American journal of therapeutics最新文献

Background: Therapeutic drug monitoring represents an improvement in treatment efficacy and helps reduce side effects. For vancomycin therapy, plasma analysis helps prevent subtherapeutic dosages, which can lead to treatment failure and the potential emergence of antibiotic resistance, while also limiting side effects caused by toxicity.

Areas of uncertainty: Although vancomycin dosing based on area under the curve (AUC) has been supported by scientific grade IIIA evidence as improving patient outcomes, it is still not widely adopted, and many questions remain unanswered. There is significant heterogeneity in therapeutic range values presented in guidelines for both point-to-point and AUC measurements, and uncertainty about when to apply these protocols in vancomycin administration. This narrative review aims to evaluate the indications and target values presented in current vancomycin monitoring guidelines, comparing them with studies where vancomycin dosing is not recommended.

Data sources: Articles related to vancomycin dosing were searched on medical databases such as Scopus, PubMed, and Google Scholar.

Therapeutic advances: All review articles and guidelines issued by scientific societies support vancomycin dosing, particularly for dialysis patients, pediatric patients, and those in intensive care units. Although target values may vary across guidelines, trough values between 10 and 20 mg/L are widely accepted. Although AUC-based dosing is more complex, it is recommended, with a therapeutic range between 400 and 700 mg/L/24 h. Although some authors challenge this approach, they reflect the opinions of a relatively small group of experts.

Conclusions: Further pharmacokinetic studies are required to furnish robust evidence and facilitate the establishment of a uniform recommendation for vancomycin drug monitoring by guidelines. In addition, it is essential to assess vancomycin dosing across all patient categories to examine the viability of theories that do not support the need for vancomycin dosing.

Background: The patterns of care for patients with advanced cancer in the last week of life are critical for ensuring quality and dignity during a vulnerable time. As patients approach end of life, the focus typically shifts from aggressive treatment to palliative care, emphasizing comfort and symptom management. The term "non-comfortoriented care" describes a set of medical interventions and treatments that prioritize prolonging life. This can lead to increased physical discomfort, emotional burden, or reduced quality of life.

Areas of uncertainty: For those who die in a medical setting, end-of-life care practices vary greatly and the care can be either comfort-oriented or noncomfort-oriented. There is a need for a clear overview of patterns for end-of-life care for patients with advanced cancer.

Data sources: Based on Whittemore's integrative review method, comprehensive searches were conducted in PubMed, Science Direct, Scopus, and Google Scholar databases. Population/Patient, Exposure, and Outcome format was used to formulate a research review question.

Therapeutics advances: Twenty-four articles were included. The key components of the patterns of care implemented during the last week of life are settings, palliative care involvement, intensity of therapeutics interventions, duration, and planning in advance. The only setting where solely comfort-oriented care was delivered was the community. In hospital settings, both comfort and noncomfort-oriented care were offered. Palliative care involvement was associated with comfort-oriented care, early recognition of dying (median 6 days), medication rationalizing, and implementation of care pathways. Noncomfort-oriented care patterns occurred in emergency departments, oncology, and general wards in acute hospitals with late recognition of dying (median 2 days) and use of inappropriate therapeutics interventions.

Conclusion: To deliver the best care in the last week of life, new strategies are necessary to guide the clinical practices and to ensure patient-centered care.

Background: Inferior rectal cancer, a malignancy occurring in the lower portion of the rectum, represents a significant clinical challenge due to its complex anatomical location and the diverse treatment approaches required for optimal patient outcomes. Over the past few decades, advancements in surgical techniques, radiotherapy, and systemic treatments have contributed to improving survival rates and minimizing morbidity associated with this disease.

Areas of uncertainty: Neoadjuvant therapy combined with tumor resection surgery has demonstrated significant improvements in survival in patients with rectal cancer. However, uncertainty persists due to variability in therapeutic responses among different groups of patients and the limited availability of long-term data on the efficacy of pathologic responses. These limitations affirm the need for further studies to optimize and personalize the therapeutic approach to rectal cancer.

Data sources: A search for information was conducted using recognized databases, including Cochrane, PubMed, Scielo, ScienceDirect, and Scopus. The search strategy was designed using specific terms such as: "rectal neoplasms" OR ("rectal AND neoplasms") OR "rectal cancer" AND ("therapeutics" OR "treatments"), to identify relevant publications.

Therapeutic advances: Minimally invasive techniques offer oncologic outcomes equivalent to open surgery with faster recovery and lower morbidity, supported by total neoadjuvant therapy, which has become the standard of care for locally advanced rectal cancer, achieving higher pathologic complete response rates (OR 2.44, 95% CI, 1.99-2.98) and longer disease-free survival (OR 2.07, 95% CI, 1.20-3.56) than conventional chemoradiotherapy. In addition, emerging targeted agents (VEGF and EGFR inhibitors) in molecularly selected patients and PD-1 blockade in dMMR tumors further improve response rates and support organ preservation strategies.

Conclusions: Despite notable advances in treatment strategies for rectal cancer, challenges remain in identifying a therapeutic modality that can improve both overall survival and disease-free survival without exposing the patient to overly aggressive interventions.