A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score

BACKGROUND

Prophylaxis of venous thromboembolism (VTE) in hospitalized medical patients is largely underused. We sought to assess the value of a simple risk assessment model (RAM) for the identification of patients at risk of VTE.

METHODS

In a prospective cohort study, 1180 consecutive patients admitted to a department of internal medicine in a 2-year period were classified as having a high or low risk of VTE according to a predefined RAM. They were followed-up for up to 90 days to assess the occurrence of symptomatic VTE complications. The primary study outcome was to assess the adjusted hazard ratio (HR) of VTE in high-risk patients who had adequate in-hospital thromboprophylaxis in comparison with those who did not, and that of VTE in the latter group in comparison with low-risk patients.

RESULTS

Four hundred and sixty-nine patients (39.7%) were labelled as having a high risk of thrombosis. VTE developed in four of the 186 (2.2%) who received thromboprophylaxis, and in 31 of the 283 (11.0%) who did not (HR of VTE, 0.13; 95% CI, 0.04-0.40). VTE developed also in two of the 711 (0.3%) low-risk patients (HR of VTE in high-risk patients without prophylaxis as compared with low-risk patients, 32.0; 95% CI, 4.1-251.0). Bleeding occurred in three of the 186 (1.6%) high-risk patients who had thromboprophylaxis.

CONCLUSIONS

Our RAM can help discriminate between medical patients at high and low risk of VTE. The adoption of adequate thromboprophylaxis in high-risk patients during hospitalization leads to longstanding protection against thromboembolic events with a low risk of bleeding.

Effects of blood-pressure measurement by the doctor on patient's blood pressure and heart rate

Changes in blood pressure in 10 or 15 min periods during which a doctor repeatedly measured blood pressure by the cuff method were monitored by a continuous intra-arterial recorder. In almost all the 48 normotensive and hypertensive subjects tested the doctor's arrival at the bedside induced immediate rises in systolic and diastolic blood pressures peaking within 1 to 4 min (mean 26.7 +/- 2.3 mm Hg and 14.9 +/- 1.6 mm Hg above pre-visit values). There were large differences between individuals in the peak response (range, 4--75 mm Hg systolic and 1--36 mm Hg diastolic) unrelated to age, sex, baseline blood pressure, or blood-pressure variability. There was concomitant tachycardia (average peak response 15.9 +/- 1.5 beats/min, range 4--45 beats/min) which was only slightly correlated with the blood-pressure rise. After the peak response blood pressure declined and at the end of the visit was only slightly above the pre-visit level. A second visit by the same doctor did not change the average size of the early pressor response or the slope of its subsequent decline.

Plasma Paraoxonase, Health, Inflammatory Conditions, and Liver Function in Transition Dairy Cows

Paraoxonase (PON) is a liver protein with hydrolase activity that is released into the blood stream. Paraoxonase may serve as an index of liver function because it is drastically reduced in chronic liver damage. Sixty-seven periparturient dairy cows were used to evaluate the relationship between plasma PON, health problems, inflammatory conditions, and liver function. Baseline plasma PON concentrations during the first 30 d in milk (DIM) were retrospectively used to group cows into quartiles. Metabolic profile, lipid metabolites (e.g., nonesterified fatty acids, beta-hydroxybutyrate), inflammatory indices (haptoglobin, ceruloplasmin), low and high density lipoprotein cholesterol, vitamin A, vitamin E, reactive oxygen metabolites, total antioxidants, and PON in plasma were measured 2 wk before to 8 wk after calving. Weekly milk yield, body condition score, and all health problems were recorded. After parturition (7 DIM), cows in the lower PON group had the lowest plasma concentrations of negative acute phase proteins compared with the higher PON group for retinol binding protein (23.2 +/- 2.86 vs. 36.0 +/- 2.96 microg/dL of vitamin A), albumin (31.6 +/- 0.73 vs. 33.9 +/- 0.75 g/L), total cholesterol (2.04 +/- 0.30 vs. 2.45 +/- 0.42 mmol/L), and the highest concentrations of haptoglobin (0.67 vs. 0.24 +/- 0.03 g/L; positive acute phase protein) and globulins (37.2 vs. 32.3 +/- 1.4 g/L). Plasma bilirubin was highest in the cows (10.1 vs. 6.2 +/- 0.6 micromol/L) in the lowest PON quartile. Plasma PON was negatively correlated with haptoglobin (r = -0.39) and bilirubin (r = -0.42) and positively correlated with retinol binding protein (r = 0.54), albumin (r = 0.38), and cholesterol (r = 0.55) fractions. A total of 82.3% of cows in the lower quartile and no cows in the upper quartile experienced serious inflammation. Lower quartile cows produced 28.1 +/- 10.3 kg of milk/d; whereas upper quartile cows produced 38.3 +/- 7.7 kg of milk/d during the first 30 DIM. A reduction in the ability of the liver to cope with the increased metabolic demand near parturition in dairy cows can be diagnosed using changes in baseline plasma PON.

Development of functionalized superparamagnetic iron oxide nanoparticles for interaction with human cancer cells

Our goal is to develop, characterize and optimize functionalized super paramagnetic iron oxide nanoparticles (SPION) demonstrating the capacity to be internalized by human cancer cells. SPION (mean diameter 9nm) were coated with various ratios to iron oxide of either polyvinyl alcohol (PVA), carboxylate-functionalized PVA, thiol-functionalized PVA and amino-functionalized PVA (amino-PVA). The interaction with cells and cytotoxicity of the SPION preparations were determined using human melanoma cells. From the four functionalized SPION preparations, only the amino-PVA SPION demonstrated the capacity to interact with, and were not cytotoxic to, human melanoma cells. This interaction with melanoma cells was dependent on the amino-PVA to iron oxide ratio, was an active and saturable mechanism displayed by all cells in a culture. These functionalized SPION were characterized by transmission electron microscopy and electrophoretic mobility. The physical comportment of SPION changed at specific PVAs to iron oxide ratios, and this ratio corresponded to the ratio of optimal interaction with cells. In conclusion, the successful development of functionalized SPION displaying potential cellular uptake by human cancer cells depends both on the presence of amino groups on the coating shell of the nanoparticles and of its ratio to the amount of iron oxide.

Low-dose chemotherapy with methotrexate and vinblastine for patients with advanced aggressive fibromatosis

BACKGROUND

This Phase II study was undertaken to assess the activity of methotrexate plus vinblastine in the treatment of patients with inoperable aggressive fibromatosis (AF) and to observe the evolution of the disease after such low-dose chemotherapy.

METHODS

Thirty patients with a median age of 27 years who were affected by primary (20%) or recurrent (80%), advanced, inoperable AF were treated with weekly methotrexate at a dose of 30 mg/m(2) plus vinblastine at a dose of 6 mg/m(2) for a median interval of 1 year. Patients with recurrent disease had received surgery, radiotherapy, tamoxifen, and antracycline-based chemotherapy. Tumor response was assessed in all patients as well as time to disease progression.

RESULTS

Eighteen patients (60%) showed stable disease or minor tumor shrinkage along with symptom relief. A partial response was detected in 12 patients (40%). No complete responses were observed, and no patients had tumor progression during treatment. Four patients received fewer than 15 cycles of chemotherapy, mainly because of severe myelotoxicity. One of these patients died of local disease progression 33 months later, and the other three patients were stable. After a median follow-up of 75 months, the 10-year actuarial progression free interval is 67%.

CONCLUSIONS

Methotrexate plus vinblastine given every 7-10 days for several months is associated with prolonged stable disease in a substantial subset of patients with advanced (inoperable) aggressive fibromatosis.

Colorectal adenomas containing invasive carcinoma. Pathologic assessment of lymph node metastatic potential

Adenomas that contain early invasive carcinoma (ACIC) represent the earliest form of clinically relevant cancer of the colorectum in most patients. In order to assess the incidence of nodal metastases of ACIC, we studied 31 patients in whom the colon was resected after endoscopic polypectomy (EP) done from 1975 to 1987. We also reviewed the pathologic features reported in individual cases and in literature series of ACIC with lymph node metastases published from 1958 to 1986. The lymph node metastatic potential of ACIC is relatively high, ranging from an average value of 8.5% in the literature of to 16.1% in our own study, and is equivalent to the range of 10%-17% that occurs in colorectal carcinomas that invade the submucosa. When an ACIC is seen in an EP specimen in which the polypectomy margin is normal, the decision as to whether the patient should enter a follow-up protocol or have radical surgical resection is determined by the assessment of the probability of the occurrence of nodal metastases. According to several authors, certain histopathologic features make it possible to distinguish between an ACIC with a high-risk of nodal metastases versus those with a low-risk. The most relevant pathologic parameters include the state of the resection margins, the grade of the invasive carcinoma, and the presence or absence of vascular invasion. Of 351 cases of ACIC that were operated on, derived from 16 literature series, 45.6% were high-risk cases and 8.5% had lymph node metastases. In our group of high-risk ACIC that had surgical resection subsequently, the lymph node metastatic rate was 35.7%. Our results help to estimate the nodal metastatic potential of early colorectal carcinomas and stress the importance of adequate pathologic evaluation in order to assess metastatic risk in these patients accurately.

The FLUKA Code: An Accurate Simulation Tool for Particle Therapy

Monte Carlo (MC) codes are increasingly spreading in the hadrontherapy community due to their detailed description of radiation transport and interaction with matter. The suitability of a MC code for application to hadrontherapy demands accurate and reliable physical models capable of handling all components of the expected radiation field. This becomes extremely important for correctly performing not only physical but also biologically based dose calculations, especially in cases where ions heavier than protons are involved. In addition, accurate prediction of emerging secondary radiation is of utmost importance in innovative areas of research aiming at in vivo treatment verification. This contribution will address the recent developments of the FLUKA MC code and its practical applications in this field. Refinements of the FLUKA nuclear models in the therapeutic energy interval lead to an improved description of the mixed radiation field as shown in the presented benchmarks against experimental data with both (4)He and (12)C ion beams. Accurate description of ionization energy losses and of particle scattering and interactions lead to the excellent agreement of calculated depth-dose profiles with those measured at leading European hadron therapy centers, both with proton and ion beams. In order to support the application of FLUKA in hospital-based environments, Flair, the FLUKA graphical interface, has been enhanced with the capability of translating CT DICOM images into voxel-based computational phantoms in a fast and well-structured way. The interface is capable of importing also radiotherapy treatment data described in DICOM RT standard. In addition, the interface is equipped with an intuitive PET scanner geometry generator and automatic recording of coincidence events. Clinically, similar cases will be presented both in terms of absorbed dose and biological dose calculations describing the various available features.

Adolescents and young adults (AYA) with cancer: a position paper from the AYA Working Group of the European Society for Medical Oncology (ESMO) and the European Society for Paediatric Oncology (SIOPE)

It is well recognised that adolescents and young adults (AYA) with cancer have inequitable access to oncology services that provide expert cancer care and consider their unique needs. Subsequently, survival gains in this patient population have improved only modestly compared with older adults and children with cancer. In 2015, the European Society for Medical Oncology (ESMO) and the European Society for Paediatric Oncology (SIOPE) established the joint Cancer in AYA Working Group in order to increase awareness among adult and paediatric oncology communities, enhance knowledge on specific issues in AYA and ultimately improve the standard of care for AYA with cancer across Europe. This manuscript reflects the position of this working group regarding current AYA cancer care, the challenges to be addressed and possible solutions. Key challenges include the lack of specific biological understanding of AYA cancers, the lack of access to specialised centres with age-appropriate multidisciplinary care and the lack of available clinical trials with novel therapeutics. Key recommendations include diversifying interprofessional cooperation in AYA care and specific measures to improve trial accrual, including centralising care where that is the best means to achieve trial accrual. This defines a common vision that can lead to improved outcomes for AYA with cancer in Europe.