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PURPOSE: Penicillin allergy is the most common drug allergy among hospitalized patients. Traditionally, aztreonam is recommended for patients labeled with penicillin allergy (PLWPA) in our institutional empirical antibiotic guidelines. Due to a global aztreonam shortage in December 2022, the antimicrobial stewardship unit recommended ceftazidime as a substitute. There is a paucity of real-world data on the safety profile of ceftazidime in PLWPA. Hence, we evaluated tolerability outcomes of ceftazidime use in PLWPA. METHODS: This retrospective cohort study compared PLWPA in Singapore General Hospital who received aztreonam (October 2022-December 2022) or ceftazidime (December 2022-February 2023). Patients were stratified according to their risk of allergic reaction (AR) based on history of penicillin allergy. The severity of AR was based on the Delphi study grading system. The primary outcome was development of AR after initiation of aztreonam or ceftazidime. The secondary tolerability outcomes include hepatotoxicity and neurotoxicity. FINDINGS: There were 168 patients in the study; 69 were men (41.1%) and the median age was 69 years (interquartile range: 59-76 years). Incidence of AR was statistically similar in both arms: 1 of 102 patients (0.98%) in the aztreonam arm vs 2 of 66 patients (3.03%) in the ceftazidime arm (P = 0.33). The patient in the aztreonam arm was deemed at medium risk of having an AR and developed localized rashes (grade 1). Both patients in the ceftazidime arm were deemed at high risk of AR and developed localized skin reaction (grade 1). Hepatotoxicity was observed in 1 patient prescribed aztreonam. No patients in the ceftazidime arm developed adverse events. IMPLICATIONS: Ceftazidime appears to be better tolerated and cheaper compared with aztreonam in PLWPA, and serves as an antimicrobial stewardship strategy to conserve broader-spectrum antibiotics use.
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PURPOSE: Palliative care in Sarawak is mainly provided by health care professionals with limited formal training in palliative care. Therefore, in 2020, collaborative work between Sarawak General Hospital, University Malaysia Sarawak, and ASCO began. This study reports on the outcome of this collaboration. METHODS: The collaboration was initiated with the first ASCO Palliative Care e-course, Train the Trainer program, International Development and Education Award-Palliative Care and translation of ASCO Palliative Care Interdisciplinary Curriculum resources. RESULTS: This collaboration has resulted in the change of practice of palliative care among the oncology team of Sarawak General Hospital. CONCLUSION: It encourages more timely palliative care referrals to ensure that patients with complex physical, psychosocial, and spiritual needs have the necessary input and support from the palliative care team throughout the course of patients' illnesses.
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Oncologia , Cuidados Paliativos , Humanos , Cuidados Paliativos/métodos , Currículo , Pessoal de SaúdeRESUMO
PURPOSE: Stereotactic body radiation therapy (SBRT) is a novel local therapy for the treatment of hepatocellular carcinoma (HCC). While effective, there is currently no reliable radiological marker to guide patient selection. In this study, we investigated the prognostic value of capsule appearance on contrast-enhanced computed tomography (CT) for patients undergoing SBRT. MATERIALS AND METHODS: Between 2006 and 2017, 156 consecutive patients with Child-Pugh score class A/B and HCC ≥â¯5â¯cm who underwent SBRT were retrospectively analysed. Baseline triple-phase CTs of the abdomen were reviewed for the presence of capsule appearances and correlated with objective response rate (ORR), overall survival (OS) and pattern of treatment failure. RESULTS: Capsule appearance on CT was present in 83 (53.2%) patients. It was associated with improved ORR by Response Evaluation Criteria in Solid Tumours (RECIST) (60.2 vs. 24.7%, pâ¯< 0.001) and Modified Response Evaluation Criteria in Solid Tumours (mRECIST) (78.3 vs. 34.2%, pâ¯< 0.001). The presence of a capsule was also associated with superior 2year local control (89.1 vs. 51.4%, pâ¯< 0.001) and 2year OS (34.1 vs. 14.8%, pâ¯< 0.01). Hepatic out-field failure was the dominant mode of progression, which was less common in patients with intact capsule (54.2 vs. 60.3%, pâ¯= 0.01). CONCLUSION: Capsule appearance on CT could potentially be a non-invasive prognostic marker for selecting HCC patients to undergo SBRT. A larger cohort is warranted to validate our findings.
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Carcinoma Hepatocelular , Neoplasias Hepáticas , Radiocirurgia , Carcinoma Hepatocelular/diagnóstico por imagem , Carcinoma Hepatocelular/radioterapia , Humanos , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/radioterapia , Radiocirurgia/métodos , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
OBJECTIVES: Voriconazole serum concentration, which is affected by several factors, is associated with treatment response and toxicity. There is paucity of data on voriconazole therapeutic drug monitoring (TDM) among Southeast Asians, who exhibit a higher prevalence of CYP2C19-poor metabolisers compared with Caucasians and East Asians. Hence, there are concerns for higher risk of voriconazole accumulation and toxicity. We aim to determine the utility of voriconazole TDM through establishing: (1) proportion of patients achieving therapeutic troughs without dose adjustments; (2) characterisation of patients with sub-therapeutic, therapeutic and supra-therapeutic levels; (3) appropriate dose titrations/dose required for therapeutic troughs; (4) correlation between troughs and adverse events, treatment response/fungal breakthrough. PATIENTS AND METHODS: A single-centre retrospective analysis of data from adults (≥21 years old) with ≥1 voriconazole trough measured at Singapore General Hospital from 2015 to 2017 was performed. RESULTS: Thirty-two patients (45.7%) among 70 patients achieved therapeutic troughs (defined as 2.0-5.5 mg/L) without dose adjustments. Eleven patients (15.7%) experienced hepatotoxicity (troughs 0.5 to >7.5 mg/L). Neurotoxicity occurred in three patients (4.3%) (troughs ≥6.7 mg/L) and all patients had symptom resolution upon dose reduction. Treatment failure of invasive fungal infection appeared less in patients with therapeutic troughs compared with sub-therapeutic troughs (11.4% vs. 14.2%). Two patients experienced treatment failure despite supra-therapeutic voriconazole troughs. CONCLUSIONS: TDM should be implemented due to significant unpredictability in dose exposure. TDM can reduce unnecessary switches to alternatives due to intolerability and rule in the possibility of resistant organisms in the event of treatment failure despite therapeutic troughs, alerting clinicians to switch to alternatives promptly.
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Antifúngicos , Monitoramento de Medicamentos , Adulto , Antifúngicos/efeitos adversos , Sudeste Asiático , Humanos , Estudos Retrospectivos , Singapura , Voriconazol/efeitos adversos , Adulto JovemAssuntos
Leucemia , Síndromes Mielodisplásicas , Humanos , Íleo , Micafungina , Comprimidos , TriazóisRESUMO
Primary liposarcoma is an extremely rare disease. We report a case of giant thoracic myxoid liposarcoma that occupied the whole left hemithorax and was successfully resected. We discuss the surgical considerations and difficulties encountered, and how we overcome these challenges. This is the third largest thoracic myxoid liposarcoma resection reported, weighing 4 kg.
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Lipossarcoma Mixoide/cirurgia , Neoplasias do Mediastino/cirurgia , Biópsia , Humanos , Lipossarcoma Mixoide/diagnóstico por imagem , Lipossarcoma Mixoide/patologia , Masculino , Neoplasias do Mediastino/diagnóstico por imagem , Neoplasias do Mediastino/patologia , Pessoa de Meia-Idade , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Carga TumoralAssuntos
Adenocarcinoma/tratamento farmacológico , Antimetabólitos Antineoplásicos/efeitos adversos , Desoxicitidina/análogos & derivados , Neoplasias Pancreáticas/tratamento farmacológico , Síndrome de Lise Tumoral/etiologia , Adenocarcinoma/patologia , Adulto , Antimetabólitos Antineoplásicos/uso terapêutico , Desoxicitidina/efeitos adversos , Desoxicitidina/uso terapêutico , Humanos , Masculino , Neoplasias Pancreáticas/patologia , Síndrome de Lise Tumoral/diagnóstico , GencitabinaRESUMO
A 74-year-old woman had carcinoma of her right breast for which surgery was performed. Four weeks following the start of tamoxifen therapy, she developed papules and plaques over her face, trunk and limbs. A skin biopsy showed perivascular and periadnexal mixed inflammatory cellular infiltrate with fibroplasia. Notably, the dermis also showed squamous epithelial islands, which in foci were noted to be closely associated with eccrine epithelium. This was confirmed with double peroxidase - alkaline phosphatase immunohistochemistry - the eccrine lumina highlighted with carcinoembryonic antigen (polyclonal) and the squamous metaplasia positive for cytokeratin 5/6. Eccrine squamous syringometaplasia was diagnosed. With close clinicopathological correlation, the cutaneous eruption was attributed to tamoxifen. Following discontinuation of the drug, the eruption resolved. Eccrine squamous syringometaplasia has been reported to occur in association with diverse conditions, including skin ulcers, burns and as a cutaneous adverse drug reaction, most commonly to chemotherapeutic drugs. This is believed to be the first report involving tamoxifen.
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Antineoplásicos Hormonais/efeitos adversos , Derme , Toxidermias , Glândulas Écrinas , Tamoxifeno/efeitos adversos , Idoso , Antineoplásicos Hormonais/administração & dosagem , Neoplasias da Mama/terapia , Derme/metabolismo , Derme/patologia , Toxidermias/metabolismo , Toxidermias/patologia , Glândulas Écrinas/metabolismo , Glândulas Écrinas/patologia , Feminino , Humanos , Metaplasia , Tamoxifeno/administração & dosagemAssuntos
Neoplasias da Mama , Oftalmoplegia , Idoso de 80 Anos ou mais , Encéfalo , Neoplasias da Mama/complicações , Neoplasias da Mama/tratamento farmacológico , Neoplasias da Mama/fisiopatologia , Neoplasias da Mama/radioterapia , Fossa Craniana Posterior/diagnóstico por imagem , Fossa Craniana Posterior/fisiopatologia , Feminino , Humanos , Imageamento por Ressonância Magnética , Metástase Neoplásica/diagnóstico , Metástase Neoplásica/radioterapia , Oftalmoplegia/complicações , Oftalmoplegia/diagnóstico , Oftalmoplegia/fisiopatologia , Oftalmoplegia/radioterapia , RadiografiaRESUMO
It is now well recognised that there are inter-ethnic differences accounting for variations in both pharmacokinetics (PK) and pharmacodynamics (PD) of drugs, resulting in differences in drug responses. Treating physicians should be aware of pharmacogenetic differences that may exist between the races while extrapolating data generated from other populations to their own patients in order to ensure optimal treatment response and minimise toxicity. This is especially crucial in the practice of oncology where many anti-cancer drugs have narrow therapeutic indices. This paper discusses some commonly used drugs in cancer treatment where inter-ethnic differences in drug safety and efficacy are known to exist that are relevant to the Asian physician.