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Yip SWS, Weinberg L, Gooi J, Sivenayagam S, Coulson TG, Barnett SA, Knight SR, Ludski J, Lee DK. Anaesthetic and perioperative considerations for extrapleural pneumonectomy and extended pleurectomy/decortication: a scoping review protocol. BMJ Open 2024; 14:e078125. [PMID: 38760041 PMCID: PMC11103232 DOI: 10.1136/bmjopen-2023-078125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 05/05/2024] [Indexed: 05/19/2024] Open
Abstract
INTRODUCTION Extrapleural pneumonectomy (EPP) and extended pleurectomy/decortication (ePD) are surgical cytoreductive techniques aimed at achieving macroscopic resection in malignant pleural tumours such as pleural mesothelioma, non-mesothelioma pleural malignancies such as thymoma and sarcoma, and rarely for pleural tuberculosis, in a more limited fashion. Despite extensive studies on both surgical techniques and consequences, a significant knowledge gap remains regarding how best to approach the perioperative anaesthesia challenges for EPP and ePD.It is unknown if the risk stratification processes for such surgeries are standardised or what types of functional and dynamic cardiac and pulmonary tests are employed preoperatively to assist in the perioperative risk stratification. Further, it is unknown whether the types of anaesthesia and analgesia techniques employed, and the types of haemodynamic monitoring tools used, impact on outcomes. It is also unknown whether individualised haemodynamic protocols are used to guide the rational use of fluids, vasoactive drugs and inotropes.Finally, there is a dearth of evidence regarding how best to monitor these patients postoperatively or what the most effective enhanced recovery protocols are to best mitigate postoperative complications and accelerate hospital discharge. To increase our knowledge of the perioperative and anaesthetic treatment for patients undergoing EPP/ePD, this scoping review attempts to synthesise the literature and identify these knowledge gaps. METHODS AND ANALYSIS This scoping review will be conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Review Protocols methodology. Electronic databases, OVID Medline, EMBASE and the Cochrane Library, will be systematically searched for relevant literature corresponding to EPP or ePD and perioperative or anaesthetic management. Data will be analysed and summarised descriptively and organised according to the three perioperative stages: preoperative, intraoperative and postoperative factors in clinical care. ETHICS AND DISSEMINATION Ethics approval was not required. The findings will be disseminated through professional networks, conference presentations and publications in scientific journals.
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Affiliation(s)
- Sui Wah Sean Yip
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Laurence Weinberg
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
- Department of Critical Care, University of Melbourne, Parkville, Victoria, Australia
| | - Julian Gooi
- Department of Cardiothoracic Surgery, The Alfred, Melbourne, Victoria, Australia
| | - Siven Sivenayagam
- Department of Cardiothoracic Surgery, Austin Health, Heidelberg, Victoria, Australia
| | - Tim G Coulson
- Anaesthesiology and Perioperative Medicine, The Alfred, Melbourne, Victoria, Australia
- Department of Anaesthesiology and Perioperative Medicine, Alfred Health and Monash University, Melbourne, Victoria, Australia
| | - Stephen A Barnett
- Department of Thoracic Surgery, Austin Health, Heidelberg, Victoria, Australia
| | - Simon R Knight
- Department of Thoracic Surgery, Austin Health, Heidelberg, Victoria, Australia
| | - Jarryd Ludski
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Dong Kyu Lee
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, Korea (the Republic of)
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Romano G, Zirafa CC, Ceccarelli I, Elia G, Davini F, Melfi F. Update in the Treatment of Pleural Tumors: Robotic Surgery Combined with Hyperthermic Intrathoracic Chemotherapy. Cancers (Basel) 2024; 16:1691. [PMID: 38730643 PMCID: PMC11083528 DOI: 10.3390/cancers16091691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 04/23/2024] [Accepted: 04/25/2024] [Indexed: 05/13/2024] Open
Abstract
(1) Background. Intracavitary hyperthermic chemotherapy (HITHOC) remains part of the complex mosaic that is the multimodal approach for advanced stage thymoma and pleural malignancies. However, robotic pleurectomy/removal of pleural lesions in combination with intrathoracic chemotherapy is not currently being investigated. The aim of this study is to evaluate the safety of robotic pleurectomy/removal of relapses and HITHOC in patients with pleural recurrence of thymoma or MPM. (2) Methods: The data of nine consecutive patients affected by thymoma relapses or MPM who underwent robotic surgery in combination with HITHOC from February 2017 to November 2022 were collected and analyzed. Surgery performed prior to intrathoracic infusion of high-temperature chemotherapy consisted of removal of recurrences (three patients) or pleurectomy (six patients). All surgeries were performed with a four-port, fully robotic technique. (3) Results: No intraoperative complications occurred. No renal complications related to infusion were recorded. One patient, who underwent pleurectomy for MPM, had a grade II Clavien-Dindo postoperative complication. Oncological follow-up showed results in line with the literature. (4) Conclusions: With the limitation of the small number of patients, robotic surgery in combination with HITHOC seems to be safe in patients with pleural relapses of thymoma and early-stage MPM.
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Affiliation(s)
- Gaetano Romano
- Minimally Invasive and Robotic Thoracic Surgery, Robotic Multispecialty Center of Surgery, University Hospital of Pisa, 56124 Pisa, Italy; (C.C.Z.); (I.C.); (F.D.); (F.M.)
| | - Carmelina Cristina Zirafa
- Minimally Invasive and Robotic Thoracic Surgery, Robotic Multispecialty Center of Surgery, University Hospital of Pisa, 56124 Pisa, Italy; (C.C.Z.); (I.C.); (F.D.); (F.M.)
| | - Ilaria Ceccarelli
- Minimally Invasive and Robotic Thoracic Surgery, Robotic Multispecialty Center of Surgery, University Hospital of Pisa, 56124 Pisa, Italy; (C.C.Z.); (I.C.); (F.D.); (F.M.)
| | - Gianmarco Elia
- Surgical, Medical, Molecular and Critical Care Pathology Department, University Hospital of Pisa, 56124 Pisa, Italy;
| | - Federico Davini
- Minimally Invasive and Robotic Thoracic Surgery, Robotic Multispecialty Center of Surgery, University Hospital of Pisa, 56124 Pisa, Italy; (C.C.Z.); (I.C.); (F.D.); (F.M.)
| | - Franca Melfi
- Minimally Invasive and Robotic Thoracic Surgery, Robotic Multispecialty Center of Surgery, University Hospital of Pisa, 56124 Pisa, Italy; (C.C.Z.); (I.C.); (F.D.); (F.M.)
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Migliore M, Fiore M, Filippini T, Tumino R, Sabbioni M, Spatola C, Polosa R, Vigneri P, Nardini M, Castorina S, Basile F, Ferrante M. Comparison of video-assisted pleurectomy/decortication surgery plus hyperthermic intrathoracic chemotherapy with VATS talc pleurodesis for the treatment of malignant pleural mesothelioma: A pilot study. Heliyon 2023; 9:e16685. [PMID: 37292347 PMCID: PMC10245266 DOI: 10.1016/j.heliyon.2023.e16685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 05/19/2023] [Accepted: 05/24/2023] [Indexed: 06/10/2023] Open
Abstract
Hyperthermic intrathoracic chemotherapy (HITHOC) adjunct to surgery for Malignant Pleural Mesothelioma (MPM) has no definite role. The primary objective of this pilot-trial was to evaluate the feasibility for future large studies. The study design was a prospective randomized three-centric pilot trial. We recruited patients diagnosed with MPM and prospectively assigned them to two groups: Group A: Video Assisted Thoracic Surgery (VATS) talc pleurodesis or Group B: Video-assisted P/D plus HITHOC. From November-2011 to July-2017 24 males and 3 females, with a median age of 68-years were enrolled (recruitment rate 5 patients/year). Preoperative stage was I-II, and 18 had epithelioid type. 14 patients were in the Group A. Operative mortality was 0. Follow-up ranged 6-80 months. The median overall survival time started to diverge at 20 months, being 19 months (95% CI 12-25) in Group A and 28 months (95% CI 0-56) in Group B. Survival rate for the epithelioid type was 15 months (95% CI 0-34) in Group A and 45 months (95% CI 0-107) in the Group B. These findings suggest that video-assisted P/D plus HITHOC may improve survival time in MPM patients undergoing surgical treatment and support the need for a larger multicenter randomized clinical trial.
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Affiliation(s)
- Marcello Migliore
- Minimally Invasive Thoracic Surgery and New Technologies University Hospital of Catania, Department of General Surgery and Medical Specialties, University of Catania, Catania, Italy
- Thoracic Surgery and Lung Transplant, Lung Health Centre, Organ Transplant Center of Excellence (OTCoE), King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Maria Fiore
- Department of Medical, Surgical and Advanced Technologies “G.F. Ingrassia”, University of Catania, Catania, Italy
| | - Tommaso Filippini
- Environmental, Genetic and Nutritional Epidemiology Research Center (CREAGEN), Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- School of Public Health, University of California Berkeley, Berkeley, CA, USA
| | - Rosario Tumino
- Cancer Registry and Histopathology Department, Provincial Health Authority (ASP 7), Ragusa, Italy
| | | | | | - Riccardo Polosa
- General Medicine, Department of Clinical & Experimental Medicine, University of Catania, Catania, Italy
| | - Paolo Vigneri
- Center of Oncology and Hematology, Department of Clinical & Experimental Medicine University of Catania, Catania, Italy
| | - Marco Nardini
- Department of Thoracic Surgery, St. James University Hospital, London, UK
| | - Sergio Castorina
- General and Thoracic Surgery, Morgagni Policlinic Hospital, Catania, Italy
| | - Francesco Basile
- General Surgery, University Hospital of Catania, Department of General Surgery and Medical Specialties, University of Catania, Catania, Italy
| | - Margherita Ferrante
- Department of Medical, Surgical and Advanced Technologies “G.F. Ingrassia”, University of Catania, Catania, Italy
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Paajanen J, Jaklitsch MT, Bueno R. Contemporary issues in the surgical management of pleural mesothelioma. J Surg Oncol 2023; 127:343-354. [PMID: 36630097 PMCID: PMC9839311 DOI: 10.1002/jso.27152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/10/2022] [Accepted: 11/11/2022] [Indexed: 01/12/2023]
Abstract
The surgical management of pleural mesothelioma (PM) can be divided into diagnostic, staging, palliation, and cytoreductive surgery. In the cytoreductive surgical setting, the combination of different treatment modalities has led to better outcomes than surgery alone. The scarcity of high-quality studies has led to heterogeneity in management of PM across the mesothelioma treatment centers. Here, we review the literature regarding the most important open questions and ongoing clinical trials.
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Affiliation(s)
- Juuso Paajanen
- The Thoracic Surgery Oncology laboratory and the International Mesothelioma Program (www.impmeso.org), Division of Thoracic Surgery and the Lung Center, Brigham and Women’s Hospital, and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Michael T. Jaklitsch
- The Thoracic Surgery Oncology laboratory and the International Mesothelioma Program (www.impmeso.org), Division of Thoracic Surgery and the Lung Center, Brigham and Women’s Hospital, and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Raphael Bueno
- The Thoracic Surgery Oncology laboratory and the International Mesothelioma Program (www.impmeso.org), Division of Thoracic Surgery and the Lung Center, Brigham and Women’s Hospital, and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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Proesmans V, Vandaele T, Van Slambrouck J, Wolthuis A, D Hoore A, Dekervel J, Van Cutsem E, Dresen R, De Hertogh G, Degezelle K, Van Raemdonck D, Nafteux P, Ceulemans LJ. Pleural decortication and hyperthermic intrathoracic chemotherapy for pseudomyxoma. Int J Hyperthermia 2022; 39:1153-1157. [PMID: 36049823 DOI: 10.1080/02656736.2022.2104938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Aim: Pleural dissemination of pseudomyxoma peritonei (PMP) is an extremely rare diagnosis, for which no standard therapy is available.Methods: We describe the successful treatment of a 67-year-old male diagnosed with left-sided intrapleural dissemination of PMP (low-grade appendiceal mucinous neoplasm), 2 years after treatment of abdominal PMP with cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy. Treatment consisted of extended pleural decortication (ePD) and oxaliplatin-based hyperthermic intrathoracic chemotherapy (HITHOC). The patient is doing well without complications or signs of recurrence, 26 months after thoracic surgery.Conclusion: ePD in combination with HITHOC is a valuable treatment for thoracic PMP.
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Affiliation(s)
- Viktor Proesmans
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Tom Vandaele
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Jan Van Slambrouck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases and Metabolism, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
| | - Albert Wolthuis
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Oncology, laboratory of Abdominal Surgical Oncology, KU Leuven, Leuven, Belgium
| | - André D Hoore
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Oncology, laboratory of Abdominal Surgical Oncology, KU Leuven, Leuven, Belgium
| | - Jeroen Dekervel
- Department of Gastro-Enterology, University Hospitals Leuven, Leuven, Belgium.,Department of Oncology, Laboratory of Clinical Digestive Oncology, KU Leuven, Leuven, Belgium
| | - Eric Van Cutsem
- Department of Gastro-Enterology, University Hospitals Leuven, Leuven, Belgium.,Department of Oncology, Laboratory of Clinical Digestive Oncology, KU Leuven, Leuven, Belgium
| | - Raphaëla Dresen
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium.,Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | - Gert De Hertogh
- Department of Imaging and Pathology, KU Leuven, Leuven, Belgium.,Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Karlien Degezelle
- Department of Cardiac Surgery, Division Perfusion, University Hospitals Leuven, Leuven, Belgium
| | - Dirk Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases and Metabolism, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
| | - Philippe Nafteux
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases and Metabolism, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
| | - Laurens J Ceulemans
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases and Metabolism, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
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Anobile DP, Montenovo G, Pecoraro C, Franczak M, Ait Iddouch W, Peters GJ, Riganti C, Giovannetti E. Splicing deregulation, microRNA and Notch aberrations: fighting the three-headed dog to overcome drug resistance in malignant mesothelioma. Expert Rev Clin Pharmacol 2022; 15:305-322. [PMID: 35533249 DOI: 10.1080/17512433.2022.2074835] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Malignant mesothelioma (MMe) is an aggressive rare cancer of the mesothelium, associated with asbestos exposure. MMe is currently an incurable disease at all stages mainly due to resistance to treatments. It is therefore necessary to elucidate key mechanisms underlying chemoresistance, in an effort to exploit them as novel therapeutic targets. AREAS COVERED Chemoresistance is frequently elicited by microRNA (miRNA) alterations and splicing deregulations. Indeed, several miRNAs, such as miR-29c, have been shown to exert oncogenic or oncosuppressive activity. Alterations in the splicing machinery might also be involved in chemoresistance. Moreover, the Notch signaling pathway, often deregulated in MMe, plays a key role in cancer stem cells formation and self-renewal, leading to drug resistance and relapses. EXPERT OPINION The prognosis of MMe in patients varies among different tumors and patient characteristics, and novel biomarkers and therapies are warranted. This work aims at giving an overview of MMe, with a special focus on state-of-the-art treatments and new therapeutic strategies against vulnerabilities emerging from studies on epigenetics factors. Besides, this review is also the first to discuss the interplay between miRNAs and alternative splicing as well as the role of Notch as new promising frontiers to overcome drug resistance in MMe.
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Affiliation(s)
- Dario P Anobile
- Department of Medical Oncology, VU University Medical Center, Cancer Center Amsterdam, 1081HV Amsterdam, Netherlands.,Department of Oncology, University of Torino, 10043 Orbassano, Italy
| | - Giulia Montenovo
- Department of Medical Oncology, VU University Medical Center, Cancer Center Amsterdam, 1081HV Amsterdam, Netherlands.,Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Camilla Pecoraro
- Department of Medical Oncology, VU University Medical Center, Cancer Center Amsterdam, 1081HV Amsterdam, Netherlands.,Dipartimento Di Scienze E Tecnologie Biologiche Chimiche E Farmaceutiche (STEBICEF), Università degli Studi di Palermo, Palermo, Italy
| | - Marika Franczak
- Department of Medical Oncology, VU University Medical Center, Cancer Center Amsterdam, 1081HV Amsterdam, Netherlands.,Department of Biochemistry, Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Widad Ait Iddouch
- Department of Medical Oncology, VU University Medical Center, Cancer Center Amsterdam, 1081HV Amsterdam, Netherlands
| | - Godefridus J Peters
- Department of Medical Oncology, VU University Medical Center, Cancer Center Amsterdam, 1081HV Amsterdam, Netherlands.,Department of Biochemistry, Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Chiara Riganti
- Department of Oncology, University of Torino, 10043 Orbassano, Italy
| | - Elisa Giovannetti
- Department of Medical Oncology, VU University Medical Center, Cancer Center Amsterdam, 1081HV Amsterdam, Netherlands.,Fondazione Pisana per la Scienza Pisa, 56100 Pisa, Italy
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Bos S, Ricciardi S, Caruana EJ, Öztürk NAA, Magouliotis D, Pompili C, Migliore M, Vos R, Meloni F, Elia S, Hellemons M. ERS International Congress 2021: highlights from Assembly 8 Thoracic Surgery and Lung Transplantation. ERJ Open Res 2022; 8:00649-2021. [PMID: 35615414 PMCID: PMC9125043 DOI: 10.1183/23120541.00649-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 02/22/2022] [Indexed: 11/05/2022] Open
Abstract
The thoracic surgery and lung transplantation assembly of the European Respiratory Society (ERS) is delighted to present the highlights from the 2021 International ERS Congress. We have selected four sessions that discussed recent advances across a wide range of topics: including digital health surveillance in thoracic surgery, emerging concepts in pulmonary metastasectomy, advances in mesothelioma care, and novel developments in lung graft allocation and monitoring. The sessions are summarised by early career members in close collaboration with the assembly faculty. We aim to give the reader an update on the highlights of the conference in the fields of thoracic surgery and lung transplantation.
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Hyperthermic Intrathoracic Chemotherapy (HITOC) after Cytoreductive Surgery for Pleural Malignancies-A Retrospective, Multicentre Study. Cancers (Basel) 2021; 13:cancers13184580. [PMID: 34572806 PMCID: PMC8470046 DOI: 10.3390/cancers13184580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 09/01/2021] [Accepted: 09/07/2021] [Indexed: 11/17/2022] Open
Abstract
Simple Summary There continues to be little research in the literature on perioperative outcomes after cytoreductive surgery (CRS) combined with intraoperative hyperthermic chemotherapy-lavage (HITOC) in patients with malignant pleural tumours. The aim of this multicentre study was to assess the results of the current practice in Germany so as to give recommendations to standardize the procedure. CRS with cisplatin-based HITOC can be performed with low major morbidity and a low rate of renal insufficiency, which was associated with the cisplatin dosage of irrigation. Abstract In the context of quality assurance, the objectives were to describe the surgical treatment and postoperative morbidity (particularly renal insufficiency). A retrospective, multicentre study of patients who underwent cytoreductive surgery (CRS) with cisplatin-based HITOC was performed. The study was funded by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation (GZ: RI 2905/3-1)). Patients (n = 350) with malignant pleural mesothelioma (n = 261; 75%) and thymic tumours with pleural spread (n = 58; 17%) or pleural metastases (n = 31; 9%) were analyzed. CRS was accomplished by pleurectomy/decortication (P/D: n = 77; 22%), extended P/D (eP/D: n = 263; 75%) or extrapleural pneumonectomy (EPP: n = 10; 3%). Patients received cisplatin alone (n = 212; 61%) or cisplatin plus doxorubicin (n = 138; 39%). Low-dose cisplatin (≤125 mg/m2 BSA) was given in 67% of patients (n = 234), and high-dose cisplatin (>125 mg/m2 BSA) was given in 33% of patients (n = 116). Postoperative renal insufficiency appeared in 12% of the patients (n = 41), and 1.4% (n = 5) required temporary dialysis. Surgical revision was necessary in 51 patients (15%). In-hospital mortality was 3.7% (n = 13). Patients receiving high-dose cisplatin were 2.7 times more likely to suffer from renal insufficiency than patients receiving low-dose cisplatin (p = 0.006). The risk for postoperative renal failure is dependent on the intrathoracic cisplatin dosage but was within an acceptable range.
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