Chemotherapy and Nail Toxicity

Chemotherapy and Nail Toxicity Hyper pigmented nails: Chemotherapy causing chromonychia Running head: Chemotherapy and nail toxicity Dr Kamal Kant sahu (M.D medicine,) Dr Gaurav Prakash (M.D medicine, DM medical oncology) Dr Pankaj Malhotra (MD medicine) Prof. Subhash Chandar Varma (MD medicine) Word count 787 Figure count 4 Table-1 References count-3 Key words: Chromonychia; leuconychia; hyperpigmeted nails; Abstract Nail toxicity are among the benign and neglected side effects linked to many chemotherapeutic drugs. Taxanes and anthracyclines are the antineoplastic drug groups most commonly implicated. Nail changes can involve several or all 20 nails and appear in temporal relationship with drug intake. Most of the time, toxicity is just a matter of concern due to cosmetic reasons, however very occasionally it may be associated with pain. True incidence of nail changes related to particular drugs are still lacking due to under-reporting and ignorance of potential side-effects among the patients, necessitating the education prior to institution of drugs and appropriate management like, avoiding potential irritants and use of topical, or oral antimicrobials, and possibly cessation or dose reduction of the offending agent or use of cryotherapy in some cases may certainly be beneficial. Introduction Chemotherapeutic drugs are associated with variety of nail changes. These nail changes are usually temporarily and use to resolve once chemo toxic drugs are stopped. Common drugs affecting are hydroxyurea, cyclophosphamide, vincristine, doxorubicin, dexamethasone, methotrexate and cytarabine. We here report our experience with two patients who developed nail changes during the course of chemotherapy for hematological malignancies Case Report 1 A 19-year-old young boy was admitted to the our hospital’s hematology ward with the symptoms of fever and lymphadenopathy in cervical and axillary region .Workup including bone marrow examination, PET CT scan, excisional biopsy of lymph node were done and diagnosis of T cell rich B lymphoblastic lymphoma STAGE IIIB was made .He received 1st cycle of RCHOP while hospitalized and later on discharged .He received rest of seven RCHOP courses on outdoor basis. Through examination during his outdoor follow up visits revealed transverse hyper pigmented bands on the nails (chromonychia). The bands were multiple, transverse, approximately 1-mm broad, spanning the entire nail breadth, dark grey colored, nonblanchable, nonpalpable with smooth overlying nail surface on the nail plates of all fingers and toes with well appreciation of intervening faintly grey colored bands of nails(Figure 1,2). Unluckily, he relapsed post eight cycles of RCHOP chemotherapy and henceforth started on 2nd lin e chemotherapy RICE (Rituximab, ifosfamide, cisplatin, etoposide), 1st course of which was given to him uneventfully recently till the time of writing this report. Case Report 2 A 55-year- old female presented to hematology clinic with complaints of pain abdomen for 6 months with history of significant loss of weight and appetite. Per abdomen examination revealed presence of abdominal lump with dimensions of 18 cm x 15 cm with no hepatosplenomegaly.Tru-cut biopsy of lump was done .Histopathological examination and immunohistochemistry confirmed high grade, B cell type non-Hodgkin’s lymphoma. She was further investigated and found to have stage IVB disease .Due to financial issues she was given CVP regimen (cyclophosphamide,doxorubicin,vincristine),however she relapsed following 3 courses by the time of writing this report. During her outdoor visits, she was found to have diffuse, black pigmentation with longitudinal striae in the nails of digits of both hands (figure 3, 4) and feet. Discussion Amongst the innumerable side effects that chemotherapeutic drugs have, mucocutaneous one are the most worrisome for the patients probably due to cosmetic reasons. Different patterns of nail discoloration like chromonychia, leukonychia (including Mees and Muehrckes lines), Beaus lines, paronychia and onycholysis have been well documented(1). Drugs commonly implicated are – vincristine, hydroxyurea, etoposide, daunorubicin, bleomycin, cyclophosphamide, dacarbazine, 5-fluorouracil and methotrexate (1, 2). The most frequent variety of chromonychia is melanonychia which is best defined as a dark pigmentation of nails observed as diffuse, transverse, or longitudinal band patterns(2).Some more common and important nail toxities have been summarized in table 1 with their description of morphology and pathophysiology of origin. Effect of cyclophosphamide on nails ranges from diffuse, black pigmentation to dark longitudinal striae , and diffuse, dark gray pigmentation located proximally, with overlying transverse, black bands(2). Doxorubicin produces commonly transverse, dark brown bands alternating with white stripes and dark brown diffuse pigmentation bands 4–5 mm wide, which affect two-thirds of the distal portion of the nail(3). Hydroxyurea produces pigmentation that has a diffuse, dark brown color which may appear as single or double transverse bands. Our patient received all of the above mentioned drugs during his due course of illness Table1. Definitions of some common nail toxities and probable pathophysiology of origin (1, 2) Conclusion Nail changes although seems to be common following chemotherapy, however goes unnoticed and underlooked in the lights of more important burning issues of chemotherapy both by physician and patient and hence true incidence of nail related changes is much more than reported especially in dark colored individuals like our patient and hence requires keen observation during follow up of these patients. References 1.Hinds G, Thomas VD. Malignancy and cancer treatment-related hair and nail changes. Dermatologic clinics. 2008;26(1):59-68, viii.. 2.Dasanu CA, Vaillant JG, Alexandrescu DT. Distinct patterns of chromonychia, Beaus lines, and melanoderma seen with vincristine, adriamycin, dexamethasone therapy for multiple myeloma. Dermatology online journal. 2006;12(6):10. 3.Gilbar P, Hain A, Peereboom VM. Nail toxicity induced by cancer chemotherapy. Journal of oncology pharmacy practice : official publication of the International Society of Oncology Pharmacy Practitioners. 2009;15(3):143-55. LEGEND OF FIGURES Figure1.Multiple hyper pigmented, transverse bands, approximately 1-mm broad, spanning the entire nail breadth, dark grey colored, nonblanchable, nonpalpable with smooth overlying nail surface on the nail plates of all fingers and toes with well appreciation of intervening faintly grey colored bands of nails. Figure2.Close up image of bilateral nails with clear depiction of hyper pigmented bands. Figure3. Multiple hyper pigmented, longitudinal striae noted in bilateral nails of fingers. Figure4. Hyper pigmented longitudinal bands predominant in distal aspect of nails

A Definition of Organizational Culture Essay

Organizational culture refers to a system of shared meaning held by members that distinguishes the organization from other organizations. Seven primary characteristics seem to capture the essence of an organization’s culture 1.Innovation and risk taking The degree to which employees are encouraged to be innovative and take risks. 2.Attention to detail The degree to which employees are expected to exhibit precision, analysis and attention to detail. 3.Outcome orientation The degree to which management focuses on results or outcomes rather than on the techniques and processes used to achieve them. 4.People orientation The degree to which management decisions take into consideration the effect of outcomes on people within the organization. 5.Team orientation The degree to which work activities are organized around teams rather than individuals. 6.Aggressiveness The degree to which people are aggressive and competitive rather than easygoing. 7.Stability The degree to which organizational activities emphasize maintaining the status quo in contrast to growth. Creating and Sustaining Culture An organization’s current customs, traditions, and general way of doing things are largely due to what it has done before and how successful it was in doing it. This leads us to the ultimate source of an organization’s culture: its founders. Free of previous customs or ideologies, founders have a vision of what the organization should be, and the firm’s small size makes it easy to impose that vision on all members. Culture creation occurs in three ways. First, founders hire and keep only employees who think and feel the same way they do. Second, they indoctrinate and socialize these employees to their way of thinking and feeling. And finally, the founders’ own behavior encourages employees to identify with them and internalize their beliefs, values, and assumptions. When the organization succeeds, the founders’ personality becomes embedded in the culture. Keeping a Culture Alive Once a culture is in place, practices within the organization maintain it by giving employees a set of similar experiences. The selection process, performance evaluation criteria, training and development activities, and promotion procedures ensure those hired fit in with the culture, reward those who support it, and penalize those who challenge it. Three forces play a particularly important part in sustaining a culture: selection practices, the actions of top management, and socialization methods. 1.Selection The explicit goal of the selection process is to identify and hire individuals with the knowledge, skills, and abilities to perform successfully. The final decision, because it’s significantly influenced by the decision maker’s judgment of how well the candidates will fit into the organization, identifies people whose values are essentially consistent with at least a good portion of the organizations. 2.Top Management The actions of top management also have a major impact on the organization’s culture. Through words and behavior, senior executives establish norms that filter through the organization about, for instance, whether risk taking is desirable, how much freedom managers give employees, what is appropriate dress, and what actions earn pay raises, promotions, and other rewards. 3.Socialization No matter how good a job the organization does in recruiting and selection, new employee’s need help adapting to the prevailing culture. That help is socialization. For example, all Marines must go through boot camp, where they prove their commitment and learn the â€Å"Marine way.† New recruits go to an internal Web portal to learn about the company and engage in some activities that help them understand the culture of the organization. After they start work, they continue to learn about the organization through an ongoing social networking application that links new workers with more established members of the firm and helps ensure that culture is transmitted over time. Why is culture important? Culture can affect business outcomes in a number of ways, both positive and negative. For example, cultures that are not aligned with corporate strategy can lead to decreased loyalty, a lack of motivation, and high employee turnover. Healthy cultures, however, impart pride and a sense of purpose to employees, leading to increased productivity and a greater understanding of corporate goals, as with the employee at the car manufacturing plant. Strategy, operational performance, and culture are all strongly related. High-performing companies often view culture as an enabler of strategy and performance, and want to create a culture that will support and enable employees in achieving those goals. Define and Establish Cultural Diversity A typical organization has an extensive range of people who have cultural and personal differences. A small business interested in fostering cultural diversity among its employees endeavors to create mutual respect for the different cultures, along with enabling personnel to reach their full potential. Acknowledging diverse cultures enables the organization to positively influence the organizational behavior that, in turn, enhances the performance and image of the organization. The business should portray the cultural diversity aspect of the organization in the mission statement. The Positive Influence of Cultural Diversity in Organizational Behavior Cultural diversity involves the differences in the composition of members of an organization in terms of nationality, race, color, gender, creed, religion or age, in other words, an array of culture found among people from diverse backgrounds. Organizational behavior refers to the nature of interactions among people and groups within an organization. The positive influence of cultural diversity facilitates members of the organization to build relationships and acknowledge each other regardless of their differences of origin and background. Transforming Organizational Behavior The patterns of behavior in the organization are influenced by the nature of interactions and degree of diversity within the organization. The business,  therefore, should seek to create an organizational culture that not only enhances the diversity of its workforce composition but also boosts individual performance. The positive influences of cultural diversity not only enable the organization to increase the scope of its reach the business also receives favorable exposure from every sector of the population due to its multicultural approach. Sustaining Positive Influence Programs Programs for positive influence should always be adjusted to suit the dynamic nature of interactions among people. Establish regular forums and educational programs in which participants are trained to be sensitive to and appreciate cultural diversity, as well as in maintaining desirable organizational behavior. Regularly post motivational quotes and messages of cultural diversity on public bulletin boards. Concentrate on creating programs that internalize cultural diversity into the organization’s behavior.

What Everybody Is Saying About Old College Personal Essay Topics and What You Need to Do

What Everybody Is Saying About Old College Personal Essay Topics and What You Need to Do Whenever you opt to ask us for expert aid, don't hesitate to speak to our support managers. You may also acquire different discounts on our site which will help you to save some more money for future orders or anything you want to spend them on. As any other academic assignment, your private essay ought to be flawless in regards to grammar and punctuation. After discovering our website, you will no longer will need to bother friends and family with these kinds of requests. An admissions officer is quite a bit more likely to bear in mind an applicant who has quite a specific essay written in a special and quirky way. Keep in mind that a high degree of detailing is a feature of all decent narrative essay examples. Despite the fact that the text will actually combine many styles, it's possible to still write it quite easily when you have ever tried to compose any text about a renowned personality. Attempt not to add new information within this section, as it is simply for summarizing the essay not for introduction new information. Be conscious of the size it must be and get started writing the narrative essay outline. Compose a list of your own personal qualities. Old College Personal Essay Topics - Is it a Scam? Your personal, professional, and academic background might be a rich supply of material for your own personal essay. Colleges want a feeling of maturity and introspectionpinpoint the transformation and demonstrate your private growth. Recall unpleasant moments which you find very beneficial for your private improvement. Think about the scene you're going to write down. Write about moving to some other city. Make certain you connect the significance of the activity to a specific experience or story to provide the essay direction. Bridget's essay is extremely strong, but there continue to be a couple little things that could be made better. Therefore, to compose a great essay you must brainstorm all thoughts concerning your life experiences. The author must be able to check at their very own character or personality through somebody else's eyes. Don't skip a word of the greatest true stories, well told. What Is So Fascinating About Old College Personal Essay Topics? If you lack ideas and don't understand where to start, we've prepared a list of private essay topics, which may assist you to start. It's possible to make use of these topics if you're out of different ideas for your private essay. Share an essay on any subject of your pick. When writing this essay, choose a subject of interest. Since there's a world of topics ahead of you, deciding upon the topic that is distinctive and interesting at the very same time, is certainly not a simple job. Verbalizing ideas loudly may help you choose the ideal essay choice. A selection of good personal narrative topics is important, as it ought to be interesting for readers. The function of the essays is to express your individual capabilities, character traits, ideas and ideas, which will force you to look different from several other applicants and present you as a creative, committed and intelligent individual. You could be quite surprised to discover that success of a personal essay may greatly be based on the subject you select. The option of compare and contrast essay topics isn't a simple task because you must demonstrate your analytical skills. On the opposing side, acquiring a list of good persuasive essay topics is insufficient. Then, it is going to be required to choose a topic for your own personal essay, and after it, you will be prepared to compose your paper. Analyze what you have to write in the essay and the way you want the readers to react to it. What's a personal essay. Although it may have quite a loose language, you should still avoid slang and cliches, which may make the text much weaker. How can you write a great argumentative essay. There is an entire array of different topics. Remember your final grade significantly is contingent on the topic. A survival program should develop into a must-have for each family in the event of natural disasters. It is critical to begin with an all-inclusive plan.

Articles Of Confederation Vs. The Constitution Essay

Jake Roseman AP GOV and Politics February 1 Articles of Confederation Vs. The Constitution There were plenty of differences between the Constitution and the Articles of Confederation. When the American Revolution ended the free states needed some sort of control that would create a unified country. There were problems such as how power between local and national governments would be divided, how laws should be made and by whom, who will govern the laws, and how will the government be created to protect individual rights came into thought. Their first attempt at solving these issues was the Articles of Confederation. The AOC was a failure for the most part, but not entirely. After it failed, the state delegates tried to revise the articles, but instead the Constitution was created. There were so many changes made and very little remained the same as the AOC. The thirteen states formed a Confederation referred to as the â€Å"league of friendship† in order to find a solution for common problems such as foreign affairs.The Articles of Confederation was the nation†™s first Constitution. The AOC made a confederation where states were independent and the national government was very weak and had little authority. No matter the population of each state, each state had one vote in the house of Congress. It was decided on by the members of this one house Congress that the new government should have no executive or judicial branch. With the articles in place, there wasn’t a strongShow MoreRelatedArticles of Confederation vs. Constitution 11415 Words   |  6 PagesARTICLES OF CONFEDERATION VS. CONSTITUTION â€Æ' There were many differences between the Articles of Confederation and the Constitution. At the end of the American Revolution the free states needed some sort of control that would generate to a unified country. 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