Outcomes with Five Fraction Image-Guided Partial Breast Irradiation to Reduced Target Volumes

PURPOSE/OBJECTIVE(S)

The use of 5-fraction partial breast irradiation has been shown in a randomized trial to provide comparable rates of local control and reduced toxicities as compared to standard fractionation whole breast irradiation. The initial technique utilized a 2 cm expansion on the lumpectomy cavity (1 cm for clinical target volume [CTV], and 1 cm planning target volume [PTV]) without consistent image guidance (ex. cone beam computed tomography [CBCT]) or motion management recommendations. We present clinical outcomes using a 5-fraction image guided PBI technique (IG-PBI) to reduced target volumes for patients with early-stage breast cancer.

MATERIALS/METHODS

A retrospective review of an IRB approved institutional registry was performed to identify patients treated with IG-PBI. A total of 258 patients with early-stage breast cancer (Stage 0-IIA) receiving IG-PBI were identified. Patients received a dose of 30 Gy in 5 fractions delivered daily or every other day. An expansion of 1 cm on the lumpectomy cavity was used for those patients using deep inspiration breath hold (DIBH) while an expansion of 1.5 cm was utilized for those not using DIBH. All patients received daily CBCT. Plans were delivered using intensity-modulated radiation therapy (IMRT) or volumetric modulated arc therapy (VMAT) technique; while the prescription isodose line covered the PTV, the 26 Gy line was allowed to expand beyond the PTV. Kaplan-Meier analyses were used to assess rates of local control and survival. Patient demographics, stage, hormone therapy use, recurrence, mortality, and toxicity data were collected. Survival was analyzed with Kaplan-Meier curve.

RESULTS

Median age at diagnosis was 67 years (range 40-87) with a median follow-up of 29 months (IQR 22-40). Forty-six (18%) patients had in situ disease, 200 (78%) patients T1 tumors, and 12 (5%) patients had T2 tumors. Two hundred thirty-four (91%) patients were White, 15 (6%) were Black, and 9 (4%) were other races. One hundred ninety-six (76%) patients received endocrine therapy, and 16 (6%) patients received chemotherapy. Thirty-two (12%) patients developed grade 1 dermatitis and no grade 2 events were observed. One (0.4%) patient had a cardiac event (aortic stenosis) 19 months after breast radiotherapy. At last follow-up, one (0.4%) patient had a local recurrence and one (0.4%) developed a distant metastasis, with no regional nodal failures. Overall, 4 (1.5%) patients had died, all due to other causes. At 3 years, locoregional control was 99.4%.

CONCLUSION

Outcomes with IG-PBI demonstrate low rates of local recurrence and limited toxicity. The use of reduced target volumes is not associated with increased rates of local recurrence.

Five Fraction Accelerated Partial Breast Irradiation vs. Intraoperative Radiation Therapy for Early-Stage Breast Cancer

PURPOSE/OBJECTIVE(S)

Accelerated partial breast irradiation (APBI) represents an alternative to whole breast irradiation (WBI), reducing the target volume and potentially treatment duration. APBI delivered in 5 fractions with intensity modulated radiation therapy (IMRT) has been shown to have comparable outcomes to WBI with reduced toxicity profiles. In contrast, intraoperative radiation therapy (IORT) offers patients the potential to complete adjuvant radiation therapy in a single treatment. While early data were initially promising, concerns regarding long-term rates of local recurrence exist. We present a comparison of 5 fraction APBI versus IORT.

MATERIALS/METHODS

We performed a retrospective review of 473 patients with early-stage breast cancer (Stage 0-IIA) treated at a single institution with 258 receiving APBI and 215 IORT from October 2011 to May 2021. APBI patients received 30 Gy in 5 fractions delivered with IMRT daily or every other day. IORT patients received 20 Gy in 1 fraction prescribed to the applicator surface delivered at the time of surgery. Kaplan-Meier analysis was used to estimate locoregional control rates and overall survival among the 2 groups.

RESULTS

Mean age was 70.7 years old (IQR:67-74) for the IORT patients and 66.6 years old (IQR:62-72) for the APBI patients (p<0.001). Median follow up was 5.7 years for IORT patients and 2.4 years for APBI patients (p<0.001). For IORT patients, 11%/83.5%/5.5% of patients and for APBI 17.8%/77.5%/4.7% of patients had Tis/T1/T2 disease (p = 0.005). With regards to adjuvant therapies, 79%/76% of IORT/APBI patients were offered endocrine therapy (p = 0.50) and 1.4%/6.2% chemotherapy (p = 0.008). Recurrence at any time was seen in 7.9% (n = 17) of patients receiving IORT as compared to 0.8% (n = 2) of patients receiving APBI. APBI was however no differences in recurrence free survival (92.6% vs. 98.5%, p = .079) or overall survival were noted (92.8% vs. 95.1%, p = 0.99).

CONCLUSION

In a series of almost 500 patients with stage 0-IIA breast cancer, IORT was associated with higher rates of locoregional recurrence compared to APBI with no survival difference at 5 years. These outcomes, consistent with other series and current guidelines, suggest a limited role for IORT as monotherapy following breast conserving surgery.

Corrigendum: Effectiveness of ertapenem for treatment of infections in children: An evidence mapping and meta-analysis

[This corrects the article DOI: 10.3389/fpsyt.2021.706625.].

Effectiveness of ertapenem for treatment of infections in children: An evidence mapping and meta-analysis

OBJECTIVES

To assess and summarize current evidence on the effectiveness and safety of ertapenem for treatment of childhood infections, in consideration of high infection prevalence in children and wide use of ertapenem.

METHODS

The following 8 databases were searched on 13th May 2021: Web of Science, Embase via Ovid SP, PubMed, The Cochrane Library (CENTRAL), Chinese BioMedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), VIP and Wanfang. The primary outcome was treatment success rate. Risk ratios (RRs) and 95% confidence interval (CI) were estimated using random-effect models. Subgroup analysis was conducted where heterogeneity was found.

RESULTS

Fifteen studies (8 randomized controlled trials, 1 observational comparative study, and 6 before and after studies) involving 2,528 patients were included in the final review. Ertapenem had similar treatment success rates with β-lactam antibiotics [relative risk (RR) = 1.08, 95% CI: 0.99-1.19]. In a subgroup analysis, similar efficacy (RR = 1.08, 95% CI: 0.97-1.20) between ertapenem and other carbapenems. Compared with β-lactam antibiotics, ertapenem did not increase the risk of any adverse events (RR = 1.02, 95%CI: 0.71-1.48), drug-related diarrhea (all non-Asian children, RR = 0.62, 95%CI: 0.31-1.25), or injection site pain (all non-Asian children, RR = 1.66, 95%CI: 0.59-4.68). Subgroup analysis showed no obvious difference between ertapenem group and carbapenems or non-carbapenems group on risk of adverse events.

CONCLUSION

Our findings suggest that ertapenem is effective and safe in treatment for children with infection. Further comparative real-world data is needed to supplement clinical evidence on the overall benefits of ertapenem in this population.

Economic burden of recurrent Clostridioides difficile infection in adults admitted to Spanish hospitals. A multicentre retrospective observational study

OBJECTIVE

Clostridioides difficile infection (CDI) is associated with increased hospital stays and mortality and a high likelihood of rehospitalization, leading to increased health resource use and costs. The objective was to estimate the economic burden of recurrent CDI (rCDI).

METHODS

Observational, retrospective study carried out in six hospitals. Adults aged ≥18 years with ≥1 confirmed diagnosis (primary or secondary) of rCDI between January 2010 and May 2018 were included. rCDI-related resource use included days of hospital stay (emergency room, ward, isolation and ICU), tests and treatments. For patients with primary diagnosis of rCDI, the complete hospital stay was attributed to rCDI. When diagnosis of rCDI was secondary, hospital stay attributed to rCDI was estimated using 1:1 propensity score matching as the difference in hospital stay compared to controls. Controls were hospitalizations without CDI recorded in the Spanish National Hospital Discharge Database. The cost was calculated by multiplying the natural resource units by the unit cost. Costs (euros) were updated to 2019.

RESULTS

We included 282 rCDI episodes (188 as primary diagnosis): 66.31% of patients were aged ≥65 years and 57.80% were female. The mean hospital stay (SD) was 17.18 (23.27) days: 86.17% of rCDI episodes were isolated for a mean (SD) of 10.30 (9.97) days. The total mean cost (95%-CI) per episode was €10,877 (9,499-12,777), of which the hospital stay accounted for 92.56.

CONCLUSIONS

There is high cost and resource use associated with rCDI, highlighting the importance of preventing rCDI to the Spanish National Health System.

Asthma control and disease burden in patients with asthma and allergic comorbidities

OBJECTIVE

To assess asthma control and associations with health-related quality of life (HRQoL) and economic outcomes among patients with asthma and allergic comorbidities treated with inhaled corticosteroids (ICS) and long-acting beta-agonists (LABA) combination therapy.

METHODS

Data from the 2011-2013 US National Health and Wellness Survey were used to identify patients with asthma currently treated with ICS and LABA combination therapy (N = 1923). Patients were included if they self-reported a physician diagnosis of asthma and at least one allergic/asthma-related comorbid condition (e.g., nasal allergies, atopic dermatitis). Asthma Control Test scores categorized patients as very poorly (scores ≤ 15; 29.3%), not well (16-19; 25.1%), or well controlled (20-25; 45.7%). Outcomes included HRQoL (SF-36v2; SF-12v2), work productivity and activity impairment, healthcare utilization (HRU), and annual indirect and direct costs. Generalized linear models, controlling for covariates, examined whether outcomes differed by asthma control.

RESULTS

Over half of the patients had very poorly or not well-controlled asthma (54.4%). Patients with very poorly controlled versus well-controlled asthma reported significantly greater decreases in HRQoL, greater overall work impairment, and higher HRU (all, p < 0.05). Very poorly controlled patients incurred over double the indirect costs and nearly one and a half times the direct and total costs of well-controlled patients.

CONCLUSIONS

Increasing level of asthma control was related to improved HRQoL and lower costs. The considerably high prevalence of uncontrolled asthma among patients on ICS and LABA suggests poor treatment adherence or unmet needs in current treatment and may require step-up therapy in appropriate patients according to clinical guidelines.

Cluster analysis and its application to healthcare claims data: a study of end-stage renal disease patients who initiated hemodialysis

Background

Cluster analysis (CA) is a frequently used applied statistical technique that helps to reveal hidden structures and “clusters” found in large data sets. However, this method has not been widely used in large healthcare claims databases where the distribution of expenditure data is commonly severely skewed. The purpose of this study was to identify cost change patterns of patients with end-stage renal disease (ESRD) who initiated hemodialysis (HD) by applying different clustering methods.

Methods

A retrospective, cross-sectional, observational study was conducted using the Truven Health MarketScan® Research Databases. Patients aged ≥18 years with ≥2 ESRD diagnoses who initiated HD between 2008 and 2010 were included. The K-means CA method and hierarchical CA with various linkage methods were applied to all-cause costs within baseline (12-months pre-HD) and follow-up periods (12-months post-HD) to identify clusters. Demographic, clinical, and cost information was extracted from both periods, and then examined by cluster.

Results

A total of 18,380 patients were identified. Meaningful all-cause cost clusters were generated using K-means CA and hierarchical CA with either flexible beta or Ward’s methods. Based on cluster sample sizes and change of cost patterns, the K-means CA method and 4 clusters were selected: Cluster 1: Average to High (n = 113); Cluster 2: Very High to High (n = 89); Cluster 3: Average to Average (n = 16,624); or Cluster 4: Increasing Costs, High at Both Points (n = 1554). Median cost changes in the 12-month pre-HD and post-HD periods increased from $185,070 to $884,605 for Cluster 1 (Average to High), decreased from $910,930 to $157,997 for Cluster 2 (Very High to High), were relatively stable and remained low from $15,168 to $13,026 for Cluster 3 (Average to Average), and increased from $57,909 to $193,140 for Cluster 4 (Increasing Costs, High at Both Points). Relatively stable costs after starting HD were associated with more stable scores on comorbidity index scores from the pre-and post-HD periods, while increasing costs were associated with more sharply increasing comorbidity scores.

Conclusions

The K-means CA method appeared to be the most appropriate in healthcare claims data with highly skewed cost information when taking into account both change of cost patterns and sample size in the smallest cluster.

Anti-nutritional factors in the roots of a local cultivar of Moringa oleifera (Lam)

The evergreen plant, Moringa oleifera (Lam) has been known to have both medicinal and nutritional properties, thus its wide use in traditional medicine in Africa and Asia. The roots, in particular, have been reported to possess antibiotic, anti-tumour and anti-oxidative activities. This study therefore seeks to determine the levels of the anti-nutritional factors and other proximate analyses in the roots of a local cultivar of Moringa oleifera which might be responsible for such activities. The concentrations of oxalates and phytates in the roots were determined using the methods of Munro and Bassir and Griffith and Thomas, respectively. The methods of Association of Analytical Chemists (AOAC) were used to estimate the amount of tannins, saponins and cyanogenic glycosides while the Technicon sequential Multi-sample amino acid analyzer (TSM) was used determine the amino acid concentration in the roots. Tannins (45 mg 100 g(-1)) and oxalates (17.08 mg 100 g(-1)) were present in the roots at higher levels while saponins (4.20mg 100 g(-1)), cyanogenic glycosides (2.72 mg 100 g(-1)) and phytates (0.07 mg 100 g(-1)) occurred at much lower levels. The roots contained (Mean +/- Standard Error of mean) %crude lipid (6.33 +/- 1.64), %crude proteins (5.02 +/- 1.52), %carbohydrates (76.75), %ash (4.97 +/- 0.53) and %moisture (6.93 +/- 0.58). The roots lacked the water-soluble vitamins pyridoxine, riboflavin and thiamine but contained ascorbic acid (48.13 mg 100 g(-1)) and niacin (5.83 mg 100 g(-1)). This study has shown that Moringa oleifera roots are rich in anti-nutritional factors and that is why they are widely used in traditional medicine in Africa, Asia and Americas for its medicinal importance.

Effect of soaked Moringa oleifera seeds on growth rates and the levels of some biochemical parameters in albino rats

Moringa oleifera is a multipurpose tree, cultivated in the tropics and sub-tropics for its nutritional and therapeutic properties. The raw matured seeds which have been reported to be used as food and clarifying agent of turbid water caused growth retardation in albino rats and this might have been due to its antinutritional contents. Owing to these adverse factors, the effect of soaking the seeds for 30 min and then compounding it as feeds was done. Its effect on growth rate and the level of some biochemical parameters on rats were investigated. The Wistar albino rats were fed for 21 days and their weights measured at 2 days interval. Aspartate and Alanine transaminases, Alkaline phosphatase and total bilirubin levels were assayed using Automated Vitros 350 Chemistry Analyzer. The growth rates of rats fed with the commercial rat pellets, Casilan diet and the processed Moringa seed diet had a range of 80.06 +/- 3.54 to 100.98 +/- 5.37, 66.70 +/- 7.54 to 55.23 +/- 7.47 and 52.99 +/- 4.15 to 35.47 +/- 2.26, respectively. The parameters assayed for the group that received the processed Moringa seed diet are 144.00 +/- 16.80 (AST), 41.00 +/- 7.05 (ALT), 66.50 +/- 8.80 (ALP) and 12.45 +/- 1.18 (Total Bilirubin). The one-way ANOVA statistical analysis indicated that there was no significant change in the parameters of all the groups at 95% significance level (p < 0.05). Hence, the soaked Moringa oleifera seed did not support growth in the animal subjects and also did not pose a threat to the liver. However, it is better to develop more suitable processing methods to improve the seed's nutritional capabilities.

Retinal folds and retinoschisis in accidental and non-accidental head injury

AIMS

To report the similarity of retinal findings in an infant who sustained an accidental head injury and an infant with non-accidental head trauma.

METHODS

Two male infants sustained head injuries with skull fractures. Case 1 was an accidental head injury and case 2 was a non-accidental head injury.

RESULTS

On examination, in case 1, there were four superficial retinal haemorrhages in the right fundus. The left eye had a haemorrhagic optic disc oedema with extensive retinal haemorrhages, retinal folds, and schitic cavities within the retina at the posterior pole. In case 2, the right fundus had a single blot haemorrhage at the posterior pole. The left fundus revealed optic disc haemorrhage and oedema with extensive retinal haemorrhages. There was a haemorrhagic retinoschisis with a retinal fold.

CONCLUSIONS

The two cases, one with accidental and the other with non-accidental injury, demonstrate very similar ophthalmic findings. This supports the argument that there may be no retinal signs seen exclusively in non-accidental head injury.

Bilateral chronic fungal dacryocystitis caused by Candida dubliniensis in a neutropenic patient

In recent years, candida species other than Candida albicans have emerged as causes of human candidiasis, particularly in HIV-infected and other immunocompromised people. C. dubliniensis, a recently described species closely related to C. albicans, first isolated from patients with AIDS in Dublin, has been implicated as an agent of oral candidiasis in HIV-positive people. However, it has also been recovered from HIV-negative people, with clinical signs of oral candidiasis and from the genital tract of some women with vaginitis. The first case of bilateral chronic fungal dacryocystitis caused by C. dubliniensis is described in an HIV-negative woman.

Heavy metal hazards of Nigerian herbal remedies

The uses of herbal products are not regulated in Nigeria and in many low-income countries and are freely available to everyone. The safety of these herbal medicines is poorly understood. This study characterizes the content of cadmium, copper, iron, nickel, selenium, zinc, lead and mercury in a random sample of Nigerian traditional products. Ready-to-use herbal products were purchased from the open market and digested using HNO3.The heavy metal content of the digested filtrate was determined by atomic absorption spectrometry Uni-cam Model 929. The result showed that 100% of the samples contained elevated amounts of heavy metals. These data alert us to the possibility of heavy metal toxicity from herbal products in Nigeria. The public health hazards from ingestion of herbal medicines should be identified and disclosed by in-depth risk assessment studies.

Lead and cadmium exposures from canned and non-canned beverages in Nigeria: a public health concern

The lead and cadmium levels of canned and non-canned foods purchased in Nigeria were studied. Fifty samples of these beverages were digested in nitric acid and were analyzed using the Atomic Absorption Spectrophotometer (AAS). The cadmium levels ranged from 0.003-0.081 mg/L for the canned and 0.006-0.071 mg/L for non-canned beverages. About 85.71% of the canned beverages had cadmium levels that exceeded the maximum contaminant level (MCL) of 0.005 mg/L set by US EPA while 82.7% non-canned beverages had cadmium levels exceeding the MCL. The mean and median levels of cadmium exceeded the MCL in both the canned and non-canned beverages. Whereas only 79.3% of the non-canned beverages showed lead levels that exceeded the US EPA's MCL of 0.015 mg/L, 100% of the canned beverages had lead levels that were greater than the MCL. The range of the lead in the canned beverages was 0.002-0.0073 and 0.001-0.092 mg/L for the non-canned beverages. The mean and median values of lead exceeded the MCL in both the canned and non-canned beverages. The calculated amount of lead and cadmium in three beverages were 0.204 mg (204 microg) and 0.177 mg (177 microg), respectively. These represent the estimated intake of a consumer who takes three of the products selected randomly in a week; assuming an average volume of one liter (1 L) for each product. Taken together 86% and 84% of the 50 beverages (canned and non-canned) studied in March, 2005 in Nigeria failed to meet the US EPA criteria for acceptable lead and cadmium levels in consumer products.

Influence of prokinetics on the gastrointestinal transit and residence times of activated charcoal

OBJECTIVE

To find the effects of prokinetics, saline cathartics and different charcoal doses on the gastrointestinal transit and residence times of activated charcoal (AC).

SETTING

Five undergraduate volunteers of College of Health Sciences, Nnamdi Azikiwe University, Nnewi Campus, Anambra State, Nigeria, were studied.

METHODS

After an overnight fast, the volunteers were given 10 g and 20 g AC with and without saline cathartics, in a simple cross-over design in which the subjects served as their own control. In another experiment, the volunteers received 10 g AC and magnesium sulphate, with propantheline (as bromide 15 mg), metoclopramide (as hydrochloride 10 mg), placebo liquid or identical placebo capsule. Gastrointestinal transit and residence times of AC were recorded.

RESULTS

Increase in the dose of AC significantly (P < 0.05) decreased the transit, but not the residence time of AC. Addition of saline cathartics (Na2SO4 and MgSO4) decreased both the transit and residence times of AC significantly (P < 0.05). Also, administration of propantheline, but not metoclopramide, produced a significant (P < 0.05) decrease in both the transit and residence times of AC. The transit and residence times were statistically (P < 0.05) different in both the magnesium sulphate group, as well as in the placebo liquid and placebo capsule groups.

CONCLUSION

Cathartic efficiency is enhanced by alteration of gastrointestinal motility with propantheline.

Saline cathartics and adsorptive capacity of activated charcoal for doxycycline

The effects of sodium chloride and sodium citrate on the in vitro adsorption of doxycycline to activated charcoal have been studied. Solutions of doxycycline alone and doxycycline with 7.5 mg/ml cathartic solutions were vortex-mixed for 30 s with different quantities of activated charcoal, incubated for 30 min at 37 degrees C and analyzed for free doxycycline spectrophotometrically at 348 nm. Addition of NaCl had a significant (p<0.05) increase while sodium citrate produced a significant (p<0.05) decrease in the adsorption of doxycycline on activated charcoal. In all, the adsorption doxycycline on activated charcoal obeyed quantity-dependent kinetics.

Adsorptive capacity of activated charcoal for rifampicin with and without sodium chloride and sodium citrate

The effects of two saline cathartics (sodium chloride and sodium citrate) on the adsorptive capacity of activated charcoal (AC) for rifampicin were studied. Solutions of rifampicin alone and rifampicin with 7.5 mg/ml cathartic solution were vortex-mixed for 30 s with different quantities of AC. These were incubated for 30 min at 37 degrees C and analyzed for free rifampicin spectrophotometrically at 320 nm. The addition of sodium citrate significantly increased (p<0.05) the adsorptive capacity of AC for rifampicin with a resulting decrease in B-50 values at both the therapeutic and simulated toxic doses. Sodium chloride addition reduced the binding of rifampicin to AC at the toxic doses. The adsorption of rifampicin to activated charcoal, both alone and with the two saline cathartics, obeyed quantity-dependent kinetics. AC may be co-administered with sodium citrate in the management of rifampicin overdose.

Rifampicin pharmacokinetics with and without ciprofloxacin

We investigated the effect of ciprofloxacin on rifampicin pharmacokinetics in five healthy subjects. Each subject received 600 mg rifampicin with 350 mL of water, and in the second phase, each subject received 600 mg rifampicin plus 500 mg ciprofloxacin with 350 mL of water. In each of the two phases, plasma rifampicin levels were measured from 1 to 24 hours. Treatment with ciprofloxacin significantly increased the half-life and also significantly decreased the maximum peak concentration of rifampicin. Area under the curve time for peak plasma concentration and volume of distribution were not significantly affected. In this study, we found that ciprofloxacin increases the half-life and reduces the maximum concentration of rifampicin in humans.

Pharmacokinetics of diethylcarbamazine: prediction by concentration in saliva

The concentration of diethylcarbamazine in saliva was used to determine pharmacokinetic parameters, in comparison to plasma and urine concentrations. Six healthy adult male volunteers were administered 150 mg diethylcarbamazine with 400 ml of water. At seven different time intervals, blood, urine and saliva samples were taken, and different pharmacokinetic parameters measured. The plasma-saliva concentration ratio was calculated as 1.53 whereas the observed ratio was 3.82. The half lives, times to reach peak plasma concentration, and elimination rate constants did not show any significant difference in the different samples. The plasma peak concentration and areas under the curve were significantly (p<0.05) increased from those of the saliva. At 24 h, when diethylcarbamazine was absent in urine, the plasma and saliva concentrations were almost zero. Diethylcarbamazine is secreted in saliva, and its concentration in saliva can be used to monitor drug therapy.