1. Gemcitabine is especially toxic to the bone marrow.
2. The most dangerous and dreaded side effect of Avastin is bowel perforation. It can even form enterocutaneous fistulas (ECF). Most insurance companies pay for it, even though it doesn't have FDA approval for a number of the purposes for which it is used.
3. Octreotide significantly shortens time to healing of ECFs in RCTs (26-27 days to 16-17), but it doesn't make a difference in mortality. http://www.ncbi.nlm.nih.gov/pubmed/22885696 Loading dose: 50-100 ug subQ q8 hours.
4. The presence of an enterocutaneous fistula is usually associated with a phase of dense adhesions, termed “obliterative peritonitis,” making early surgery a hazardous undertaking. Obliterative peritonitis may resolve as early as six weeks in a closed abdomen, but may persist for 6 to 12 months in a patient with an open abdomen. (uptodate)
5. The decision of when to perform an ostomy on someone during a debulking surgery is a function of how easy/possible it would be to rejoin the bowel (i.e. not too much necrosis, etc)
6. Major trials comparing CDT to surgery:
--TOPAS (n=544, randomized to surgery or urokinase. amputation free survival same at 1 year, fewer major surgeries but worse bleeding complications in CDT group)
--STILE (n=393, randomized to surgery, alteplase, urokinase). Equivalent 30 day death/amputation rate, more bleeding with CDT (esp lower fibrinogen/longer PTT; risk of intracranial bleed 1-2%). Highest risk patients (diabetes, infrapopliteal clot, critical ischemia) had a better 1 year survival than surgery (32 vs 7%). CDT is better for acute ischemia, surgery better for chronic. Alteplase lyses faster than urokinase; same efficacy.
7. Urokinase was originally discovered in the urine; it is synthesized by (among many things, probably) kidney tubular epithelial cells. tPA is found on endothelial cells; it is a serine protease, and not only does it cleave plasminogen to plasmin, it can cleave extracellular matrix proteins and aid in the metastasis of tumor cells. In fact, certain aggressive tumors have upregulated tPA expression. Be wary of doing something like a pelvic cancer biopsy in someone undergoing tPA therapy. If you seed the peritoneum during the biopsy, the tPA might make things worse.
8. In OB, 38 degrees C is a fever. Other places use 38.3-38.6. Lower your threshold for anyone who may be neutropenic or otherwise immunocompromised.
9. Everyone who is on opiates, consider a bowel regimen. A good one is pericolase BID and milk of mag daily.
10. Ask during a post-chemo checkup: hearing, eyesight, swallowing, GI (d/c/n/v), GU (bleeding/dysuria/difficulty urinating), CV/pulm (SOB, CP, leg edema/pain, palp). Check hands, feet, nails.