Results of a two-center, before and after study of piperacillin-tazobactam versus ampicillin and gentamicin as empiric therapy for suspected sepsis at birth in neonates ≤ 1500 g

OBJECTIVE

We changed from ampicillin and gentamicin (AG) to piperacillin-tazobactam (PT) for routine treatment of suspected early-onset sepsis. The rationale for this change included ototoxic and renal toxic effects of gentamicin, resistance to gentamicin in late-onset infections and emergence of ampicillin resistant Escherichia coli. A before and after study was designed before the start of PT administration to monitor whether PT was associated with altered outcomes within the 501 to 1500 g birth weight (Very Low Birth Weight) population.

METHOD

Both unmatched and matched comparisons of AG (2007 to 2009) and PT (2010 to 2011) exposed infants are reported. Cohorts were evaluated for initial effectiveness for congenital infections, subsequent morbidities and mortality.

RESULTS

Data from 714 patients were collected (499 AG and 215 PT in the unmatched and 301 AG and 183 PT in the matched cohorts). No significant differences in demographics or initial Apgar scores were noted in the unmatched or matched comparisons. There were significant differences in many of the outcomes of interest in both the matched and unmatched comparisons including less necrotizing enterocolitis (NEC) and less diaper rash with PT versus AG. The only adverse finding with PT was a small, but statistically significant elevation in alkaline phosphatase.

CONCLUSIONS

Use of PT as the initial empiric antibiotic for very low birth weight infants was not associated with adverse microbiological outcomes. There was no increase in major morbidities. Although outcomes were superior in ≤ 1500 g infants treated with PT when compared with AG, the study design does not allow us to conclude that others will see a reduction in NEC or diaper rash if they implement this alternative.

Prediction of outcomes in patients with Ph+ chronic myeloid leukemia in chronic phase treated with nilotinib after imatinib resistance/intolerance

The purpose was to assess predictive factors for outcome in patients with chronic myeloid leukemia (CML) in chronic phase (CML-CP) treated with nilotinib after imatinib failure. Imatinib-resistant and -intolerant patients with CML-CP (n=321) were treated with nilotinib 400 mg twice daily. Of 19 baseline patient and disease characteristics and two response end points analyzed, 10 independent prognostic factors were associated with progression-free survival (PFS). In the multivariate analysis, major cytogenetic response (MCyR) within 12 months, baseline hemoglobin ≥ 120 g/l, baseline basophils <4%, and absence of baseline mutations with low sensitivity to nilotinib were associated with PFS. A prognostic score was created to stratify patients into five groups (best group: 0 of 3 unfavorable risk factors and MCyR by 12 months; worst group: 3 of 3 unfavorable risk factors and no MCyR by 12 months). Estimated 24-month PFS rates were 90%, 79%, 67% and 37% for patients with prognostic scores of 0, 1, 2 and 3, respectively, (no patients with score of 4). Even in the presence of poor disease characteristics, nilotinib provided significant clinical benefit in patients with imatinib-resistant or -intolerant CML. This system may yield insight on the prognosis of patients.

Paediatric admissions to the British military hospital at Camp Bastion, Afghanistan

INTRODUCTION

International humanitarian law requires emergency medical support for both military personnel and civilians, including children. Here we present a detailed review of paediatric admissions with the pattern of injury and the resources they consume.

METHODS

All paediatric admissions to the hospital at Camp Bastion between 1 January and 29 April 2011 were analysed prospectively. Data collected included time and date of admission, patient age and weight, mechanism of injury, extent of wounding, treatment, length of hospital stay and discharge destination.

RESULTS

Eighty-five children (65 boys and 17 girls, median age: 8 years, median weight: 20 kg) were admitted. In 63% of cases the indication for admission was battle related trauma and in 31% non-battle trauma. Of the blast injuries, 51% were due to improvised explosive devices. Non-battle emergencies were mainly due to domestic burns (46%) and road traffic accidents (29%). The most affected anatomical area was the extremities (44% of injuries). Over 30% of patients had critical injuries. Operative intervention was required in 74% of cases. The median time to theatre for all patients was 52 minutes; 3 patients with critical injuries went straight to theatre in a median of 7 minutes. A blood transfusion was required in 27 patients; 6 patients needed a massive transfusion. Computed tomography was performed on 62% of all trauma admissions and 40% of patients went to the intensive care unit. The mean length of stay was 2 days (range: 1-26 days) and there were 7 deaths.

CONCLUSIONS

Paediatric admissions make up a small but significant part of admissions to the hospital at Camp Bastion. The proportion of serious injuries is very high in comparison with admissions to a UK paediatric emergency department. The concentration of major injuries means that lessons learnt in terms of teamwork, the speed of transfer to theatre and massive transfusion protocols could be applied to UK paediatric practice.

Massive inguinoscrotal bladder hernia

Inguinoscrotal bladder hernias are rare, occurring in 1-4% of all inguinal hernias. Massive inguinoscrotal bladder hernias, where >50% of the bladder is found in the hernia sac are extremely rare. Patients can suffer significant morbidity from such a hernia. These include sepsis, unilateral or bilateral ureteric obstruction, renal failure and strangulation with secondary ischaemia of the bladder wall and bladder rupture. Inguinoscrotal bladder hernias are most commonly diagnosed at the time of surgery. This may lead to significant complications for the patient, particularly if undetected during surgery.

Integrated Cancer System: a perspective on developing an integrated system for cancer services in London

This article explores the potential for integrated cancer systems to improve the quality of care and deliver cost efficiencies and improve outcomes for cancer patients. Currently, patients in the UK still have poorer survival rates than comparable countries such as Canada, Sweden, Norway and Australia. Improving the quality of cancer services is a key policy objective and cancer is a priority outcome measure in both the NHS and Public Health Outcomes Framework. Evidence suggests that better integrated delivery has the potential to improve the quality and reduce the cost of healthcare, and ultimately improve health outcomes. One of the key themes from the Model of Care for Cancer Services (1) was that cancer services should be commissioned along pathways and that provider networks should be established to deliver care. London has two integrated cancer systems; one covering north central and east London (London Cancer) and the other covering west and south London (London Cancer Alliance). There a number of areas in cancer care that the current model of service provision has failed to adequately address and which have the potential to improve significantly though implementation of integrated services. These include improving early diagnosis, reducing inequalities in access to treatment and outcomes and maximising research and training across the system. Important drivers for the integration of cancer services are strong clinical leadership, shared informatics systems, focusing on quality of services and improving patient experience. Emerging needs of integrated cancer in London are around strengthening the involvement of primary care, public health and the third sector; working to develop sufficient capacity and expertise in primary care and collaborating more closely with commissioners to develop integrated systems.

P5-13-24: A Predictive Model of Early Systemic Disease Relapse after Standard Adjuvant Therapy for Breast Cancer

Background

Early relapse after adjuvant therapy for breast cancer is very discouraging and remains a major problem. We sought to identify predictors of early relapse risk and build a predictive model for relapse using prospectively collected data for patients seen at the Markey Cancer Center starting 2007 to date.

Methods: Of the 1098 new patients seen, 814 patients had stage I-III disease and were further analyzed for predictors of early relapse risk. Univariate analyses were performed for key variables including patient age, tumor size, grade, estrogen receptor (ER) status, progesterone receptor (PgR) status, and HER2 status. A multivariate Cox regression model was built to identify predictors of systemic relapse and model-building was performed using step-wise model selection to determine candidate models. A risk score was developed based on the linear combination of covariates in the final Cox model. Time-dependent predictive curves, a newly developed statistical methodology, were used to evaluate the predictive accuracy of the proposed risk score.

Results: Median patient age was 57 years (Range 25–92) and 88% were white. Forty six (46) % had stage I disease, 36% stage II, and 18% stage III. Median follow up time was 2.3 years. Of this 814 patient cohort, 708 patients had complete baseline covariate data and were used to build the candidate models. The final Cox regression model included 5 covariates that were significantly associated with risk of early relapse: stage III disease (p = 0.0011), grade III (p = 0.0028), PgR-negative status (p = 0.0121), HER2−negative status (p = 0.0305), and node-positive status (p = 0.0360). These five covariates were then used to calculate an early recurrence risk score, which is the weighted average of these risk factors when present, with the weights being the coefficients from the Cox regression model. The 1-year, 2-year and 3-year predictive curves for this risk score decrease considerably, especially for the 2-year and 3-year curves, indicating good predictive accuracy of the risk score. The highest risk score group, which represents 4.8% of the population, has a 1-year, 2-year and 3-year relapse probabilities of 13.0% (95% CI: 4.1%, 27.3%), 39.4 % (95% CI: 20.1%, 58.3%), and 52.3% (95% CI: 28.5%, 71.5%), respectively. In comparison, for the overall population, the corresponding 1-year, 2-year, and 3-year relapse probabilities were only 1.1% (95% CI: 0.5%, 2.1%), 4.2% (95% CI: 2.7%, 6.1%) and 6.2% (95% CI: 4.2%, 8.6%), respectively.

Conclusions: The developed risk score based on stage, tumor grade, PgR, HER2, and node status is highly predictive of early relapse in breast cancer patients after standard adjuvant therapy. Our model can be used to identify patients with high risk of early disease relapse who may otherwise benefit from enrollment on novel adjuvant therapeutic trials to improve their outcome.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-13-24.

Workplace health improvement: perspectives of environmental health officers

BACKGROUND

Environmental health practice in the field of occupational health and safety is traditionally concerned with protecting health relating to the workplace. However, little is currently known about environmental health officers' (EHOs) perceptions of their role in workplace health improvement, a pertinent topic in light of the recent government agenda for improving the health of the workforce in the UK.

AIMS

To explore how EHOs perceive workplace health improvement and its relevance to their professional role.

METHODS

A qualitative methodology was employed, using a case-study design with thematic analysis of 15 transcripts of in-depth telephone interviews with EHOs working in London, UK.

RESULTS

EHOs view themselves primarily as enforcement officers, with legislation guiding their understandings of workplace health. Many interpret work-related ill health in terms of safety and physical injury and do not feel competent in assessing broader psychosocial elements of ill health. However, a few EHOs welcomed the opportunity to promote health in the workplace, recognizing the importance of prevention.

CONCLUSIONS

This study indicates a gap between the contemporary EHO role framed by professional bodies as holistic and contributing to public health goals and the role perceived by EHOs 'on the ground'. A more traditional, protective and enforcement-based approach persists among EHOs in this sample, and few feel they have skills to address determinants beyond physical hazards to health. Yet, a minority of EHOs adopted a more health-promoting approach, suggesting that the potential contribution of EHOs to the workplace health improvement agenda should be explored further.

Chromium effects on glucose tolerance and insulin sensitivity in persons at risk for diabetes mellitus

OBJECTIVE

To investigate the effects of daily chromium picolinate supplementation on serum measures of glucose tolerance and insulin sensitivity in patients at high risk for type 2 diabetes mellitus.

METHODS

We conducted a randomized, double-blind, placebo-controlled, modified cross-over clinical trial with 6-month sequences of intervention and placebo followed by a 6-month postintervention assessment. Adult patients with impaired fasting glucose, impaired glucose tolerance, or metabolic syndrome were enrolled. Participants received 6-month sequences of chromium picolinate or placebo at 1 of 2 dosages (500 or 1000 mcg daily). Primary outcome measures were change in fasting plasma glucose, 2-hour plasma glucose during oral glucose tolerance testing, fasting and 2-hour insulin, and homeostasis model assessment of insulin resistance (HOMA-IR). Secondary outcomes included anthropometric measures, blood pressure, endothelial function, hemoglobin A1c, lipids, and urinary microalbumin.

RESULTS

Fifty-nine participants were enrolled. No changes were seen in glucose level, insulin level, or HOMA-IR (all P>.05) after 6 months of chromium at either dosage level (500 mcg or 1000 mcg daily) when compared with placebo. None of the secondary outcomes improved with either chromium dosage compared with placebo (P>.05).

CONCLUSIONS

Chromium supplementation does not appear to ameliorate insulin resistance or impaired glucose metabolism in patients at risk for type 2 diabetes and thus is unlikely to attenuate diabetes risk.