COVID-19-positive cancer patients undergoing active anticancer treatment: An analysis of clinical features and outcomes.

BACKGROUND: Cancer patients, particularly those on active anticancer treatment, are reportedly at a high risk of severe coronavirus disease 2019 (COVID-19) infection and death. This study aimed to describe the clinical characteristics and outcomes of patients diagnosed with COVID-19 whilst on anticancer treatment in a developing country. METHODS: This is a retrospective observational study of all adult cancer patients at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Pakistan, from March 15, 2020 to July 10, 2020, diagnosed with COVID-19 within 4 weeks of receiving anticancer treatment, where a purposive sampling was performed. Cancer patients who did not receive anticancer treatment and clinical or radiological diagnosis of COVID-19 without a positive reverse transcription-polymerase chain reaction (RT-PCR) test were excluded. The primary endpoint was all-cause mortality after 30 days of COVID-19 test. Data was analyzed with SPSS version 23 (SPSS Inc., Chicago, IL, USA). Categorical parameters were computed using chi-square test, keeping p value < 0.05 as significant. RESULTS: A total of 201 cancer patients with COVID-19 were analyzed. The median age of patients was 45 (18-78) years. Mild symptoms were present in 162 (80.6%) patients, whereas severe symptoms were present in 39 (19.4%) patients. The risk of death was statistically significant (p < .05) amongst patients with age greater than 50 years, metastatic disease, and ongoing palliative anticancer treatment. Anticancer treatment (chemotherapy, radiotherapy, hormonal therapy, targeted therapy, and surgery) received within preceding 4 weeks had no statistically significant (p > .05) impact on mortality. CONCLUSIONS: In cancer patients with COVID-19, mortality appears to be principally driven by age, advanced stage of the disease, and palliative intent of cancer treatment. We did not identify evidence that cancer patients on chemotherapy are at significant risk of mortality from COVID-19 correlating to those not on chemotherapy.

Clinical Response to CHOP vs. R-CHOP in Adult Patients with Diffuse Large B-Cell Lymphomas

Purpose: The purpose of this study was to address the question of "superiority of R-CHOP versus CHOP", with addition of Rituximab to CHOP, regarding survival of patients suffering from DLBCL. Patients and methods: A cohort retrospective design was used to conduct this study in a tertiary care hospital. A total of 100 patients (50 in each group) were randomly selected. The primary and secondary end points were EFS, OS, PFS and DFS. Kaplan Meier survival curve analysis (log rank, Breslow and Tarone ware tests) was employed to compare probability of survival for the two groups (CHOP/ R-CHOP). Results: The mean primary and secondary clinical indicators were estimated for each group (EFS, 1.7; 3.09 with a p value P=0.02), (OS, 0.60; 0.43 with a p value P=0.40), (PFS, 1.73; 3.57 with a p value P=0.002), (DFS, 0.02; 0.48 with a p value of P=0.00). Conclusion:The results for differences in clinical response were statistically significant in favor of the R-CHOP group.

Pharmacoeconomic analysis of treatment of patients infected with hepatitis C virus.

Hepatitis C infection imposes a high economic burden globally. It has been estimated that in 2012, the healthcare cost of Hepatitis C virus (HCV) was $6.5 billion. Furthermore, it has been projected that the cost will reach at $9.1 billion by the year 2024.Frequency of hepatitis C in Pakistan is significantly higher (4.5%) when compared to the populations like India (0.7%), Nepal (1.0), Myanmar (2.5%), Iran (0.8%), China (1%) and Afghanistan (1.1%). The current standard of care for chronic infection with hepatitis C virus is 24 or 48 weeks of therapy with Pegylated interferon-alfa-2a (Peg INF) +Ribavirin (RV) or Interferon alfa-2a (INF) + RV. The objective of this study was to determine that which combination is more effective and the gain in sustained virologic response (SVR) is worth the incremental cost. In total 84 patients were enrolled who received current standard treatment of care for chronic infection with HCV either 24 or 48 weeks of therapy with Peg INF + RV or INF + RV. A pharmacoeconomic analysis was done including fixed and variable cost (comprising concomitant therapies, emergency visits and hospital admissions) of both treatment regimens were calculated and compared with the SVR accomplished by the patients. It was concluded that the Peg INF + RV is cost effective as compared with conventional INF + RV for the treatment of adult patients infected with HCV genotype 3a under a varied array of possibilities regarding treatment costs and effectiveness.

Effects of multidisciplinary teams and an integrated follow-up electronic system on clinical pharmacist interventions in a cancer hospital.

Background The aim of drug therapy is to attain distinct therapeutic effects that not only improve patient's quality of life but also reduce the inherent risks associated with the therapeutic use of drugs. Pharmacists play a key role in reducing these risks by developing appropriate interventions. Whether to accept or reject the intervention made by the pharmacist is a relevant consultant's decision. Objective To evaluate the impact of electronic prompts and follow-up of rejected pharmacy interventions by clinical pharmacists in an in-patient setting. Setting Shaukat Khanum Cancer Hospital & Research Center, Lahore, Pakistan. Method The study was conducted in two phases. Data for 3 months were collected for each phase of the study. Systematic and quantifiable consensus validity was developed for rejected interventions in phase 1, based on patient outcome analyses. Severity rating was assigned to assess the significance of interventions. Electronic prompts for follow-on interventions in phase 2 were then developed and implemented, including daily review via a multidisciplinary team (MDT) approach. Main outcome measure Validity of rejected interventions, acceptance of follow-on interventions before and after re-engineering the pharmacy processes, rejection rate and severity rating of follow-on interventions. Result Of a total of 2649 and 3064 interventions that were implemented during phase 1 and phase 2, 238 (9%) and 307 (10%) were rejected, respectively. Additionally, 133 (56%) were inappropriate rejections during phase 1. The estimated reliability between pharmacists regarding rejected interventions was 0.74 (95% CI of 0.69, 0.79, p 0.000). Prospective data were analysed after implementing electronic alerts and an MDT approach. The acceptance rate of follow-on interventions in phase 2 was 60% (184). Conclusion Electronic prompts for follow-on interventions together with an MDT approach enhance the optimization of pharmacotherapy, increase drug rationality and improve patient care.

Impairment of liver synthetic function and the production of plasma proteins in primary breast cancer patients on doxorubicincyclophosphamide (AC) protocol.

Doxorubicin and Cyclophosphamide (AC protocol) combination is usually considered as a first line therapy in newly diagnosed breast cancer patients. Thus, a retrospective observational study was conducted to monitor the effect of AC protocol on liver synthetic functions and production of plasma proteins in breast cancer patients, reporting to specialized cancer care hospital of Lahore, Pakistan. A total of 75 patients (n=75) on AC protocol with breast cancer were observed in this study. The patient data including age, gender, body surface area, dosage, disease status and laboratory biochemical values were recorded by reviewing historical treatment records. Pre-treatment values were taken as baseline values for albumin, globulin, blood urea nitrogen (BUN), albumin/globulin (A/G) ratio and total proteins. The baseline values were compared after each cycle of by applying ANOVA using statistical tool SPSS® version 21. The plasma levels of blood urea nitrogen (BUN), total protein and globulin dropped significantly (p<0.05) in patients of all age groups. However, the albumin levels were not significantly changed (p>0.05). The A/G ratio level increased (p<0.05) as a result of reduction in globulin levels. Significant changes in plasma protein levels were observed in the elderly patients (50 to 65 years) than patients between 20 to 50 years of age. AC protocol impairs liver synthetic functions as observed by decreased blood urea nitrogen (BUN) and plasma protein levels.

Reduction in chemotherapy order errors with computerised physician order entry and clinical decision support systems.

BACKGROUND: Medication errors in chemotherapy are frequent and lead to patient morbidity and mortality, as well as increased rates of re-admission and length of stay, and considerable extra costs. Objective: This study investigated the proposition that computerised chemotherapy ordering reduces the incidence and severity of chemotherapy protocol errors. METHOD: A computerised physician order entry of chemotherapy order (C-CO) with clinical decision support system was developed in-house, including standardised chemotherapy protocol definitions, automation of pharmacy distribution, clinical checks, labeling and invoicing. A prospective study was then conducted in a C-CO versus paper based chemotherapy order (P-CO) in a 30-bed chemotherapy bay of a tertiary hospital. Both C-CO and P-CO orders, including pharmacoeconomic analysis and the severity of medication errors, were checked and validated by a clinical pharmacist. A group analysis and field trial were also conducted to assess clarity, feasibility and decision making. RESULTS AND CONCLUSION: The C-CO was very usable in terms of its clarity and feasibility. The incidence of medication errors was significantly lower in the C-CO compared with the P-CO (10/3765 [0.26%] versus 134/5514 [2.4%]). There was also a reduction in dispensing time of chemotherapy protocols in the C-CO. The chemotherapy computerisation with clinical decision support system resulted in a significant decrease in the occurrence and severity of medication errors, improvements in chemotherapy dispensing and administration times, and reduction of chemotherapy cost.

Development of an in-house hospital information system in a hospital in Pakistan.

OBJECTIVES: To review our experience of development and implementation of an electronic hospital information system, its costs and return on investment as well as incorporation of some key quality standards. METHODS: Cost and saving trends of the project were calculated using different tools including project expense, cost saving through cessation of printing radiology films and paper. Net present value with payback period was utilized to evaluate the efficiency of the health information systems. Qualitative improvements in different healthcare functions were also analyzed. RESULTS: The total saving of the project was approximately US$ 5.1 million with net saving of US$ 3.5 million for the period from 2001 to 2011. The net present value of the project is US$ 3.2 million with a payback period of 3.4 years. CONCLUSIONS: Electronic hospital information systems and health records hold the potential to be useful tools for quality improvement and error reduction. Adoption of such systems, however, has been slow and erratic, worldwide. Utilizing the concept of net present value, development of such a system may be financially viable for some institutions. Instead of simply replacing paper, these systems may also be used to improve information management and improve quality of patient care.

A prospective study of cefepime versus ticarcilline/clavulanate as empirical treatment of febrile neutropenia in lymphoma patients.

OBJECTIVE: To check the effectiveness of ticarcillin clavulanate versus cefepime as monotherapy in febrile neutropenia in lymphoma patients and also to check tolerability profile of both drugs. METHODS: We randomly assigned 107 neutropenic patients to receive either cefepime or ticarcillin/clavulanate. The clinical efficacy and tolerability profile of both drugs were compared using either cefepime or ticarcillin clavulanate (TC) as an empirical treatment for management of febrile neutropenia in lymphoma patients only with same characteristics at time of presentation. RESULTS: A significant difference in efficacy of the two treatment arms was noted. A successful outcome was reported with 28 (51%) out of 55 in cefepime arm compared to 16 (42%) out of 52 patients in ticarcillin/clavulanate group (p = 0.35; 95% Confidence). The distribution of time for defervesence was estimated for each treatment group and a trend to a shorter time for defervesence was found in the CEFEPIME group (48.4 hour for cefepime, 58.28 hour for TC group; p = 0.018). For microbiologically documented infections, the successful eradication rate was 49% (6 of 14 patients) for TC group as compared to 83% (10 of 12 patients) for cefepime group. This difference was statistically significant for microbiologically documented infections. Twenty seven (52%) patients of TC group and 19 (35%) of cefepime group required modifications of antibiotic regimen. The most frequent modifications consisted of the addition of either an amino glycoside (amikacin) or glycopeptides (vancomycin). CONCLUSION: CEFEPIME regimen was more effective than TC regimen, with a consistent trend toward a better outcome associated with cefepime compared to Ticarcillin/clavulanate.

Comparative immunogenicity of a genetically derived and a plasma pooled hepatitis B vaccine in normal adult volunteers.

OBJECTIVE: This study compares the seroconversion rate after vaccination with genetically derived and plasma pooled vaccine in normal healthy adult volunteers. POPULATION AND METHODS: Forty volunteers of either sex were randomly divided into two groups comprising equal numbers of subjects. The mean (+/- SD) age and weight of the subjects in group A were 27.52 +/- 3.48 years and 65.60 +/- 8.06kg, respectively, while the mean (+/- SD) values for the individuals in group B were 30.75 +/- 3.78 years and 68.55 +/- 6.59kg. Recombinant and plasma pooled vaccines were administered as single 20 microg and 3 microg intramuscular injections to the respective groups of volunteers on days 1, 30, and 180. An automated system (AxSYM, based on microparticle enzyme immunoassay) was used to measure the seroconversion rate in serum harvested from an 8 mL blood sample collected within 1 month of the third dose (i.e., on day 210), from each volunteer. RESULTS: Both of the vaccines were well tolerated by all individuals and no adverse reaction was reported or observed during the study. The subject seroconversion rate corrected with reference to the cut-off rate after vaccination with DNA-derived vaccine was significantly greater (p < 0.05) than that observed after the administration of plasma pooled-derived vaccine (51.64 +/- 17.00 versus 22.96 +/- 12.04). CONCLUSION: The vaccine response, as indicated by the seroconversion rate (concentration of anti-HBs in mIU/mL) in the group vaccinated with genetically derived vaccine was observed to be better (p < 0.01) when matched with the International Antibody Standard.