This document discusses chemotherapy-induced lung disease. It notes that over 150 drugs have been described as causing adverse pulmonary reactions, with the first reported drug being busulfan in the 1960s. All parts of the respiratory system can be affected, with less than 10% of patients receiving chemotherapy developing pulmonary toxicities. Common patterns of toxicity include interstitial pneumonitis/fibrosis, hypersensitivity pneumonitis, non-cardiac pulmonary edema, and acute pneumonia. Specific drugs are associated with each pattern. Diagnosis involves considering the possibility, knowledge of associated drug toxicities, and excluding other likely causes through testing including radiography, BAL, and biopsy.
The discovery of malignant cells in pleural fluid
and/or parietal pleura signifies disseminated or
advanced disease and a reduced life expectancy in
patients with cancer.Median survival following
diagnosis ranges from 3 to 12 months and is
dependent on the stage and type of the underlying
malignancy. The shortest survival time is observed
in malignant effusions secondary to lung cancer
and the longest in ovarian cancer, while malignant
effusions due to an unknown primary have an
intermediate survival time.Historically, studies
showed that median survival times in effusions due
to carcinoma of the breast are 5-6 months.
However, more recent studies have suggested
longer survival times of up to 15 months. A
comparison of survival times in breast cancer
effusions in published studies to 1994 calculated
a median survival of 11 months.9
Currently, lung cancer is the most common
metastatic tumour to the pleura in men and breast
cancer in women.Together, both malignancies
account for 50- 65% of all malignant effusions. Lymphomas, tumours of the genitourinary
tract and gastrointestinal tract account for
a further 25% Pleural effusions from an
unknown primary are responsible for 15% of all
malignant pleural effusions.Few studies have
estimated the proportion of pleural effusions due to
mesothelioma: studies from 1975, 1985 and 1987
identified mesothelioma in 1/271, 3/472 and 22/592
patients, respectively, but there are no more recent
data to update this in light of the increasing incidence
of mesothelioma.
The discovery of malignant cells in pleural fluid
and/or parietal pleura signifies disseminated or
advanced disease and a reduced life expectancy in
patients with cancer.Median survival following
diagnosis ranges from 3 to 12 months and is
dependent on the stage and type of the underlying
malignancy. The shortest survival time is observed
in malignant effusions secondary to lung cancer
and the longest in ovarian cancer, while malignant
effusions due to an unknown primary have an
intermediate survival time.Historically, studies
showed that median survival times in effusions due
to carcinoma of the breast are 5-6 months.
However, more recent studies have suggested
longer survival times of up to 15 months. A
comparison of survival times in breast cancer
effusions in published studies to 1994 calculated
a median survival of 11 months.9
Currently, lung cancer is the most common
metastatic tumour to the pleura in men and breast
cancer in women.Together, both malignancies
account for 50- 65% of all malignant effusions. Lymphomas, tumours of the genitourinary
tract and gastrointestinal tract account for
a further 25% Pleural effusions from an
unknown primary are responsible for 15% of all
malignant pleural effusions.Few studies have
estimated the proportion of pleural effusions due to
mesothelioma: studies from 1975, 1985 and 1987
identified mesothelioma in 1/271, 3/472 and 22/592
patients, respectively, but there are no more recent
data to update this in light of the increasing incidence
of mesothelioma.
Managing Immune-Related Adverse Events to Ensure Optimal Cancer Immunotherapy...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck, presented by Blanca Ledezma, MSN, NP, AOCNP® Nurse Practitioner
Hematology/Oncology
University of California, Los Angeles (UCLA) Health, will provide insight into the nurse’s view on managing immune-related adverse events to ensure optimal cancer immunotherapy outcomes.
Immune checkpoint inhibitors, which alter immune regulatory pathways and promote cell-mediated destruction of tumor cells, have revolutionized the treatment of cancer in recent years, with numerous therapeutic agents approved and several targets under investigation (Chennamadhavuni et al, 2022). However, up to 90% of patients receiving immune checkpoint inhibitors experience immune-related adverse events, which can affect a wide variety of organ systems and can occur at any time during treatment or even after treatment completion (NCCN, 2023). Immune-related adverse events are associated with significant morbidity as well as the risk of therapy discontinuation, which can have an unpredictable impact on patients’ disease course. Therefore, it is critical for nurses to understand the mechanism, identification, and timely management of immune-related adverse events (Shankar et al, 2022). In this activity presented by Blanca Ledezma, MSN, NP, AOCNP®, Nurse Practitioner at the University of California, Los Angeles (UCLA) Health, will provide insight into the nurse’s view on managing immune-related adverse events to ensure optimal cancer immunotherapy outcomes.
TARGET AUDIENCE
Oncology nurses, nurse practitioners, clinical nurse specialists, and other health care professionals involved in the management of patients with immune-related adverse events (IRAEs).
LEARNING OBJECTIVES
Upon completion of this activity, participants should be able to:
Discuss how the mechanisms of action of immunotherapies influence their safety profile
Identify risk factors predisposing patients to IRAEs
Distinguish IRAEs from chemotherapy- and targeted therapy-related adverse events
Coordinate with the interdisciplinary health care team to apply evidence-based guidelines and best practices in personalized nursing management plans for patients with IRAEs
Develop patient counseling strategies promoting awareness, self-monitoring, and escalated reporting of IRAEs
Lung cancer is a major cause of cancer deaths with approximately 80% of cases accounting to nonsmall cell lung cancer (NSCLC) . In NSCLC target therapy, epidermal growth factor receptor (EGFR) is a promising candidate.
2 types (a) cellular NSIP
(b) Fibrotic NSIP (more common)
Fibrosis may involve alveolar septa, peribronchivascular interstitium, interlobular septa and visceral pleura.
Prognosis of fibrotic NSIP is worse , cellular NSIP has good prognosis.
HRCT finding may show both, airspace and interstitial patterns
Managing Immune-Related Adverse Events to Ensure Optimal Cancer Immunotherapy...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck, presented by Blanca Ledezma, MSN, NP, AOCNP® Nurse Practitioner
Hematology/Oncology
University of California, Los Angeles (UCLA) Health, will provide insight into the nurse’s view on managing immune-related adverse events to ensure optimal cancer immunotherapy outcomes.
Immune checkpoint inhibitors, which alter immune regulatory pathways and promote cell-mediated destruction of tumor cells, have revolutionized the treatment of cancer in recent years, with numerous therapeutic agents approved and several targets under investigation (Chennamadhavuni et al, 2022). However, up to 90% of patients receiving immune checkpoint inhibitors experience immune-related adverse events, which can affect a wide variety of organ systems and can occur at any time during treatment or even after treatment completion (NCCN, 2023). Immune-related adverse events are associated with significant morbidity as well as the risk of therapy discontinuation, which can have an unpredictable impact on patients’ disease course. Therefore, it is critical for nurses to understand the mechanism, identification, and timely management of immune-related adverse events (Shankar et al, 2022). In this activity presented by Blanca Ledezma, MSN, NP, AOCNP®, Nurse Practitioner at the University of California, Los Angeles (UCLA) Health, will provide insight into the nurse’s view on managing immune-related adverse events to ensure optimal cancer immunotherapy outcomes.
TARGET AUDIENCE
Oncology nurses, nurse practitioners, clinical nurse specialists, and other health care professionals involved in the management of patients with immune-related adverse events (IRAEs).
LEARNING OBJECTIVES
Upon completion of this activity, participants should be able to:
Discuss how the mechanisms of action of immunotherapies influence their safety profile
Identify risk factors predisposing patients to IRAEs
Distinguish IRAEs from chemotherapy- and targeted therapy-related adverse events
Coordinate with the interdisciplinary health care team to apply evidence-based guidelines and best practices in personalized nursing management plans for patients with IRAEs
Develop patient counseling strategies promoting awareness, self-monitoring, and escalated reporting of IRAEs
Lung cancer is a major cause of cancer deaths with approximately 80% of cases accounting to nonsmall cell lung cancer (NSCLC) . In NSCLC target therapy, epidermal growth factor receptor (EGFR) is a promising candidate.
2 types (a) cellular NSIP
(b) Fibrotic NSIP (more common)
Fibrosis may involve alveolar septa, peribronchivascular interstitium, interlobular septa and visceral pleura.
Prognosis of fibrotic NSIP is worse , cellular NSIP has good prognosis.
HRCT finding may show both, airspace and interstitial patterns
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
2. Drug Induced Lung Disease
Drug induced lung disease is increasing
being recognized with over 150 drugs
described as causing adverse pulmonary
reactions.
In the 1960s, the first drug reported to induce
chemotherapy-related lung disease was busulfan.
All parts of the respiratory system can be
affected.
Overall, less than 10% of patients who
receive chemotherapeutic agents develop
pulmonary toxicities
4. Sign and symptoms
symptoms may occur acutely or insidiously
cough, fever, dyspnea
Crackles.
PFT- ↓ DLCO
5. Problems in Recognition
Drugs are given as part of multidrug regimens
and offending agent may not be clear
Other conditions, such as pulmonary infection,
pulmonary thromboembolic disease or
progression of cancer, occur considerably
more frequently
No pathognomonic clinical, radiographic or
pathologic findings
New agents or new combinations are
frequently being used and unrecognized or
new types of toxicity occur.
6. Recognition
High index of suspicion
Knowledge of patterns of toxicity
associated with drugs
Exclusion of other likely entities
7. Laboratory Findings
↑ TLC, ESR and CRP
↑Serum Krebs von den Lunge-6 (KL-6)
expressed by type II alveolar pneumocytes
may be useful for ruling out other causes of pneumonitis.
8. Radiologic Findings
HRCT –findings are not specific.
Interstitial, alveolar, or mixed infiltrative patterns
Pleural effusion with or without parenchymal lung
disease
Lymphadenopathy is typically not present
9. Bronchoalveolar lavage
several studies reported the presence of a
characteristic or predominant cells associated with
particular drugs but results are variable.
Useful to exclude atypical or typical infections.
Histologic Findings
not mandatory, cannot confirm the diagnosis
it helps support it and can exclude other diseases
may show diffuse alveolar damage, organizing
pneumonia, nonspecific pneumonitis, or
neutrophilic alveolitis
10. Patterns of Toxicity
Interstitial pneumonitis/fibrosis
Hypersensitivity pneumonitis
Non cardiac pulmonary edema
Acute pneumonia
12. Interstitial Pneumonitis/Fibrosis
Presentation is subacute
to chronic
Dyspnea and dry cough
Bibasilar crackles
Radiographs show
increased marking,
peripherally/ bases can
progress to honeycombing
15. Interstitial Pneumonitis/Fibrosis
Mechanism of Toxicity
BAL in animals and humans in bleomycin
induced show increased number of neutrophils
and in some cases eosinophils (similar to IPF)
Direct toxicity with imbalance in oxidant -
antioxidant systems
Vascular damage with influx of inflammatory
cells and fibroblasts; induction of cytokines
Increased TGF- Beta
Imbalance between the protease and
antiprotease system
16. •Bleomycin induces reactive oxygen radicals by forming a complex
with Fe3+
• Iron chelators ameliorate the pulmonary toxicity of bleomycin in
animal models
17. Incidence of toxicity is 4% but subclinical
toxicity based on PFTS is 25%
Bleomycin hydrolase - major enzyme
responsible for metabolism
lung and skin have the lowest levels of the enzyme
most common targets for bleomycin toxicity
18. Bleomycin Toxicity
Risk Factors
Dose > 450 units, although toxicity can occur
at any dose
Radiation to thorax
Supplemental oxygen – no safe threshold
Age >70 years
Elevated Creatinine
? Use of GCSF
animal studies suggest GCSF t/t is associated
with bleomycin-induced pulmonary toxicity
data in humans are conflicting
19. Some data suggest that continuous infusion
of bleomycin may be associated with less
pulmonary toxicity than bolus therapy;
however, these data are inconclusive
20. Bleomycin Pulmonary Toxicity
Interstitial fibrosis most common, rare
hypersensitivity pneumonitis
Treatment involves no further drug, possible
corticosteroids, avoidance of oxygen/radiation
if possible
Late exacerbations can occur
21. Cyclophosphamide
MOA- reactive oxygen species.
Endothelial swelling; pneumocyte
dysplasia; lymphocytic and histiocytic
infiltration; fibrosis.
bibasilar reticular pattern;
<1% incidence; no direct dose
dependence
Drug withdrawal; corticosteroids may be
22. Hypersensitivity Pneumonitis
Acute to subacute
presentation with
systemic symptoms
fever, fatigue, arthralgia –
dyspnea and cough may
be late
Eosinophilia may be
present
Radiographs show air
space disease
25. Methotrexate Toxicity
Usually presents with malaise, myalgias,
fever, cough and dyspnea, skin rash in some
cases
Radiographs vary from normal to mild
atelectasis to bilateral alveolar infiltrates:
Gallium scans are positive
Dramatic response to corticosteroids
Seldom leads to fibrosis
26. Methotrexate Pneumonitis
Mechanism of Toxicity
Immunological mechanism, supported by
BAL findings and dramatic response to
steroids
lymphocytic alveolitis is a consistent
finding in methotrexate pneumonitis
imbalance of the CD4-to-CD8 ratio
27. Taxanes
Paclitaxel
Associated with hypersensitivity reaction
during infusion with dyspnea, bronchospasm,
urticaria, rash and hypotension ( up to 1/3
patients)
suspension vehicle (Cremophor El) causes, not
the drug.
Premed with steroids, antihistamines and H2
blockers ameliorates( 1% incidence)
Docetaxel - Little data
28. Paclitaxel Pulmonary Toxicity
Syndromes
Dyspnea during infusion – common
Hypersensitivity pneumonitis –
Subacute development of dyspnea
CT scans show transient ground glass
infiltrate or interstitial infiltrates
Usually resolves spontaneously or with
corticosteroids
Rare presentations of acute
pneumonia/intersitial fibrosis
29. Non Cardiac Pulmonary Edema
Respiratory distress occurs
over several hours
Subacute capillary leak syndrome
Can be associated with
effusions and edema
Radiographs show diffuse
bilateral alveolar filling
densities
Usually responds to
withdrawal of offending drug
Found with
gemcitabine/ATRA
30. Non Cardiac Pulmonary Edema
Alltrans retinoic acid
Gemcitabine
Cytarabine ( ARA C)
Imatinib, azathioprine, G-CSF, IL-2, MMC,
nitrogen mustards, paclitaxel, interferon α,
pentostatin, decitabine, vinorelbine
31. ATRA
All trans retinoic acid
Fluid overload develops with weight gain,
peripheral edema, pleural effusion
Patients present with dyspnea and edema
and usually weight gain.
Increased risk with elevated WBC
Can be treated with corticosteroids.
32. Gemcitabine
Dyspnea reported in up to 10% with severe
dyspnea in 5% -Self limited
– Acute hypersensitivity with bronchospasm
– Capillary leak
Infiltrates – subtle capillary leak to interstitial
infiltrate to pulmonary edema picture
– Usually responds to holding drug or giving steroids
33. Acute Pneumonia
Syndrome similar to non cardiac pulmonary
edema
– Respiratory distress develops over several hours
– Bilateral interstitial-alveolar infiltrates
Improvement but persistent pulmonary
abnormalities persist
Pathology studies show inflammatory cells
with endothelial inflammation as well as
vascular leak
35. Mitomycin-Vinca Alkaloid
Reactions
Syndrome of acute dyspnea without other
respiratory symptoms within hours of receiving
vinca alkaloid in patients on mitomycin
Respiratory failure can occur
Treated with supportive care and combinations
of diuretics, bronchodilators and
corticosteroids
Improvement occurs but chronic toxicity occurs
36. Gefitinib
Main toxicity is mild acne like rash and
limited diarrhea
Interstitial lung disease has been reported
which can be serious – up to 2%
Unclear mechanism
augmentation of pulmonary fibrosis by decreasing
EGFR phosphorylation resulting in a decrease in
regenerative epithelial proliferation
37. Diffuse ground glass opacities have been
observed on CT imaging
38. Bevacizumab
Recombinant humanized monoclonal
antibody targets vascular endothelial growth
factor (VEGF)
– Approved for colorectal cancer; under study for
breast cancer, renal cancer and lung cancer
Side effects
– Thromboembolic events
– Hypertension
– Hemorrhage
– Gastrointestinal perforation
39. Serious tumor related bleeding with
hemoptysis /hematemesis in 6 cases, all
with centrally located pulmonary tumors
close to major blood vessels.
(Clin Res Cancer 2004; 10: 4258S)
40. Imatinib/Dasatinib
Mechanism of Injury- Unknown
one case of imatinib Hypersensitivity suggested
by high number of lymphocytes with low
CD4/CD8 ratio
Exudative pleural effusion/pulmonary
edema; eosinophilic infiltration;
interstitial inflammation/fibrosis
41. M-TOR INHIBITORS
Sirolimus
Possibly evoking Th1 response and
recruitment of an inflammatory
response in lung.
BOOP, lymphocytic alveolitis
5%-15% incidence
Risks factors include late switch to drug
and/or renal impairment.
Temsirolimus/Everolimus
.5%–5% incidence