NUTRI-ONCOCARE: Nuevo modelo integralde atención nutricional para prevenir y tratar la desnutrición en pacientes con cáncer / NUTRI-ONCOCARE: New integral nutrition care model to prevent and treat malnutrition in cancer patients

Objetivo: La máxima expresión de la desnutrición en los pacientesoncológicos es la caquexia cancerosa, siempre vinculada a un pronósticodesfavorable. Dado su carácter evolutivo se recomienda detectar y actuarprecozmente en aquellos pacientes con riesgo nutricional. El objetivo esdefinir un algoritmo de actuación para el abordaje nutricional de pacientes con tumores sólidos.Método: Mediante la técnica de grupo nominal se reunió a especialistas en farmacia hospitalaria, nutrición y oncología que establecieron unapriorización de temas relacionados con el estado nutricional y su abordaje en pacientes con tumores sólidos. Su discusión y análisis permitierondiseñar un algoritmo de actuación.Resultados: El algoritmo diferencia dos grupos de pacientes según lalocalización del tumor y su impacto en el estado nutricional: los tumores dealto riesgo (grupo 1) incluyen cánceres de cabeza y cuello, del tracto digestivo superior y colorrectal, y los tumores de bajo riesgo (grupo 2) englobanel resto de neoplasias. Los pacientes del grupo 1 (a excepción de aquellos con cáncer colorrectal) son directamente valorados nutricionalmenteen los primeros 3-5 días tras su presentación en el comité de tumores, iniciando el soporte nutricional requerido en ese momento. Los pacientes delgrupo 2 y los diagnosticados de cáncer colorrectal son cribados (medianteNUTRISCORE) tras su presentación en el comité, derivándose a consulta nutricional a aquellos con riesgo positivo para realizar una evaluación completa y proponer opciones de tratamiento, y reevaluándose periódicamentelos pacientes sin riesgo nutricional. (AU)

Objective: The maximum expression of malnutrition in cancer patientsis cancerous cachexia, always linked to an unfavorable prognosis. Givenits evolutionary nature it is recommended to detect and act early in thosepatients with nutritional risk. The objective is to propose an action algorithm for the nutritional approach of patients with solid tumors.Method: Through the nominal group technique, specialists in hospitalpharmacy, nutrition and oncology who established a prioritization ofissues related to nutritional status and its approach in patients with solidtumors were brought together. Their discussion and analysis allowed us todesign a performance algorithm.Results: The algorithm differentiates two groups of patients accordingto the location of the tumor and its impact on nutritional status: high-risktumors (group 1) include cancers of the head and neck, upper digestivetract and colorectal and low-risk tumors (group 2) include the rest of theneoplasms. Group 1 patients (with the exception of those with colorectalcancer) are directly assessed nutritionally in the first 3-5 days after theirpresentation in the Tumor Committee, starting the nutritional support required at that time. Patients in group 2 and those diagnosed with colorectalcancer are screened (through NUTRISCORE) after their presentation in theCommittee, those with positive risk being referred to nutritional consultationto perform a complete evaluation and propose treatment options. Patients without nutritional risk are periodically re-evaluated. Follow-up is plannedaccording to cancer therapy, with continuous monitoring in each treatmentcycle or during the perioperative period. (AU)

NUTRI-ONCOCARE: New integral nutrition care model to prevent and treat malnutrition in cancer patients.

OBJECTIVE: The maximum expression of malnutrition in cancer patients is  cancerous cachexia, always linked to an unfavorable prognosis. Given its  evolutionary nature it is recommended to detect and act early in those patients with nutritional risk. The objective is to propose an action  algorithm for the nutritional approach of patients with solid tumors. METHOD: Through the nominal group technique, specialists in hospital pharmacy, nutrition and oncology who established a prioritization  of issues related to nutritional status and its approach in patients with  solid tumors were brought together. Their discussion and analysis allowed  us to design a performance algorithm. RESULTS: The algorithm differentiates two groups of patients according to  the location of the tumor and its impact on nutritional status: high-risk tumors (group 1) include cancers of the head and neck, upper  digestive tract and colorectal and low-risk tumors (group 2) include the  rest of the neoplasms. Group 1 patients (with the exception of those with  colorectal cancer) are directly assessed nutritionally in the first 3-5 days  after their presentation in the Tumor Committee, starting the nutritional  support required at that time. Patients in group 2 and those diagnosed  with colorectal cancer are screened (through NUTRISCORE) after their  presentation in the Committee, those with positive risk being referred to  nutritional consultation to perform a complete evaluation and propose  treatment options. Patients without nutritional risk are periodically re- evaluated. Follow-up is planned according to cancer therapy, with  continuous monitoring in each treatment cycle or during the perioperative  period. CONCLUSIONS: From the nominal group technique, agreements were reached to propose an algorithm of nutritional approach of the cancer patient. The adoption of the proposed algorithm could reduce  variability in institutional clinical practice, promoting a timely and adequate nutritional approach in cancer patients.

Objetivo: La máxima expresión de la desnutrición en los pacientes oncológicos es la caquexia cancerosa, siempre vinculada a un  pronóstico desfavorable. Dado su carácter evolutivo se recomienda  detectar y actuar precozmente en aquellos pacientes con riesgo  nutricional. El objetivo es definir un algoritmo de actuación para el  abordaje nutricional de pacientes con tumores sólidos.Método: Mediante la técnica de grupo nominal se reunió a especialistas en farmacia hospitalaria, nutrición y oncología que establecieron una priorización de temas relacionados con el estado nutricional y su  abordaje en pacientes con tumores sólidos. Su discusión y análisis  permitieron diseñar un algoritmo de actuación.Resultados: El algoritmo diferencia dos grupos de pacientes según la localización del tumor y su impacto en el estado nutricional: los tumores  de alto riesgo (grupo 1) incluyen cánceres de cabeza y cuello, del tracto  digestivo superior y colorrectal, y los tumores de bajo riesgo (grupo 2)  engloban el resto de neoplasias. Los pacientes del grupo 1 (a excepción de aquellos con cáncer colorrectal) son directamente valorados  nutricionalmente en los primeros 3-5 días tras su presentación en el  comité de tumores, iniciando el soporte nutricional requerido en ese  momento. Los pacientes del grupo 2 y los diagnosticados de cáncer  colorrectal son cribados (mediante NUTRISCORE) tras su presentación en  el comité, derivándose a consulta nutricional a aquellos con riesgo positivo para realizar una evaluación completa y proponer opciones de tratamiento, y reevaluándose periódicamente los pacientes sin riesgo nutricional. El  seguimiento se planifica según la terapia oncológica, con una  monitorización continua en cada ciclo de tratamiento o durante el periodo  perioperatorio.Conclusiones: A partir de la técnica de grupo nominal, se alcanzaron acuerdos para proponer un algoritmo de abordaje nutricional  precoz del paciente con cáncer. La adopción del algoritmo propuesto podría reducir la variabilidad en la práctica clínica institucional, promoviendo un  enfoque nutricional oportuno y adecuado en pacientes con cáncer.

Adequacy of Parenteral Nutrition in Preterm Infants According to Current Recommendations: A Study in A Spanish Hospital.

BACKGROUND: In preterm infants, it is important to ensure adequate nutritional intake to accomplish foetal growth requirements. This study evaluated clinical practice regarding the prescription of parenteral nutrition in preterm infants in the neonatology unit of a tertiary hospital. METHODS: It was a retrospective observational study of a sample of preterm infants (n = 155) born between January 2015 and December 2017 who were prescribed parenteral nutrition. Compliance with the hospital's protocol and with the guidelines of the scientific societies American Society for Parenteral and Enteral Nutrition (ASPEN), European Society for Clinical Nutrition and Metabolism (ESPEN) and Spanish Society of Clinical Nutrition and Metabolism (SENPE) was evaluated. The differences in macronutrient intake and total duration of parenteral nutrition were analysed according to gestational age and birth weight. RESULTS: The established protocol was followed in a high percentage (95.5%-100%) except with respect to the initiation of supplying established trace elements (64.9%). Compliance with the recommendations set forth in the guidelines was between 82.1% and 100%, with the exception of the initial carbohydrate intake recommended by ASPEN and ESPEN, for which compliance was 8.3%. Lower gestational age and birth weight were correlated with longer duration of parenteral nutrition (p < 0.001). CONCLUSIONS: A lower gestational age and birth weight are related to a longer duration of parenteral nutrition. The results of this study demonstrate the importance of developing and evaluating protocols in clinical practice.

Stability and compatibility of ondansetron with haloperidol in parenteral admixtures.

BACKGROUND: The chemical stability of coadministered ondansetron (OND) and haloperidol (HAL) in parenteral admixtures has not been described yet. OBJECTIVE: The aim of the present work is to study the chemical stability and the compatibility of OND and HAL admixtures. METHODS: Normal saline solution and dextrose were used to prepare the admixture solutions of the drugs; the materials of the containers were the original plastic bags of the diluents and the stability was studied at 20°C. Compatibility was studied by visual inspection of no colour change and turbidity or precipitation appearance. The concentration of the drugs was studied by ultraviolet detection high-performance liquid chromatography. The method was validated following the Food and Drug Administration and European Medicines Agency guidelines, and the assay enables the measurement of both drugs with a linear calibration curve (r=0.999) over the concentration range 10-100 µg/mL, with acceptable values of linearity, precision and accuracy. Darunavir was used as internal standard. RESULTS: Most of the admixtures have an adequate concentration until 24 hours(less than 10% of loss). 25% of the samples show a higher loss at 24 hours, and the chemical stability of these samples is 12 hours. CONCLUSIONS: The stability and compatibility of OND and HAL in the coadministered admixtures in Viaflo plastic bags with normal saline or dextrose are suggested at 12 hours.

Pharmacokinetic monitoring of chronic treatment with digoxin from Primary Health Care / Seguimiento farmacocinético del tratamiento crónico con digoxina desde Atención Primaria

Objective: To assess the pharmacokinetic monitoring of SDC performed from primary healthcare (PH) in patients with chronic treatment. Methods: Cross-sectional retrospective study of patients with chronic treatment with digoxin belonging to the department of a General University Hospital. Data were analized: age, sex, diagnosis, number of serum digoxin concentration determinations, date and origin of the request for monitoring, analytical result and pharmacokinetic assessment are collected. Results: 624 patients are undergoing chronic treatment with digoxin, 68% women, mean age 78.4 (39-98) years. 308 (49.4%) patients haven’t analytical determination of SDC (Group 1), 183 (29.3%) patients have a SDC occasionally performed with a request from specialist care (Group 2) and 133 (21,3%) patients have CSD performed with a request from primary healthcare doctors, with an average of 2.42 monitoring per patient and year (Group 3). These are those patients who have pharmacokinetic monitoring of chronic treatment with digoxin. Of the group 2.25 (13.6%) patientes were hospital admission from emergency department for presenting digitalis intoxication with CSD>2 ng/ml, and 39 (21.3%) patients for low dosing with CSD (AU)

Objetivo: Evaluar el seguimiento farmacocinético de las CSD que se realiza desde Atención Primaria (AP) en pacientes con tratamiento crónico. Métodos: Estudio trasversal observacional retrospectivo de pacientes en tratamiento crónico con digoxina que pertenecen al departamento de un Hospital General Universitario. Se recogen datos de edad, sexo, diagnóstico, número de determinaciones séricas de digoxina realizadas, fecha y origen de la solicitud de monitorización, resultado analítico y valoración farmacocinética. (Infradosificación, normodosificación o supradosificación). Resultados: 624 pacientes están en tratamiento crónico con digoxina: 68% mujeres, edad media 78,4 (39-98) años. 308 (49,4%) pacientes no tienen realizada ninguna determinación analítica de CSD (Grupo 1), 183 (29,3%) pacientes tienen CSD realizadas de manera esporádica con solicitud tramitada desde Atención Especializada (Grupo 2) y 133 (21,3%) pacientes tienen CSD realizadas de manera periódica con solicitud cursada por médicos de AP, con un promedio de 2,42 monitorizaciones por paciente y año (Grupo 3). Estos son los que tienen un seguimiento farmacocinético del tratamiento crónico con digoxina. Del Grupo 2,25(13,6%) entran por el Servicio de Urgencias por presentar intoxicación digitálica con CSD>2 ng/ml, y 39 (21,3%) pacientes por baja dosificación con CSD (AU)

Pharmacokinetic monitoring of chronic treatment with digoxin from Primary Health Care.

INTRODUCTION: The serum digoxin concentration (SDC) should be between 0.8 and 2 ng/ml. The objective is to assess the pharmacokinetic monitoring of SDC performed from primary healthcare (PH) in patients with chronic treatment. METHODS: Cross-sectional retrospective study of patients with chronic treatment with digoxin belonging to the department of a General University Hospital.Data were analized: age, sex, diagnosis, number of serum digoxin concentration determinations, date and origin of the request for monitoring, analytical result and pharmacokinetic assessment are collected. RESULTS: 624 patients are undergoing chronic treatment with digoxin, 68% women, mean age 78.4 (39-98) years. 308 (49.4%) patients haven't analytical determination of SDC (Group 1), 183 (29.3%) patients have a SDC occasionally performed with a request from specialist care (Group 2) and 133 (21,3%) patients have CSD performed with a request from primary healthcare doctors, with an average of 2.42 monitoring per patient and year (Group 3). These are those patients who have pharmacokinetic monitoring of chronic treatment with digoxin. Of the group 2.25 (13.6%) patientes were hospital admission from emergency department for presenting digitalis intoxication with CSD>2 ng/ml, and 39 (21.3%) patients for low dosing with CSD<0.5 ng/ml. Group 3.4 (3%) patients presented digitalis intoxication and 5 (3.8%) for insufficient dosing. CONCLUSIONS: A small proportion of patients undergoing chronic treatment with digoxin are under pharmacokinetic monitoring and a reduction in complications derived from inappropriate CSD compared to those not under pharmacokinetic follow-up is observed.

Introducción: La concentración sérica de digoxina (CSD) debe situarse entre 0,8 y 2 ng/ml. El objetivo es valuar el seguimiento farmacocinético de las CSD que se realiza desde Atención Primaria (AP) en pacientes con tratamiento crónico.Métodos: Estudio trasversal observacional retrospectivo de pacientes en tratamiento crónico con digoxina que pertenecen al departamento de un Hospital General Universitario. Se recogen datos de edad, sexo, diagnóstico, número de determinaciones séricas de digoxina realizadas, fecha y origen de la solicitud de monitorización, resultado analítico y valoración farmacocinética. (Infradosificación, normodosificación o supradosificación).Resultados: 624 pacientes están en tratamiento crónico con digoxina: 68% mujeres, edad media 78,4 (39-98) años. 308 (49,4%) pacientes no tienen realizada ninguna determinación analítica de CSD (Grupo 1), 183 (29,3%) pacientes tienen CSD realizadas de manera esporádica con solicitud tramitada desde Atención Especializada (Grupo 2) y 133 (21,3%) pacientes tienen CSD realizadas de manera periódica con solicitud cursada por médicos de AP, con un promedio de 2,42 monitorizaciones por paciente y año (Grupo 3). Estos son los que tienen un seguimiento farmacocinético del tratamiento crónico con digoxina.Del Grupo 2,2(13,6%) entran por el Servicio de Urgencias por presentar intoxicación digitálica con CSD>2 ng/ml, y 39 (21,3%) pacientes por baja dosificación con CSD<0,5ng/ml. Del Grupo 3,4 (3%) presentan intoxicación digitálica y 5 (3,8%) infradosificación.Conclusiones: Una pequeña parte de los pacientes que se encuentran en tratamiento crónico con digoxina están en seguimiento farmacocinético. Se observa una reducción de las complicaciones derivadas de CSD inapropiadas con respecto a los que no están en seguimiento farmacocinético.

Administración de medicamentos por vía subcutánea en cuidados paliativos / Subcutaneous drug administration in palliative care

Objetivo: Elaborar una guía que recopile toda la información disponible en la bibliografía para el personal sanitario sobre la administración de medicamentos por vía subcutánea en pacientes de cuidados paliativos de la Unidad de Hospitalización a Domicilio. Método: Se diseña una tabla resumen de fármacos susceptibles de ser administrados por vía subcutánea en pacientes de cuidados paliativos mediante la revisión de los informes técnicos de los laboratorios fabricantes y de otra literatura publicada por organizaciones científicas, además de la búsqueda bibliográfica en Pubmed® y Micromedex®. Resultados: Se han revisado 65 fármacos y se ha elaborado una guía de recomendaciones en función de si existe información de su administración por vía subcutánea o, si por el contrario, esta contraindicado su uso. Conclusiones: Aunque mayoritariamente los laboratorios fabricantes no disponen de datos, la información recopilada en esta guía permitirá el manejo de la vía subcutánea de algunos de los medicamentos más utilizados en cuidados paliativos (AU)

Objective: Develop a guide that compiles all the information available in the literature for healthcare staff on the administration of drugs subcutaneously in palliative care patients of the Hospital Unit of home. Method: It is designed a summary table of drugs likely to be administered subcutaneously in palliative care patients through the revision of the technical reports of the manufacturers and other literature published by scientific organizations, in addition to the literature search on Pubmed® and Micromedex®. Results: We have reviewed 65 drugs and a guide has been developed of recommendations depending on whether there is information of his administration by subcutaneous or, if on the contrary, its use is contraindicated. Conclusions: Although mainly manufacturers laboratories do not have data, information collected in this guide will allow the management of the subcutaneous route of some of the most commonly used medications in palliative care (AU)

[Subcutaneous drug administration in palliative care]. / Administración de medicamentos por vía subcutánea en cuidados paliativos.

OBJECTIVE: Develop a guide that compiles all the information available in the literature for healthcare staff on the administration of drugs subcutaneously in palliative care patients of the Hospital Unit of home. METHOD: It is designed a summary table of drugs likely to be administered subcutaneously in palliative care patients through the revision of the technical reports of the manufacturers and other literature published by scientific organizations, in addition to the literature search on Pubmed® and Micromedex®. RESULTS: We have reviewed 65 drugs and a guide has been developed of recommendations depending on whether there is information of his administration by subcutaneous or, if on the contrary, its use is contraindicated. CONCLUSIONS: Although mainly manufacturers laboratories do not have data, information collected in this guide will allow the management of the subcutaneous route of some of the most commonly used medications in palliative care.

Objetivo: Elaborar una guía que recopile toda la información disponible en la bibliografía para el personal sanitario sobre la administración de medicamentos por vía subcutánea en pacientes de cuidados paliativos de la Unidad de Hospitalización a Domicilio. Método: Se diseña una tabla resumen de fármacos susceptibles de ser administrados por vía subcutánea en pacientes de cuidados paliativos mediante la revisión de los informes técnicos de los laboratorios fabricantes y de otra literatura publicada por organizaciones científicas, además de la búsqueda bibliográfica en Pubmed® y Micromedex®. Resultados: Se han revisado 65 fármacos y se ha elaborado una guía de recomendaciones en función de si existe información de su administración por vía subcutánea o, si por el contrario, esta contraindicado su uso. Conclusiones: Aunque mayoritariamente los laboratorios fabricantes no disponen de datos, la información recopilada en esta guía permitirá el manejo de la vía subcutánea de algunos de los medicamentos más utilizados en cuidados paliativos.

Unrecognized delayed toxic lithium peak concentration in an acute poisoning with sustained release lithium product.

A 32-year-old female with a history of bipolar disorder was admitted after taking approximately 16 g of an extended-release lithium carbonate formulation in an attempted suicide. Five hours after consumption, the lithium serum level was 3.2 mEq/L. Fourteen hours after consumption, the lithium level was 5.1 mEq/L and the patient was asymptomatic. Due to a level > 4 mEq/L, the patient was transferred to a renal medicine service for hemodialysis. The lithium concentration 6 hours after the hemodialysis was 2.54 mEq/L. Thirty seven hours after the consumption (15 hours after hemodialysis), lithium levels increased up to 6.09 mEq/L. A second hemodialysis session was performed, which successfully reduced the serum lithium concentration to 1.86 mEq/L. Lithium levels 85 hours after the consumption were 0.61 mEq/L and the patient was transferred to the Psychiatry Department. Unrecognized delayed toxic peak lithium concentration may appear in an acute poisoning with a sustained release lithium product. Therefore, patients presenting with acute intoxication with extended release formulations should be managed with caution, and continued drug monitoring is suggested.

Acute seizures due to a probable interaction between valproic acid and meropenem.

OBJECTIVE: To report a probable interaction between meropenem and valproic acid that resulted in the development of epileptic seizures. CASE SUMMARY: A 21-year-old woman presented to our emergency department because of a new-onset, generalized tonic-clonic seizure and was admitted to the intensive care unit. Treatment with valproic acid 1000 mg as a continuous intravenous infusion over 24 hours was initiated. On day 6, the serum concentration of valproic acid was 52.5 microg/mL. On day 13, treatment with intravenous meropenem 1 g 3 times daily was started. On day 15, when the patient was afebrile, numerous myoclonic episodes occurred involving her arms and face; the serum concentration of valproic acid at that time was 42 mug/mL. The valproic acid dose was increased to 2880 mg. Two days later, a generalized tonic-clonic seizure occurred despite the increased dosage, and the plasma concentration of valproic acid fell to 7 microg/mL. The valproic acid dose was increased the following day to 3600 mg; however, the serum concentrations remained <10 microg/mL. On day 19, based on the results of a blood culture and the suspicion of an interaction between meropenem and valproic acid, meropenem therapy was suspended. The serum concentration of valproic acid was 52.4 microg/mL on day 27. Three days later, the patient was asymptomatic and was discharged. DISCUSSION: Coadministration of valproic acid and other drugs that are metabolized by the hepatic cytochrome P450 isoenzyme system can lead to clinically relevant interactions by induction or inhibition of enzymes in shared metabolic pathways. In view of studies in experimental models, the interaction between carbapenem antibiotics and valproic acid is at least possible. Use of the Naranjo probability scale indicated a probable relationship between acute seizures and a meropenem-valproic acid interaction in this patient. CONCLUSIONS: This case report provides strong evidence for an interaction between valproic acid and meropenem. Clinicians should be aware of this potential interaction that may be associated with a serious adverse effect as the result of the decrease of the valproic acid serum concentrations.