Impacts of conservative treatment on the clinical manifestations of obstructive sleep apnea-systematic review and meta-analysis.

INTRODUCTION: Obstructive sleep apnea (OSA) is a chronic disease with a high populational prevalence that is characterized as airway closure during sleep. Treatment is multidisciplinary and varies according to each case. Continuous positive airway pressure (CPAP), oral appliances, and surgery are the primary therapeutic options. Non-invasive conservative treatments such as sleep hygiene, positional therapy, physical exercises, and weight loss aim to reduce the worsening of the disease while being complementary to the invasive primary treatment. OBJECTIVE: To analyze the impact of non-invasive conservative therapies on the clinical manifestations of OSA syndrome (OSA), compared with other interventions. METHOD: This was a systematic review with meta-analysis. The searches were performed without filters for the time period, type of publication, or language. Randomized clinical trials on subjects over 18 years of age diagnosed with untreated OSA were included. Responses to non-invasive conservative treatment were compared with responses to the primary intervention. Primary outcomes were assessed using the Epworth Sleepiness Scale and/or Functional Outcomes of Sleep Questionnaire (FOSQ). RESULTS: A total of eight studies were included in the review. The heterogeneity of the effect was estimated at 89.77%. Six studies compared conservative treatment with CPAP, one with oral appliances, and one with oropharyngeal exercises. Using the Epworth Sleepiness Scale measurements, the standardized difference in the estimated means, based on the random-effects model, was 0.457 (95% CI (1.082 to 0.169)) and the mean result did not differ significantly from zero (z = 1.43; p = 0.153). The conservative therapies assessed in this study improved the subjective quality of sleep, although the post-treatment ESE scores did not show significant results. The reduction in AHI and better outcomes in the evaluated domains, as well as in cognition and mood, were superior in the groups that received CPAP and IOD. CONCLUSION: The most commonly used treatments of choice for OSA are invasive, including the use of CPAP, oral appliances, and surgeries, being the most utilized options. This study demonstrated that non-invasive conservative treatments, such as sleep hygiene, yield results as effective as invasive treatments. Further studies are needed to confirm this result and to predict whether invasive treatment can be used as the primary treatment or only as a supplement.

Hydrodynamic cavitation-assisted acid pretreatment and fed-batch simultaneous saccharification and co-fermentation for ethanol production from sugarcane bagasse using immobilized cells of Scheffersomyces parashehatae.

A new alternative for hydrodynamic cavitation-assisted pretreatment of sugarcane bagasse was proposed, along with a simultaneous saccharification and co-fermentation (SSCF) process performed in interconnected columns. Influential variables in the pretreatment were evaluated using a statistical design, indicating that an ozone flow rate of 10 mg min-1 and a pH of 5.10 resulted in 86 % and 72 % glucan and xylan hydrolysis yields, respectively, in the subsequent enzymatic hydrolysis process. Under these optimized conditions, iron sulfate (15 mg L-1) was added to assess Fenton pretreatment, resulting in glucan and xylan hydrolysis yields of 92 % and 71 %, respectively, in a material pretreated for 10 min. In SSCF, ethanol volumetric productivities of 0.33 g L-1 h-1 and of 0.54 g L-1 h-1 were obtained in batch and fed-batch operation modes, achieving 26 g L-1 of ethanol in 48 h in the latter mode.

Synchronous Observation of Bell Nonlocality and State-Dependent Contextuality.

Bell nonlocality and Kochen-Specker contextuality are two remarkable nonclassical features of quantum theory, related to strong correlations between outcomes of measurements performed on quantum systems. Both phenomena can be witnessed by the violation of certain inequalities, the simplest and most important of which are the Clauser-Horne-Shimony-Holt (CHSH) and the Klyachko-Can-Binicioglu-Shumovski (KCBS), for Bell nonlocality and Kochen-Specker contextuality, respectively. It has been shown that, using the most common interpretation of Bell scenarios, quantum systems cannot violate both inequalities concomitantly, thus suggesting a monogamous relation between the two phenomena. In this Letter, we show that the joint consideration of the CHSH and KCBS inequalities naturally calls for the so-called generalized Bell scenarios, which, contrary to the previous results, allows for joint violation of them. In fact, this result is not a special feature of such inequalities: We provide very strong evidence that there is no monogamy between nonlocality and contextuality in any scenario where both phenomena can be observed. We also implement a photonic experiment to test the synchronous violation of both CHSH and KCBS inequalities. Our results agree with the theoretical predictions, thereby providing experimental proof of the coexistence of Bell nonlocality and contextuality in the simplest scenario, and lead to novel possibilities where both concepts could be jointly employed for quantum information processing protocols.

Long-term outcome of redo discectomy for recurrent lumbar disc herniations.

PURPOSE: Recurrent lumbar disc herniation (RLDH) is an important cause of morbidity and healthcare costs. The goal of this investigation is to assess surgical outcomes and their predictors in patients who underwent revision discectomy for RLDH, with a minimum follow-up of ten years, to shed light on the best treatment to offer to these patients. METHODS: Patients who underwent revision discectomy to treat RLDH between 2004 and 2011 in our Department were enrolled. Demographic, clinical, and surgical data were collected. The need of third intervention for RLDH was the primary outcome. Patient's satisfaction, Core Outcome Measures Index, Oswestry Disability Index, and EuroQoL-5D scores were also evaluated. RESULTS: This study includes 55 patients, with a mean follow-up time of 144 months [112-199]. In this period, a third intervention was needed in 30.9% (n = 17) of patients. Most recurrences took place in the first 2 years after the second surgery (58.8%, n = 10) and the risk of needing a third surgery decreased over time. After 5 years, the probability of not having surgery for recurrence was 71% [CI 95%: 60-84%], with a tendency to stabilize after that. An interval between the first discectomy and the surgery for recurrence shorter than 7.6 months was identified as a predictor for a second recurrence. CONCLUSION: The risk of needing a third surgery seems to stabilize after five years. Patients with an early recurrence after the first discectomy seem to have a higher risk of a new recurrence, so an arthrodesis might be worth considering.

Neuroprotection is improved by watertightness of fetal spina bifida repair in the sheep model.

OBJECTIVES: A contributing factor to unsuccessful prenatal spina bifida aperta (SBA) repair via an open approach may be incomplete neurosurgical repair causing persistent in-utero leakage of cerebrospinal fluid (CSF) and exposure of the fetal spinal cord to amniotic fluid. We aimed to investigate the neurostructural and neurofunctional efficacy of watertight prenatal SBA repair in a validated SBA fetal lamb model. METHODS: A well-powered superiority study was conducted in the validated SBA fetal lamb model (n = 7 per group). The outcomes of lambs which underwent watertight or non-watertight multilayer repair through an open approach were compared to those of unrepaired SBA lambs (historical controls) at delivery (term = 145 days). At ∼75 days, fetal lambs underwent standardized induction of lumbar SBA. At ∼100 days, they were assigned to an either watertight or non-watertight layered repair group based on an intraoperative watertightness test using subcutaneous fluorescein injection. At 1-2 days postnatally, as primary outcome, we assessed reversal of hindbrain herniation using magnetic resonance imaging (MRI). Secondary proxies of neuroprotection were: absence of CSF leakage at the repair site; hindlimb motor function based on joint-movement score, locomotor grade and Motor Evoked Potential (MEP); four-score neuroprotection scale, encompassing live birth, complete hindbrain herniation reversal, absence of CSF leakage and joint-movement score ≥ 9/15; and brain and spinal cord histology and immunohistochemistry. As the watertightness test cannot be used clinically due to its invasiveness, we developed a potential surrogate intraoperative three-score skin-repair-quality scale based on visual assessment of the quality of the skin repair (suture inter-run distance ≤ 3 mm, absence of tear and absence of ischemia), with high quality defined by a score ≥ 2/3 and low quality by a score < 2/3, and assessed its relationship with improved outcome. RESULTS: Compared with unrepaired lambs, lambs with watertight repair achieved a high level of neuroprotection (neuroprotection score of 4/4 in 5/7 vs 0/7 lambs) as evidenced by: a significant 100% (vs 14%) reversal of hindbrain herniation on MRI; low CSF leakage (14% vs 100%); better hindlimb motor function, with higher joint-movement score, locomotor grade and MEP area under the curve and peak-to-peak amplitude; higher neuronal density in the hippocampus and corpus callosum; and higher reactive astrogliosis at the SBA lesion epicenter. Conversely, lambs with non-watertight SBA repair did not achieve the same level of neuroprotection (score of 4/4 in 1/7 lambs) compared with unrepaired lambs, with: a non-significant 86% (vs 14%) reversal of hindbrain herniation; high CSF leakage (43% vs 100%); no improvement in motor function; low brain neuron count in both the hippocampus and corpus callosum; and small spinal astroglial cell area at the epicenter. Both watertight layered repair and high (≥ 2/3) intraoperative skin-repair-quality score were associated with improved outcome, but the watertightness test and skin-repair-quality scale could not be used interchangeably due to result discrepancies. CONCLUSIONS: Watertight layered fetal SBA repair is neuroprotective since it improves brain and spinal-cord structure and function in the fetal lamb model. This translational research has important clinical implications. A neurosurgical technique that achieves watertightness should be adopted in all fetal centers to improve neuroprotection. Future clinical studies could assess whether a high skin-repair-quality score (≥ 2/3) correlates with neuroprotection. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Systematic review of the registered clinical trials for oncological hyperthermia treatment.

BACKGROUND: The use of heat to treat various diseases is called hyperthermia treatment (HT). Since the 1970s, the anti-cancer effects of HT have been investigated. Different HT techniques can be categorized as local, regional and whole-body hyperthermia treatment (WBHT). We aim to provide a summary of recent research done on HT to treat cancer. METHODS: In July 2020 ClinicalTrials.gov were systematically searched for all trials including hyperthermia and cancer registered between 2000 and 2020. Studies were excluded when they did not concern hyperthermal treatment, when they were not oncological studies, when they were observational or other non-interventional studies. RESULTS: Of 1654 identified trials, 235 were included. Of these 235 studies, 123 described the use of HIPEC (52.3%), 44 other types of regional HT (18.7%), 45 local HT (19.1%) and 15 WBHT (6.4%). A steady increase (720%) in research to hyperthermic intraperitoneal chemotherapy (HIPEC) can be observed in the last decade. Although HIPEC is the most researched HT modality, an evolution in other HT technologies could be observed during the past decade. CONCLUSIONS: Research to HT to treat cancer has expanded fast. Some techniques, for example HIPEC start to be used outside of research context, but overall, more research is needed to establish a clear effect of these HT techniques.

Manutenção do ritmo sinusal após retorno à prática esportiva em paciente com fibrilação atrial tratado com descondicionamento / Maintenance of sinus rhythm after return to sports practice in a patient with atrial fibrillation treated with deconditioning

O exercício físico reduz risco de doenças cardiovasculares, metabólicas e está relacionada a aumento do bem-estar e longevidade. Alguns estudos sugerem redução do risco de arritmias, como a fibrilação atrial, em até 19% em homens e 9% em mulheres. Contudo, observa-se prevalência superior, de até 3,5 vezes, de desenvolvimento de fibrilação atrial em praticantes de exercícios de muito alta intensidade ou competitiva, tornando essa a arritmia mais frequente no atleta. Os indivíduos sob maior risco são homens, praticantes de endurance de alta intensidade e com alto volume. A presença de fibrilação atrial, ainda que paroxística, impacta negativamente sobre a capacidade funcional e performance nesses indivíduos, seja pela redução do débito cardíaco pela perda da contração atrial ou pela perda de controle da frequência cardíaca pelo sistema nervoso autônomo. A evidência atual disponível para guiar o manejo desses pacientes se baseia em estudos randomizados em pacientes portadores de FA não atletas, estudos menores em atletas ou em consenso de especialista e o tratamento se baseia nos pilares de controle de ritmo farmacológico ou intervencionista por meio de ablação por radiofrequência ou destrainamento. Esse relato de caso tem como objetivo apresentar a evolução de paciente atleta com fibrilação atrial tratado de forma não invasiva, com destreinamento, de forma a revisar e ampliar o conhecimento sobre o tema. RELATO DE CASO: Paciente, sexo masculino, 42 anos, sem comorbidades prévias, pratica esporte competitivo desde os 15 anos nas modalidades: mountain bike, triátlon e maratona. Procura atendimento médico, sem queixas, solicitando liberação para realização de prova triathlon ironman. Ao exame físico apresentava ausculta cardíaca com frequência de 50 bpm e ritmo irregular, sem outras alterações. O eletrocardiograma apresentava ritmo de fibrilação atrial com baixa resposta ventricular. Foi realizada investigação de cardiopatia estrutural com ecocardiograma que revelou átrio esquerdo aumentado, com volume indexado de 40ml/ m2. Função biventricular preservada. Sem outros achados. Em teste ergométrico, apresentava resposta adequada da frequência cardíaca ao esforço, com excelente capacidade funcional e sem alterações sugestivas de isquemia. Holter evidenciava apenas presença de fibrilação atrial. Foi optado então por tratamento com destreinamento por 3 meses. Após, paciente realizou holter que apresentava ritmo sinusal. Foi mantido seguimento por um ano, com repetição de holter 24h que se manteve em ritmo sinusal.

Malnutrition and nutritional deficiencies in children with cerebral palsy: a systematic review and meta-analysis.

OBJECTIVES: This systematic review study and meta-analysis sought to estimate the prevalence of malnutrition and nutritional deficiencies in children with cerebral palsy (CP). STUDY DESIGN: This is a systematic review and meta-analysis. METHODS: The systematic review was conducted according to the PRISMA guidelines. The articles were chosen using the PubMed, Embase, Scopus, Web of Science, Cochrane Library, SciELO, and Lilacs databases and the bibliographical reference lists of the articles. No limitations were placed on the time of publication, but the articles had to include children from 0 to 18 years old with CP who presented the prevalence of malnutrition and nutritional deficiencies. The methodological quality of the articles was assessed using the verification list for analytical cross-sectional studies, the Newcastle-Ottawa scale, and the Cochrane Collaboration tool for randomized studies. The meta-analysis of proportions was conducted based on the prevalence data for malnutrition or nutritional deficiencies. The study is registered in PROSPERO under CRD number 42020175068. RESULTS: Sixty-seven articles (N = 453,804) published between 1986 and 2019 were included. Most of the articles presented a low risk of bias and no publication was excluded for quality reasons. The most widely used anthropometric index for diagnosing nutritional status was weight-to-age and the estimated prevalence of malnutrition was 40% (95% CI = 28.0-53.0). Nutrient deficiency was investigated by nine publications, with hypocalcemia and reduced serum concentrations of zinc, copper, and vitamin D being reported the most. CONCLUSIONS: We found a high rate of malnutrition in the population in this review, moreover, we suggest that some nutritional deficiencies are associated with food deficit and that the socio-economic and age factors of these children may relate with the poor nutritional outcome. This makes monitoring and personalized nutritional management necessary, in accordance with the characteristics and particularities of children with CP.

Challenges, burden and emotional impact on Portuguese athletes during COVID-19 pandemic / Retos e impacto emocional de la pandemia en los deportistas portugueses durante la pandemia de COVID-19 / Os desafios e o impacto emocional nos atletas portugueses durante a pandemia COVID-19

This study aimed to explore how contextual variables associated with the period of confinement during pandemic can differentiate symptoms of anxiety, depression, and stress. It also intended to understand the concerns that were experienced by athletes when resuming their sport practice and how these could be associated with psychopathological indicators. The sample comprised 265 athletes who completed self-reported questionnaires. Results demonstrated that there were differences in psychopathological indicators in terms of hours of training per week, and the type of contact that athletes have with their coach. Athletes reported concerns regarding the resumption of sport practice, and that were associated with anxiety, depression, and stress symptoms. This study may contribute in warning the sports community about the impact of contextual variables-related to critical moments of this pandemic. Sports communities should encourage the preservation of the athlete's physical activities, as well as supporting coaches in continuing to guide athlete's training. (AU)

Este estudio tuvo como objetivo explorar como las variables contextuales asociadas con el período de confinamiento de la pandemia pueden discriminar los síntomas de ansiedad, depresión y estrés. También se pretendió comprender las preocupaciones al retomar práctica deportiva y como estas podrían estar asociadas con indicadores psicopatológicos. La muestra incluyó 265 deportistas que completaron cuestionarios de autorespuesta. Los resultados demostraron que existen diferencias en los indicadores psicopatológicos en las horas de entrenamiento y el tipo de contacto que los deportistas tienen con su entrenador. Los atletas reportaron preocupaciones con respecto a la reanudación de la práctica deportiva después del período de confinamiento social, que se asociaron con síntomas de ansiedad, depresión y estrés. Este estudio puede contribuir a advertir a la comunidad deportiva sobre el impacto de las variables contextuales relacionadas con esta pandemia. Las comunidades deportivas deben fomentar la preservación de las actividades físicas, y apoyar a los entrenadores para que sigan guiando el entrenamiento de sus atletas. (AU)

O objetivo deste estudo foi explorar como é que variáveis contextuais associadas ao período de confinamento resultante da pandemia COVID-19 podem discriminar sintomas de ansiedade, depressão e stress em atletas. Adicionalmente, pretendeu-se explorar as preocupações mais experienciadas pelos atletas aquando da retoma da sua prática desportiva, e como é que estas se associam a indicadores psicopatológicos. Participaram neste estudo 265 atletas que completaram medidas de autorrelato. Os resultados demonstraram que existem diferenças nos indicadores psicopatológicos em termos de horas de treino por semana e do tipo de contacto que os atletas mantiveram com o treinador. Este estudo demonstrou que os atletas reportam preocupações relativamente à retoma da sua prática após o período de confinamento, e que estas preocupações foram associadas a sintomas de ansiedade, depressão e stress. Este estudo tem importantes implicações práticas, alertando a comunidade desportiva para o impacto de variáveis contextuais associadas à pandemia. As comunidades desportivas devem encorajar a preservação das rotinas dos atletas, e incentivar os treinadores a continuarem a orientar o treino dos seus atletas. (AU)

Use of fermentation processes for improving the dissolution of phosphorus and its recovery from waste activated sludge.

Recycling phosphorus from waste activated sludge has attracted a lot of interest to tackle the problem of phosphorus stocks depletion and the increase in food demand. In this study, the use of fermentation processes was investigated to enhance phosphorus dissolution from waste activated sludge to improve its recycling. Two fermentation processes, bioacidification and dark fermentation, were used on two different sludges fermented with wheat starch syrup in continuous operating conditions. Hydrogen yield from the co-substrate fermentation with waste activated sludge reached 3.9 mmolH2.gCODcosubstrate-1 yield during dark fermentation process and was negligible during bioacidification. Dissolved phosphorus in the waste activated sludge increased by 68% during bioacidification and by 43% during dark fermentation. In both processes, phosphorus dissolution was accompanied by iron, calcium and magnesium dissolution. Results show that fermentation enhances phosphorus dissolution in waste activated sludge to improve its recovery along with hydrogen and organic acids.

Tolerability of long-term temperature controlled whole-body thermal treatment in advanced cancer-bearing dogs.

Aim: In oncology, thermal therapy is the application of external heat to fight cancer cells. The goal of whole-body thermal treatment (WBTT) is to raise the patient's core temperature to 39-42 °C, and represents the only thermal treatment modality that can act on both the primary tumor and distant metastases. However, WBTT carries potential risks for toxicity when applied without accurate thermometry and monitoring.Methods: ElmediX has developed a medical device, HyperTherm, to deliver long-term controlled and accurate WBTT (41.5 °C, up to 8 h). The safety of the device and thermal treatment protocol was initially evaluated in minipigs, and we present the confirmation of tolerability of WBTT in dogs with advanced cancer, in combination with a reduced dose of radiotherapy or chemotherapy.Results: Thermometry in liver, rectum, and tumor confirmed a homogeneous heating of these body parts. Monitoring of clinical parameters showed acceptable and reversible changes in liver, cardiac, muscle and coagulation parameters, as was expected. Combination of WBTT with both radiotherapy and chemotherapy only caused some low-grade adverse events.Conclusion: We conclude that our findings support the safe use of HyperTherm-mediated WBTT for canine patients with advanced malignancies. They also tend to support a genuine therapeutic potential for long-term WBTT which needs to be confirmed on a larger dog patient population. Combined with previously reported safety results in minipigs, these contribute to support the ongoing clinical evaluation of WBTT in advanced human cancer patients.

Multi-Matrix Approach for the Analysis of Bicalutamide Residues in Oncology Centers by HPLC-FLD.

Cytostatics are toxic pharmaceuticals, whose presence in surfaces puts healthcare workers at risk. These drugs might also end up in hospital effluents (HWW), potentially damaging aquatic ecosystems. Bicalutamide is a cytostatic extensively consumed worldwide, but few analytical methods exist for its quantification and most of them require advanced techniques, such as liquid chromatography mass spectrometry (LC-MS), which are very complex and expensive for large monitoring studies. Therefore, a simple but reliable multi-matrix high performance liquid chromatographic method, with fluorescence detection, was developed and validated to rapidly screen abnormal concentrations of bicalutamide in HWW and relevant contamination levels of bicalutamide in indoor surfaces (>100 pg/cm2), prior to confirmation by LC-MS. The method presents good linearity and relatively low method detection limits (HWW: 0.14 ng/mL; surfaces: 0.28 pg/cm2). Global uncertainty was below 20% for concentrations higher than 25 ng/mL (HWW) and 50 pg/cm2 (surfaces); global uncertainty was little affected by the matrix. Therefore, a multi-matrix assessment could be achieved with this method, thus contributing to a holistic quantification of bicalutamide along the cytostatic circuit. Bicalutamide was not detected in any of the grab samples from a Portuguese hospital, but an enlarged sampling is required to conclude about its occurrence and exposure risks.

Instruments to evaluate undergraduate healthcare student learning styles globally: A scoping review.

BACKGROUND: Recognizing learning styles is important to maximizing learning outcomes and many instruments are available to investigate learning styles. OBJECTIVE: To investigate instruments with evidence of validity and reliability most commonly used to evaluate undergraduate healthcare student learning styles globally. METHOD: This scoping review of literature was guided by The Joanna Briggs Institute's recommendations for conducting scoping reviews and the PRISMA-ScR (extension for scoping reviews). The protocol is available for access. DATA SOURCES: Databases searched included Cumulative Index to Nursing and Allied Health Literature, PubMed, Web of Science, and Scopus. Inclusion criteria were: fully accessible; written in English, Portuguese, or Spanish; and used reliable and/or validated instruments to describe healthcare student learning styles. Articles were excluded if the sample included healthcare professionals, there was no report of the instrument validity and reliability, or was not fully accessible. Data were extracted from each article and entered into Microsoft Office Excel documents for analysis. RESULTS: Forty-seven articles were selected for full review, including cross-sectional, interventional, and longitudinal studies. Eleven instruments were identified with evidence of reliability and validity for assessing undergraduate healthcare student learning styles globally. The most frequently used instruments were Visual, Aural, Read-Write, and Kinesthetic; Kolb's Learning Styles Inventory; and the Honey-Alonso Questionnaire. Most instruments were developed based on a theoretical framework and/or model. CONCLUSION: This scoping review adds to the literature an overview of available instruments which measure healthcare student learning styles with evidence of both reliability and validity. The results indicate the need for further studies to improve learning style instruments for use in intervention studies aimed at improving the teaching-learning process for healthcare students.

Structural and histochemical attributes of secretory ducts and cavities in leaves of four species of Calophyllaceae J. Agardh in Amazonian savannas.

This study represents an important contribution to the structural, histochemical and biological understanding of ducts and cavities in leaves of four species of Calophyllaceae that occur in Amazonian savannas. Samples of adult leaves were processed using light, scanning and transmission electron microscopy, as per usual methods for plant anatomy. In paradermal sections, the lumina of ducts are elongated while those of cavities are short. Ducts occur exclusively in the central rib and are abundant in Kielmeyera rubriflora Cambess and Kielmeyera coriacea Mart. and Zucc and larger than in Calophyllum brasiliense Cambess and Caraipa densifolia Mart. In mesophyll, the type of secretory structure and distribution pattern of the ducts and cavities are distinct. In most species, the secreted metabolites are similar and consist of phenolic compounds, lipids, essential oils with oleoresins, mucilage, neutral polysaccharides, proteins and alkaloids, except in K. coriacea, which does not contain oleoresin. The secretion is probably synthesized by mitochondria, rough endoplasmic reticulum, ribosomes and dictyosomes and is externalized toward the lumen by granulocrine and eccrine processes. In addition to being of diagnostic value for species identification, the attributes of the lumen shape, type of secretory structure, distribution pattern, identified metabolites and secretion mechanism are important for understanding the biological roles of ducts and cavities. The identified metabolites reveal a capacity for adaptation, resistance and protection from the action of herbivores and pathogens, and in water retention.

Cytostatics in Indoor Environment: An Update of Analytical Methods.

Periodic and adequate environmental monitoring programs are crucial to assess and reduce the occupational exposure of healthcare workers to cytostatics. The analytical methods employed should be rapid, reliable, sensitive, standardized, and include multiple compounds. A critical overview of recent overall procedures for surface and air contamination with cytostatics in workplace settings is presented, with a focus on sampling, sample preparation, and instrumental considerations. Limitations are also addressed and some recommendations and advice are provided. Since dermal absorption is the main exposure route, surface contamination is the preferred indicator of biological uptake and its methods have significantly improved. In contrast, cytostatics' inhalation is rare; thus, air contamination has been poorly studied, with little improvement. Still, some elements of the analytical methods have not been extensively explored, namely: the amount of wetting solution, the extraction procedure, surface chemistry and roughness, recovery studies from specific surfaces, and cytostatics stability (in surfaces and during shipping and storage). Furthermore, complete validation data (including precision, accuracy, and instrumental and method detection limits) and estimation of global uncertainty are still lacking in most studies, thus preventing method comparison and proposal of standardized procedures.