The objective of this study was to understand outcomes of patients treated with ALK inhibitors, especially when ALK inhibitors are followed by other ALK inhibitors. A systematic literature review was conducted in PubMed, Embase, and Cochrane through July 17, 2017. Conference abstracts (three meetings in past 2 years) also were searched. Of 504 unique publications, 80 met inclusion criteria (47 clinical trials, 33 observational studies). Observational studies have the potential to provide information for ALK inhibitors used sequentially. Ten observational studies reported median overall survival of crizotinib-led sequences ranging from 30.3 to 63.75 months from initiation of crizotinib; 49.4-89.6 months from metastatic non-smallcell lung cancer diagnosis; and 15.5-22.0 months from initiation of the second-generation ALK inhibitor after initial crizotinib. Sequencing of ALK inhibitors may benefit patients progressing on initial ALK inhibitors.
The implementation of intravenous workflow management technology was unable to detect a statistically significant greater percentage of sterile product preparation errors compared with the baseline time period. Statistical significance was achieved during three of the first four months following implementation ( P < 0.05); however, this statistically significant increase was not maintained when the entire post-implementation sample was included.
S uccessful thoracotomy in the prehospital environment is becoming more widely accepted. 1 2 Here we present the case of cardiac arrest secondary to penetrating chest injury and the successful prehospital thoracotomy that followed. The resuscitation was associated with the spontaneous return of motor activity and later, hospital discharge. The implication for the immediate need for anaesthesia and paralysis is discussed together with a description of the surgical technique. CASE REPORTA teenage male youth sustained a stab wound to the left chest, in the third intercostal space at the junction of the medial and middle thirds of the clavicle. This wound was part of a deliberate self harm attempt. On arrival of the medical team-15 minutes from 999 call-he was thrashing and taking a few agonal breaths, this rapidly deteriorated to cardiac arrest within the first few seconds of assessment.The patient was placed on the floor of his first floor flat and endotracheal intubation was undertaken by the medical team paramedic; cannulation was achieved by a first responder paramedic and the medical team doctor undertook bilateral thoracostomies in the right and left 4th intercostal space, midaxillary line. This revealed a small haemothorax on the left side. The thoracostomies were joined by a skin incision using a 22 blade scalpel through skin and subcutaneous fat. Heavy duty shears were placed through the thoracostomy and used to cut through muscle and sternum thus making a large clamshell thoracotomy.With the chest open the pericardium was visualised as a blue, tense sac. Mosquito forceps were used to tent the pericardium and it was incised with scissors and widely opened. A large clot was removed and the operator's right index finger used to occlude a hole in the posterior aspect of the left upper heart. As the hole was occluded the heart began to fill and beat, restoring a carotid pulse. There was no anterior wound.The patient attempted to breathe and then localised both upper limbs towards the chest incision. He was rapidly sedated and paralysed with midazolam 10 mg and pancuronium 8 mg. The patient was then lifted down two flights of stairs and taken to the nearest accident and emergency/cardiothoracic centre still with digital occlusion of the hole. Treatment at scene lasted 18 minutes. Bleeding from the internal mammary vessels was controlled with mosquito forceps.On arrival, (journey time four minutes) he was maintaining a heart rate of 100 beats per minute and a systolic blood pressure of between 60 and 90 mm Hg. A cardiothoracic response enabled haemostatic sutures to be placed while in the resuscitation room before transfer to theatre for definitive closure. He was then transferred to the intensive care unit.The postoperative course was initially difficult requiring a second thoracotomy for intrathoracic bleeding. Sepsis caused a syndrome of renal failure requiring haemofiltration. However by day eight he was alert and appropriate neurologically, requiring no cardiovascular support and doing well. Subsequently he...
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