domains relating to perioperative care including administration of reversal agents and instructions on timing of surgery as well as others. Logistic regression was used to evaluate effects of dedicated protocols on time to surgery. ResultsDedicated protocols for management of patients taking warfarin and DOACs were present at 41 (52.6 %) and 43 (55.1 %) hospitals respectively. For patients taking warfarin, 39/41 (95.1 %) protocols specified the dose of vitamin k and the most common was 5 milligrams intravenously (n=21). INR threshold values for proceeding to surgery varied between protocols; 1.5 (n=28), 1.8 (n=6), and 2 (n=6). For patients taking DOACs, 35/43 (81.4 %) and 8/43 (18.6 %) protocols advised timing of surgery based on renal function and absolute time from last dose respectively. Analysis of 10,197 patients from 78 hospitals showed fewer patients taking DOACs received surgery within 36 h of admission at hospitals with a dedicated protocol compared to those without (adjusted OR 0.73, 95% CI 0.54–0.99, p=0.040), while there were no differences among patients taking warfarin (adjusted OR 1.64, 95% CI 0.75–3.57, p=0.219). ConclusionsAround half of hospitals employed a dedicated anticoagulation management protocol for femoral fragility fracture patients, and substantial variation was observed in guidance between protocols. Dedicated protocols currently being used at hospitals were ineffective at improving the defined targets for time to surgery.

Management of patients with high C-reactive protein levels after elective colorectal surgery: Pilot study on a proactive diagnostic and therapeutic approach (GESPACE)

To evaluate the feasibility and benefit of a diagnostic and therapeutic algorithm for management of patients presenting with a high C-reactive protein (CRP) level after colorectal surgery. Prospective study including patients with CRP>125mg/L at the 4th postoperative day following elective colorectal surgery. The protocol involved CT-scan of which the results were to orient subsequent management: antibiotics, radiological drainage, endoscopy or surgical redo. Success (primary endpoint) consisted in the proportion of patients with total duration of hospitalization fewer than 15d. Secondary endpoints were: applicability of the protocol in real-life conditions, number of stomas created, duration of hospitalization in an intensive care unit. One hundred and six (106) patients were included: 51 patients (48%) presented with postoperative complications, of which 21 (41%) were severe. No death occurred. Among the included patients, 68% had a hospital stay<15d. Major deviations from the management algorithm occurred in 38% of cases. No patients had an early endoscopy. There was no significant difference with regard to the secondary endpoints according to whether or not the protocol was strictly observed. It is necessary to define a protocol for management of patients presenting with high CRP levels after colorectal surgery, the objective being to reduce the impact of complications and to avoid excessive lengthening of hospital stay. The protocol begins with CT-scan, which is to orient subsequent management.

#1112 A simplified lung ultrasound guided management protocol of pulmonary congestion in hemodialysis

Abstract Background and Aims Pulmonary congestion PC is frequent in Hemodialysis HD and holds a negative prognostic value. Lung ultrasound LUS is accurate in detecting and quantification PC, however, there are many methods to use LUS to evaluate PC. Here we validate a simplified LUS guided pulmonary congestion management protocol in HD patients that can be easily integrated in clinical practice, while studying at the same time the impact of such method on blood pressure control. Methods A prospective randomized multi-centric trial including stable HD patients in 3 countries. Patients were randomized into two groups: active and control group. All patients had a bedside LUS at the end of their mid-week session every two weeks according to the following time-line: Day 1, 15, 30, 45, 60. Lung ultrasound was performed according to the 8-zone method, and a B line score BLS was obtained. A global BLS of more than 6 was considered reflecting a significant PC level. The dry weight was adapted according to the standard of care in the control group. In the active group, in addition to the standard of care, if BLS was more than 6 at day 1 then the dry weight was reduced by 500 g. The same procedure was repeated at Day 15. (The maximum global dry weight modification per patient was 1 kg) (Fig. 1). Home blood pressure monitoring HBPM was also obtained weekly all through the study period. Results 28 stable HD patients (21 males) were enrolled in the study up until now. Mean age was 66.4 years, 14 were diabetics, 4 with stable ischemic heart disease, 1 heart failure and 27 were suffering from hypertension. Mean dialysis vintage was 35.8 months, and mean residual urine volume was 548 ml/24H. Mean session time was 4 hours. Main study population characteristics are described in Table 1. In the active group, mean BLS at day 1 (13.5) was significantly reduced, and reached (7.57) at day 60. (P &amp;lt; 0.001, ES:1.55) (Fig. 2). This was in parallel with a little but significant reduction in the dry weight (P: 0.03, ES: 0.6) but without a statistically greater UF values (P: 0.23) (Table 2). A significant reduction in home blood pressure was also observed by the HBPM readings, especially in the diastolic BP (P: 0.004). In the control group, the mean BLS at day 1 was (12.1). This level did not change all through the study time line, as it was (12.1) at day 60. No significant difference was observed in the dry weight, or ultrafiltration rate UF or home blood pressure values (Table 3). Conclusion Our simplified LUS guided management protocol was able to safely reduce the pulmonary congestion in HD patients in addition to better controlling their blood pressure. This protocol can be applied easily in every HD unit, and may be added to the standard of care to better estimate the dry weight in HD patients.