Role of isavuconazole in the treatment of invasive fungal infections

Despite recent advances in both diagnosis and prevention, the incidence of invasive fungal infections continues to rise. Available antifungal agents to treat invasive fungal infections include polyenes, triazoles, and echinocandins. Unfortunately, individual agents within each class may be limited by spectrum of activity, resistance, lack of oral formulations, significant adverse event profiles, substantial drug–drug interactions, and/or variable pharmacokinetic profiles. Isavuconazole, a second-generation triazole, was approved by the US Food and Drug Administration in March 2015 and the European Medicines Agency in July 2015 for the treatment of adults with invasive aspergillosis (IA) or mucormycosis. Similar to amphotericin B and posaconazole, isavuconazole exhibits a broad spectrum of in vitro activity against yeasts, dimorphic fungi, and molds. Isavuconazole is available in both oral and intravenous formulations, exhibits a favorable safety profile (notably the absence of QTc prolongation), and reduced drug–drug interactions (relative to voriconazole). Phase 3 studies have evaluated the efficacy of isavuconazole in the management of IA, mucormycosis, and invasive candidiasis. Based on the results of these studies, isavuconazole appears to be a viable treatment option for patients with IA as well as those patients with mucormycosis who are not able to tolerate or fail amphotericin B or posaconazole therapy. In contrast, evidence of isavuconazole for invasive candidiasis (relative to comparator agents such as echinocandins) is not as robust. Therefore, isavuconazole use for invasive candidiasis may initially be reserved as a step-down oral option in those patients who cannot receive other azoles due to tolerability or spectrum of activity limitations. Post-marketing surveillance of isavuconazole will be important to better understand the safety and efficacy of this agent, as well as to better define the need for isavuconazole serum concentration monitoring.

Transoral Surgery or Radiotherapy for Oropharyngeal Carcinoma - Is It Either Or…?

The management of oropharyngeal carcinoma represents an increasing clinical challenge, because of its rising incidence, particularly in younger patients as a result of human papillomavirus (HPV) infection, and because significant technological advances have occurred in radiotherapy and surgery over the last 10 years that have increased treatment options for patients, with little robust evidence yet of their relative merits. As a result, there is a lack of clinical consensus on the optimum treatment modality, reflected in wide variation in practice between different cancer networks across the UK. Here, we consider the evidence base for minimally invasive transoral surgery and for intensity-modulated radiotherapy-based primary treatment for oropharyngeal cancer, in terms of both oncological and functional outcomes. Management strategies for HPV-positive and HPV-negative disease, and for different stages of the disease, are considered. There is currently an unparalleled opportunity to shape the future management of oropharyngeal cancer, which is dependent on recruiting patients to ongoing clinical trials, in order to build an evidence base to support a clinical consensus on the optimal treatment strategies. It appears likely that future evidence-based decision-making will use both primary radiotherapy and primary surgical treatment modalities to maximise patient benefit.

Focus on JNJ-Q2, a novel fluoroquinolone, for the management of community-acquired bacterial pneumonia and acute bacterial skin and skin structure infections

JNJ-Q2 is a novel, fifth-generation fluoroquinolone that has excellent in vitro and in vivo activity against a variety of Gram-positive and Gram-negative organisms. In vitro studies indicate that JNJ-Q2 has potent activity against pathogens responsible for acute bacterial skin and skin structure infections (ABSSSI) and community-acquired bacterial pneumonia (CABP), such as Staphylococcus aureus and Streptococcus pneumoniae. JNJ-Q2 also has been shown to have a higher barrier to resistance compared to other agents in the class and it remains highly active against drug-resistant organisms, including methicillin-resistant S. aureus, ciprofloxacin-resistant methicillin-resistant S. aureus, and drug-resistant S. pneumoniae. In two Phase II studies, the efficacy of JNJ-Q2 was comparable to linezolid for ABSSSI and moxifloxacin for CABP. Furthermore, JNJ-Q2 was well tolerated, with adverse event rates similar to or less than other fluoroquinolones. With an expanded spectrum of activity and low potential for resistance, JNJ-Q2 shows promise as an effective treatment option for ABSSSI and CABP. Considering its early stage of development, the definitive role of JNJ-Q2 against these infections and its safety profile will be determined in future Phase III studies.

Injection of botulinum toxin for the treatment of post-laryngectomy pharyngoesophageal spasm-related disorders

Introduction Pharyngoesophageal spasm (PES) can cause dysphagia, central valve leak (CVL), and dypshonia in post-laryngectomy patients. Botulinum toxin has been used effectively for the treatment of PES, but data regarding patient-reported outcomes and efficacy for CVL are limited. We evaluated the results of botox injection for PES spasm using subjective and objective measures. Methods Data were collected prospectively (February 2010 to August 2013) on 13 patients undergoing botox injection for PES as identified by video fluoroscopy. We collected digital voice recordings, air-pressure measurements (APMs) for speech, and quality of life (QoL) data before and after the procedure: University of Washington QoL questionnaire (UW-QoL), MD Anderson Swallowing Inventory (MDADI) and the Voice Handicap Index (VHI-30). Results APMs for a sustained vowel decreased by 18% after botox injection, whereas maximum phonatory times increased by 63% (mean increase, 8 to 13 seconds). Sustained vowel amplitude decreased (mean, 87db to 83db) with an associated reduction in sustained vowel frequency (117Hz to 77Hz). MDADI scores improved by 10.2% overall, and UW-QoL scores showed an improvement in score of 7.6%. Mean scores for VHI-30 deteriorated by 2% overall but, when considering only those patients experiencing dysphonia, an improvement of 9.4% was seen. There was an overall net reduction for the CVL cohort of 12 speech valves in the year after injection. Conclusions Our series confirm the safety and objective efficacy of botox injection for PES. QoL measurements were less convincing, and this disparity between subjective and objective measurements must be considered when treating such patients.

Upper airway obstruction in a patient with Ehlers-Danlos syndrome

We report a case of recurrent airway obstruction episodes resulting from laryngeal hypermobility in a patient with Ehlers-Danlos syndrome. A 44-year-old woman, with known Ehlers-Danlos syndrome, presented with recent onset of episodes of upper airway obstruction due to hypermobility of her larynx. A suitable conservative management strategy proved elusive and the patient finally underwent a thyrohyoidopexy. The patient remains symptom free nine months after the procedure. This is the first report of spontaneous life threatening upper airway obstruction due to hypermobility of the suprahyoid suspensory soft tissues in Ehlers-Danlos syndrome.

Tracheal stenosis following percutaneous dilatational tracheostomy using the single tapered dilator: an MRI study

Despite widespread adoption of percutaneous dilatational tracheostomy within the critical care setting, there is still uncertainty regarding long-term complications, particularly in relation to missed or subclinical tracheal stenosis. In this study, all patients underwent tracheostomy using a single tapered dilator ≥ three months prior to enrollment and were evaluated using magnetic resonance imaging, spirometry and questionnaire. Tracheal area was recorded and deemed to be stenotic if a reduction of ≥10% was found. Fifty patients underwent magnetic resonance imaging and 49 attended for interview. Five patients were diagnosed with tracheal stenosis-none were symptomatic. Six of the 50 tracheostomies were technically difficult. Spirometry was not predictive of stenosis. A post critical care exercise tolerance of less than 100 metres was found in four tracheal stenosis patients. The prevalence of subclinical tracheal stenosis following percutaneous tracheostomy is low, with limited clinical significance. No patients required corrective surgery for tracheal stenosis. Routine airway follow-up in asymptomatic patients appears to be unwarranted.

Anaesthesia for massive retrosternal thyroidectomy in a tertiary referral centre

BACKGROUND

Retrosternal goitre (RSG) is an uncommon problem encountered rarely by anaesthetists working outside specialized head and neck (H&N) surgical units. Traditional anaesthetic teaching warns of difficult airway management in these patients. The incidence and extent of these problems is unclear.

METHODS

We have performed a retrospective review of the anaesthetic management all patients with massive RSG (extending to the aortic arch or beyond) presenting for thyroidectomy at University Hospital Aintree from January 2007 to May 2012.

RESULTS

Five hundred and seventy-three patients underwent a thyroidectomy procedure at Aintree University Hospitals NHS Foundation Trust (AUH) between January 2007 and May 2012. Of these, 34 cases were documented as having a RSG. Review of each patient's preoperative computerized tomography imaging identified 19 patients with massive RSG. There was one case of failed intubation. All other patients underwent uneventful tracheal intubation via direct laryngoscopy. All glands were removed through the neck with no requirement to proceed to sternotomy. There were no instances of postoperative respiratory problems or tracheomalacia. Three patients suffered recurrent laryngeal nerve (RLN) injuries.

CONCLUSION

When managed within a dedicated H&N operating theatre we have found a low incidence of difficult tracheal intubation, difficult mechanical ventilation nor postoperative respiratory difficulties in patients with massive RSG and mid-tracheal compression because of benign multi-nodular goitre. Surgical complications, however, are more frequent than those associated with cervical thyroidectomy with RLN injury and postoperative bleeding more likely.

Validation of a novel diagnostic standard in HPV-positive oropharyngeal squamous cell carcinoma

Background:

Human papillomavirus (HPV) testing in oropharyngeal squamous cell carcinoma (OPSCC) is now advocated. Demonstration of transcriptionally active high-risk HPV (HR-HPV) in fresh tumour tissue is considered to be the analytical ‘gold standard'. Clinical testing has focused on formalin-fixed paraffin-embedded (FFPE) tissue at the expense of sensitivity and specificity. Recently, a novel RNA in situ hybridisation test (RNAscope) has been developed for the detection of HR-HPV in FFPE tissue; however, validation against the ‘gold standard' has not been reported.

Methods:

A tissue microarray comprising FFPE cores from 79 OPSCC was tested using HR-HPV RNAscope. Analytical accuracy and prognostic capacity were established by comparison with the reference test; qRT–PCR for HR-HPV on matched fresh-frozen samples.

Results:

High-risk HPV RNAscope had a sensitivity and specificity of 97 and 93%, respectively, against the reference test. Kaplan–Meier estimates of disease-specific survival (DSS, P=0.001) and overall survival (OS, P<0.001) by RNAscope were similar to the reference test (DSS, P=0.003, OS, P<0.001) and at least, not inferior to p16 immunohistochemistry +/− HR-HPV DNA-based tests.

Conclusion:

HR-HPV RNAscope demonstrates excellent analytical and prognostic performance against the ‘gold standard'. These data suggest that the test could be developed to provide the ‘clinical standard' for assigning a diagnosis of HPV-related OPSCC.

Percutaneous tracheostomy: a 6 yr prospective evaluation of the single tapered dilator technique

BACKGROUND

The single tapered dilator (STD) percutaneous dilatational tracheostomy (PDT) technique now appears to be the single most common method of performing a tracheostomy in the critical care unit (CCU).

METHODS

A single-centre, prospective evaluation of all PDTs performed in an adult mixed surgical and medical CCU between November 2003 and October 2009 was done. All procedures were undertaken by critical care physicians. A proforma recorded intraoperative complications and technical difficulties encountered during the procedure; all patients were followed up for a minimum of 3 months for delayed complications.

RESULTS

A tracheostomy was performed on 589 patients during the study period. PDT was attempted in 576 patients and successfully completed in 572. PDT was abandoned in four patients due to bleeding, with three of these subsequently undergoing surgical tracheostomy (ST). ST was performed in 17 patients. Intraoperative technical difficulties were encountered in 149 (26%) cases. Sixteen (3%) procedures were deemed as having early complications. A further four (0.7%) cases had significant late complications including two tracheo-innominate fistulae (TIF). Both TIF patients died as a result of their complications giving a mortality directly attributable to PDT of 0.35%. There were no differences with respect to the occurrence of complications according to grade of operator.

CONCLUSIONS

PDT performed by the STD technique is a relatively safe procedure with more than 96% of procedures performed without any early or late complications. Using this technique, more than 97% of tracheostomies undertaken during the study period were performed percutaneously. Further audit at a national level is warranted to fully evaluate long-term complications after PDT.

Nutlin-3, the small-molecule inhibitor of MDM2, promotes senescence and radiosensitises laryngeal carcinoma cells harbouring wild-type p53

BACKGROUND

Primary radiotherapy (RT) is a mainstay of treatment for laryngeal squamous cell carcinoma (LSCC). Although the cure rates for early (T1) vocal cord tumours are high, RT proves ineffective in up to a third of T3 carcinomas. Moreover, RT is associated with debilitating early- and late-treatment-related toxicity, thus finding means to de-escalate therapy, while retaining/augmenting therapeutic effectiveness, is highly desirable. p53 is a key mediator of radiation responses; we therefore investigated whether Nutlin-3, a small-molecule inhibitor of MDM2 (mouse double minute 2; an essential negative regulator of p53), might radiosensitise LSCC cells.

METHODS

We performed clonogenic assays to measure radiosensitivity in a panel of LSCC cell lines (for which we determined p53 mutational status) in the presence and absence of Nutlin-3.

RESULTS

LSCC cells harbouring wild-type p53 were significantly radiosensitised by Nutlin-3 (P<0.0001; log-rank scale), and displayed increased cell cycle arrest and significantly increased senescence (P<0.001) in the absence of increased apoptosis; thus, our data suggest that senescence may mediate this increased radiosensitivity.

CONCLUSION

This is the first study showing Nutlin-3 as an effective radiosensitiser in LSCC cells that retain wild-type p53. The clinical application of Nutlin-3 might improve local recurrence rates or allow treatment de-escalation in these patients.

Outcome of late-onset hospital-acquired pneumonia related to causative organism

Pneumonia caused by Pseudomonas spp. has been associated with an increase in mortality in critical care patients. Previous assessments, however, have failed to compare outcome solely with other pathogens associated with hospital-acquired pneumonia (HAP). We have performed a retrospective review of all critical care patients with late-onset HAP (hospital inpatient stay >72 h at time of diagnosis) due to pure respiratory cultures of Pseudomonas spp., meticillin-resistant Staphylococcus aureus (MRSA) or non-pseudomonal Gram-negative (NPGN) organisms from 1998 to 2007. Casenote review involved assessments of illness severity, clinical pulmonary infection scoring (CPIS), critical care and hospital survival, and critical care length of stay. Out of 252 casenotes, 204 were reviewed. There were 186 treated cases of pneumonia. Ten patients had both pseudomonal and NPGN pneumonias during the same admission and two patients presented with community-acquired infections due to these organisms. These 12 patients were excluded from further analysis. Of the remaining 174 patients, 80 were infected with pseudomonas, 40 with MRSA and 54 had NPGN organisms. The three groups of patients were well-matched, with similar age, sex, CPIS scores, incidence of bacteraemia and Acute Physiology and Chronic Health Evaluation II scores at diagnosis. There were no outcome differences between the groups with respect to hospital and critical care survival and critical care length of stay. In this series, there appears to be no survival disadvantage associated with pseudomonal pneumonia when compared with other hospital-acquired organisms associated with HAP, where disease severity between the groups is similar.

Role of routine chest radiography after percutaneous dilatational tracheostomy

BACKGROUND

The role of routine chest radiography (CXR) after percutaneous dilatational tracheostomy (PDT) has been questioned.

METHODS

We performed a prospective observational study, on a mixed medical/surgical critical care unit in a university teaching hospital. We studied all patients undergoing PDT as part of their critical care management from November 1, 2003 until July 31, 2007. All PDTs were performed under bronchoscopic guidance. After PDT, we reviewed the immediate post-procedural films to assess the utility of routine postoperative CXR. For the purposes of CXR review, we considered a procedure to be either uncomplicated or technically difficult. Clinically relevant CXR findings were new barotrauma (pneumothorax, pneumomediastinum) or a significant change in consolidation from the pre-procedure film.

RESULTS

A total of 384 patients underwent PDT during the study period. Of these, 345 had immediate post-procedural CXRs available for review. There were 252 PDTs (73%) documented as uncomplicated. There were 93 (27%) technically difficult procedures, with 107 adverse events recorded. In 82 (24%) procedures, these difficulties were described as minor procedural complications [multiple attempts at needle insertion (> or = 3), minor bleeding or tracheal ring fracture]. Significant complications (mal-placement in the anterior mediastinum and major bleeding) were documented in 12 (3.5%) patients. New abnormalities were noted on 8 (2.3%) immediate post-procedural CXRs. In only one patient was there a new CXR change in an uncomplicated PDT.

CONCLUSIONS

Immediate CXR after uncomplicated PDT performed under bronchoscopic guidance rarely reveals unexpected radiological abnormalities. The role of CXR after PDT appears to be restricted to those patients undergoing technically difficult and complicated procedures. A change in practice to this effect will lead to reductions in both medical costs and exposure of staff and patients to ionizing radiation.

Head and neck cancer waiting times

The guidelines for treating cancer changed in December 2005 to no longer than 62 days from urgent referral to treatment, or 31 days from diagnosis to treatment. The use, by general practitioners, of suspected head and neck cancer proformas has reduced the time taken from referral to first outpatient appointment from 15 days in 2003 to 5.5 days in 2005. The introduction of specific radiology request forms for suspected malignancy has allowed easier identification of requests for imaging and subsequently a shorter waiting time for radiological investigations from 23 days in 2003 to 10 days in 2005. The appointment of a new dedicated head and neck cancer consultant at Aintree and the provision of another linear accelerator have reduced the waiting time for surgery from 68 days in 2003 to 39 days in 2005 and radiotherapy from 86 days in 2003 to 52.6 days in 2005. Patients not referred as suspected cancer patients who subsequently receive primary radiotherapy for a head and neck cancer fall outside the 62 day rule, being treated on average 70 days after referral.

In vitro metabolism of the epoxide substructure of cryptophycins by cytosolic glutathione S-transferase: species differences and stereoselectivity

The enzyme kinetics of the glutathione (GSH) conjugation of cryptophycin 52 (C52, R-stereoisomer) and cryptophycin 53 (C53, S-stereoisomer) by cytosolic glutathione S-transferases (cGSTs) from human, rat, mouse, dog and monkey liver were studied. Vmax, Km, and CLint values for glutathione conjugation of C52 (R-stereoisomer) were 0.10 +/- 0.01 nmol min-1 mg-1, 3.24 +/- 0.23 microM, and (3.15 +/- 0.09) x 10(-2) ml min-1 mg-1, respectively, in human cytosol. Due to limited solubility relative to the Km, only CLint values were determined in rat ((7.76 +/- 0.10) x 10-2 ml min-1 mg-1) and mouse ((7.61 +/- 0.50) x 10(-2) ml min-1 mg-1) cytosol. Enzyme kinetic parameters could not be determined for C53 (S-stereoisomer). Microsomal GSH conjugation in human, rat, and mouse was attributed to cytosolic contamination. No GSH conjugation was seen in any biological matrix from dog or monkey. There was little GSH conjugation of C53 by cytosol or microsomes from any species. The metabolism of C52 and C53 by epoxide hydrolase was also investigated. No diol product was observed in any biological matrix from any species. Thus, cGSTs are primarily responsible for C52 metabolism.

Acoustic parameters of snoring sound to compare natural snores with snores during 'steady-state' propofol sedation

OBJECTIVES

To investigate the acoustic similarity between natural and sedation-induced snores.

DESIGN

Prospective observational study.

SETTING

University Hospital Aintree, Liverpool, UK.

PARTICIPANTS

Twenty-one patients, who had already had overnight snore recordings, completed a pre-operative sleep nasendoscopic examination. Endoscopic examination of the upper aero-digestive tract was performed at sequentially increasing, steady-state sedation levels, using intravenous propofol administered according to a weight/time-based algorithm to predict blood and effect site (tissue) concentrations. At each sedation level at which snoring occurred, snoring sound was recorded. From these samples, snore files, comprising the inspiratory sound of each snore were created. Similarly, from natural snores recorded pre-operatively, snore files, comprising the inspiratory sounds of the first 100 snores with the patient sleeping in a supine position, were also created.

MAIN OUTCOME MEASURES

Snore duration (s), loudness (dBA), periodicity (%) and energy ratios for the frequency sub-bands 0-200, 0-250 and 0-400 Hz.

RESULTS

Snore loudness increased significantly (P < 0.0001), whilst energy ratios for frequency bands 0-200, 0-250 and 0-400 Hz all decreased significantly as sedation level increased (P < 0.001). A significant difference between natural snoring and snoring induced at the lowest sedation level was shown (P < 0.0001). Endoscopic examination was not tolerated at this sedation level.

CONCLUSIONS

The acoustic characteristics of sedation-induced and natural snores are sufficiently different to recommend the need for further research to determine whether the technique of sleep nasendoscopy is, in fact, a valid predictor of outcome of snoring surgery.

Snoring Surgery: A Retrospective Review

OBJECTIVE

To undertake a retrospective, questionnaire review of surgery for heavy snoring, to ascertain patients' perception of the procedure and its effect on their snoring.

PATIENTS AND METHODS

A specifically designed postal questionnaire was sent to 261 patients who underwent snoring surgery at University Hospital Aintree, Liverpool, UK, between April 1993 and March 2000. One hundred ninety-three patients responded (73.9%), including 151 men and 42 women. Mean age was 49.0 years (range, 24-74 yrs).

RESULTS

Twenty-two patients had a uvulopalatopharyngoplasty, 53 a traditional laser palatoplasty and uvulectomy, and 118 an uvulopalatal elevation palatoplasty. There was a 26% patient-reported postoperative infection rate. Morbidity regarding postoperative swallowing, pharyngeal sensation or voice change appeared minimal. Seventy-six percent scored postoperative pain as "moderate" or "severe," irrespective of the operation performed (P = 0.989). Thirty-seven percent of patients perceived an improvement in postoperative sleep quality. Twenty-four percent of patients reported no improvement in snoring after surgery. Forty-three percent reported an initial improvement that was not sustained for 2 years, whereas 34% of patients benefited from an improvement sustained for longer than 2 years, irrespective of the operation performed (P = 0.143). Only 47%, with hindsight, would have undergone surgery.

CONCLUSION

These data highlight that snoring surgery has a high postoperative morbidity rate and a high failure rate. Research endeavors should be directed to the development of a strategy which enables reliable preoperative identification of patients' who enjoy sustained benefit postoperatively.

Percutaneous cervical pharyngostomy: a traditional technique revisited

Enteral tube feeding is widely used in intensive care units, high dependency units and general wards. In some patients, an adequate intake is not maintained because patients cannot tolerate the tube. Insertion of an enteral feeding tube via a pharyngostomy is simple and potentially more easily tolerated. We describe our experience with three critically ill patients, using disposable vascular access equipment and a dilational technique. All three patients received markedly increased nutrition, but one patient suffered haemorrhagic complications.

Conservative management of epistaxis: are we putting patients at risk of developing venous thromboembolic complications?

A retrospective study of 1585 patients, admitted with epistaxis to a busy District General Hospital in the United Kingdom between 1990 and 2000, was undertaken in order to identify the relationship between hospital admission for epistaxis and the development of a venous thromboembolic event. Only one person (0.06%) developed pulmonary embolus (PE) within 6 weeks of hospital admission. No one developed a deep vein thrombosis (DVT). This compares with the incidence of DVT and fatal PE in the general population. In our study population, the incidence of both PE and DVT was found to be no greater than that seen within the community and certainly less than the incidence seen within a group of high risk hospitalised patients. We conclude that hospital admission for epistaxis does not place the patient at increased risk of thromboembolic disease.