COVID-19 ; Humans ; Intensive Care Units ; Nutrition Therapy ; Nutritional Support ; Pandemics/prevention & control*

INTRODUCTIONThe advent of prostate specific antigen (PSA) has resulted in an increased incidence of early detection of prostate cancer recurrence. Patients treated with androgen deprivation therapy (ADT) become hormone-resistant after 18 to 24 months. In patients with biochemical failure, where there is a rise in PSA but no objective evidence of metastases, or in whom there are small volume metastases but who are asymptomatic, there is no standard of care after ADT. Ketoconazole, an antimycotic which affects the synthesis of androgens and other steroids, has shown direct cytotoxic effects in prostate cancer cell lines in in-vitro studies. This study describes our experience with ketoconazole treatment for hormone refractory prostate cancer (HRPC).

MATERIALS AND METHODSA retrospective study of HRPC patients given ketoconazole at the National Cancer Centre and The Cancer Institute from 2004 to 2005 was performed. All eligible patients had histologically proven adenocarcinoma of the prostate and a rising PSA level despite ADT with orchidectomy or luteinising hormone-releasing hormone (LHRH) agonist therapy. All patients received 200 mg of ketoconazole thrice daily. Response was defined as a decline in PSA of at least 50% from the pre-treatment level and confirmed by a second PSA value 4 or more weeks later. The endpoints evaluated were the presence and duration of a response and the toxicity profile of the treatment.

RESULTSA total of 32 patients with HRPC were treated with ketoconazole. Twelve (38%) of the 32 patients had a greater than 50% decrease in their PSA values. The median duration of response was 6.75 months. The median time to reach PSA nadir was 3.5 months. Five patients continue to exhibit progression-free response at the time of writing. Ketoconazole was generally well tolerated. Eighteen (56%) patients recorded mild toxicities related to ketoconazole. There were no grade 3 or 4 toxicities.

CONCLUSIONSLow-dose ketoconazole bridges the gap in the continuum of treatment for patients who have failed ADT and in whom cytotoxic chemotherapy would have a significant impact on the quality of life. Its good toxicity profile, low cost and ease of administration makes it a viable option for this group of patients.

Adenocarcinoma ; Aged ; Aged, 80 and over ; Androgen Antagonists ; administration & dosage ; therapeutic use ; Androgens ; biosynthesis ; Humans ; Ketoconazole ; administration & dosage ; pharmacology ; Male ; Middle Aged ; Prostate-Specific Antigen ; Prostatic Neoplasms ; drug therapy ; Retrospective Studies ; Singapore

Carcinoma ; diagnostic imaging ; secondary ; Humans ; Male ; Middle Aged ; Nasopharyngeal Neoplasms ; pathology ; Pancreatic Neoplasms ; diagnostic imaging ; secondary ; Ultrasonography

Bone Neoplasms ; diagnosis ; secondary ; Carcinoma, Renal Cell ; diagnosis ; secondary ; Humans ; Kidney Neoplasms ; pathology ; Male ; Middle Aged ; Patella ; Sternum

INTRODUCTIONParenteral nutrition (PN) is indicated for patients who are unable to progress to oral or enteral nutrition. There are no local studies done on estimating the cost of PN in acute settings. The aims of this study are to describe the demographics, costs of PN and manpower required; and to determine the avoidable PN costs for patients and hospital on short-term PN.

MATERIALS AND METHODSPatient data between October 2011 and December 2013 were reviewed. Data collected include demographics, length of stay (LOS), and the indication/duration of PN. PN administration cost was based on the cost of the PN bags, blood tests and miscellaneous items, adjusted to subsidy levels. Manpower costs were based on the average hourly rate.

RESULTSCosts for PN and manpower were approximately S$1.2 million for 2791 PN days. Thirty-six cases (18.8%) of 140 PN days were short-term and considered to be avoidable where patients progressed to oral/enteral diet within 5 days. These short-term cases totalled $59,154.42, where $42,183.15 was payable by the patients. The daily costs for PN is also significantly higher for patients on short-term PN (P <0.001).

CONCLUSIONIn our acute hospital, 90% of patients referred for PN were surgical patients. Majority of the cost comes from the direct daily cost of the bag and blood tests, while extensive manpower cost was borne by the hospital; 18.8% of our cohort had short-term avoidable PN. Daily PN may cost up to 60% more in patients receiving short-term PN. Clinicians should assess patient's suitability for oral/enteral feeding to limit the use of short-term PN.

Enteral Nutrition ; Health Care Costs ; Health Manpower ; economics ; Hematologic Tests ; economics ; Hospitals ; Humans ; Length of Stay ; economics ; Medical Overuse ; economics ; prevention & control ; Nutritional Support ; economics ; utilization ; Parenteral Nutrition ; economics ; utilization ; Singapore ; Time Factors

INTRODUCTIONThe near terminal patient with skeletal metastasis may suitably be palliated with an intramedullary nail whereas another patient with good survival potential may benefit from a more extensive resection and reconstructive procedure. In a previous study by the senior author (Nathan et al, 2005), life expectancy in patients operated on for bone metastases correlated with clinical and haematological parameters in a normogram. We performed a cross-cultural comparison to validate this normogram.

MATERIALS AND METHODSWe randomly selected 73 patients who had undergone surgery for metastatic bone disease between 28 December 2000 and 11 March 2009. The time to deaths was recorded from hospital records and telephone interviews. Multiple parameters including clinical, radiological and haematological were evaluated for significant prognostic value using Kaplan-Meier survivorship analysis. Statistically significant parameters were entered into a Cox regression model for statistically independent significance. A multi-tier prediction of survival was performed by workers from various levels of seniority.

RESULTSAt the time of analysis, there were 40 deaths (55%). Median survival was 15.8 (95% CI, 7.9 to 23.7) months. Kaplan-Meier analysis showed that low haemoglobin (P = 0.0000005), presence of lymph node metastases (P = 0.00008), multiple bone metastases (P = 0.003), presence of visceral metastases, (P = 0.007), low lymphocyte count (P = 0.02) and low serum albumin (P = 0.02) were significantly associated with poor survival. By Cox regression analysis, presence of visceral metastases (P = 0.002), presence of lymph node metastases (P = 0.0002) and low haemoglobin (P = 0.01) were shown to be independent factors in the prediction of survival. Survivorship readings were superimposed onto the previous normogram and found to be similar. Independent blinded use of the normogram allowed good prediction of survival. There was a tendency to underestimate survival when patients survived beyond 1 year of skeletal metastasis.

CONCLUSIONOur findings are similar to that of the previous study in showing a relationship between the above-mentioned parameters and survival. This is despite differences in patient demographic characteristics and management protocols. Use of the tools may allow better siting of most appropriate surgery in metastatic bony disease.

Bone Neoplasms ; mortality ; surgery ; Decision Support Systems, Clinical ; Female ; Humans ; Male ; Middle Aged ; Prognosis ; Proportional Hazards Models ; Survival Analysis ; Terminal Care

INTRODUCTIONSensori-neural hearing loss (SNHL) is a frequent complication of conventional radiotherapy for head and neck tumours, especially nasopharyngeal carcinoma. To manage radiation-induced ototoxicity appropriately, an understanding of the cellular and molecular basis of this complication is necessary.

MATERIALS AND METHODSA medline search of relevant literature was done, focusing on the radiation-induced cellular and molecular processes that lead to hair cell death in the cochlea.

RESULTSRadiation-induced SNHL occurs in the cochlea, with the retro-cochlear pathways remaining functionally intact. By simulating radiotherapy regimes used clinically, radiation-induced cochlear cell degeneration in the absence of damage to the supporting structures and blood vessels has been demonstrated in animals. This could be due to apoptotic cochlear cell death, which has been shown to be associated with p53 upregulation and intra-cellular reactive oxygen species (ROS) generation. Oxidative stress may initiate the upstream processes that lead to apoptosis and other cell death mechanisms.

CONCLUSIONSA model of radiation-induced SNHL based on a dose and ROS-dependent cochlear cell apoptosis, is proposed. This model supports the feasibility of cochlear implantation, should one be clinically indicated. It can explain clinical observations such as radiation-induced SNHL being dose-dependent and affects the high frequencies more than the lower frequencies. It also opens up the possibility of preventive strategies targeted at different stages of the apoptotic process. Antioxidants look promising as effective agents to prevent radiation-induced ototoxicity; they target upstream processes leading to different cell death mechanisms that may co-exist in the population of damaged cells.

Animals ; Cell Death ; Cell Line ; Cochlea ; radiation effects ; Genes, p53 ; Hair Cells, Auditory ; radiation effects ; Hearing Loss, Sensorineural ; etiology ; genetics ; physiopathology ; Humans ; Mice ; Radiation Injuries ; complications ; Reactive Oxygen Species ; metabolism

Adult ; Anticarcinogenic Agents ; therapeutic use ; Breast Neoplasms ; drug therapy ; pathology ; Disease Progression ; Female ; Humans ; Interdisciplinary Communication ; Neoplasm Staging ; Pregnancy ; Pregnancy Complications, Neoplastic ; drug therapy ; pathology ; Treatment Outcome

Adenocarcinoma ; pathology ; therapy ; Choriocarcinoma, Non-gestational ; pathology ; therapy ; Combined Modality Therapy ; Female ; Humans ; Lung Neoplasms ; secondary ; Middle Aged ; Neoplasms, Germ Cell and Embryonal ; pathology ; therapy ; Urinary Bladder Neoplasms ; pathology ; therapy ; Uterine Neoplasms ; pathology ; therapy

INTRODUCTIONThis study evaluates determinants, expectations, association with quality of life (QOL) and doctor's awareness of Complementary and Alternative Medicine (CAM) use in Singapore cancer patients.

MATERIAL AND METHODSWe interviewed 316 patients visiting the Cancer Centre of the National University Hospital on behaviour, attitudes and expectations towards CAM and assessed QOL via Euroqol Questionnaire (EQ-5D). Medical information was obtained from oncologists.

RESULTSOne hundred and seventy-three patients (55%) reported CAM use after cancer diagnosis. Chinese ethnicity, tertiary education, age <65 years and previous CAM use were independent predictors of CAM use. Fifty-one per cent of CAM users informed their doctors about their use and 15% of doctors reported to be aware of CAM use in these patients. Thirty-seven per cent believed CAM to be equally or more effective than conventional cancer therapies and 78% expected at least basic knowledge about CAM from their oncologists. Twenty-fi ve per cent of patients reported concurrent use of oral CAM and chemotherapy, of which oncologists were unaware in 86% of cases. CAM users had higher EuroQol utility scores than non-CAM users (0.79 versus 0.73, respectively, P = 0.03), in particularly those aged >or=65 years and those with stage IV disease.

CONCLUSIONSingapore cancer patients show high prevalence of CAM use, high expectations regarding its effectiveness and doctors' knowledge on CAM and many use it concurrently with chemotherapy or radiotherapy. Since oncologists are generally unaware of CAM use in their patients, doctor-patient communication on CAM use needs to be improved. The association of CAM use and higher QOL scores in some subgroups deserves further exploration.

Adolescent ; Adult ; Aged ; Aged, 80 and over ; Complementary Therapies ; utilization ; Female ; Humans ; Interviews as Topic ; Male ; Middle Aged ; Neoplasms ; therapy ; Quality of Life ; Singapore ; Surveys and Questionnaires ; Young Adult