Novel fondaparinux protocol for anticoagulation therapy in adults with renal failure and suspected heparin-induced thrombocytopenia: a retrospective review of institutional protocol.

INTRODUCTION: The literature recommends against the use of fondaparinux in patients with kidney failure and dialysis as it may, with repeated dosing, accumulate and put patients at risk of bleeding. The management of patients with thrombosis in the presence of heparin-induced thrombocytopenia HIT requires the introduction of an alternative anticoagulant like bivalirudin or argatroban. When these drugs are not available, fondaparinux, remains the only alternative. In similar scenarios, there are few studies addressing how to administer it.  METHODS: We developed a protocol for fondaparinux in patients with renal failure where pharmacokinetic parameters are altered, and levels changed only after hemodialysis or in cases of residual renal activity. Patients received a full first dose except for high risk of bleeding. We targeted a peak anti-factor Xa activity level of 0.6-1.3 units/ml and changed the subsequent dose accordingly. Furthermore, we monitored the patients for signs of bleeding, a drop in hemoglobin level, or clinical signs of thrombosis.  DISCUSSION: We described 10 patients with kidney failure and suspected HIT taking fondaparinux. All the patients achieved therapeutic anti-factor Xa activity levels. However, one developed new-onset venous thromboembolism (VTE) despite therapeutic anti-factor Xa levels. Another patient experienced a bleeding episode. We believe that these two patients developed complications due to their medical conditions rather than the use of fondaparinux. CONCLUSION: Fondaparinux can be safely used in kidney failure using our protocol. However, despite its safety profile and relative success, this case series was small. More robust studies need to be conducted prior to drawing conclusions.

New Fondaparinux Protocol to Reduce the Risk of Blood Thickening and Blood Clots Formation in Adults with Kidney Disease and Heparin-induced Thrombocytopenia (drop in platelets after the use of heparin): A Test Study.Fondaparinux is a drug used to treat patients suffering from thrombosis (clot in blood) and prevent vessels occlusions. When patients have kidney disease, the ideal treatment for thrombosis would be heparin; and, in case of Heparin Induced Thrombocytopenia (HIT), an unexpected drop in platelets after the use of heparin, the ideal treatment would be argatroban or bivalirudin. Fondaparinux can be used for HIT. However, studies recommend against its use in kidney disease as it might accumulate and cause bleeding.We were put in a challenging situation where we had patients with life-threatening thrombosis, kidney disease, HIT and unavailability of both argatroban and bivalirudin. Our only option was fondaparinux. We had to devise a safe and efficient protocol. The starting dose was the one used had the patient had a normal kidney function. Then, anti-Factor Xa activity was regularly measured with the target level 0.6-1.3units/ml 4 h after a dose. The dose was individualized, changed based on the Factor Xa activity result, the risk of bleeding or thrombosis, the overall kidney function and the need for dialysis.Our protocol was tested on 10 patients. All our patients could reach the target and safe Factor Xa activity. We had 2 exceptions. The first had a clotting event despite having therapeutic Factor Xa activity and the second was a very sick cancer patient who was bleeding despite skipping many doses of fondaparinux. We consider that these 2 cases developed complications due to their medical conditions rather than the use of fondaparinux.We concluded that fondaparinux can be safely used in patients with kidney disease, granted that Factor Xa activity is measured, the risk of bleeding is weighed to the risk of thrombosis and the dose is individualized. However, our sample size is small and further studies with a larger number of patients are needed to draw a conclusion.

Robotic resection for hydatid disease of the liver.

Robotic-assisted surgery for the management of hepatic echinococcosis was introduced in 2016. The advantage it offers over laparoscopy is less rigidity with the use of the 360° rotation of the Endo-Wrist technology, thus allowing the preservation of the integrity of the liver tissue. Herein, we report the first successful robotic resection of the left lobe of the liver for hydatid disease in the Middle East. Our patient is a 71-year-old man found to have a large left hepatic lobe hydatid disease on CT scan. The hydatid liver disease was resected completely with an operation time of 130 min and minimal intraoperative blood loss. Patient did well postoperatively and was discharged home on day 2. Our experience shows that robotic surgery for hydatid disease of the liver can be safely performed, with an excellent outcome to the patient. It also provides unique technical advantages in the field of minimal-invasive surgery.

High-Cost Cancer Treatment Across Borders in Conflict Zones: Experience of Iraqi Patients in Lebanon.

PURPOSE: Conflict-induced cross-border travel for medical treatment is commonly observed in the Middle East. There has been little research conducted on the financial impact this has on patients with cancer or on how cancer centers can adapt their services to meet the needs of this population. This study examines the experience of Iraqi patients seeking care in Lebanon, aiming to understand the social and financial contexts of conflict-related cross-border travel for cancer diagnosis and treatment. PATIENTS AND METHODS: After institutional review board approval, 60 Iraqi patients and caregivers seeking cancer care at a major tertiary referral center in Lebanon were interviewed. RESULTS: Fifty-four respondents (90%) reported high levels of financial distress. Patients relied on the sale of possessions (48%), the sale of homes (30%), and vast networks to raise funds for treatment. Thematic analysis revealed several key drivers for undergoing cross-border treatment, including the conflict-driven exodus of Iraqi oncology specialists; the destruction of hospitals or road blockages; referrals by Iraqi physicians to Lebanese hospitals; the geographic proximity of Lebanon; and the lack of diagnostic equipment, radiotherapy machines, and reliable provision of chemotherapy in Iraqi hospitals. CONCLUSION: As a phenomenon distinct from medical tourism, conflict-related deficiencies in health care at home force patients with limited financial resources to undergo cancer treatment in neighboring countries. We highlight the importance of shared decision making and consider the unique socioeconomic status of this population of patients when planning treatment.

Illness cognition and health anxiety in parents of children with cancer.

Purpose: Health anxiety is a clinical entity characterized by a pathological fear of illness. Illness cognition refers to persistent positive or negative thoughts an individual has towards illness. Evidence has shown that patients with chronic conditions who possess negative illness cognitions experience greater social, emotional, and physical difficulties than patients with positive illness cognitions. This study aims to measure the prevalence of health anxiety in a population of parents of children with cancer, and investigate the association between positive and negative illness cognitions and health anxiety. Methods: We interviewed 105 parents of children with cancer and administered Arabic versions of the Illness Cognition Questionnaire - Parent Version and the Short Health Anxiety Inventory. Results: The mean parental age was 37.7 years with the majority of participants being mothers (78.1%) and married (94.3%) and with 35.2% having completed university education. The average age of the child with cancer was 8.4 years, with the largest proportion of children suffering from leukemia. The prevalence of health anxiety among parents of children with cancer was 21%. The following two dimensions of illness cognition were significantly associated with health anxiety: Helplessness (B = 0.222, p = 0.021) and lower Acceptance (B = -0.242, p = 0.008). Other variables associated with health anxiety were perceived inadequate income (B = -0.238, p = 0.021) and personal illness or illness of a family member/close friend (B = 0.251, p = 0.013). Conclusions: Parents of children with cancer may experience health anxiety. Predictors of health anxiety include feelings of helplessness, lower acceptance, inadequate income, and extended family illnesses.