Tamoxifen case on Endometrial Adenocarcinoma (MCQ)

Question
A 46-year-old female presents with irregular menstrual bleeding that has persisted recently. Her medical history consists of
2 full-term pregnancies and
invasive ductal carcinoma of the breast that was successfully treated with tamoxifen. 
She was recently diagnosed with type 1 endometrioid adenocarcinoma.

Which of the following factors most likely increased this patient's risk for developing this cancer?
  • A. Family history of breast cancer.
  • B. Oral contraceptive use.
  • C. Her pre-premenopausal stat.
  • D. multiple pregnancies.
  • E. Tamoxifen used to treat breast cancer.

Check your answer ...

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Continuous IV Checklist

Administering Intravenous Push Medication Through an Existing Infusion (Continuous IV)

1.

Start hand hygiene and wear a suitable glove.

2.

Check doctor order and review patient file for allergies.

3.

Check medication compatibilities with current active medications.

4.

Verify rate of administration.

5.

Start preparing the required dose.

6.

Verify correct patient.

7.

Assess IV for signs and symptoms of infiltration or phlebitis (and if present, stop until new IV site is obtained).

8.

Turn off IV by turning off pump and/or clamping the tubing directly above the access port.

9.

Swab access port with alcohol or other antiseptic agent according to institutional policy.

10.

If medication is not compatible with IV solution, flush IV line with 2 to 5 mL of normal saline before administration of medication. If medication is compatible with IV solution, normal saline flush is not necessary; continue to next step.

11.

Connect medication syringe to access port via needleless adaptor.

12.

Pull back on plunger of syringe to observe blood return (which verifies placement of IV in vein).

13.

Gently instill medication over required time frame (typically 2 to 5 minutes).

14.

Assess patient carefully during administration for any adverse reactions.

15.

Disconnect syringe when medication is completed.

16.

Flush IV line with 3 to 5 mL of normal saline, instilling at same rate of medication administration in order to administer the medication left in tubing at proper infusion rate.

17.

Turn IV back on or unclamp tubing, then readjust rate appropriately.

18.

Dispose of syringe in sharps container.

19.

Remove gloves, perform hand hygiene, and document medication administration.

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First Order Vs. Zero Order Kinetics

Trying to understand first order and zero order kinetics

{My own study points.}

First Order Kinetics

  • Higher plasma concentrations means higher metabolization rate.
  • Metabolism is directly proportional with drug concentrations.
  • Drug is eliminated from the body related to the plasma levels.
  • Constant half-life. (Metabolize 50% of drug)

Zero Order Kinetics

  • Higher plasma concentrations doesn't mean higher metabolization rate.
  • Metabolism is independent from plasma concentrations.
  • Drug concentration in the body increase with time disregarding the elimination rate leading to toxic side effects.
  • Constant rate of drug metabolism.

Conclusion:

First order is Good, Zero order is BAD.

First order is occurring with most medications.


First order: constant proportion of the drug is eliminated per unit time.
Zero order: constant amount of the drug is eliminated per unit time.

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ISBAR

The communication structure Identify, Situation, Background, Assessment and Recommendation (ISBAR) was created to standardise the effective transfer of information in the US armed forces. ISBAR was adopted by the public health service in the 2000s

ISBAR STRUCTURE

POSSIBILITIES

Identify

Introduction (Hello Dr. my name is) 

  • Who are you?
  • Where are you?
  • Patient's name, age, gender and department

Situation

Situation (What’s this about?) 

  • I'm calling because... (describe)
  • I have observed major changes... (ABCDE)
  • I have measured the following values...
  • (RR*, Sp020, pulse/heart rhythm, BPA, capillary refill time, etc...)
  • I have received test results...

Background

Background (Brief & pertinent info) 


If it's urgent and/or you are concerned — speak up.

Brief and relevant case history


Admission diagnosis and date

Previous illnesses of significance

Relevant problems and treatment/interventions to date

Allergies

Assessment

Assessment (Your analysis and consideration of options) 

  • I think the problem/reason for the patient's condition is related to (respiration, circulation, neurology).
  • I don't know what the problem is but the patient's condition has deteriorated.
  • The patient is unstable, we need to do something.
  • I am concerned.

Recommendation

Recommendation (What do you want the physician to do?)

I suggest.../What interventions do you recommend?

  • Immediate intervention
  • Investigation/treatment
  • How often should I...

When should I next make contact? When will you be here?

Confirm messages and interventions with a closed loop.

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Doxorubicin chemo preparation

Doxorubicin MOA

Doxorubicin inhibits DNA and RNA synthesis by intercalation between DNA base pairs by inhibition of topoisomerase II and by steric obstruction. Doxorubicin intercalates at points of local uncoiling of the double helix. Although the exact mechanism is unclear, it appears that direct binding to DNA (intercalation) and inhibition of DNA repair (topoisomerase II inhibition) result in blockade of DNA and RNA synthesis and fragmentation of DNA. Doxorubicin is also a powerful iron chelator; the iron-doxorubicin complex can bind DNA and cell membranes and produce free radicals that immediately cleave the DNA and cell membranes.

Questions:

For those who prepare chemotherapy, we always need detailed guidelines for the preparation of Doxorubicin, and all the chemo handling and preparing precautions.

Does your preparation depend on the route of administration?

Do we use the beads in all preparations, or only for the chemoembolization? 

Do we only need a chemo vertical laminar flow hoods, or the equipment we use should ensure closed system?

Answers:

Doxorubicin is like any other hazardous drug that requires to be prepared under certain conditions stated in USP 800. You may refer to the latest version online. It should answer all your question regarding the precautions you must follow. Closed system devices are not enough by itself to prepare biohazard meds including chemotherapy without a primary engineering control device.

Doxorubicin is mixed with beads for particular procedure called chemoembolization in hepatocellular carcinoma and its given as intra-arterial injection by a trained provider (usually radiologist). But it is never mixed with beads for other routes.

Doxorubicin is given intravenously as a push, intermittent infusion, or continue infusion. This is usually decided by the treatment protocol you would use. For example, in AC protocol (doxorubicin and cyclophosphamide) for breast carcinoma, doxorubicin is given as IV push over 10-12 minutes. While in a more complicated protocol such as R-EPOCH, it is combined with other chemotherapy drugs and is infused as a continuous infusion over 24 hours for multiple days.

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How tech is transforming healthcare

How tech is transforming healthcare

1

Wearables

Data captured from health devices could provide precious information to provide accurate care to the patients.
As we noticed wearable gadgets are increasing in numbers as well as accuracy.

2

Augmented Reality

Allowing the healthcare providers to jump instantly between patients, or view organs, or even project radiology images over the body during operations to reduce mistakes.
Combining live video-streaming with Augmented Reality surgeons carrying out operations are able to consult the other side of the world. Who says that you can’t be in two places at once?

3

Online Consultation

The patient, who can afford it, can always consult with their preferred healthcare providers online and even afford a sort of on-call medical service, other than emergency services.

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innohep – tinzaparin sodium

innohep®

Bringing the freedom to focus

innohep®

tinzaparin sodium

Get ready to meet your new friend

“A baby is something you carry inside you for nine months, in your arms for three years, and in your heart until the day you die.”

- Mary Mason -

Antenatal assessment and management (to be assessed at booking and repeated if admitted)

Any previous VTE except a Single event related to major surgery

HIGH RISK

Requires antenatal prophylaxis with LMWH
refer to trust-nominated thrombosis in pregnancy expert/team

Hospital admission

Single previous VTE related to major surgery

High-risk thrombophilia + no VTE

Medical comorbidities e.g. cancer, heart failure, active SLE, IBD or inflammatory polyarthropathy, nephrotic syndrome, type 1 DM with nephropathy, sickle cell disease, current IVDU

Any surgical procedure e.g. appendicectomy

OHSS(first trimester only)

INTERMEDIATE RISK

Consider antenatal prophylaxis with LMWH

Obesity (BMI > 30KG/M2)

Age

Parity ≥ 3

Smoker

Gross varicose veins

Current pre-eclampsia

Immobility, e.g. paraplegia, PGP

Family history of unprovoked or estrogen-provoked VTE in first-degree relative

Low-risk thrombophilia

Multiple pregnancy

IVF/ART

Transient risk factors:

Dehydration/hyperemesis; current systemic infection; long-distance travel

Fewer than three risk factors

Four or more risk factors:
Prophylaxis from first trimester

Three risk factors:
Prophylaxis from 28 weeks

LOWER RISK

Mobilisation and avoidance of dehydration

For more information

Regarding the timing of first antenatal and/or postnatal thromboprophylactic dose; please refer to RCOG Green-Top Guideline No. 37a (thrombosis and Embolism during Pregnancy and the Puerperium, Reducing the risk - Published 13/04/2015)

Royal College of Obstetricians and Gynaecologists 

Postnatal assessment and management (to be assessed on delivery suite)

Any previous VTE
anyone requiring antenatal LMWH
High-risk thrombophilia
Low-risk thrombophilia + FHx

HIGH RISK

At least 6 weeks, postnatal prophylactic LMWH

caesarean section in labour

BMI ≥ KG/M2

Readmission or prolonged admission (≥3 days) in the puerperium

Any surgical procedure int the puerperium except immediate repair of the perineum

Medical comorbidities e.g. cancer, heart failure, active SLE, IBD or inflammatory polyarthropathy, nephrotic syndrome, type 1 DM with nephropathy, sickle cell disease, current IVDU

INTERMEDIATE RISK

At least 10 days postnatal prophylaxis with LMWH

NB if presisting > 3 risk factors; consider extending thromboprophylaxis with LMWH

Age > 35 years
Obesity (BMI > 30KG/M2)
Parity ≥ 3
Smoker
Elective caesarean section
Family history of VTE
Low-risk thrombophilia
Gross varicose veins
Current systemic infection
Current pre-eclampsia
Immobility, e.g. paraplegia, PGP, long-distance travel
Multiple pregnancy
Preterm delivery in this pregnancy (<37+0 weeks)
Stillbirth in this pregnancy
Mid-cavity rotational or operative delivery
Prolonged labour (< 24 hours)
PPH > 1 litre or blood transfusion
Family history of unprovoked or estrogen-provoked VTE in first-degree relative
Low-risk thrombophilia
Multiple pregnancy
IVF/ART
Two or more risk factors
Fewer than two risk factors

LOWER RISK

Mobilisation and avoidance of dehydration

Antenatal and post natal prophylactic dose of LMWH

Weight < 50KG = 20MG enoxaparin / 2500UNITS dalteparin / 3500UNITS tinzaparin daily.
Weight 50-90KG = 40MG enoxaparin / 5000UNITS dalteparin / 4500UNITS tinzaparin daily.
Weight 91-130KG = 60MG enoxaparin / 7500UNITS dalteparin / 7000UNITS tinzaparin daily.
Weight 131-170KG = 80MG enoxaparin / 10000UNITS dalteparin / 9000UNITS tinzaparin daily.
Weight > 170KG = 0.6MG/KG enoxaparin / 75UNITS/KG dalteparin / 75UNITS/KG tinzaparin daily.

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octaplex – Prothrombin Complex Concentrate

Accurate prevention and fast control of life-threatening bleeding.
octaplex® provides a rapid and complete reversal of vitamin K antagonists (VKA) induced coagulopathy due to:
  • Easy storage at room temperature and quick availability.
  • Small infusion volume with no risk of fluid overload.
  • Short infusion time.
  • No need for blood type matching.
  • Balanced content of vitamin K coagulation factors and inhibitory proteins.
octaplex is ready to be used in life-threatening bleeding, unlike FFP:

octaplex®

FFP

20-40ML

2100ML (30ML/KG)

10 minutes

14-50 hours

Blood matching not required

Blood matching is required

Used immediately in room temperature

-25°C
thawing time: 30 minutes

References:
  1. Dowlatshahi, D., Butcher, K. S., Asdaghi, N., Nahirniak, S., Bernbaum, M. L., Giulivi, A., … Coutts, S. B. (2012). Poor Prognosis in Warfarin-Associated Intracranial Hemorrhage Despite Anticoagulation Reversal. Stroke, 43(7), 1812-1817. doi:10.1161/strokeaha.112.652065
  2. Lubetsky, A., Hoffman, R., Zimlichman, R., Eldor, A., Zvi, J., Kostenko, V., & Brenner, B. (2004). Efficacy and safety of a prothrombin complex concentrate (Octaplex®) for rapid reversal of oral anticoagulation. Thrombosis Research, 113(6), 371-378. doi:10.1016/j.thromres.2004.04.004
  3. Management of severe perioperative bleeding. (2014). European Journal of Anaesthesiology, 31(4), 247. doi:10.1097/eja.0000000000000066
  4. Varga, C., Al-Touri, S., Papadoukakis, S., Caplan, S., Kahn, S., & Blostein, M. (2012). The effectiveness and safety of fixed low-dose prothrombin complex concentrates in patients requiring urgent reversal of warfarin (CME). Transfusion, 53(7), 1451-1458. doi:10.1111/j.1537-2995.2012.03924.x

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