Diagnoses and visit length in complementary and mainstream medicine

<p>Abstract</p> <p>Background</p> <p>The demand for complementary medicine (CM) is growing worldwide and so is the supply. So far, there is not much insight in the activities in Dutch CM practices nor in how these activities differ from mainstream general practice. Comparisons on diagnoses and visit length can offer an impression of how Dutch CM practices operate.</p> <p>Methods</p> <p>Three groups of regularly trained physicians specialized in CM participated in this study: 16 homeopathic physicians, 13 physician acupuncturists and 11 naturopathy physicians. Every CM physician was asked to include a maximum of 75 new patients within a period of six months. For each patient an inclusion registration form had to be completed and the activities during a maximum of five repeat visits were subsequently registered. Registrations included patient characteristics, diagnoses and visit length. These data could be compared with similar data from general practitioners (GPs) participating in the second Dutch national study in general practice (DNSGP-2). Differences between CM practices and between CM and mainstream GP data were tested using multilevel regression analysis.</p> <p>Results</p> <p>The CM physicians registered activities in a total of 5919 visits in 1839 patients. In all types of CM practices general problems (as coded in the ICPC) were diagnosed more often than in mainstream general practice, especially fatigue, allergic reactions and infections. Psychological problems and problems with the nervous system were also diagnosed more frequently. In addition, each type of CM physician encountered specific health problems: in acupuncture problems with the musculoskeletal system prevailed, in homeopathy skin problems and in naturopathy gastrointestinal problems. Comparisons in visit length revealed that CM physicians spent at least twice as much time with patients compared to mainstream GPs.</p> <p>Conclusions</p> <p>CM physicians differed from mainstream GPs in diagnoses, partly related to general and partly to specific diagnoses. Between CM practices differences were found on specific domains of complaints. Visit length was much longer in CM practices compared to mainstream GP visits, and such ample time may be one of the attractive features of CM for patients.</p

Evaluation of Post-Cardiopulmonary Bypass Coagulation Disorders by Differential Diagnosis with a Multichannel Modified Thromboelastogram: A Pilot Investigation

We assessed a modified multichannel thromboelastogram for differentiation of the causes of coagulopathy after cardiopulmonary bypass and its suitability as a therapy guide. Thirty adult patients undergoing surgery with cardiopulmonary bypass, who revealed a coagulopathy as observed by a prolonged activated clotting time of >150 sec after the application of protamine, were enrolled. Therapy was based on the results obtained by the computerized four-channel thromboelastogram with baseline, heparinase (2 IU/mL), heparinase/abciximab (5 µg/mL), and heparinase/fresh frozen plasma (25%) channels. The mean activated clotting time before therapy was 162.2 ± 7.8 sec. Based on differential diagnosis with the modified multichannel thromboelastogram, two patients received protamine (30 mg), five desmopressin (0.4 µg/kg), 19 patients three units of fresh frozen plasma, two patients platelet transfusions, and two patients both protamine (30 mg) and three units of fresh frozen plasma. After therapy, there was a significant (p < .01) decrease of the activated clotting time to a mean value of 127 ± 8.3 sec. Therapy based on the synoptic modified multichannel thromboelastogram analysis provides a guide for effective therapy of coagulopathy. However, elaboration is desirable, and larger clinical trials are necessary for a final evaluation of the protocol

Assessment of the Resonance Thromboelastograph CS-3 for Differentiation of Coagulation Disorders: A Pilot in vitro Investigation of Simulated Post-Cardiopulmonary Bypass Coagulopathies

Resonance thromboelastography (RTG), a further development of the thromboelastogram (TEG), has been designed for improved differentiation of the effect of the plasmatic coagulation factors (increasing F-leg) and platelets (decreasing P-leg) on clot formation. It is based on the effect of clot elasticity on the resonance of a swinging wire. We assessed the RTG for its ability to differentiate coagulation disorders that frequently occur after cardiac surgery. The RTG was performed with a CS-3 Analyzer. Samples from 10 healthy volunteers were investigated after the following preparations: (1) baseline values, (2) dilution to a hematocrit of 30% and 20% with either hydroxyl ethyl starch (HES) 10% or plasma; (3) addition of 0.25, 0.5, and 1.0 IU/mL porcine heparin with and without heparinase; and (4) addition of 1.0, 3.0, 4.0, and 5.0 µg/mL of the antiplatelet agent abciximab (ReoPro™). Increasing concentrations of abciximab led to a slower decrease or in the case of higher concentrations, to a persistent elevation of the platelet leg of the RTG. Dilution of the hematocrit with plasma had no effect on the fibrin and platelet leg; whereas, dilution with HES 10% led to an inhibition of the fibrin and platelet leg. Dilution of the plasmatic coagulation factors resulted in an inhibition of both the fibrin and the platelet leg. The addition of 0.25 and 0.5 IU/mL of heparin led to an increased coagulation time and inhibition of the fibrin and platelet legs. These effects were eliminated by the addition of heparinase. The RTG enables the evaluation of platelet function under the condition of a nonimpaired plasma coagulation system. Depletion of plasma coagulation factors and the administration of small amounts of heparin do not enable the distinction between residual effects of an anticoagulant, coagulation factor deficiency, or impaired platelet function. However, the heparin effects can be eliminated by the addition of heparinase. Further improvement may be achieved using a modified RTG by adding plasma coagulation factors in one channel for an improved evaluation of platelet function, even under the condition of a loss of procoagulants

TLD-1, a novel liposomal doxorubicin, in patients with advanced solid tumors: Dose escalation and expansion part of a multicenter open-label phase I trial (SAKK 65/16).

BACKGROUND TLD-1 is a novel liposomal doxorubicin that compared favorably to conventional doxorubicin liposomal formulations in preclinical models. This phase I first-in-human study aimed to define the maximum tolerated dose (MTD), recommended phase 2 dose (RP2D), safety and preliminary activity of TLD-1 in patients with advanced solid tumors. PATIENTS AND METHODS We recruited patients with advanced solid tumors who failed standard therapy and received up to 3 prior lines of palliative systemic chemotherapy. TLD-1 was administered intravenously every 3 weeks up to a maximum of 9 cycles (6 for patients with prior anthracyclines) from a starting dose of 10 mg/m2, according to an accelerated titration design followed by a modified continual reassessment method. RESULTS 30 patients were enrolled between November 2018 and May 2021. No dose-limiting toxicities (DLT) were observed. Maximum administered dose of TLD-1 was 45 mg/m2, RP2D was defined at 40 mg/m2. Most frequent treatment-related adverse events (TRAE) of any grade included palmar-plantar erythrodysesthesia (PPE) (50% of patients), oral mucositis (50%), fatigue (30%) and skin rash (26.7%). Most common G3 TRAE included PPE in 4 patients (13.3%) and oral mucositis in 2 (6.7%). Overall objective response rate was 10% in the whole population and 23.1% among 13 patients with breast cancer; median time-to-treatment failure was 2.7 months. TLD-1 exhibit linear pharmacokinetics, with a median terminal half-life of 95 h. CONCLUSIONS The new liposomal doxorubicin formulation TLD-1 showed a favourable safety profile and antitumor activity, particularly in breast cancer. RP2D was defined at 40 mg/m2 administered every 3 weeks. (NCT03387917)

Blood transfusion determines postoperative morbidity in pediatric cardiac surgery applying a comprehensive blood-sparing approach

OBJECTIVE: Recently we suggested a comprehensive blood-sparing approach in pediatric cardiac surgery that resulted in no transfusion in 71 infants (25%), postoperative transfusion only in 68 (24%), and intraoperative transfusion in 149 (52%). We analyzed the effects of transfusion on postoperative morbidity and mortality in the same cohort of patients. METHODS: The effect of transfusion on the length of mechanical ventilation and intensive care unit stay was assessed using Kaplan-Meier curves. To assess whether transfusion independently determined the length of mechanical ventilation and length of intensive care unit stay, a multivariate model was applied. Additionally, in the subgroup of transfused infants, the effect of the applied volume of packed red blood cells was assessed. RESULTS: The median length of mechanical ventilation was 11 hours (interquartile range, 9-18 hours), 33 hours (interquartile range, 18-80 hours), and 93 hours (interquartile range, 34-161 hours) in the no transfusion, postoperative transfusion only, and intraoperative transfusion groups, respectively (P < .00001). The corresponding median lengths of intensive care unit stay were 1 day (interquartile range, 1-2 days), 3.5 days (interquartile range, 2-5 days), and 8 days (interquartile range, 3-9 days; P < .00001). The multivariate hazard ratio for early extubation was 0.24 (95% confidence interval, 0.16-0.35) and 0.37 (95% confidence interval, 0.25-0.55) for the intraoperative transfusion and postoperative transfusion only groups, respectively (P < .00001). In addition, the cardiopulmonary time, body weight, need for reoperation, and hemoglobin during cardiopulmonary bypass affected the length of mechanical ventilation. Similar results were obtained for the length of intensive care unit stay. In the subgroup of transfused infants, the volume of packed red blood cells also independently affected both the length of mechanical ventilation and the length of intensive care unit stay. CONCLUSIONS: The incidence and volume of blood transfusion markedly affects postoperative morbidity in pediatric cardiac surgery. These results, although obtained by retrospective analysis, might stimulate attending physicians to establish stringent blood-sparing approaches in their institutions