By H. Dawson. University of California, San Diego.

This discoloration is harm- ✔ If your chemotherapy may cause bleeding cheap sildenafil 100 mg overnight delivery erectile dysfunction drugs egypt, you can de- less; it does not indicate bleeding order sildenafil 75mg amex crestor causes erectile dysfunction. Also, report to a crease the likelihood by shaving with an electric razor, health care provider if you have edema, shortness of avoiding aspirin and other nonsteroidal anti-inflammatory breath, and excessive fatigue. Doxorubicin may need drugs (including over-the-counter Advil, Aleve, and others), to be stopped if these symptoms occur. If you notice excessive bruising, bleeding gums ✔ With methotrexate, avoid alcohol, aspirin, and pro- when you brush your teeth, or blood in your urine or bowel longed exposure to sunlight. A stool softener or bulk laxative loss is temporary; your hair will grow back! For example, more malig- Numerous combinations have been developed for use in spe- nant cells are likely to be destroyed by combining cell cific types of cancer. Selection and scheduling of individual cycle–specific and cell cycle–nonspecific drugs. The drugs in a multidrug regimen are based on efforts to maximize first group kills only dividing cells; the second group effectiveness and minimize adverse effects. Characteristics of kills cells during any part of the life cycle, including the effective drug combinations include the following: resting phase. For example, one drug can be chosen to dam- so that maximal tolerated doses may be given. It is CHAPTER 64 DRUGS USED IN ONCOLOGIC DISORDERS 927 preferable to use drugs that are not toxic to the same soon as possible after surgery, given in maximal tol- organ system (eg, bone marrow, kidney) and to use drugs erated doses just as if advanced disease were present, that do not exert their toxic effects at the same time. Intravenous drug administration should be performed by sive drugs because it rarely causes myelosuppression. Infusion should be through a large, upper ex- pneumonitis and pulmonary fibrosis). When possible, veins of the antecubital fossa, wrist, dorsum of the hand, and the arm where an axillary lymph node dissection has been done should be Dosage Factors avoided. An indwelling central venous catheter is often inserted for clients with poor peripheral venous access Dosage must be calculated and regulated carefully to mini- or who require many doses of chemotherapy. With bleomycin, a test dose of 1 to 2 mg subcutaneously kidney and liver function, and previous chemotherapy or should be given before starting full doses. High doses, to the limits of tolerance of normal tissues to decrease severe hypersensitivity reactions with dys- (eg, bone marrow), are usually most effective. Doses are usually calculated according to body surface deaths have occurred despite premedication. With pa- area, which includes both weight and height, and ex- clitaxel, one regimen is oral dexamethasone 20 mg at pressed as milligrams of drug per square meter of body 2 12 and 6 hours before, with IV diphenhydramine 50 mg surface area (mg/m ). Doses also can be expressed as and cimetidine 300 mg, famotidine 20 mg, or ranitidine milligrams per kilogram of body weight (mg/kg). This reduces risk and severity of cytopenia, stomatitis, diarrhea, and renal or hepatic hypersensitivity reactions and fluid retention. Total dose limits for doxorubicin (550 mg/m2) and Hormonal Therapy bleomycin (450 units) should not be exceeded. Decreasing the hormones that stimulate tumor growth in Administration Factors these tissues can decrease symptoms and prolong survival. Dosage schedules are largely determined by clinical tors for estrogen indicates a likely response to hormonal ther- trials and should be followed as exactly as possible.

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Spine 28:1258–62 REVIEW Max Aebi Spinal metastasis in the elderly Abstract Bony metastases are a fre- columbar spine a posterior decom- quent problem in elderly patients af- pression and posterolateral vertebral fected by cancer sildenafil 25mg amex erectile dysfunction treatment natural, and those with bony body resection through a posterior metastases involve the spine in ap- approach only generic sildenafil 50 mg amex impotence 36, with a concomitant prox. The most frequent spinal reconstruction and stabilization, has metastases (60%) are from breast, shown to work sufficiently well. The chance the middle and lower cervical spine that an elderly patient (60–79 years the anterior approach with anterior old) is affected by bony metastases is decompression and anterior column four times higher in men and three reconstruction is most effective and times higher in women than a mid- has a low morbidity, whereas the oc- dle-aged patient (40–59 years old). The outcome should be long the survival of this particular determined by the survival time in an patient group, the spinal metastases ambulatory, independent status, where may become a mechanical issue, thus pain is controlled, and the patient is requesting surgical treatment. Surgical manage- ent classification systems have been ment shows the greatest improve- proposed to rationalize surgical indi- ment in pain reduction, but also in cations, some concentrating solely other domains of quality of life. Since most of the modalities for spinal metastases in- surgical options are of palliative cluding surgery are not available and character, it is more important to base are ethically difficult to achieve, the decision on an overall clinical each case remains an interdiscipli- classification including the different nary, shared decision making process treatment modalities – irradiation, for what is considered best for a pa- chemotherapy, steroids, bisphospho- tient or elderly patient. However, nates, and surgery – to make a shared whenever surgery is an option, it M. In case surgery is indicated should be planned before irradiation in Orthopedic Surgery, – neural compression, pathological since surgery after irradiation has a University of Berne, fracture, instability, and progressive significant higher complication rate. Box 8354, deformity, nursing reasons – the most 3001 Berne, Switzerland straightforward procedures should be Keywords Spinal metastases · Tel. In the thora- Spinal tumor · Vertebral tumor 121 Introduction prevalent in the elderly such as prostate cancer and multi- ple myeloma (Table 1). Prostate cancer, for example, is at Bony metastases are a frequent event in breast, prostate, least six times more frequent in men aged 60 – 79 years lung, kidney urinary bladder, and thyroid cancer as well as than in those 40 – 59 years old. Breast cancer is almost in multiple myeloma and other hematological malignan- double and lung cancer five times higher in the elderly (60 – cies which may, however, be considered as primary tu- 79 years) than in the middle-aged (40 – 59 years). About 10% of the cancer patients are attained by though cancer is one of the major causes of morbidity and metastases located in the spine [23, 36] (incidence 1999, mortality, elderly persons are often excluded not only SEER and NPCR Registries, United States Cancer Statis- from clinical cancer studies but also from standard treat- tics; SEER Cancer Statistics Review 1975–2000, National ment, and generally also from cancer screening because Cancer Institute). Among adults 60% of spinal metastases comorbidity and frailty alter the risk benefit of screening are either from breast, lung, or prostate cancer. Renal and (World Health Organization report: Pain in the elderly gastrointestinal malignancies each account for about 5% with cancer, www. There is of spinal metastases, and thyroid carcinomas and melanomas clearly an underrepresentation of older persons in drug occurring with a lesser frequency [2, 24] (incidence 1999, studies, as documented by the United States Food and SEER and NPCR Registries, United States Cancer Statis- Drug Administration (http://cbsnewyork. Since these tumors are increasingly ac- derly because it usually affects the quality of life by re- cessible to treatment by surgery, radiation therapy, and ducing the endurance, the capacity to ambulate, and the chemotherapy, thus prolonging the survival of the affected ability for physical activity. Due to their age these patients patients, there is also an increased probability of them be- often have other diseases which already limit their quality ing affected by metastases, i. Metastatic disease involving the spine most often af- fects the vertebral bodies of the thoracic, lumbar, cervical, and sacral spine. Pathological anatomy and classification 5% of patients with cancer metastases develop cord com- pression. It is postulated that incidence 1999, SEER and NPCR Registries, United the venous blood return is shifted into the paravertebral States Cancer Statistics; SEER Cancer Statistics Review plexus via the intervertebral and basivertebral veins due to 1975–2000, National Cancer Institute; World Health Or- increased intra-abdominal and intrathoracic pressure. The average age of are seeded by this mechanism into the capillary network patients affected by secondary spinal tumors is 55 – 60 years of the vertebral bodies. Due to its avascular nature the when considering all metastases; however, it is sig- disc is usually spared from tumor involvement: however, nificantly higher when considering tumors that are more the most frequently and severely affected part of the ver- tebra is the vertebral body (in about 80%) followed by the pedicles and the posterior elements. This constellation ex- plains why most of the spinal metastasis are located in Table1 Probability of developing invasive cancer (percentages) front of the spinal cord or dural sac ending up with an an- at selected ages with spinal metastasis (from) terior epidural compression. More than 90% of spinal 40–59 years old 60–79 years old metastases are extradural and only 5% intradural and less than 1% intramedullar. Finally there is also the Lung cancer option of direct spread through direct tumor infiltration Male 1. The system differentiates between intra- groups covering most of the possibilities of spinal metas- compartmental, extracompartmental, and multiple tumor tases appearance: involvement.

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Although the menus in Chapter 6 suggest two shakes a day buy cheap sildenafil 25mg online impotence definition, you may continue to eat real food with the following substitutions buy 25mg sildenafil fast delivery erectile dysfunction pump on nhs. Here are some options: I BREAKFAST Your best option for breakfast is egg whites. This will give your body quality protein and all the essential amino acids it needs. I ask you to use egg whites instead of whole eggs because most of the fat and calories of the egg are housed in the yolk. Start off your day with an egg white omelet full of your favorite vegetables. I LUNCH Combine a source of lean protein (6 ounces of salmon, tuna, or chicken breast) with a hearty serving of your favorite steamed vegetable. THE ULTIMATE BODY NUTRITION PLAN 129 TLFeBOOK I DINNER Instead of a shake, you can make yourself a large salad with a lean source of protein. Pile on the vegetables (except for carrots), and place your favorite lean protein on top; this may range from grilled chicken breast to salmon to tuna. TIMING YOUR MEALS WITH YOUR WORKOUTS Exactly when you have your meals and snacks and shakes depends in part on what time of day you work out. I highly recommend you do your workouts in the morning, and the meal plan in Chapter 5 makes that assumption. Research shows that people who exercise in the morning tend to eat better all day long. An early morning exercise session also puts your body in fat-burning mode early in the day. That said, if you need to exercise at a different time of day in order to fit exercise into your schedule, by all means do. I THE MORNING WORKOUT The optimal time to work out on this program is at 7 A. I THE MIDAFTERNOON WORKOUT You want some food in your tank to power your workout, but not so much food that you feel sick and sluggish. I THE EVENING WORKOUT If you exercise at night, your shake will be your last meal. Make sure to have a substantial lunch and protein rich midafternoon snack (such as 4 ounces of chicken or tuna). A protein shake is one of the safest late-night calorie options and will give your muscles what they need to fully recover after your workout. Antioxidants (Vitamins C and E and Coenzyme Q10) These powerful antiox- idants lend their electrons to free radicals in your body, making the radicals more stable and preventing them from destroying cells. This can prevent a host of problems from general aging to heart disease to cancer to arthritis. You can get all these antioxidants, plus a dose of other helpful vitamins and minerals, from a few commercially available multivitamin and mineral supplements sold in health food stores. One of the best energy boosters around, ginseng can also help boost your immunity and overall wellness. Take a vitamin supplement that provides 100 percent of the daily recommended allowance. For the first two weeks of this program you will be cutting dairy products out of your diet, which is one reason why I suggest you supplement with calcium.

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