Therapeutics and Clinical Risk Management最新文献

Purpose: Fast-track surgery is a developing trend in medical care. It is a core challenge for clinical anesthesia to reasonably reduce the dosage of opioids and relieve postoperative pain. Serratus anterior plane block (SAPB) is a novel analgesic technique with such advantages as easy operation, good safety, and few side effects.

Patients and methods: In total, 60 patients aged 18 to 65 years who were diagnosed with lung cancer and scheduled for thoracoscopic resection were randomly assigned to receive SABP or local infiltration anesthesia. We analyzed the time within 48 hrs after operation to visual analogue scale (VAS) pain score of 4 or higher and the number of patients requiring additional analgesics at 6 hrs and 12 hrs after operation.

Results: The estimated median time to VAS ≥4 was 4 hrs (1.32 to 6.68) in the control group and 11 hrs (6.71 to 15.29) in the SAPB group (log-rank test: P=0.008). The number of patients requiring additional analgesics at 6- and 12 hrs after operation was significantly lower in the SAPB group than that in the control group (P<0.05).

Conclusion: Compared with local infiltration, SAPB provided extended postoperative analgesia after thoracoscopic surgery with reduced consumption of additional analgesics in the early postoperative stage.

This review summarizes the current research and outlooks regarding the obstacles to diagnosing and treating early alpha-1-antitrypsin deficiency (AATD). It draws on prior systematic reviews and expert surveys to discover precisely what difficulties exist in early diagnosis and treatment of AATD and elucidate potential solutions to ease these difficulties. The perceived rarity of AATD may translate to a condition poorly understood by primary care physicians, and even many respiratory physicians, which results in opportunities for diagnosis being missed, especially in mild or asymptomatic patients. There are diagnostic techniques involving biomarkers and home testing methods which could improve the rate of early diagnosis. With respect to treatment, AATD involves treating two separate pathologies, lung disease and liver disease. The only specific AATD treatment, augmentation therapy, has proven ability in treating lung disease but not liver disease. Alpha-1-antitrypsin (AAT) synthesized in the liver can form damaging polymers that also result in reduced circulating AAT levels and, whilst liver transplantation is used to effectively treat AATD, it is inappropriate in early disease. Novel therapeutic areas such as gene editing and increasing autophagy are therefore being researched as future treatments. Ultimately, diagnosis and treatment are intrinsically linked in AATD, with earlier diagnosis leading to better treatment options and thus better patient outcomes.

Objective: This study was performed to describe the clinical characteristics and outcomes of patients with toad poisoning in Thailand.

Methods: We carried out a retrospective study of patients with toad poisoning from the Ramathibodi Poison Center Toxic Exposure Surveillance System during a 5-year period (2012-2016).

Results: We studied 36 patients poisoned by toad toxin. The median age was 31 years. Most patients were male (66.7%) and had ingested toad meat (50%). The most common presentation was gastrointestinal (GI) symptoms with a median onset of 2 h after ingestion. Twelve patients presented with bradycardia; seven presented with shock and one with cardiac arrest. In the initial EKGs of all patients, the most common abnormality was sinus bradycardia.Two patients developed cardiac arrest early during management in the emergency room (within 15 minutes after ER arrival or within 4.5 h after ingestion). During admission, one patient developed sinus bradycardia, and two developed bradyarrhythmia; however, all three were stable. No tachyarrhythmias such as ventricular tachycardia were detected in any patient. Some patients (11.1%) presented with hyperkalemia. Serum digoxin was detected in five of seven patients tested, ranging from 0.43 to >8 ng/mL. Most patients (75%) were admitted to the hospital; the median duration of hospitalization was 2 d (range 0.5-5 d). The overall mortality rate was 8.3%, and all three patients that died ate toad meat and/or eggs and developed cardiac arrest. All patients received supportive with/without symptomatic care including GI decontamination, inotropic drugs, cardiac pacing, and management of hyperkalemia. One patient received intravenous calcium for hyperkalemia but did not develop dysrhythmia after calcium administration. One patient received digoxin-specific antibody fragments (DsFab), after which he clinically improved and was discharged.

Conclusion: Toad poisoning commonly caused GI symptoms and bradycardia. However, in severe cases, death occurred. Tachyarrhythmia was not observed. Supportive, symptomatic care might be the main therapies for this poisoning, especially if DsFab is not available.

Purpose: In pediatric patients, the most common reason for delaying surgical intervention is an upper respiratory tract infection (URI). To date, there has been no consensus regarding the optimal timeframe for deferring surgery in children with URI. We conducted this study to evaluate whether a URI symptom-free period and other risk factors affect the incidence of perioperative respiratory adverse events (RAEs).

Patients and methods: The study population included 267 pediatric patients (aged 0 to 13 years) with a recent URI episode who underwent surgery under general anesthesia. Following a retrospective review of medical records, several risk factors including a URI symptom-free period for intra- and postoperative RAEs were analyzed using univariate and multivariate logistic regression analyses.

Results: RAEs occurred in 23 of 267 patients (8.6%). Univariate analysis revealed that abnormal preoperative chest images (odds ratio [OR], 7.48; 95% confidence interval [CI], 2.46-22.68, p < 0.001) and emergency operations (OR, 2.84; 95% CI, 1.03-7.81, p = 0.04) were associated with RAEs. Four variables (abnormal preoperative chest images, emergency operations, age under 1 year and symptom-free period of 7-13 days) with a significance of <0.20 in the univariate logistic regression analysis were selected as candidate risk factors for the multivariate model. Among the four variables, abnormalities in preoperative chest images (OR, 7.60; 95% CI, 2.28-25.3, p = 0.001) and a symptom-free period of 7-13 days (OR, 0.13; 95% CI, 0.02-0.88, p = 0.04) were independently associated with RAEs in multivariate logistic regression analysis.

Conclusion: For pediatric patients who require surgery and have a recent history of URI, procedures should be performed after a URI symptom-free period of at least 1-2 weeks. Confirming the absence of abnormalities in preoperative chest images can reduce the incidence of perioperative RAEs.

Background: Distant metastasis in early T1-2 (diameter≤5 cm) stage lung adenocarcinoma (ET-LUAD) patients largely affect treatment strategies in clinical practice. However, the associated mechanism remains unclear and related studies is less. This study aimed to establish and validate a novel nomogram to predict the risk of distant metastasis in ET-LUAD.

Methods: A total of 258 patients diagnosed with ET-LUAD and not receiving any treatment were recruited into this study. The patients were randomly divided into a training cohort and validation cohort in a ratio of 1:2. Univariate and multivariate logistic regression analysis was used to select the most significant predictive risk factors associated with distant metastasis in the training cohort. The established nomogram was validated by the consistency index (C-index), calibration curve, and decision curve analysis (DCA).

Results: There were 124 patients with confirmed distant metastasis and 134 patients with non-distant metastases ET-LUAD were enrolled in the study. Multivariate logistic hazards regression analysis identified independent risk factors associated with distant metastasis to include platelet-to-lymphocyte ratios (PLR), lactate dehydrogenase (LDH), neural-specific enolase (NSE), carcinoembryonic antigen (CEA) and cytokeratin 19 fragments (Cyfra211), which were included in the establishment of the nomogram. The nomogram achieved a high consistency (C-index=0.792), good calibration, and high clinical application value in the validation cohort.

Conclusion: The established nomogram can be used to predict distant metastasis in high-risk ET-LUAD nonmetastasis patients and can also be used by doctors to guide preventive and individualized treatment for ET-LUAD patients.

Purpose: Aseptic implant loosening is still a feared complication in the field of orthopaedics. Presumably, a chronic inflammatory response is induced by wear particles, which leads to osteoclast generation, bone degradation and hence loosening of the implant. Since it has been demonstrated in the literature that most implants are in fact colonized by bacteria, the question arises whether aseptic implant loosening is truly aseptic. The aim of this study was to investigate a possibly enhanced inflammatory response to metal wear particles in the context of subclinical infection.

Patients and methods: Tissue samples were collected intra-operatively from patients undergoing implant-exchange surgery due to aseptic loosening. Histopathological analysis was performed, as well as gene expression analysis for the pro-inflammatory cytokine Interleukin-8. By a series of in vitro experiments, the effect of metal wear particles on human monocytes, polymorphonuclear neutrophiles and osteoblasts was investigated. Additionally, minor amounts of lipoteichoic acid (LTA) and the bacterial heat shock protein GroEL were added.

Results: Histopathology of tissue samples revealed an accumulation of metal wear particles, as well as a cellular infiltrate consisting predominately of mononuclear cells. Furthermore, high expression of IL-8 could be detected in tissue surrounding the implant. Monocytes and osteoblasts in particular showed an increased release of IL-8 after stimulation with metal wear particles and in particular after stimulation with bacterial components and wear particles together.

Conclusion: We were able to show that minor amounts of bacterial components and metal wear particles together induce an enhanced inflammatory response in human monocytes and osteoblasts. This effect could significantly contribute to the generation of bone-resorbing osteoclasts and hence implant-loosening.

Purpose: The low sensitivity and false-negative results of nucleic acid testing greatly affect its performance in diagnosing and discharging patients with coronavirus disease (COVID-19). Chest computed tomography (CT)-based evaluation of pneumonia may indicate a need for isolation. Therefore, this radiologic modality plays an important role in managing patients with suspected COVID-19. Meanwhile, deep learning (DL) technology has been successful in detecting various imaging features of chest CT. This study applied a novel DL technique to standardize the discharge criteria of COVID-19 patients with consecutive negative respiratory pathogen nucleic acid test results at a "square cabin" hospital.

Patients and methods: DL was used to evaluate the chest CT scans of 270 hospitalized COVID-19 patients who had two consecutive negative nucleic acid tests (sampling interval >1 day). The CT scans evaluated were obtained after the patients' second negative test result. The standard criterion determined by DL for patient discharge was a total volume ratio of lesion to lung <50%.

Results: The mean number of days between hospitalization and DL was 14.3 (± 2.4). The average intersection over union was 0.7894. Two hundred and thirteen (78.9%) patients exhibited pneumonia, of whom 54.0% (115/213) had mild interstitial fibrosis. Twenty-one, 33, and 4 cases exhibited vascular enlargement, pleural thickening, and mediastinal lymphadenopathy, respectively. Of the latter, 18.8% (40/213) had a total volume ratio of lesions to lung ≥50% according to our severity scale and were monitored continuously in the hospital. Three cases had a positive follow-up nucleic acid test during hospitalization. None of the 230 discharged cases later tested positive or exhibited pneumonia progression.

Conclusion: The novel DL enables the accurate management of hospitalized patients with COVID-19 and can help avoid cluster transmission or exacerbation in patients with false-negative acid test.

Purpose: To adapt and validate the Global Trigger Tool (IHI-GTT), which identifies and analyzes adverse events (AE) in hospitalized patients and their measurement properties in the Portuguese context.

Methods: A retrospective cross-sectional study was based on a random sample of 90 medical records. The stages of translation and cross-cultural adaptation of the IHI-GTT were based on the Cross-Cultural Adaptation Protocol that originated from the Portuguese version, GTT-PT, for the hospital context in medical-surgical departments. Internal consistency, reliability, reproducibility, diagnostic tests, and discriminatory predictive value were investigated.

Results: The final phase of the GTT-PT showed insignificant inconsistencies. The pre-test phase confirmed translation accuracy, easy administration, effectiveness in identifying AEs, and relevance of integrating it into hospital risk management. It had a sensitivity of 97.8% and specificity of 74.8%, with a cutoff point of 0.5, an accuracy of 83%, and a positive predictive value of 69.8% and a negative predictive value of 0.98%.

Conclusion: The GTT-PT is a reliable, accurate, and valid tool to identify AE, with robust measurement properties.

Purpose: This retrospective study compared effectiveness between ≤4 cycles and ≥5 cycles of L-asparaginase/pegaspargase-based chemoradiation in newly diagnosed low-risk extranodal natural killer/T-cell lymphoma (ENKTL), nasal type classified according to the Prognostic Index of Natural Killer (PINK) lymphoma model.

Patients and methods: Patients were categorized into ≤4-cycle (2-4 chemotherapy cycles, n = 166) and ≥5-cycle groups (5-6 cycles, n = 86). Propensity score matching analysis was used to reduce potential confounding bias between the two groups. Treatment responses, adverse events, and survival outcomes between the two groups were analyzed.

Results: No matter before or after matching (65 in the ≤4-cycle group, 65 in the ≥5-cycle group), response rates and survival outcomes were similar between the ≤4-cycle and ≥5-cycle groups. Incidences of grade 1-2 anemia and transaminase elevation were higher in the ≥5-cycle group. After matching, for stage IE disease, there were no differences in response rates and survival outcomes between the two groups. For stage IIE disease, the complete response rate was higher in the ≥5-cycle group (72.4% vs 92.6%, p = 0.049), and the 3-year overall survival (65.5% vs 85.2%, p = 0.024) and 3-year progression-free survival (58.6% vs 81.5%, p = 0.027) rates were significantly extended in the ≥5-cycle group.

Conclusion: When chemoradiotherapy strategies with L-asparaginase/pegaspargase-based regimens are applied to modern low-risk ENKTL patients classified according to the PINK model, it may be better to moderately extend chemotherapy courses in patients with stage IIE disease.