ObjectivesLow-molecular-weight heparins are widely used in clinical practice for the treatment or prophylaxis of venous thromboembolism (VTE). As these drugs are eliminated mainly by renal means, any renal function impairment may lead to higher plasma concentrations and increase the risk of bleeding. This study aims to evaluate whether in clinical practice there is an increase in the occurrence of bleeding in patients with renal insufficiency (RI) during treatment or prophylaxis with dalteparin, and to analyse the risk factors potentially influencing the appearance of such bleeding events.MethodsPatients were sampled from the Universitary Severo Ochoa Hospital, Leganés, Spain. This was a retrospective cohort study with a 1 year inclusion period, conducted at a Spanish university hospital with 400 beds, on patients undergoing treatment or prophylaxis for VTE with dalteparin for a minimum of 3 days. The main outcome measure was the number of patients who had bleeding events, independently of their severity, during dalteparin administration in patients with RI.Results367 patients were included in the study. Bleeding occurred in 17.9% of patients in the group with RI and in 7.3% of patients with normal renal function (NRF). Most haemorrhages in both cohorts were grade 2 on the WHO scale (64.7% in the RI group and 69.2% in the NRF group). Logistic regression analysis allowed the presence of RI (MDRD-4 (Modification of Diet in Renal Disease) <50 mL/min) to be identified as a risk factor.ConclusionPatients with RI treated with dalteparin face a higher risk of bleeding than those with NRF, which seems to make it necessary to monitor and seek new dosage adjustments for these patients.Impact on practice statements: This study yields new data on dalteparin in RI, which has not been widely studied before.
BackgroundNivolumab is a monoclonal antibody that binds to the PD-1 receptor and blocks interaction with its PD-L1 and PD-L2. This binding releases PD-1 pathway-mediated immune responses against tumour cells. Nivolumab has demonstrated efficacy in non-small-cell lung cancer (NSCLC), renal cancer, and head and neck cancer in monotherapy. Also, in metastatic melanoma in monotherapy or combined with ipilimumab. The toxicity grade was classified by Common Terminology Criteria for Adverse Effects v.4 (CTCAE): grade 1- mild, grade 2- moderate, grade 3- severe, grade 4- life-threatening consequences and grade 5- death related to AE. Its most common adverse effects (AE) (≥10%) at a dose of 3 mg/kg iv in monotherapy described in clinical trial phases II and III were asthaenia (in 34% of patients), rash (19%), pruritus (14%), diarrhoea (13%) nausea (13%) and anorexia (10%). Ninety per cent were mild or moderate (G1–2) and 10% were severe (G≥3).PurposeWith the aim of assessing the safety of nivolumab (3 mg/kg iv) in the clinical practice and compare it with clinical trials’ results, a transversal analysis was conducted on patients treated with nivolumab in a university hospital from June 2016 to March 2017.Material and methodsOur study included 13 patients (92% males) of whom 62% had a NSCLC diagnosis (43% squamous ethyology, 57% adenocarcinoma), 15% renal cancer and 23% metastatic head and neck cancer. Treatments were discontinued in seven (53%) of those patients following disease progression or patient’s death, but none of them because of toxicity.ResultsMost frequent AEs (≥10%) were: hyperglycaemia (36%), anaemia (14%), arthromyalgias (14%) and asthaenia (11%), and the less frequent were: nausea (7%), hypertriglyceridaemia (7%), pruritus (4%), anorexia (4%) and hepatic toxicity with high transaminases levels (4%). According to CTCAE, 39% of AE were grade 1, 32% grade 2% and 29% grade ≥3. Eight severe AE were described as follows hyperglycemia (four), hypertriglyceridaemia (two), asthaenia (one) and arthromyalgia (one).ConclusionIn our clinical practice we had found hyperglycaemia as the most common AE compared with asthaenia in clinical trials. The proportion of grade ≥3 was higher than in clinical trials (29% vs 10%, respectively).References and/or AcknowledgementsThanks to all my co-workers for carrying out this study with me.No conflict of interest
ResumenLos tumores neuroendocrinos (TNE) presentan dificultad en el diagnóstico por sus síntomas inespecíficos y el manejo es un reto. Se presenta el caso de un varón de 78 años de edad, con dolor crónico en hemiabdomen superior. Ingresó a emergencia con obstrucción intestinal y síntomas de síndrome carcinoide (SC). En cirugía se resecó tumor ileal con resultado anatomopatológico de tumor neuroendocrino, cromogranina positivo, índice proliferativo ki 67 de 2 a 3%. El paciente continuó con síntomas de SC, altos niveles de 5-HIA, metástasis hepáticas en RMN. Se inició octreotide con adecuada respuesta clínica. La experiencia con el presente caso indica estar alerta con los síntomas de TNE funcionantes, debido al aumento en su incidencia. Es de utilidad solicitar marcadores inmunohistoquimicos. La identificación de un TNE con índice de mitosis y proliferación bajo indica buen pronóstico. Palabras clave: Tumor neuroendocrino ileal, síndrome carcinoide, tumores neuroendocrinos. Abstract The neuroendocrine tumor (NET) is of difficult diagnosis due to nonspecific symptoms; management is also a challenge. We present the case of a 78 year-old male who suffered of chronic upper abdominal pain and was admitted to emergency with intestinal obstruction and symptoms of carcinoid syndrome (CS). At surgery an ileal tumor was resected with pathology report of NET positive for chromogranin A and ki 67 proliferative index of 2-3%. The patient continued with CS symptoms and presented high levels of 5-HIAA and liver metastases by MRI. Octreotide was started with good outcome. Experience with this case indicates to be alert at symptoms of functioning NET, due to an increase in its incidence. It is useful to request immunohistochemical markers. Identification of NET with low grade mitosis and proliferation signal good prognosis.
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