Standardized direct oral anticoagulants prescription for treatment of acute venous thromboembolism in the emergency department: A quality improvement initiative

INTRODUCTION

Direct oral anticoagulants (DOACs) are commonly used for the treatment and prevention of venous thromboembolism (VTE). However, prescription errors with DOACs can lead to patient dissatisfaction and harm. This study aimed to evaluate the impact of a standardized prescription for DOACs for VTE on prescription appropriateness.

MATERIALS AND METHODS

The study included patients discharged from the Emergency Department (ED) with a DOAC prescription for an acute VTE. A standardized prescription tool was developed and implemented, and patients were divided into pre- and post-intervention groups. The appropriateness of prescriptions was assessed using the Medication Appropriateness Index (MAI).

RESULTS

A total of 161 patients with VTE were included in the study. The post-intervention group showed a significant increase in prescriptions with an MAI rating of "appropriate" and a decrease in ratings of "inappropriate." Improvements were observed in loading dose duration, maintenance dose frequency and duration, and inclusion of necessary drug coverage codes.

CONCLUSION

The implementation of a standardized prescription for DOACs in the management of VTE in the ED significantly improved medication appropriateness and reduced inappropriate prescriptions. Standardized prescriptions have the potential to enhance patient safety and optimize care by providing clear and uniform guidance to healthcare providers. Further research is needed to explore the effectiveness of medication prescription software systems in real-world clinical settings to improve prescribing practices.

Investigations on Caesium Dispersion and Molybdenum Coating on SPIDER Components

SPIDER is the 100 keV full-size Negative Ion Source prototype of the ITER Neutral Beam Injector, operating at Consorzio RFX in Padova, Italy. The largest Negative Ion Source in the world, SPIDER generates an RF driven plasma from which Deuterium or Hydrogen negative ions are produced and extracted. At the end of 2021, a scheduled long-term shutdown started to introduce major modifications and improvements aiming to solve issues and drawbacks identified during the first three years of SPIDER operations. The first action of the shutdown period was the disassembly and characterization of the SPIDER beam source after removal from the vacuum vessel and its placement inside the clean room. Each component was carefully assessed and catalogued, following a documented procedure. Some source components, i.e., the Plasma Grid, Extraction Grid and Bias Plate, revealed the presence of different and non-uniform red, white and green coatings that might be correlated to back-streaming positive ions impinging on grid surfaces, electrical discharges and caesium evaporation. Thus, several analyses have been carried out to understand the nature of such coatings, with the study still ongoing. The evidence of caesium evaporation and deposition on molybdenum-coated SPIDER components, such as the formation of oxides and hydroxides, is demonstrated through surface characterization analyses with the use of the Scanning Electron Microscope (SEM), X-ray Diffraction (XRD) and X-ray Photoelectron Spectroscopy (XPS).

Risk factors for postoperative eye pain in patients with non-painful eye disease undergoing pars plana vitrectomy: the VItrectomy Pain (VIP) study

BACKGROUND

Pars plana vitrectomy (PPV), a surgical procedure used to treat different ophthalmic pathologies, could be associated with moderate to severe eye pain. The aim of the present study was to evaluate the incidence of postoperative eye pain and its risk factors following PPV in a selected population of patients with non-painful eye disease, receiving regional anesthesia and moderate sedation with benzodiazepines, without use of narcotics.

METHODS

Single-center, prospective observational cohort study. We recorded the presence of pain at operating room discharge, at 6 and 24 hours, using the numeric rating scale (NRS). We recorded also age, sex, ethnic origin, American Society of Anaesthesia physical status (ASA PS) classification, Charlson Comorbidity Index, the etiology of the vitreoretinal pathology, length of surgery, and type of surgical procedure performed.

RESULTS

Eye pain (NRS>3) was present in three patients (0.7%) at operating room discharge, 59 (13.2%) at six and 65 (14.6%) at 24 hours after surgery. LASSO logistic regression analysis identified age, ASA PS, race, along with tamponade as independent risk factors for eye pain at six hours. Scleral buckling was selected for eye pain at 24 hrs.

CONCLUSIONS

A protocol for pain control after PPV should be considered, especially in younger, non-Caucasian people, and patients with high ASA PS grade. Moreover, attention must be paid when additional surgical procedures are requested, restricting them to selected patients, and using the appropriate agent for intraocular tamponade.

First operation in SPIDER and the path to complete MITICA

The requirements of ITER neutral beam injectors (1 MeV, 40 A negative deuterium ion current for 1 h) have never been simultaneously attained; therefore, a dedicated Neutral Beam Test Facility (NBTF) was set up at Consorzio RFX (Padova, Italy). The NBTF includes two experiments: SPIDER (Source for the Production of Ions of Deuterium Extracted from Rf plasma), the full-scale prototype of the source of ITER injectors, with a 100 keV accelerator, to investigate and optimize the properties of the ion source; and MITICA, the full-scale prototype of the entire injector, devoted to the issues related to the accelerator, including voltage holding at low gas pressure. The present paper gives an account of the status of the procurements, of the timeline, and of the voltage holding tests and experiments for MITICA. As for SPIDER, the first year of operation is described, regarding the solution of some issues connected with the radiofrequency power, the source operation, and the characterization of the first negative ion beam.

Beam and installation improvements of the NIO1 ion source

The NIO1 (Negative Ion Optimization phase 1) source can provide continuous beam operation, which is convenient for systematic parameter and equipment studies. Even in the pure volume production regime, the source yield was found to depend on conditioning procedures. Magnetic configuration tests continued adding magnets to the existing setup; the filter field component B_x has been progressively extended to span the -12 to 5 mT range, and as a trend, source performances improved with |B_x|. The progress of camera beam diagnostics and of the quality of the volume-produced H^- beam is also shown. The status, off-line results, and reliability of a first NIO1 cesium oven are discussed; other upgrades in preparation (cavity ring down spectrometer, the end calorimeter, and conceptual tests of the energy recovery system) are also listed.

Design and comparison of the Cs ovens for the test facilities ELISE and SPIDER

Negative ion sources for fusion rely on the formation of negative hydrogen (or deuterium) ions by conversion of atomic hydrogen and positive hydrogen ions at a low work function caesiated surface. Cs is thus evaporated into the source to decrease the surface work function, which may change due to the removal and redistribution of Cs during plasma phases. To maintain a temporarily stable low work function during 1 h plasma, continuous evaporation of caesium is required, and this is performed by temperature controlled Cs ovens. The Cs ovens for ELISE (IPP Garching) and SPIDER (Consorzio RFX) are based on the evaporation of liquid Cs from a reservoir located at one end of the oven, which is controlled by the reservoir temperature. The ampoule Cs oven of ELISE is in operation since 2015, allowing for controllable and stable evaporation. The SPIDER oven is based on the ELISE oven although it required significant changes due to the vacuum environment and the oven location (at the back-plate instead of the sidewalls), leading to a different design of the oven and the nozzle. First investigations on the SPIDER oven in a dedicated test stand show that Cs evaporation is controllable, stable, and reproducible.

Castellated tiles as the beam-facing components for the diagnostic calorimeter of the negative ion source SPIDER

This paper presents the results of numerical simulations and experimental tests carried out to assess the feasibility and suitability of graphite castellated tiles as beam-facing component in the diagnostic calorimeter of the negative ion source SPIDER (Source for Production of Ions of Deuterium Extracted from Radio frequency plasma). The results indicate that this concept could be a reliable, although less performing, alternative for the present design based on carbon fiber composite tiles, as it provides thermal measurements on the required spatial scale.

Development and tests of molybdenum armored copper components for MITICA ion source

In order to prevent detrimental material erosion of components impinged by back-streaming positive D or H ions in the megavolt ITER injector and concept advancement beam source, a solution based on explosion bonding technique has been identified for producing a 1 mm thick molybdenum armour layer on copper substrate, compatible with ITER requirements. Prototypes have been recently manufactured and tested in the high heat flux test facility Garching Large Divertor Sample Test Facility (GLADIS) to check the capability of the molybdenum-copper interface to withstand several thermal shock cycles at high power density. This paper presents both the numerical fluid-dynamic analyses of the prototypes simulating the test conditions in GLADIS as well as the experimental results.

Steady state thermal-hydraulic analyses of the MITICA cooling circuits

Megavolt ITER Injector Concept Advancement is the full scale prototype of the heating and current drive neutral beam injectors for ITER, to be built at Consorzio RFX (Padova). The engineering design of its components is challenging: the total heat loads they will be subjected to (expected between 2 and 19 MW), the high heat fluxes (up to 20 MW/m(2)), and the beam pulse duration up to 1 h, set demanding requirements for reliable active cooling circuits. In support of the design, the thermo-hydraulic behavior of each cooling circuit under steady state condition has been investigated by using one-dimensional models. The final results, obtained considering a number of optimizations for the cooling circuits, show that all the requirements in terms of flow rate, temperature, and pressure drop are properly fulfilled.

Final design of the beam source for the MITICA injector

The megavolt ITER injector and concept advancement experiment is the prototype and the test bed of the ITER heating and current drive neutral beam injectors, currently in the final design phase, in view of the installation in Padova Research on Injector Megavolt Accelerated facility in Padova, Italy. The beam source is the key component of the system, as its goal is the generation of the 1 MeV accelerated beam of deuterium or hydrogen negative ions. This paper presents the highlights of the latest developments for the finalization of the MITICA beam source design, together with a description of the most recent analyses and R&D activities carried out in support of the design.

MAGnesium-oral supplementation to reduce PAin in patients with severe PERipheral arterial occlusive disease: the MAG-PAPER randomised clinical trial protocol

INTRODUCTION

Magnesium exerts analgaesic effects in several animal pain models, as well as in patients affected by acute postoperative pain and neuropathic chronic pain. There is no evidence that magnesium can modulate pain in patients with peripheral arterial occlusive disease (PAOD). We describe the protocol of a single-centre randomised double-blind clinical trial aimed at assessing the efficacy of oral magnesium supplementation in controlling severe pain in patients with advanced PAOD.

METHODS AND ANALYSIS

Adult patients affected by PAOD at stages III and IV of Lèriche-Fontaine classification, who are opioid-naïve, and who have been admitted to our Acute Pain Service for intractable pain, will be eligible. Patients will be randomised to the control group, treated with standard therapy (oxycodone and pregabalin) plus placebo for 2 weeks, or to the experimental group (standard therapy plus magnesium oxide). Patients will be evaluated on days 0, 2, 4, 6, 8, 12 and 14; the following information will being collected: daily oxycodone dose; average and maximum pain (Numerical Rating Scale); pain relief (Pain Relief Scale); characteristics of the pain (Neuropathic Pain Scale); impact of pain on the patient's daily activities (Brief Pain Inventory). The primary outcome will be oxycodone dosage needed to achieve satisfactory analgaesia on day 14. Secondary outcomes will be pain relief on day 2, time needed to achieve satisfactory analgaesia and time needed to achieve a pain reduction of 50%. A sample size calculation was performed for the primary outcome, which estimated a required sample size of 150 patients (75 per group).

ETHICS AND DISSEMINATION

Ethical approval of the study protocol has been obtained from Comitato Etico Provinciale di Brescia, Brescia, Italy. Trial results will be disseminated through scientific journal manuscripts and scientific conference presentations.

TRIAL REGISTRATION NUMBER

NCT02455726.

First negative ion beam measurement by the Short-Time Retractable Instrumented Kalorimeter Experiment (STRIKE)

The Source for Production of Ion of Deuterium Extracted from Rf plasma (SPIDER) test facility is under construction in Padova to optimise the operation of the beam source of ITER neutral beam injectors. The SPIDER beam will be characterised by the instrumented calorimeter STRIKE, whose main components are one-directional carbon-fibre-carbon-composite tiles. A small-scale version of the entire system has been employed in the BAvarian Test MAchine for Negative ions (BATMAN) testbed by arranging two prototype tiles in the vertical direction. The paper presents a description of the mini-STRIKE system and of the data analysis procedures, as well as some results concerning the BATMAN beam under varying operating conditions.

Diagnostics of the ITER neutral beam test facility

The ITER heating neutral beam (HNB) injector, based on negative ions accelerated at 1 MV, will be tested and optimized in the SPIDER source and MITICA full injector prototypes, using a set of diagnostics not available on the ITER HNB. The RF source, where the H(-)∕D(-) production is enhanced by cesium evaporation, will be monitored with thermocouples, electrostatic probes, optical emission spectroscopy, cavity ring down, and laser absorption spectroscopy. The beam is analyzed by cooling water calorimetry, a short pulse instrumented calorimeter, beam emission spectroscopy, visible tomography, and neutron imaging. Design of the diagnostic systems is presented.

Thermal and electrostatic simulations of the diagnostic calorimeter for the source for production of ion of deuterium extracted from RF plasma beam

To study and optimise negative ion production for the ITER neutral beam injectors, a test facility is under construction in Padova with the aim of testing beam characteristics and to verify the source proper operation. The instrumented calorimeter STRIKE (short-time retractable instrumented kalorimeter experiment) is being developed to characterise the SPIDER (Source for Production of Ion of Deuterium Extracted from RF plasma) beam during short operations. The paper presents an investigation of the response of STRIKE measurement systems. It results that biasing is necessary to cope with the influence of secondary electrons on current measurements; moreover, despite the discretisation of the recorded thermal patterns introduced by the pixels of thermal cameras, a sufficient spatial resolution is expected.

Design and specifications of the diagnostics for the instrumented calorimeter of source for the production of ions of deuterium extracted from radio frequency plasma

In the development of the neutral beam injector for ITER experiment, the test facility SPIDER is going to be built. To measure the beam parameters, several diagnostics are used. One of them is the Short-Time Retractable Instrumented Kalorimeter Experiment (STRIKE) which measures beam uniformity, beamlet divergence, and stripping losses. This contribution gives an overview of the diagnostics dedicated to these measurements: thermal cameras, thermocouples, current sensors, and electrostatic sensors. The specifications of these diagnostics have been defined according to the results of electrostatic and thermal simulations. A failure modes and effects analysis has been performed during the design. Consequently the project of the STRIKE diagnostics has been optimized to reduce the possible failure risks.

Progress in the MITICA beam source design

In the framework of the development of the ITER neutral beam (NB) system, a test facility is planned to be built in Padova. A full size prototype of the ITER heating NB injector (MITICA) shall be built and tested at full beam power (17 MW) as per ITER requirements. The design of the MITICA beam source has further progressed following updated optimization and overall integration criteria. In the paper, the major design choices and revisions are presented, together with some results of numerical analyses carried out in order to assess the electrostatic and thermo-mechanical behaviour of the source.

Antioxidant activity of tomato products as studied by model reactions using xanthine oxidase, myeloperoxidase, and copper-induced lipid peroxidation

The antioxidant content and activity of commercial tomato products differing in variety and processing were studied. Two procedures for extracting hydrophilic and lipophilic antioxidants, namely, two-step 0.1 M phosphate buffer (pH 3.0 and 7.4) extraction and tetrahydrofuran extraction followed by petroleum ether fractionation, were developed. Carotenoids (lycopene, beta-carotene, and lutein) and ascorbic acid were analyzed by HPLC with spectrophotometric and electrochemical detectors, respectively. Total phenolics were determined by using the Folin-Ciocalteu reagent. The antioxidant activity was studied by the following three model systems: (a) the xanthine oxidase (XOD)/xanthine system, which generates superoxide radical and hydrogen peroxide; (b) the myeloperoxidase (MPO)/NaCl/H(2)O(2) system, which produces hypochloric acid; and (c) the linoleic acid/CuSO(4) system, which promotes lipid peroxidation. Results showed that the hydrophilic and lipophilic fractions of all tomato products were able to affect model reactions, whatever reactive oxygen species and catalysts were used to drive oxidation. In the XOD/xanthine system both the hydrophilic and lipophilic fractions displayed an inhibitory activity. The hydrophilic fractions were more effective (I(50) ranging from 680 to 3200 microg, dry weight) than the lipophilic fractions (I(50) ranging from 4000 to 7750 microg, dry weight). In the MPO/NaCl/H(2)O(2) system the hydrophilic fractions inhibited oxidation (I(50) ranging from 2300 to 2900 microg, dry weight), whereas the lipophilic fractions had a lower inhibitory effect at the same concentration. Conversely, in the copper-catalyzed lipid peroxidation only the lipophilic fractions were effective (I(50) ranging from 1030 to 2100 microg, dry weight), whereas the hydrophilic fractions had a pro-oxidant effect in the same concentration range. The extent of inhibition varied according to the tomato sample in the superoxide and hydrogen peroxide generating system and in lipid peroxidation, but was substantially the same in the HClO generating system. Fresh tomato varieties differed considerably in the antioxidant activities of their hydrophilic and lipophilic fractions. Processed tomatoes showed a significantly lower antioxidant activity than fresh tomatoes in their hydrophilic fractions but had a high antioxidant activity in their lipophilic fractions. Because the oxidative reactions produced by the above-mentioned model systems are also involved in the pathogenesis of several chronic diseases, the antioxidant activity of tomato fractions might be related to their in vivo activity. Hence, these measurements may be used for optimizing tomato technologies.

Chromatographic determination of vitamins in foods

Chromatographic methods for the determination of water- and fat-soluble vitamins in foods are reviewed. For each vitamin, sample preparation, detection problems and chromatographic conditions are presented and discussed. High-performance liquid chromatography (HPLC) is becoming a standard method in vitamin assay, especially for routine work. HPLC systems can be automated using in-line solid-phase extraction and column switchings, resulting in very sensitive methods, even when simple UV detection is employed.