Systemic sclerosis, or scleroderma, is a complex medical disorder characterized by limited or diffuse skin thickening with frequent involvement of internal organs such as lungs, gastrointestinal tract, or kidneys. Docetaxel is a chemotherapeutic agent which has been associated with cutaneous side effects. An uncommon cutaneous side effect of docetaxel is scleroderma-like skin changes that extend from limited to diffuse cutaneous systemic sclerosis. Several case reports have been published regarding the association of docetaxel and systemic sclerosis. However, those reports demonstrated the association between docetaxel and scleroderma-like skin changes without internal organ involvement. Here, we report a case of systemic sclerosis with pulmonary arterial hypertension and a microangiopathic kidney involvement induced by docetaxel chemotherapy. After an exhaustive literature review, this could be the first case of docetaxel-induced systemic sclerosis involving internal organs.
Hepatocellular carcinoma is one of the most common liver malignancies in the United States. Poor prognosis is associated with paraneoplastic syndromes such as hypercalcemia, hypercholesterolemia, or hypoglycemia. Hypercalcemia as a paraneoplastic syndrome of hepatocellular carcinoma has been rarely reported. We report a mortality case of incidentally diagnosed hepatocellular carcinoma associated with humoral hypercalcemia of malignancy. The patient demonstrated a fulminant disease course with an unexpected fatal outcome within 40 days of initial diagnosis. Our case can suggest importance of early definitive treatment of hepatocellular carcinoma, extremely close monitoring, and aggressive medical treatment when it is associated with humoral hypercalcemia of malignancy.
BackgroundRecent data suggest antibiotic-related harm occurs in 1 in 5 hospitalized patients. The purpose of this study was to critically evaluate potential adverse-drug-events (ADE) associated with antimicrobial administration in hospitalized family medicine (FAM) patients.MethodsRetrospective cohort of adults receiving antimicrobial therapy for respiratory, urinary, and skin infection on an inpatient FAM ward between January 2017 and March 2018. Primary endpoint: potential ADEs up to 30-day post-therapy, identified using inpatient and outpatient electronic medical records. ADEs were classified as mild, moderate, or severe; Naranjo scores were used to classify causality. Other endpoints included risk associated with ADE, subsequent 30-day readmissions, and infections due to multidrug-resistant organisms up to 90-days post-therapy.Results1,499 antibiotic days were assessed in 150 hospitalized adults. Fifty-four patients with at least one potential ADE (68 total) were identified. By Naranjo score, 10 (6.7%) patients had “probable” antibiotic related ADEs (score 5–8), all others were “possible” (score 1–4). Excluding patients with diarrhea receiving concomitant laxatives, 36 patients (24%) suffered from 50 potential ADEs, approximately 3.33 per 100 antibiotic days (Table 1). Thirteen (9.3%) had serious ADEs; 6 were receiving concomitant medications which may have contributed to harm, primarily nephrotoxins (5/6). Alteration of antimicrobial therapy was attributed to ADEs in 12/54 cases (22.2%) while 6 (11.1%) led to 30-day hospital or emergency department (ED) revisits. ADEs were not associated with any specific antimicrobial. Patients with ADEs were more likely to have ED/hospital revisits (OR = 2.42 [1.16–5.05]) and receive more total antibiotic days (11 [6–15] vs. 8 days [6–12 days], P = 0.036) compared with those who did not. ConclusionOne in four hospitalized FAM patients receiving antimicrobials experienced potential ADE. While varying in nature and severity, antimicrobial ADEs contribute to serious harm. These findings underscore need for improved awareness and judicious use.Disclosures S. L. Davis, Achaogen: Scientific Advisor, Consulting fee. Allergan: Scientific Advisor, Consulting fee. Melinta: Scientific Advisor, Consulting fee. Nabriva: Scientific Advisor, Consulting fee. Zavante: Scientific Advisor, Consulting fee.
BackgroundInpatient antibiotics are estimated 30–50% inappropriate and novel antimicrobial stewardship (AS) strategies to engage prescribers are needed. The objective of this study was to describe the implementation of a customized antibiotic use and outcome report with family medicine (FAM) providers and the impact on prescribing behaviors for routine infections in hospitalized adults.MethodsSingle-center quasiexperiment before and after AS/FAM collaborative intervention. January–March 2017 Standard of Care: routine audit and feedback. FAM leadership worked with AS pharmacists to design reporting process. January–March 2018 Monthly Interventions: reports of antimicrobial use, appropriateness, harms; positive-deviance cases highlighting successful stewardship; education and survey of rotating FAM providers; handheld prescribing tools/guidelines. Consecutive admissions to the adult FAM ward with respiratory, urinary, and skin infections were evaluated. Primary endpoint: duration of optimal prescribing. Each day of therapy (DOT) was classified as optimal, suboptimal, unnecessary, or inappropriate. Antimicrobials were stratified by spectrum and propensity to cause harm. Secondary endpoints: use of broad-spectrum agents, appropriate duration of therapy, and safety.ResultsAdults (n = 150, 76 pre, 74 post) were similar in age, comorbid conditions, and antimicrobial indications (Figure 1). Following intervention, unnecessary antimicrobial days decreased from 2 to 0 days (P < 0.001) per patient, optimal therapy selection increased from 25% to 58% (P < 0.001). Narrow-spectrum agents increased from 41% to 59% (P = 0.05) while use of broader (52 vs. 48%) and extended spectrum agents (57 vs. 44%) were not significantly different in the cohort. Guideline concordant duration of therapy improved from 37% to 57% (P = 0.015). Concurrent unit-wide DOTs of broad and extended agents decreased (Figure 2).ConclusionReporting unit-specific antimicrobial use, harms and successes, without change in standard audit and feedback, improved antimicrobial prescribing and quality of care. These findings support the need to engage front-line providers like FAM in stewardship interventions and reporting. Disclosures S. L. Davis, Achaogen: Scientific Advisor, Consulting fee. Allergan: Scientific Advisor, Consulting fee. Melinta: Scientific Advisor, Consulting fee. Nabriva: Scientific Advisor, Consulting fee. Zavante: Scientific Advisor, Consulting fee.
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