ChemInform Research Articles

Bleeding Complications of Anticoagulation Therapy in Clinical Practice—Epidemiology and Management: Review of the Literature

Due to their very wide range of indications, anticoagulants are one of the most commonly used drug groups. Although these drugs are characterized by different mechanisms of action, the most common complication of their use is still bleeding episodes, the frequency of which depends largely on the clinical condition of the patient using such therapy. For this reason, to this day, the best method of preventing bleeding complications remains the assessment of bleeding risk using scales such as HAS-BLED. There are many reports in the literature assessing the occurrence of this type of complication after the use of drugs affecting the coagulation process, as well as many reports comparing individual groups of drugs with different mechanisms of action. However, there are still no clear guidelines that would indicate which group of anticoagulants should be preferred in particular groups of patients. The aim of our article is to summarize the data collected so far regarding the safety of using specific groups of anticoagulants and the frequency of bleeding complications after their use.

Brazilian Physicians’ Attitudes and Feelings Towards Palliative Care in Pediatrics

Brazilian Physicians’ Attitudes and Feelings Towards Palliative Care in Pediatrics

School Suspension and Expulsion: Policy Statement.

Exclusionary school discipline practices-ie, suspension and expulsion-represent some of the most severe consequences a school district can implement for unacceptable student behavior. Suspension and expulsion were traditionally used for student behaviors that caused serious harm, such as bringing a weapon to school. Currently, the most common indications for exclusionary school discipline are for behaviors that are neither violent nor criminal. There is little evidence that exclusionary school discipline practices make schools safer or deter future misbehavior. American Indian/Alaska Native students, Black students, students whose caregivers have low socioeconomic status, male students, lesbian, gay, bisexual, transgender, and queer or questioning students, and students with disabilities are disproportionately disciplined with suspension and expulsion. In addition, exclusionary school discipline in the preschool period can be harmful to early childhood development. Children and adolescents affected by exclusionary school discipline are at higher risk for dropping out of high school and for involvement with the juvenile justice system. Both of those experiences are associated with a worse profile of physical and mental health outcomes. A multidisciplinary and trauma-informed approach to reducing exclusionary school discipline practices is described. Recommendations are provided at both the practice level for pediatric health care providers and at the systems level for both pediatric health care providers and educators.

Integrating Simulation in Pediatric Health Care: Collaboration of Primary and Acute Care Pediatric Nurse Practitioners Across Settings

Pediatric nurse practitioner (PNP) education continues to evolve. Clinical placement availability significantly impacts student’s exposure to complex pediatric patients. The intricacy of pediatric health care demands innovative educational approaches, especially in managing high-risk, low-frequency emergencies. Simulation-based education is a vital tool to bridge learning gaps and enhance core competencies, particularly in diagnosing and managing pediatric patients across diverse health care settings. Here we explore a collaborative formative simulation experience for primary care PNPs and acute care PNPs, focusing on a single patient transitioning through primary care, emergency, and acute care settings. Results demonstrate enhanced student satisfaction and self-confidence, underscoring the efficacy of such simulations in preparing future pediatric health care providers. Opportunities for improvement and future directions are discussed, highlighting the significance of interprofessional collaboration and continuous innovation in PNP education.

Predictive utility of a combination of the modified caprini risk assessment score and D-dimer for the evaluation and management of lower extremity venous thrombosis after lung cancer surgery

ObjectiveThe objective of this study was to examine the utility of a combination of the modified Caprini score and D-dimer levels for the evaluation and management of lower extremity venous thrombosis following lung cancer surgery. The purpose was to offer insights for developing clinical intervention programs.MethodsThe study sample consisted of 224 patients who underwent surgery for lung cancer at the First Central Hospital of Baoding City. General patient data and D-dimer levels on the first day post-surgery were collected. The modified Caprini risk assessment score was calculated. All patients underwent ultrasonography of the lower limb veins before and after surgery to identify venous thrombosis in the lower limb veins. Differences in lower extremity venous thrombosis and D-dimer levels among patients in various modified Caprini score groups were compared and analyzed.ResultsBased on the modified Caprini risk assessment score, all patients were categorized into three groups: the low-risk, medium-risk, and high-risk groups. The groups did not differ significantly in terms of age, but the differences in the rates of lower extremity venous thrombosis in the low, intermediate, and high-risk Caprini risk groups (16.5%, 19.2%, and 37.1%, respectively) were statistically significant. Out of the total 224 patients, 47 (21%) were diagnosed with venous thromboembolisms post-surgery, and all of them had thrombosis of the intermuscular veins of the lower extremity. The difference in the modified Caprini risk assessment score between patients with and without lower extremity venous thrombosis was statistically significant (P = 0.035), as were the postoperative D-dimer levels (1.28 ± 1.64 vs. 2.69 ± 2.77, respectively; P < 0.05) between these two groups of patients. The modified Caprini risk assessment score showed an association with lower extremity venous thrombosis (r = 0.15, P = 0.56) with an area under the receiver operating characteristic curve (AUC) of 0.59.ConclusionIn this study, we found that combining the modified Caprini risk assessment score with D-dimer measurements enhanced the accuracy of assessing the severity of deep vein thrombosis (DVT). This combination can be beneficial in evaluating thrombosis risk post-lung cancer surgery and holds significant clinical utility.

Under- not over-nutrition is associated with adverse outcomes in cancer surgery

Under- not over-nutrition is associated with adverse outcomes in cancer surgery

Policy and practice review consensus statements and clinical guidelines on managing pediatric trauma and orthopedics during the COVID-19 pandemic: a systematic review on the global response for future pandemics and public health crises

IntroductionThe COVID-19 pandemic has been recognized as an unprecedented global health crisis. Over 7 million mortalities have been documented with many paediatric fatalities. Trauma and orthopaedic care, much like other specialities, were marginalized due to resource allocation during the pandemic which affected paediatric care. This is the first systematic review to centralise and compile the recommended published guidelines from professional bodies in principally English speaking countries on managing paediatric trauma and orthopaedic care. These guidelines will be required to be implemented sooner and more effectively in case of future pandemics with similar impact.MethodsA search was conducted on PubMed/MedLine, Cochrane Library and Embase using terms including p(a)ediatric or child* and/or COVID* or coronavirus or SARS-CoV-2 and/or trauma and/or orthop(a)edic* with a simplified MeSH heading [mh] in order to make the search as comprehensive as possible. General terminology was utilized to make the search as exhaustive as possible for this systematic review. Another search was conducted on resources available in the public domain from professional bodies publishing on consensus statements and clinical practice guidelines in countries where English is the principal language managing pediatric trauma and orthopedics. The review adhered to PRISMA guidance.ResultsThe search revealed a total of 62 results from both databases and professional bodies. Duplicates were removed. This was then reviewed to identify a total of 21 results which fit the inclusion criteria and included within the main analysis. The guidelines from professional bodies were outlined and categorized into aspects of clinical care.DiscussionThe impact of COVID-19 pandemic has compelled for changes in clinical practice and pediatric management. The systematic review highlights the relevant guidelines on service provision for pediatric patients including indications for urgent referrals, surgical prioritization, reasons for follow-up and trauma guidelines. The rationale for care during the unpredictable evolution of the COVID-19 pandemic may have the potential to be translated and replicated in future pandemics of similar significance.

Fermentative production of 3-hydroxypropionic acid by using metabolically engineered Klebsiella pneumoniae strains

3-Hydroxypropionic acid (3-HP) is an industrially important platform chemical for super-absorbent or biodegradable polymers. Its production via biological methods is expected to be more competitive than chemical methods. Klebsiella pneumoniae is the most promising host due to its innate capabilities for 3-HP and vitamin-B12 production, ease of culture, and ease of engineering. In this study, step-by-step metabolic engineering and fermentation technologies were used to enhance the production of 3-HP. K. pneumoniae-derived ydcW gene was overexpressed using a plasmid after screening candidate genes. Major competing pathways encoded by dhaT, yqhD, ldhA, glpK, poxB, and pta-ackA were blocked. Additionally, it was demonstrated that simultaneous reinforcement of two native aldehyde dehydrogenase encoded by the ydcW gene preferring NADPH and the puuC gene preferring NADH, synergistically improved 3-HP production. Additional reinforcement of the acs gene to reduce acetate accumulation resulted in 93.7 g/L of 3-HP with a yield of 0.42 g/g·glycerol over a 72-h fed-batch fermentation. This performance is deemed sufficient for industrial applications.

Development and validation of a questionnaire (QSPC-Q) for assessment of quality and strengthening of primary care in Brazil.

The performance evaluation of services through instruments is relevant, as it can support thoughts, actions and political approaches to meet a social need. The objective of the article was to develop and validate the Quality and Strengthening of Primary Care Questionnaire (QSPC-Q) for professionals and users based on Starfield attributes and Donabedian pillars. A mixed sequential study was performed to develop the QSPC-Q. The test was applied to 149 doctors and 795 users of basic health units. Psychometric properties was assessed by testing internal consistency using Cronbach's alpha and exploratory factor analysis. Reproducibility od scale was assessed using intraclass cognitive and test-retest correlation. The final version of the follow-up consisted of 45 items aimed at physicians (Cronbach's alpha = 0.921) and 33 at users (Cronbach's alpha = 0.86); the intraclass respiratory capacity was 0.88. An exploratory factor analysis identified 13 factors associated with the pattern components. A short version with 29 items for professionals was also elaborated. Professional QSPC-Q (short and braided versions) and user QSPC-Q were valid.

Follow Up Care After Penile Sparing Surgery for Penile Cancer: Current Perspectives

Follow Up Care After Penile Sparing Surgery for Penile Cancer: Current Perspectives

Robotic Surgery for Gynecologic Cancer: Optimism or Controversy in Surgical Oncology?

Robotic Surgery has made possible to remove cancerous organs and tissues in gynecologic cancer patients with less invasive methods. Gynecologist have observed that these minimally invasive surgeries often result in fewer complications and a faster recovery time. As robotic technology continues to develop, the potential advantages of robotic surgery in gynecologic oncology are becoming increasingly evident. Robotic Surgery offers greater precision and control during complex procedures, which can lead to improved patient outcomes and fewer complications. Robotic surgery can often outcome in smaller hospital halts and a rapid return to normal activities. Consequently, more and more GOs are adopting Robotic Surgery to provide their patients with the most advanced and effective treatment options available. Robotic Surgery is now a viable option compared to traditional open surgery. Since its extensive use, negligibly aggressive surgery has become a suitable choice not only for those with severe obesity, but also for women with gynecologic cancers, where traditional open surgery is often associated with significant complications. This review investigates the rationale behind Robotic Surgery, evaluates early results, analyzes its cost-effectiveness and implications for surgical training, and explores innovative applications of robotic-surgical procedure in the treatment of gynecologic cancer.

C-Reactive Protein-to-Albumin Ratio as a Predictive Indicator for Evaluating Tolerability in S-1 Adjuvant Chemotherapy after Curative Surgery for Pancreatic Cancer: An External Validation Cohort Study

Background: S-1 in adjuvant chemotherapy (AC) administration after pancreatic cancer (PC) surgery has been standardized in Japan. The Ehime study confirmed that a postoperative higher C-reactive protein-to-albumin ratio (CAR) value predicted the risk of adverse event (AE)-related S-1 non-completion as an AC in patients with PC after curative surgery. This study aimed to investigate the index to predict S-1 tolerance among patients who underwent curative surgery for PC (the Dokkyo study). Methods: This retrospective validation cohort study included 172 patients at the Department of Hepato-Biliary Pancreatic Surgery, Dokkyo Medical University, Japan, from January 2010 to December 2022. All patients underwent nutritional screening using the postoperative CAR. S-1 completion status and its effect on prognosis were systematically followed up and investigated. We conducted a statistical analysis of predictive markers to investigate their association with S-1 completion. Results: Patients were categorized into the S-1 completion (N = 91) and non-completion (N = 81) groups. The S-1 completion group demonstrated a significantly lower CAR than the S1 non-completion group. Moreover, the current study revealed a significant difference in the S-1 completion rate, applying the CAR cutoff value of 0.05 established in the Ehime study. Additionally, univariate and multivariate analyses confirmed that a CAR of &lt;0.05 was significantly associated with S-1 completion. Conclusions: The Dokkyo study confirmed the results observed in the Ehime study. Consequently, an increased postoperative CAR value appeared as a universal applicable marker for the risk factor of AE-related S-1 non-completion after curative surgery for patients with PC.

The Role of Transurethral BPH Surgeries in Management of Urinary Symptoms in Prostate Cancer Patients, Narrative Review.

Prostate cancer and benign prostate hyperplasia (BPH) are two ubiquitous pathologies that may coexist. A significant percentage of patients with different stages of prostate cancer suffer lower urinary tract symptoms (LUTS) due to associated BPH. We aimed to review the literature regarding the role of transurethral surgeries in the management of prostate cancer patients and the different available management options. The evidence in literature for the use of BPH surgeries in prostate cancer patients is based mainly on low-quality retrospective studies. In patients on active surveillance, BPH surgeries are beneficial in relieving LUTS without oncological risk and can eliminate the contribution of adenoma to PSA level. In patients with advanced prostate cancer, palliative BPH surgery can relieve LUTS and urinary retention with unclear oncological impact; however some reports depict that the need for BPH surgery in advanced prostate cancer is associated with poorer prognosis. In patients receiving radiotherapy, various studies showed that transurethral resection of prostate (TURP) is associated with increased radiotoxicity despite some recent reports encouraging the use of Holmium Laser Enucleation of the Prostate (HoLEP) to improve urinary symptom scores before radiotherapy. The most commonly reported techniques utilized are TURP, photoselective vaporization of prostate (PVP) and HoLEP. The use of BPH surgery is justified for relieving LUTS in selected prostate cancer patients on active surveillance or in advanced stages, however the use in the pre-radiotherapy settings remains controversial. Future prospective and randomized controlled trials are required for validating the benefits and assessing potential hazards.

Measuring the Integration of Stereotactic Ablative Radiotherapy Plus Surgery for Early-Stage Non-Small Cell Lung Cancer (MISSILE): Long-Term Clinical Outcomes.

For early-stage non-small cell lung cancer (NSCLC), surgery is the preferred approach in operable patients, whereas stereotactic ablative radiotherapy (SABR) is preferred for medically inoperable patients. The combination of neoadjuvant SABR followed by surgery was tested in the MISSILE phase II trial. We report long-term outcomes, beyond 5 years of follow-up. Patients diagnosed with T1-2N0M0 NSCLC with good performance status and adequate lung function were enrolled. Patients underwent neoadjuvant SABR followed by lobectomy/wedge resection. Forty enrolled patients received SABR, of which 36 patients proceeded to surgery. The pathologic and major complete response rates were 60% and 63%, respectively. Median follow-up was 6.6 years following surgery. Five-year overall, disease-free and cancer-specific survival were 66.7% (95% CI: 48.8-79.5), 58.3% (95% CI: 40.7-72.4) and 76.4% (95% CI: 58.2-87.4). Five-year local, regional and distant control were 93.5% (95% CI: 76.3-98.4), 80.1% (95% CI: 62.7-90.0) and 82.4% (95% CI: 64.9-91.7). After SABR and surgery, 16.7% (n=6) of patients experienced related grade ≥ 3 adverse events and there were no grade 5 events. The combined approach of SABR and surgery was safe and demonstrated reasonable long-term clinical outcomes, but similar to surgery alone.

Impact of general anesthesia type on chronic postsurgical pain following video-assisted thoracoscopic surgery for lung cancer: a retrospective propensity-matched cohort study.

Anesthetic agents are potential modifiable factors that can mitigate chronic postsurgical pain (CPSP) development. This study aimed to investigate the association between propofol-based total intravenous anesthesia (TIVA) and the occurrence of CPSP following video-assisted thoracoscopic surgery (VATS) for lung cancer resection. This single-center retrospective cohort study included adult patients with lung cancer who underwent elective VATS between January 2018 and December 2022. Patients were divided based on the maintenance anesthetic used (propofol vs. sevoflurane). The primary outcome was the presence of CPSP, defined as any level of surgical site pain recorded within 3-6 months postoperatively. The authors investigated the association between anesthetic agents and CPSP using propensity score matching with stabilized inverse probability of treatment weighting (sIPTW) to adjust for confounders. Additionally, multivariable logistic regression was used to further adjust for intraoperative opioid use that sIPTW could not account for. The robustness of these associations was evaluated using the E-value. Of the 833 patients analyzed, 461 received propofol and 372 sevoflurane. The overall incidence of CPSP was 43.3%. After sIPTW, the use of TIVA was significantly associated with a lower incidence of CPSP (odds ratio [OR]: 0.75, 95% confidence interval [CI]: 0.57-0.99, P = 0.041), and remained significant after adjusting for intraoperative remifentanil equivalent dose (OR: 0.73, 95% CI: 0.55-0.96, P = 0.026). The E-values were 1.08 and 1.17, respectively. Propofol-based TIVA is associated with reduced CPSP occurrence in VATS for lung cancer. Further prospective studies are needed to confirm the results.

Factors associated with colon cancer fragmentation in the Keystone state.

120 Background: Fragmentation of cancer care delivery across multiple providers can impact care quality and patient outcomes. Management of non-metastatic colon cancer often involves adjuvant chemotherapy, which increases the risk of potentially deleterious care dispersion. This study assesses the extent of care fragmentation across different inpatient facilities and examines patient characteristics associated with inpatient care fragmentation. Methods: We adapt the modified Herfindahl-Hirschman market concentration index to construct a Fragmentation Index (FI) capturing the distribution of a patient’s care across inpatient facilities. For patients who underwent oncologic surgery for colon cancer from 2010-2016, we calculate FI for the 15 months post-diagnosis if at least 2 admissions occur during the study period. We use Pennsylvania Cancer Registry data linked to all-payer statewide facility discharge records to estimate the relationship between FI and patient demographics, rurality, area deprivation index (ADI), and payer status using adjusted multivariable linear regression models. Results: For the operative cohort (28.6% Stage I, 34.7% Stage II, 36.7% Stage III, n = 7803), 86% of patients lived in urban areas, 9.5% in large towns and 5% in rural areas. 60% had Medicare, 6.1% Medicaid and 7.1% were uninsured or had unknown payer status. 52% of patients were female and 87% were non-Hispanic White. The overall mean FI was 0.192; 60% (n = 4693) had an FI of 0, indicating all admissions were at the same hospital, and among those with FI&gt; 0 (n = 3110), mean FI was 0.483. The mean FI for patients potentially eligible for adjuvant chemotherapy (Stage II, III) was 0.188: 61% of patients had an FI of 0 and among those with FI &gt; 0 (n = 2173), mean FI was 0.482. Stratification by stage reveals similar proportions of FI &gt; 0.5 (stage I: 24.6%, stage II: 22.3%, stage III: 21.3%). Increased care dispersion was observed in patients from large towns (ΔFI 0.04, CI 0.03—0.06) or rural areas (ΔFI 0.04, CI 0.02—0.08) relative to urban areas, as well as for patients with relatively higher number of hospitalizations (ΔFI 0.04, CI 0.03—0.04). Less care dispersion was seen in patients with stage III disease (relative to stage I ΔFI -0.02, CI -0.03 — -0.01), uninsured status (relative to private insurance ΔFI -0.03, CI -0.05 – -0.01) or residence in the most disadvantaged ADI quartile (relative to Q1 ADI ΔFI -0.02, CI -0.04 — 0.00). Conclusions: Among patients with operatively managed colon cancer, slightly more than half did not experience inpatient care fragmentation. As expected, a higher number of total admissions and non-urban residence were associated with increased inpatient care dispersion. However, our findings of more concentrated care among patients with stage III disease, higher levels of relative economic disadvantage, and uninsured status suggest potentially complex and divergent forces driving hospital selection, to be explored in future work.

Preoperative nutritional counseling and immuno-nutrition as part of prehabilitation leads to successful body weight preservation and or weight gain in patients undergoing surgery for gastrointestinal cancers

Preoperative nutritional counseling and immuno-nutrition as part of prehabilitation leads to successful body weight preservation and or weight gain in patients undergoing surgery for gastrointestinal cancers

Changes in body composition following curative surgery for colorectal cancer: Insights from InBody720 measurements

Changes in body composition following curative surgery for colorectal cancer: Insights from InBody720 measurements

A Novel Approach to Personalized Personality Assessment with the Attachment-Caregiving Questionnaire: First Evidence in Favor of Interpretation-Oriented Inventory Designs

In clinical psychology and psychiatry, personality is usually assessed using questionnaires developed through factor analysis (FA). Essential domains are identified, which correspond to questions/items defining a (sub)scale, and each question is rigidly assigned to one scale, giving the item the same meaning regardless of how the respondent may interpret it. However, this rigidity might hinder the instrument’s assessment capability. We tested this hypothesis using the Attachment-Caregiving Questionnaire (ACQ), a clinical and personality self-report that—through extra-scale information—allows the clinician to infer the possible different meanings that the subjects attribute to the items. Considering four psychotherapy patients, we compared the scoring of their ACQs provided by expert clinicians to the detailed information gained from therapy and the patients. Our results indicated that questions could be interpreted differently—receiving the same score for different (clinically relevant) reasons—potentially impacting personality assessment and clinical decision-making. Moreover, accounting for multiple interpretations requires a specific questionnaire design. Overall, our analysis suggests that a meaning-sensitive, personalized read of a personality self-report may improve profiling and treatment, implying the necessity of more advanced pattern recognition than the one produced by FA or similarly rigid methods, which artificial intelligence may provide. More evidence is required to support these preliminary findings.

Evaluating the reproducibility and validity of maximal mouth opening measurement techniques

A limitation of the maximal mouth opening (MMO) is a frequent complication of oral (cancer) surgery. The measurement between the right central incisors is considered the golden standard for assessing MMO, although it has been noted to overestimate MMO in edentulous patients. This study aims to evaluate the reproducibility and validity of four MMO techniques and to determine the extent to which they are dependent on the remaining dentition. Four methods for capturing the MMO were recorded in consecutive patients with mixed dentition. The degree of agreement between the different measurement methods was compared using Bland-Altman plots. To investigate the reproducibility of each method, intersession, interobserver and intraobserver reliability were calculated for measurements performed by two clinicians across two sessions. Two subgroups were created based on dentition: (A) cases missing at least one right central incisor, and (B) patients with both right central incisors present. All but one intraclass correlation coefficient (ICC) demonstrated excellent reproducibility (ICC > .9). The highest ICC values were found for the intraoral MMO(iMMO) and corrected intraoral MMO(ciMMO) method. A significant relationship between the MMO in both subgroups was identified only for the intraoral Range of Motion (iROM) method (p=.010*). The findings suggest that the current golden standard for measuring MMO does not adequately account for the absence of the right central incisor(s). Two of the proposed methods, which include corrections for missing incisors, should be incorporated into future clinical trials on MMO.