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Yamashita Y, Yamazaki H, Kawaji Y, Tamura T, Hatamaru K, Itonaga M, Ashida R, Kitano M. Utility of a partially covered metal stent for salvage sealing therapy for bleeding caused by duodenal invasion of pancreatobiliary cancers: Case series. DEN OPEN 2024; 4:e253. [PMID: 37304247 PMCID: PMC10256867 DOI: 10.1002/deo2.253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 05/12/2023] [Accepted: 05/29/2023] [Indexed: 06/13/2023]
Abstract
Pancreatobiliary cancer-related gastrointestinal bleeding caused by duodenal invasion can be a life-threatening condition that is hard to control. It is unclear whether a covered self-expandable metal stent (CSEMS) is useful for hemostasis of bleeding related to advanced pancreatobiliary cancer. The aim of this study was to evaluate the utility of a CSEMS for hemostasis of bleeding caused by duodenal invasion of pancreatobiliary cancer. Between January 2020 and January 2022, seven patients in whom a duodenal CSEMS was inserted to control pancreatobiliary cancer-related bleeding were enrolled. The technical and clinical success rates with respect to hemostasis, procedure time, and adverse events were assessed. All patients were inoperable cases (six with pancreatic cancer [five, stage IV; one, stage III]; and one with gallbladder cancer [stage IV]) in whom CSEMs were inserted to treat refractory bleeding caused by cancer invasion. Hemostasis was achieved in all cases (100% [7/7]). The mean procedure time was 17 ± 7.9 min. There were no adverse events, including migration and rebleeding. No rebleeding occurred up until the time of death in any of the cases (mean follow-up period, 73 ± 27 days). Deployment of duodenal CSEMS is a useful salvage therapy for bleeding caused by advanced pancreatobiliary cancer invasion.
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Affiliation(s)
- Yasunobu Yamashita
- Second Department of Internal MedicineWakayama Medical UniversityWakayamaJapan
| | - Hirofumi Yamazaki
- Second Department of Internal MedicineWakayama Medical UniversityWakayamaJapan
| | - Yuki Kawaji
- Second Department of Internal MedicineWakayama Medical UniversityWakayamaJapan
| | - Takashi Tamura
- Second Department of Internal MedicineWakayama Medical UniversityWakayamaJapan
| | - Keiichi Hatamaru
- Second Department of Internal MedicineWakayama Medical UniversityWakayamaJapan
| | - Masahiro Itonaga
- Second Department of Internal MedicineWakayama Medical UniversityWakayamaJapan
| | - Reiko Ashida
- Second Department of Internal MedicineWakayama Medical UniversityWakayamaJapan
| | - Masayuki Kitano
- Second Department of Internal MedicineWakayama Medical UniversityWakayamaJapan
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Shibuki T, Fukushi K, Inoue K, Taira T, Satake T, Watanabe K, Sasaki M, Imaoka H, Mitsunaga S, Ikeda M. Covered self-expandable metallic stent placement for tumor bleeding from duodenal invasion in patients with unresectable pancreatic cancer. DEN OPEN 2024; 4:e361. [PMID: 38601268 PMCID: PMC11004547 DOI: 10.1002/deo2.361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 03/22/2024] [Accepted: 03/31/2024] [Indexed: 04/12/2024]
Abstract
Patients with unresectable pancreatic cancer often present with duodenal bleeding, a potentially life-threatening complication. In our case series of six unresectable pancreatic cancer patients with tumor bleeding, we explored the efficacy and safety of placement of a covered self-expandable metallic stent in the duodenum as a treatment option; we achieved a hemostasis rate of 67% (4/6), with a rebleeding rate of 50% (2/4). No complications occurred with stent placement, except for food impaction in one patient. Covered self-expandable metallic stent placement is a moderately effective treatment option for tumor bleeding in patients with unresectable pancreatic cancer. Although its hemostatic efficacy is limited, covered self-expandable metallic stent placement is safe and beneficial in some cases, warranting consideration in this disease setting with limited treatment options.
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Affiliation(s)
- Taro Shibuki
- Department of Hepatobiliary and Pancreatic OncologyNational Cancer Center Hospital EastChibaJapan
- Department for the Promotion of Drug and Diagnostic Development, Division of Drug and Diagnostic Development PromotionTranslational Research Support Office, National Cancer Center Hospital EastChibaJapan
| | - Ko Fukushi
- Department of Hepatobiliary and Pancreatic OncologyNational Cancer Center Hospital EastChibaJapan
| | - Kanae Inoue
- Department of Hepatobiliary and Pancreatic OncologyNational Cancer Center Hospital EastChibaJapan
| | - Tomonao Taira
- Department of Hepatobiliary and Pancreatic OncologyNational Cancer Center Hospital EastChibaJapan
| | - Tomoyuki Satake
- Department of Hepatobiliary and Pancreatic OncologyNational Cancer Center Hospital EastChibaJapan
| | - Kazuo Watanabe
- Department of Hepatobiliary and Pancreatic OncologyNational Cancer Center Hospital EastChibaJapan
| | - Mitsuhito Sasaki
- Department of Hepatobiliary and Pancreatic OncologyNational Cancer Center Hospital EastChibaJapan
| | - Hiroshi Imaoka
- Department of Hepatobiliary and Pancreatic OncologyNational Cancer Center Hospital EastChibaJapan
| | - Shuichi Mitsunaga
- Department of Hepatobiliary and Pancreatic OncologyNational Cancer Center Hospital EastChibaJapan
| | - Masafumi Ikeda
- Department of Hepatobiliary and Pancreatic OncologyNational Cancer Center Hospital EastChibaJapan
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3
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Shibuki T, Sasaki M, Yamaguchi S, Inoue K, Taira T, Satake T, Watanabe K, Imaoka H, Mitsunaga S, Fujisawa T, Tomizawa K, Oyoshi H, Nakamura M, Hojo H, Ikeda M. Palliative radiotherapy for tumor bleeding in patients with unresectable pancreatic cancer: a single-center retrospective study. Radiat Oncol 2023; 18:178. [PMID: 37907912 PMCID: PMC10617159 DOI: 10.1186/s13014-023-02367-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/23/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Patients with unresectable pancreatic cancer (PC) sometimes experience gastrointestinal bleeding (GIB) due to tumor invasion of the gastrointestinal tract (tumor bleeding); no standard treatment has been established yet for this complication. Palliative radiotherapy (PRT) could be promising, however, there are few reports of PRT for tumor bleeding in patients with unresectable PC. Therefore, we evaluated the outcomes of PRT for tumor bleeding in patients with unresectable PC. METHODS We reviewed the medical records of patients with unresectable PC diagnosed at our institution between May 2013 and January 2022, and identified patients with endoscopically confirmed tumor bleeding who had received PRT. PRT was administered at a total dose of 30 Grays (Gy) in 10 fractions, 20 Gy in 5 fractions, or 8 Gy in a single fraction, and the dose selection was left to the discretion of the attending radiation oncologists. RESULTS During the study period, 2562 patients were diagnosed as having unresectable PC at our hospital, of which 225 (8.8%) developed GIB. Among the 225 patients, 63 (2.5%) were diagnosed as having tumor bleeding and 20 (0.8%) received PRT. Hemostasis was achieved in 14 of the 20 patients (70%) who received PRT, and none of these patients developed grade 3 or more adverse events related to the PRT. The median time to hemostasis was 8.5 days (range 7-14 days). The rebleeding rate was 21.4% (3/14). The median hemoglobin level increased significantly (p < 0.001) from 5.9 to 9.1 g/dL, and the median volume of red blood cell transfusion tended (p = 0.052) to decrease, from 1120 mL (range 280-3360 mL) to 280 mL (range 0-5560 mL) following the PRT. The median overall survival (OS) was 52 days (95% confidence interval [CI] 39-317). Of the 14 patients in whom hemostasis was achieved following PRT, chemotherapy could be started/resumed in seven patients (50%), and the median OS in these patients was 260 days (95% CI 76-not evaluable [NE]). Three patients experienced rebleeding (21.4%), on days 16, 22, and 25, after the start of PRT. CONCLUSION This study showed that PRT is an effective and safe treatment modality for tumor bleeding in patients with unresectable PC.
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Affiliation(s)
- Taro Shibuki
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, Japan.
| | - Mitsuhito Sasaki
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, Japan
| | - Shota Yamaguchi
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, Japan
| | - Kanae Inoue
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, Japan
| | - Tomonao Taira
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, Japan
| | - Tomoyuki Satake
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, Japan
| | - Kazuo Watanabe
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, Japan
| | - Hiroshi Imaoka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, Japan
| | - Shuichi Mitsunaga
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, Japan
| | - Takeshi Fujisawa
- Department of Radiation Oncology and Particle Therapy, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, Japan
| | - Kento Tomizawa
- Department of Radiation Oncology and Particle Therapy, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, Japan
| | - Hidekazu Oyoshi
- Department of Radiation Oncology and Particle Therapy, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, Japan
| | - Masaki Nakamura
- Department of Radiation Oncology and Particle Therapy, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, Japan
| | - Hidehiro Hojo
- Department of Radiation Oncology and Particle Therapy, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, Japan
| | - Masafumi Ikeda
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, Japan
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Guan T, Laguna A, Soares A, Legasto CS, Block S, Saunders IM, Alvarez K, Pon T, Patel N, Mahajan A, Lee A. Evaluation of direct oral anticoagulants versus low molecular weight heparins for venous thromboembolism treatment in patients with gastrointestinal malignancies. J Thromb Thrombolysis 2023; 56:439-446. [PMID: 37421494 DOI: 10.1007/s11239-023-02858-y] [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] [Accepted: 06/24/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Direct oral anticoagulant (DOAC) use in cancer-associated venous thromboembolism (CA-VTE) has increased due to updates in recent guidelines and literature. However, select guidelines caution against DOAC use in patients with gastrointestinal (GI) malignancies due to reported increased bleeding events. The objective of this study was to compare the safety and effectiveness of DOACs versus low-molecular-weight heparins (LMWHs) for CA-VTE treatment in patients with GI malignancies. PATIENTS AND METHODS This multicenter, retrospective cohort study included patients with primary GI malignancies who received therapeutic anticoagulation with a DOAC or LMWH for CA-VTE between January 1, 2018, and December 31, 2019. The primary outcome was the incidence rate of bleeding events (major, clinically relevant non-major, or minor bleeding events) within a 12-month period following the initiation of therapeutic anticoagulation. The secondary endpoint was the incidence rate of recurrent VTE events within a 12-month period following the start of therapeutic anticoagulation. RESULTS After screening, 141 patients met inclusion criteria. The incidence rate of all bleeding events significantly differed between DOAC (4.98 events/100 person-months) and LWMH (10.2 events/100 person-months) recipients. The corresponding incidence rate ratio (IRR) with the DOAC group serving as the reference was 2.05 (p = 0.01), with the majority of bleeds in both groups presenting as minor bleeds. No difference was found between the incidence rate of recurrent VTE within a 12-month period of starting therapeutic anticoagulation between groups (IRR 3.08, p = 0.06). CONCLUSION Our results suggest that DOACs do not pose an additional bleeding risk compared to LMWH in patients with certain GI malignancies. Careful selection of DOAC therapy with respect to bleeding risk is still warranted.
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Affiliation(s)
- Tiffany Guan
- Department of Pharmaceutical Services, University of California, San Francisco Medical Center, San Francisco, CA, USA.
| | - Arianna Laguna
- Department of Pharmacy Services, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Alisha Soares
- Department of Pharmacy, University of California, San Diego Health, La Jolla, CA, USA
| | - Carlo S Legasto
- Department of Pharmaceutical Services, University of California, San Francisco Medical Center, San Francisco, CA, USA
| | - Shanna Block
- Department of Pharmacy, University of California, San Diego Health, La Jolla, CA, USA
| | - Ila M Saunders
- Skaggs School of Pharmacy & Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, USA
| | - Kathryn Alvarez
- Department of Pharmacy Services, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Tiffany Pon
- Department of Pharmacy Services, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Nimish Patel
- Skaggs School of Pharmacy & Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, USA
| | - Anjlee Mahajan
- Department of Hematology/Oncology, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Angela Lee
- Department of Pharmaceutical Services, University of California, San Francisco Medical Center, San Francisco, CA, USA
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Willems RAL, Michiels N, Lanting VR, Bouwense S, van den Broek BLJ, Graus M, Klok FA, Groot Koerkamp B, de Laat B, Roest M, Wilmink JW, van Es N, Mieog JSD, Ten Cate H, de Vos-Geelen J. Venous Thromboembolism and Primary Thromboprophylaxis in Perioperative Pancreatic Cancer Care. Cancers (Basel) 2023; 15:3546. [PMID: 37509209 PMCID: PMC10376958 DOI: 10.3390/cancers15143546] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/27/2023] [Accepted: 07/06/2023] [Indexed: 07/30/2023] Open
Abstract
Recent studies have shown that patients with pancreatic ductal adenocarcinoma (PDAC) treated with neoadjuvant chemo(radio)therapy followed by surgery have an improved outcome compared to patients treated with upfront surgery. Hence, patients with PDAC are more and more frequently treated with chemotherapy in the neoadjuvant setting. PDAC patients are at a high risk of developing venous thromboembolism (VTE), which is associated with decreased survival rates. As patients with PDAC were historically offered immediate surgical resection, data on VTE incidence and associated preoperative risk factors are scarce. Current guidelines recommend primary prophylactic anticoagulation in selected groups of patients with advanced PDAC. However, recommendations for patients with (borderline) resectable PDAC treated with chemotherapy in the neoadjuvant setting are lacking. Nevertheless, the prevention of complications is crucial to maintain the best possible condition for surgery. This narrative review summarizes current literature on VTE incidence, associated risk factors, risk assessment tools, and primary thromboprophylaxis in PDAC patients treated with neoadjuvant chemo(radio)therapy.
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Affiliation(s)
- R A L Willems
- Department of Functional Coagulation, Synapse Research Institute, 6217 KD Maastricht, The Netherlands
- Thrombosis Expert Center Maastricht, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- Department of Internal Medicine, Section Medical Oncology, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- CARIM, School for Cardiovascular Diseases, 6229 ER Maastricht, The Netherlands
| | - N Michiels
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - V R Lanting
- Department of Internal Medicine, Section Vascular Medicine, University of Amsterdam, Amsterdam UMC Location, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, 1081 HV Amsterdam, The Netherlands
- Tergooi Hospitals, Internal Medicine, 1201 DA Hilversum, The Netherlands
| | - S Bouwense
- Department of Surgery, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- NUTRIM, Maastricht University Medical Center, 6229 ER Maastricht, The Netherlands
| | - B L J van den Broek
- Department of Surgery, Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands
| | - M Graus
- Department of Internal Medicine, Section Medical Oncology, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- GROW, Maastricht University Medical Center, 6229 ER Maastricht, The Netherlands
| | - F A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - B Groot Koerkamp
- Department of Surgery, Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands
| | - B de Laat
- Department of Functional Coagulation, Synapse Research Institute, 6217 KD Maastricht, The Netherlands
- CARIM, School for Cardiovascular Diseases, 6229 ER Maastricht, The Netherlands
- Department of Platelet Pathophysiology, Synapse Research Institute, 6217 KD Maastricht, The Netherlands
| | - M Roest
- Department of Platelet Pathophysiology, Synapse Research Institute, 6217 KD Maastricht, The Netherlands
| | - J W Wilmink
- Cancer Center Amsterdam, 1081 HV Amsterdam, The Netherlands
- Department of Medical Oncology, Amsterdam University Medical Center, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - N van Es
- Department of Internal Medicine, Section Vascular Medicine, University of Amsterdam, Amsterdam UMC Location, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, 1081 HV Amsterdam, The Netherlands
| | - J S D Mieog
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - H Ten Cate
- Thrombosis Expert Center Maastricht, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- CARIM, School for Cardiovascular Diseases, 6229 ER Maastricht, The Netherlands
| | - J de Vos-Geelen
- Department of Internal Medicine, Section Medical Oncology, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- GROW, Maastricht University Medical Center, 6229 ER Maastricht, The Netherlands
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Choi JH, Lee KJ, Paik WH, Park N, Chun JW, Lee SH, Ryu JK, Kim YT. Acetylsalicylic acid for metal stent in malignant distal common bile duct obstruction: A randomized controlled trial. Hepatobiliary Pancreat Dis Int 2022; 21:493-499. [PMID: 34937686 DOI: 10.1016/j.hbpd.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 11/24/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Endoscopic biliary drainage is the treatment of choice for patients with malignant distal common bile duct obstruction. Self-expandable metal stents have clinical advantages including an increased duration of patency that may be prolonged by acetylsalicylic acid (ASA) use. The aim of this study was to investigate whether ASA had a positive effect on the patency of self-expandable metal stents compared with placebo. METHODS This prospective, multicenter, double-blinded, and randomized placebo-controlled trial was conducted from October 2017 to May 2020 in Korea. Patients who underwent palliative endoscopic biliary drainage with self-expandable metal stents for malignant distal bile duct obstruction were enrolled, and allocated to ASA treatment or placebo. The study outcomes were the rate of stent dysfunction at 6 months, duration of stent patency, risk factors for stent dysfunction, and any adverse events. RESULTS Interim analysis included 24 and 28 patients in the ASA and placebo groups, respectively. There was no significant difference between the ASA and placebo groups in stent dysfunction (25.0% vs. 20.7%, P = 0.761) or the duration of stent patency (150.97 ± 10.55 vs. 158.07 ± 8.70 days, P = 0.497). Six patients experienced suspected ASA-related adverse events, and there was one lethal case. CONCLUSIONS ASA did not prolong stent patency. This study was terminated early because of the possibility of serious adverse events related to ASA treatment of these patients receiving palliative care.
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Affiliation(s)
- Jin Ho Choi
- Department of Internal Medicine, Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Kyong Joo Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Woo Hyun Paik
- Department of Internal Medicine, Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea.
| | - Namyoung Park
- Department of Internal Medicine, Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Won Chun
- Department of Internal Medicine, Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Hyub Lee
- Department of Internal Medicine, Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Ji Kon Ryu
- Department of Internal Medicine, Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Yong-Tae Kim
- Department of Internal Medicine, Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Kamposioras K, Geraghty J, Appleyard J, Dawod M, Papadimitriou K, Lamarca A, Anthoney A. Pancreaticobiliary Malignancies in the Emergency Room: Management of Acute Complications and Oncological Emergencies. J Gastrointest Cancer 2021; 53:1050-1065. [PMID: 34648136 PMCID: PMC9630225 DOI: 10.1007/s12029-021-00718-7] [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] [Accepted: 09/22/2021] [Indexed: 11/29/2022]
Abstract
Background Management of pancreaticobiliary (PB) malignancies remains a clinical challenge. In this review, we focus on the management of oncological emergencies in PB malignancies and the potential complication of associated therapeutic interventions. Methods Biobliographic review of current evidence on the management of oncological emergencies, their potential complications, as well as synthesis of recommendations was performed. The pathogenesis, frequency, related symptoms as well as appropriate investigations are presented. Results The oncologic emergencies in PB patients were summarised in six categories: (1) hematological (including febrile neutropaenia, thrombocytopenia, coagulopathies), (2) gastrointestinal (gastric outlet and biliary obstruction, gastrointestinal bleeding), (3) thromboembolic events, (4) ascites, (5) metabolic disorders and (6) neurologic complications. The pathogenesis, frequency, related symptoms as well as appropriate investigations are also presented. Conclusion Patients with PB malignancies are at increased risk of a wide variation of medical emergencies. Clinical knowledge, early recognition and collaboration with the relevant specialties are critical to manage these complications effectively, tailoring overall management around the actual prognosis and individuals’ expectations.
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Affiliation(s)
| | - Joe Geraghty
- Department of Gastroenterology, Manchester Royal Infirmary, Manchester, UK
| | | | - Mohammed Dawod
- The Christie NHS Foundation Trust, Manchester, Greater Manchester, UK
| | | | - Angela Lamarca
- The Christie NHS Foundation Trust, Manchester, Greater Manchester, UK.,Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Alan Anthoney
- Leeds Institute of Medical Research, St James' Institute of Oncology, St James' University Hospital, University of Leeds, Leeds, LS9 7TF, UK.
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Minhem MA, Nakshabandi A, Mirza R, Alsamman MA, Mattar MC. Gastrointestinal hemorrhage in the setting of gastrointestinal cancer: Anatomical prevalence, predictors, and interventions. World J Gastrointest Endosc 2021; 13:391-406. [PMID: 34630889 PMCID: PMC8474699 DOI: 10.4253/wjge.v13.i9.391] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/27/2021] [Accepted: 08/06/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Gastrointestinal hemorrhage (GIH) is a common complication with gastrointestinal cancers (GIC). There is no comprehensive research that examines GIH in different types of GIC.
AIM To study the prevalence, predictors, and interventions of GIH based on the anatomical location of GIC.
METHODS This is a retrospective analysis of the 2016-2018 National Inpatient Sample database, the largest inpatient care database in the United States. All adult inpatients (≥ 18-year-old) were included. ICD-10-CM codes were used to identify patients with GIH and GIC. Prevalence of GIH was obtained based on the anatomical location of GIC. Predictors of GIH in the GIC population were studied using multivariate analysis. Interventions including endoscopy were compared to the non-intervention group to determine the differences in inpatient mortality.
RESULTS Out of a total of 18173885 inpatients, 321622 (1.77%) cases had a diagnosis of GIC. Within GIC patients, 30507 (9.5%) inpatients had GIH, which was significantly (P < 0.001) more than the prevalence of GIH in patients without GIC (3.4%). The highest to lowest GIH rates are listed in the following order: Stomach cancer (15.7%), liver cancer (13.0%), small bowel cancer (12.7%), esophageal cancer (9.1%), colorectal cancer (9.1%), pancreatic cancer (7.2%), bile duct cancer (6.0%), and gallbladder cancer (5.1%). Within gastric cancer, the GIH rate ranged from 14.8% in cardia cancer to 25.5% in fundus cancer. Within small bowel cancers, duodenal cancers had a higher GIH rate (15.6%) than jejunal (11.1%) and ileal cancers (5.7%). Within esophageal cancers, lower third cancers had higher GIH (10.7%) than the middle third (8.0%) or upper third cancers (6.2%). When studying the predictors of GIH in GIC, socioeconomic factors such as minority race and less favorable insurances (Medicaid and self-pay) were associated with significantly higher GIH on multivariate analysis (P < 0.01). Chemotherapy and immunotherapy were also identified to have a lower risk for GIH [odds ratios (OR) = 0.74 (0.72-0.77), P < 0.001]. Out of 30507 GIC inpatients who also had GIH, 16267 (53.3%) underwent an endoscopic procedure, i.e., upper endoscopy or colonoscopy. Inpatient mortality was significantly lower in patients who underwent endoscopy compared to no endoscopy [5.5% vs 14.9%, OR = 0.42 (0.38-0.46), P < 0.001].
CONCLUSION The prevalence of GIH in patients with GIC varies significantly based on the tumor’s anatomical location. Endoscopy, which appears to be associated with a substantial reduction in inpatient mortality, should be offered to GIC patients with GIH. Nevertheless, the decision on intervention in the GIC population should be tailored to individual patient's goals of care, the benefit on overall care, and long-term survival.
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Affiliation(s)
- Mohamad A Minhem
- Internal Medicine, Loyola University Medical Center, Maywood, IL 60153, United States
| | - Ahmad Nakshabandi
- Department of Gastroenterology, Medstar Georgetown University Hospital, Washington, DC 20007, United States
| | - Rabia Mirza
- School of Medicine, Georgetown University, Washington, DC 20007, United States
| | - Mohd Amer Alsamman
- Department of Gastroenterology, Medstar Georgetown University Hospital, Washington, DC 20007, United States
| | - Mark C Mattar
- Department of Gastroenterology, Medstar Georgetown University Hospital, Washington, DC 20007, United States
- School of Medicine, Georgetown University, Washington, DC 20007, United States
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9
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Aguilera Munoz L, de Mestier L, Lamallem H, Jaïs B, Maire F, Lévy P, Rebours V, Hammel P. Gastrointestinal bleeding in patients with pancreatic cancer: Causes and haemostatic treatments. United European Gastroenterol J 2020; 8:1106-1114. [PMID: 32615874 DOI: 10.1177/2050640620939788] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Gastrointestinal bleeding is a rare but severe complication of pancreatic ductal adenocarcinoma. OBJECTIVE The purpose of this study was to describe the causes and treatments of non-postoperative gastrointestinal bleeding in patients with pancreatic ductal adenocarcinoma, and explore the parameters associated with therapeutic effectiveness. METHODS This was a single-centre observational retrospective study (2000-2017) with data collected from the prospectively coded diagnostic hospital's database system including patients with pancreatic ductal adenocarcinoma who had a gastrointestinal bleeding episode. Effectiveness of haemostatic treatment was assessed according to transfusion requirements and immediate and long-term haemostatic efficacy; the latter defined as no bleeding recurrence. RESULTS The population included 72 patients with pancreatic ductal adenocarcinoma who had 94 episodes of gastrointestinal bleeding. The main causes of gastrointestinal bleeding were gastroduodenal tumour invasion (56.4%) and oesophageal variceal bleeding due to left-sided portal hypertension (19.1%). In cases of gastrointestinal bleeding caused by tumour invasion, the main treatment was therapeutic endoscopy (41.5%). Among patients who had gastrointestinal bleeding by tumour invasion treated by endoscopy or radiation therapy, haemostatic immediate efficacy rates were 70.6% and 100%, respectively. Bleeding recurrence rates were 35.3% and 25.0%, for patients treated by endoscopy or radiation therapy, respectively, for a first episode of gastrointestinal bleeding by tumour invasion. Transfusion requirements, before and after treatment, were not different in patients treated by haemostatic radiation therapy for gastrointestinal bleeding by tumour invasion compared to other treatments (odds ratio 0.3, 95% CI (0.06-1.59); p = 0.16). The median survival after all-cause gastrointestinal bleeding was 2.72 months (1.43-4.01). CONCLUSION Gastroduodenal tumour invasion was the main cause of gastrointestinal bleeding in patients with pancreatic ductal adenocarcinoma; haemostatic radiation therapy is a potential interesting option for gastrointestinal bleeding treatment in this context.
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Affiliation(s)
- Lina Aguilera Munoz
- Department of Digestive Oncology, Beaujon Hospital, University of Paris, Clichy, France.,Department of Pancreatology, Beaujon Hospital, University of Paris, Clichy, France
| | - Louis de Mestier
- Department of Pancreatology, Beaujon Hospital, University of Paris, Clichy, France
| | - Hanah Lamallem
- Department of Radiotherapy, Hartmann's Oncology Center, Levallois-Perret, France
| | - Bénédicte Jaïs
- Department of Digestive Endoscopy, Beaujon Hospital, University of Paris, Clichy, France
| | - Frédérique Maire
- Department of Pancreatology, Beaujon Hospital, University of Paris, Clichy, France
| | - Philippe Lévy
- Department of Pancreatology, Beaujon Hospital, University of Paris, Clichy, France
| | - Vinciane Rebours
- Department of Pancreatology, Beaujon Hospital, University of Paris, Clichy, France
| | - Pascal Hammel
- Department of Digestive Oncology, Beaujon Hospital, University of Paris, Clichy, France
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Maraveyas A, Haque F, Muazzam IA, Ilyas W, Bozas G. Increased dose primary thromboprophylaxis in ambulatory patients with advanced pancreatic ductal adenocarcinoma, a single centre cohort study. Thromb J 2020; 18:9. [PMID: 32514256 PMCID: PMC7257220 DOI: 10.1186/s12959-020-00222-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 05/11/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Advanced pancreatic ductal adenocarcinoma (aPDAC) patients have a lifetime all type thromboembolic event (ATTE) rate of 25-35%. Efficacy and safety of increased dose primary thromboprophylaxis (IDPTP) with low molecular heparin (LMWH) given for 3 months has been shown in two prospective randomized trials. OBJECTIVES To report on efficacy -reduction of all type thromboembolic events (ATTE)-, safety -incidence of Major Bleeding (MB)- and compliance in a single-centre cohort of aPDAC patients receiving first line chemotherapy and LMWH-IDPTP. METHODS From May 2009 to October 2016, 82 patients received IDPTP -LMWH with dalteparin. Schedule: 55 kg and below: 7500 IU, between 55 and 80 kg: 10,000 IU, above 80 kg: 12,500 IU. MB is reported using the International Society of Thrombosis and Haemostasis (ISTH) criteria. ATTE was defined as any arterial or venous event, incidental or clinically symptomatic, including visceral VTE. RESULTS Mean and median time on dalteparin was 10.2 (95%CI 8.1, 12.4) and 8.0 (95%CI 6.2, 9.7) months respectively. ATTE was observed in 7 (8.5%) of patients, with a median time on IDPTP of 6.2 months (95% CI 10.0, 13.2). MB was seen in 10 (12.2%) patients with a median time on IDPTP of 4.5 months (95% CI 1.6, 7.4). Six major bleeds (60%) were the direct or indirect result of aPDAC. Eighty-one patients had died at the time of data collection with a median overall survival time of 8.7 months (95%CI 6.4, 11.0). Thromboembolism and bleeding were late events. No impact of thromboembolism or bleeding on overall survival was observed. CONCLUSIONS IDPTP-dalteparin was associated with lower ATTE occurrence rates than expected and comparable major bleeding rates. ATTE and MB were late events, the majority of MB was from direct or indirect result of locally progressing aPDAC. Since these conditions can frequently arise in aPDAC, IDPTP should be regularly reviewed beyond 3 months.
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Affiliation(s)
- Anthony Maraveyas
- Queen’s Centre for Oncology and Haematology, Castle Hill Hospital, Hull University Teachng Hospitals (HUTH), Cottingham, HU16 5JQ UK
- Joint Centre for Cancer Studies, Faculty of Health Sciences, The Hull York Medical School, University of Hull, Cottingham, HU6 7RX UK
| | - Farzana Haque
- Queen’s Centre for Oncology and Haematology, Castle Hill Hospital, Hull University Teachng Hospitals (HUTH), Cottingham, HU16 5JQ UK
- Joint Centre for Cancer Studies, Faculty of Health Sciences, The Hull York Medical School, University of Hull, Cottingham, HU6 7RX UK
| | - Iqtedar Ahmed Muazzam
- Queen’s Centre for Oncology and Haematology, Castle Hill Hospital, Hull University Teachng Hospitals (HUTH), Cottingham, HU16 5JQ UK
| | - Waqas Ilyas
- Queen’s Centre for Oncology and Haematology, Castle Hill Hospital, Hull University Teachng Hospitals (HUTH), Cottingham, HU16 5JQ UK
| | - George Bozas
- Queen’s Centre for Oncology and Haematology, Castle Hill Hospital, Hull University Teachng Hospitals (HUTH), Cottingham, HU16 5JQ UK
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11
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Afzal A, Suhong L, Gage BF, Schoen MW, Carson K, Thomas T, Sanfilippo K. Splanchnic vein thrombosis predicts worse survival in patients with advanced pancreatic cancer. Thromb Res 2019; 185:125-131. [PMID: 31812026 DOI: 10.1016/j.thromres.2019.11.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 11/11/2019] [Accepted: 11/19/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Pancreatic cancer is a thrombogenic malignancy with nearly half of venous thrombotic events occurring in the splanchnic circulation. The effect of splanchnic vein thrombosis on mortality in pancreatic cancer is unknown. We studied the effect of splanchnic vein thrombosis on mortality in veterans with advanced pancreatic adenocarcinoma, and explored the association of anticoagulant therapy on mortality and hemorrhage. METHODS Using International Classification of Diseases (ICD) codes, we identified eligible patients and outcomes in the Veterans Health Administration database. Using Cox proportional hazards regression, we analyzed the association between splanchnic vein thrombosis and mortality among patients with advanced pancreatic cancer. We used propensity score inverse probability-of-treatment weighting to balance the groups who did and did not receive anticoagulation. To understand the role of anticoagulant therapy, we used Cox proportional hazards regression to analyze mortality and competing risk analysis to assess the risk of hemorrhage. RESULTS Of the patients with advanced pancreatic cancer (N = 6164), 122 developed splanchnic vein thrombosis. Splanchnic vein thrombosis was associated with a two-fold increase in mortality, aHR 2.02, 95% CI 1.65-2.47. The finding held true after restricting the analysis to patients undergoing treatment for pancreatic cancer, and after adjusting for immortal time bias by a 30-day landmark analysis. Anticoagulant therapy did not affect mortality (aHR 0.99, 95% CI 0.65-1.51), and increased the risk of hemorrhage (aHR 2.7, 95% CI 1.02-7.07). CONCLUSION Splanchnic vein thrombosis predicts worse survival in patients with advanced pancreatic adenocarcinoma. Anticoagulant therapy may not mitigate this increased mortality, and increases the risk of hemorrhage.
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Affiliation(s)
- Amber Afzal
- St Louis Veterans Health Administration Medical Center Research Service, St. Louis, MO, United States of America; Division of Hematology, Department of Medicine, Washington University School of Medicine in St Louis, MO, United States of America.
| | - Luo Suhong
- St Louis Veterans Health Administration Medical Center Research Service, St. Louis, MO, United States of America
| | - Brian F Gage
- Division of General Medical Sciences, Department of Medicine, Washington University School of Medicine in St Louis, MO, United States of America
| | - Martin W Schoen
- St Louis Veterans Health Administration Medical Center Research Service, St. Louis, MO, United States of America
| | - Kenneth Carson
- St Louis Veterans Health Administration Medical Center Research Service, St. Louis, MO, United States of America
| | - Theodore Thomas
- St Louis Veterans Health Administration Medical Center Research Service, St. Louis, MO, United States of America
| | - Kristen Sanfilippo
- St Louis Veterans Health Administration Medical Center Research Service, St. Louis, MO, United States of America; Division of Hematology, Department of Medicine, Washington University School of Medicine in St Louis, MO, United States of America
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12
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Arif H, Suchniak-Mussari K, Cothron K, Toney R. Duodenal Invasion of Pancreatic Cancer Resulting in Hematemesis. J Gastrointest Cancer 2018; 50:960-961. [PMID: 30014262 DOI: 10.1007/s12029-018-0143-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Hamza Arif
- Department of Internal Medicine, Allegheny General Hospital, 320 E North Ave, Pittsburgh, PA, 15212, USA.
| | - Kristen Suchniak-Mussari
- Department of Gastroenterology, Hepatology and Nutrition, Allegheny General Hospital, 320 E North Ave, Pittsburgh, PA, 15212, USA
| | - Kyle Cothron
- Department of Radiology, Allegheny General Hospital, 320 E North Ave, Pittsburgh, PA, 15212, USA
| | - Rachel Toney
- Department of Gastroenterology, Hepatology and Nutrition, Allegheny General Hospital, 320 E North Ave, Pittsburgh, PA, 15212, USA
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13
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Advances in managing and preventing thromboembolic disease in cancer patients. Curr Opin Support Palliat Care 2018; 11:347-354. [PMID: 29068809 DOI: 10.1097/spc.0000000000000309] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW To update on new data for low-molecular weight heparins (LMWHs) and the direct oral anticoagulants (DOACs) for the treatment and prevention of cancer-associated thrombosis (CAT), to discuss progress with the risk-adaptive management scores (RAMS) and update on increased dose primary thromboprophylaxis (IDPTP). RECENT FINDINGS In a pooled meta-analysis of 1132 cancer patients who received DOACs vs. vitamin K analogues (VKAs), recurrence of venous thromboembolism (VTE) was reduced from 6.0% on VKA schedules to 3.9% on DOACs. In a randomized trial of warfarin vs. once daily sc. tinzaparin (175 IU/kg), cumulative 6-month VTE incidence reduced from 10.5 to 7.2% [hazard ratio, 0.65 (95% confidence interval, 0.41-1.03); P = 0.07]. Despite early suggestions that DOACs may have a role in CAT, 3-6 months of LMWH remain the standard for initial treatment of CAT. A prospective comparison of RAMS found the Vienna CATS or the PROTECHT scores superior to the Khorana score but concluded that RAMS did not perform well enough to be used in the clinic. An efficacy scale of LMWHs in pancreatic cancer facilitates IDPTP. Practical implementation of IDPTP was needed to control the 40% VTE incidence of the HALO-109-202 study in metastatic pancreatic cancer. SUMMARY DOACs have some encouraging data, but LMWHs remain the standard for CAT treatment. RAMS generated to predict VTE occurrence or recurrence are still of unproven significance and IDPTP for advanced pancreatic cancer has tools and guidance for implementation.
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Mehta AJ. Alcoholism and critical illness: A review. World J Crit Care Med 2016; 5:27-35. [PMID: 26855891 PMCID: PMC4733453 DOI: 10.5492/wjccm.v5.i1.27] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 10/07/2015] [Accepted: 12/04/2015] [Indexed: 02/06/2023] Open
Abstract
Alcohol is the most commonly used and abused drug in the world, and alcohol use disorders pose a tremendous burden to healthcare systems around the world. The lifetime prevalence of alcohol abuse in the United States is estimated to be around 18%, and the economic consequences of these disorders are staggering. Studies on hospitalized patients demonstrate that about one in four patients admitted to critical care units will have alcohol-related issues, and unhealthy alcohol consumption is responsible for numerous clinical problems encountered in intensive care unit (ICU) settings. Patients with alcohol use disorders are not only predisposed to developing withdrawal syndromes and other conditions that often require intensive care, they also experience a considerably higher rate of complications, longer ICU and hospital length of stay, greater resource utilization, and significantly increased mortality compared to similar critically ill patients who do not abuse alcohol. Specific disorders seen in the critical care setting that are impacted by alcohol abuse include delirium, pneumonia, acute respiratory distress syndrome, sepsis, gastrointestinal hemorrhage, trauma, and burn injuries. Despite the substantial burden of alcohol-induced disease in these settings, critical care providers often fail to identify individuals with alcohol use disorders, which can have significant implications for this vulnerable population and delay important clinical interventions.
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