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PURPOSE: ChemoPalRx is a novel provider order entry mobile application for chemotherapy. This study aims to evaluate the accuracy of prescribing chemotherapy using ChemoPalRx versus handwritten orders at a safety-net hospital in Los Angeles. METHODS: In a cross-sectional study from October 2019 to December 2019, we evaluated all outpatient chemotherapy orders for accuracy. Our primary predictor was type of prescription, dichotomized as handwritten or ChemoPalRx. Primary outcome was accuracy, dichotomized as accurate if no error was made on an order and as inaccurate if any error was made. Preplanned subgroup analyses were performed with covariates including provider experience, complexity of order, and day of order submission. We characterized error type and analyzed our data using univariate and multivariate logistic regression models. RESULTS: Among 288 orders (78.5% handwritten; 21.5% ChemoPalRx), prescription accuracy was higher among ChemoPalRx (93.5%) compared with handwritten orders (81.4%; P = .012). In multivariate analysis, prescription accuracy remained superior for ChemoPalRx after adjusting for provider experience, complexity of order, and day of order submission (adjusted odds ratio, 1.82; P = .012). Compared with handwritten orders, ChemoPalRx orders had less missing or incorrect information (1.6% v 13.7%; P = .0016). ChemoPalRx orders were also more accurate on prescriptions that contained two or fewer medications (92.2% v 80.2%; P = .032), submitted on the highest patient-volume clinic day of the week (96.7% v 83.2%; P = .035), and generated by a senior fellow or an attending (97.3% v 76.9%; P = .001). CONCLUSION: ChemoPalRx is associated with improved chemotherapy prescription accuracy over handwritten orders in the safety-net hospital setting and may serve as an alternative prescribing tool for oncology practices.
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Aplicativos Móveis , Estudos Transversais , Prescrições de Medicamentos , Humanos , Oncologia , Erros de MedicaçãoRESUMO
INTRODUCTION: Landmark trials repeatedly demonstrate that pertuzumab and trastuzumab plus standard chemotherapy have the best outcomes in human epidermal growth factor receptor 2 (HER2) positive breast cancer in the neoadjuvant, adjuvant, and metastatic setting. However, many of these multicenter landmark trials lack diversity and studied largely Caucasian populations. Our goal is to address this under-representation of minorities, and compare pathologic complete response (pCR) rates in our predominantly Hispanic population with HER2 positive breast cancer receiving the same neoadjuvant chemotherapy (NACT) at Olive View-UCLA Medical Center (OVMC) to that of pCR rates observed in the TRYPHAENA trial. METHODS: For this retrospective cohort study, we compiled a list of 53 patients aged 18 and older, 52 female and 1 male, with HER2 positive breast cancer identified by fluorescence in situ hybridization treated at OVMC from December 2015 to May 2018. Our population was 57% Hispanic, 13% white, 13% Filipino, 11% Asian, 2% black, and 4% other. The complete list included patients receiving standard neoadjuvant, adjuvant, and metastatic chemotherapy regimens. We analyzed 23 female patients with HER2 positive breast cancer staged I to IIIC, receiving standard NACT (docetaxel, carboplatin, trastuzumab, and pertuzumab). Metastatic HER2 positive breast cancer patients were excluded. The primary outcome studied was pCR rates after receiving NACT. pCR was defined as the absence of invasive cancer cells from tissue samples removed after surgery. Secondary outcomes measured were side effects of chemotherapy. pCR rates and side effects were compared to TRYPHAENA. Data regarding insurance status, breast cancer detection modality, and time to seek medical attention were recorded. RESULTS: 50% of our patients who received NACT achieved pCR. Our pCR rates mirrored those observed in the TRYPHAENA trial (51.9%). The most common side effect observed in our population was diarrhea. A higher proportion (37.5%) of our patients had liver function test (LFT) elevation compared to the TRYPHAENA trial (3.9%). Baseline LFTs were normal prior to treatment in 96% of patients. In terms of modality of detection, 70% were self-palpated, 26% were detected through routine mammography, and 4% were found incidentally. Average time from mass discovery to seeking medical attention was 3.4 months. Only 26% had medical insurance at diagnosis. Although not included in our study, 28% of our patients were initially diagnosed with stage IV metastatic disease. Conclusion: Our study found that pCR rates in our primarily Hispanic population compared well to the response rates observed in landmark trials with largely Caucasian populations. Genetic variations in chemo-sensitivity may have a minimal influence on cancer care outcomes in this population.
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A 70-year-old Indian male with a history of a Gleason 7 (3+4) prostate cancer presented with abdominal ascites. Imaging was remarkable for peritoneal carcinomatosis as well as possible metastases to the bladder and seminal vesicle. Given the atypical pattern of presentation, further investigation was performed with studies of the ascites fluid. Cytology from the ascites fluid returned consistent with malignant cells of prostatic origin. His treatment course included androgen deprivation therapy (ADT), docetaxel, abiraterone, and cabazitaxel. He had eventual progression and worsening of his disease and performance status and was transitioned to hospice. This case demonstrated the importance of pursuing a thorough diagnostic evaluation, when faced with a rare presentation of a common malignancy. Furthermore, it illustrated the challenges incurred when tailoring standard regimens to best address the needs of the whole patient and not simply their disease.
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BACKGROUND: While in children intussusception is often idiopathic, in adults it is commonly caused by a pathologic condition functioning as a lead point. It is important to note that a variety of pathologic conditions may trigger intussusception, with malignancy being a relatively frequent culprit in adults; this should be considered high on the differential diagnosis during evaluation. CASE SUMMARY: This is a case of a 40-year-old female presenting to the emergency department (ED) with three days of acute on chronic, peri-umbilical abdominal pain described as waxing and waning, and pressure-like in nature. Initial computed tomography (CT) of the abdomen and pelvis with contrast in the ED (after her pain had resolved) re-demonstrated a previously noted 13 mm lesion in the gastric antrum but no clear cause of the pain. Endoscopic ultrasound was pursued, and the mass lesion was sampled via fine needle biopsy. Post-procedure the patient experienced another episode of severe pain which prompted a repeat stat CT abdomen and pelvis with contrast; this re-demonstrated the 13 mm antral lesion and in addition was remarkable for a gastro-gastric intussusception. An upper gastrointestinal gastrograffin series was ordered (completed only after the pain had subsided) and showed resolution of the intussusception. Histopathology was consistent with a diagnosis of low-grade neuroendocrine tumor (NET). Surgery was initially deferred during the hospitilization given the low grade pathology of the lesion; however further multidisciplinary discussion between Surgery, Oncology, and Gastroenterology recommended resection given the patient's recurrent abdominal pain with the NET functioning as a lead point for further intussusception, and the patient thus underwent robotically-assisted wedge resection. CONCLUSION: We present a unique case of severe, intermittent, peri-umbilical pain related to gastro-gastric intussusception caused by an antral NET lead point. The case highlights the importance of considering neoplasms as the cause of intussusception in adults and the greater diagnostic yield when imaging is obtained while symptoms (in this case severe, episodic abdominal pain) are most apparent.