Appropriateness of acute-care antibiotic prescriptions for community-acquired infections and surgical antibiotic prophylaxis in England: analysis of 2016 national point prevalence survey data

BACKGROUND

Estimates of inappropriate prescribing can highlight key target areas for antimicrobial stewardship (AMS) and inform national targets.

OBJECTIVES

To (1) define and (2) produce estimates of inappropriate antibiotic prescribing levels within acute hospital trusts in England.

METHODS

The 2016 national Healthcare-Associated Infections (HAI), Antimicrobial Use (AMU) and AMS point prevalence survey (PPS) was used to derive estimates of inappropriate prescribing, focusing on the four most reported community-acquired antibiotic indications (CAIs) in the PPS and surgical prophylaxis. Definitions of appropriate antibiotic therapy for each indication were developed through the compilation of national treatment guidelines. A Likert-scale system of appropriateness coding was validated and refined through a two-stage expert review process.

RESULTS

Antimicrobial usage prevalence data were collected for 25,741 individual antibiotic prescriptions, representing 17,884 patients and 213 hospitals in England. 30.4% of prescriptions for the four CAIs of interest were estimated to be inappropriate (2054 prescriptions). The highest percentage of inappropriate prescribing occurred in uncomplicated cystitis prescriptions (62.5%), followed by bronchitis (48%). For surgical prophylaxis, 30.8% of prescriptions were inappropriate in terms of dose number, and 21.3% in terms of excess prophylaxis duration.

CONCLUSIONS

The 2016 prevalence of inappropriate antibiotic prescribing in hospitals in England was approximated to be 30.4%; this establishes a baseline prevalence and provided indication of where AMS interventions should be prioritized. Our definitions appraised antibiotic choice, treatment duration and dose number (surgical prophylaxis only); however, they did not consider other aspects of appropriateness, such as combination therapy - this is an important area for future work.

Characterizing social and policy determinants of hospital length of stay among paediatric inpatients with diabetes using linked population-based data

Background

Evidence is limited on the non-medical factors influencing hospital length of stay (LOS) among paediatric inpatients with diabetes, notably potential social and policy correlates. This study aimed to characterize the associations of socioeconomic status and health policy environment with diabetes-attributable LOS to help inform accountability monitoring of a provincial comprehensive diabetes strategy aiming to minimize time in hospital among this high-risk population.

Data and methods

This retrospective population-based study drew on multiple linked administrative and geospatial databases among all children aged 18 and under with a diabetes-related hospitalization in the province of New Brunswick, Canada, during the four-year period following implementation of an insulin pump funding program. Multiple linear regression was used to assess the role of access to the public insulin pump resourcing scheme and relative neighbourhood deprivation as predictors of days spent in acute care, controlling for age, sex, and place of residence.

Results

Among the paediatric inpatient population (N = 386), 21% had accessed social resources made available through the insulin pump funding policy and 42% resided in the most materially deprived neighbourhoods. Diabetes-related hospital stays averaged 3.87 days. Paediatric inpatients having accessed resources through the social insurance policy spent significantly fewer days in hospital (1.34 days less [95% CI: 0.63–2.05]) than those who had not, all else being equal. Observed differences in LOS by neighbourhood socioeconomic deprivation were not found to be statistically significant in the multivariate analysis.

Conclusion

Findings from this context of universal medical coverage suggested that public policy for supplemental financing of assistive technologies among children with diabetes may be associated with reduced burden to the hospital system. The causes of socioenvironmental disparities in LOS require further investigation to inform interventions to mitigate preventable patient-level variations in hospital-based health outcomes.

Feasibility of a Group-based Telehealth Psychosocial Intervention for Women with Non-Small Cell Lung Cancer (NSCLC)

Purpose of study: As women with lung cancer are particularly vulnerable to psychological distress and social isolation, which may be further exacerbated by current COVID-19 physical distancing precautions, we examined the feasibility and acceptability of a group-based telehealth psychosocial intervention for this understudied patient population. Methods: Women with a recent diagnosis (3 months) of non based telehealth psychosocial intervention for this understudied patient population. Methods: Women with a recent diagnosis (3 months) of non-small cell lung cancer (NSCLC) currently undergoing treatment completed baseline measures of computer literacy and were randomized to a group-based telehealth psychosocial intervention consisting of ether coping skills or attention control (AC) psychoeducation. Both arms consisted of five, 60 min. telehealth (video conference over Zoom) sessions. Groups were comprised of 3–5 members and led by a masters-level clinician. Participants completed one “practice run” with technology prior to starting the group session. After the final session, patients rated overall experience of intervention delivery and telehealth platform. Results: Seventy patients (mean age = 66 yrs, 54% >65 yrs; 71% non-Hispanic White; 50% college educated; 75% advanced stage) consented (63% consent rate) and 65 were randomized to intervention or AC. At baseline, 47% of patients indicated daily computer use while 50% said they rarely or never use a computer. Attendance was high in both arms with 63% of patients attending all sessions (means: intervention = 3.18; AC = 3.56). Across arms, 89% preferred group delivery and 92% preferred online delivery. The majority used a smartphone or tablet to participate (72%). Regarding the Zoom platform, 71% said it was easy to use, 65% would recommend it to others, and 41% felt comfortable with it after one use. Only 44% thought that telehealth was the same as it would have been in-person. Conclusions: The present findings suggest the feasibility and acceptability of delivering a group-based psychosocial intervention via telehealth for middle to older aged women with NSCLC undergoing treatment, which may be particularly beneficial to address isolation during the current season of physical distancing.

A new fast response cryogenic evaporative calorimeter

We present the principle and implementation of a new type of fast response evaporative calorimeter designed to work at cryogenic temperatures and above-ambient pressures. It is capable of measuring input energy from an electric pulse and the thermal output energy by measuring the evaporation of liquid nitrogen through a mass flow meter. This system may be used to measure either the steady heat output from the system submersed under the cryogen or the heat output that results from a fast square-wave profile electrical pulse of duration from 10 µs or longer. The energy output of metal capillary-wire composite systems has been measured calorimetrically. A four-wire measurement was used to monitor the input electric energy with an uncertainty less than 5% for a typical pulse. Mass flow meters and pressure regulation systems were used to monitor the rate of evaporation of liquid nitrogen with a typical precision of 2 std.-ml/min. For a typical pulse, the integrated mass flow of nitrogen could be determined with an uncertainty less than 3%. The pressure controllers and ballast compliance volumes allow the system to return to a steady state of mass flow in less than 2 min following an electric pulse. The system is capable of housing and measuring four separate wire-capillary systems in a single Dewar. On average, a calibration resulted in 3.9 std. ml evaporated per joule of input energy. This corresponds to a 97% efficiency for this calorimeter.

Effects of recombinant bovine interleukin-8 (rbIL-8) treatment on health, metabolism, and lactation performance in Holstein cattle I: Production and functional characterization of rbIL-8 in vitro and in vivo

In the present study, we standardized processes of cloning and purification of recombinant bovine interleukin-8 (rbIL-8) from bacterial culture and assessed its biological activity in Holstein cattle. Plasmid containing a subclone of bovine IL-8 was expressed using Escherichia coli BL21 and cell lysate was purified by chromatography. The presence of rbIL-8 was assessed by Western blot analyses and function was confirmed in vitro using a chemotaxis chamber. Based on optical density values, chemoattractant properties of rbIL-8 were 10-fold greater compared with control wells. Two in vivo studies were conducted to assess the biological activity of rbIL8. For study 1, one-year-old Holstein heifers (n = 20) were randomly allocated to receive a single intravaginal administration containing 1,125 µg of rbIL-8 diluted in 20 mL of saline solution (rbIL-8, n = 10) or a single intravaginal administration of 20 mL of saline solution (control, n = 10). For study 2, nonpregnant lactating Holstein cows (n = 31) were randomly allocated to receive an intrauterine administration with 1,125 µg of rbIL-8 diluted in 20 mL of saline solution (rbIL-8, n = 11), a positive control consisting of resin-purified lysate of E. coli BL21 not transfected with the plasmid coding for rbIL-8 diluted in 20 mL of saline solution (E. coli, n = 10), and a negative control administered with 20 mL of saline solution (control, n = 10). An increase in vaginal neutrophils was observed in heifers treated with rbIL-8 within 3 h of treatment, but not in control heifers. Additionally, intrauterine administration of rbIL-8 increased the proportion of PMN cells in uterine cytological samples from 3.5% before treatment to 75.8% 24 h later-an increase that was not observed in the negative control group and cows treated with resin-purified lysate of E. coli. To further evaluate the effect of local and systemic rbIL-8 stimulation on the dynamics of circulating white blood cells, a third study was conducted. In study 3, nonpregnant 8-mo-old Holstein heifers (n = 30) were randomly allocated into 1 of 3 treatment groups: intravenous rbIL-8 (1,125 µg of rbIL-8 diluted in 5 mL of saline solution, n = 10); intravaginal rbIL-8 (1,125 µg of rbIL-8 diluted in 20 mL of saline solution; n = 10); or intravaginal saline (20 mL of saline solution, n = 10). Intravenous injection of rbIL-8 resulted in a transient increase in rectal temperature, which was greater at 2 h after treatment compared with cows treated intravaginally with rbIL-8 or heifers treated with saline solution. Heifers treated with rbIL-8 intravenously displayed a marked reduction in neutrophils, basophils, lymphocytes, and monocytes within the first 4 h posttreatment compared with heifers treated intravaginally. However, at 6 h after treatment, heifers treated with rbIL-8 intravenously displayed a rebound in white blood cell counts caused by an increase in neutrophil counts. These results show that the presented purification method is effective and results in biologically active rbIL-8 that can be used safely to modulate immune responses in cattle.

Abstract OT1-05-02: OPTIMA: A prospective randomized trial to validate the clinical utility and cost-effectiveness of gene expression test-directed chemotherapy decisions in high clinical risk early breast cancer

Background:Multi-parameter tumour gene expression assays (MPAs) are widely used to estimate individual patient residual risk and to guide chemotherapy use in hormone-sensitive, HER2-negative early breast cancer. The TAILORx trial supports MPA use in a node-negative population. Evidence for MPA use in node-positive breast cancer is limited. OPTIMA (Optimal Personalised Treatment of early breast cancer usIng Multi-parameter Analysis) (ISRCTN42400492) aims to validate MPAs as predictors of chemotherapy sensitivity in a largely node-positive breast cancer population where prospective RCT (Randomised Controlled Trial) evidence is lacking.

Methods: OPTIMA is a partially blinded multi-center RCT with an adaptive two-stage design. The main eligibility criteria are women and men age 40 or older with resected ER-positive, HER2-negative invasive breast cancer and up to 9 involved axillary lymph nodes. Randomisation is to standard management (chemotherapy and endocrine therapy) or to MPA-directed treatment using the Prosigna (PAM50) test. Those with a Prosigna tumour score (ROR_PT) >60 receive standard management whilst those with a low score (≤60) are treated with endocrine therapy alone. Endocrine therapy for pre-menopausal women includes ovarian suppression. The co-primary outcomes are (1) Invasive Disease Free Survival (IDFS) and (2) cost-effectiveness of test-directed treatment. Secondary outcomes include IDFS in patients with low-score tumours and quality of life. An integrated qualitative recruitment study addresses challenges to consent and recruitment and will build on experience from the feasibility study that a multidisciplinary approach at sites is important for recruitment success. Tumour blocks will be banked to allow evaluation of additional MPA technologies. Recruitment of 4500 patients over 5 years will permit demonstration of 3% non-inferiority of test-directed treatment, assuming 5-year IDFS of 85% with standard management, equivalent to a HR of 1.22. Inclusion of patients from the feasibility study will increase the power to test for non-inferiority.

Results: The OPTIMA main trial opened in January 2017. Overall recruitment (including the feasibility study) will reach 1000 in August 2018. Recruitment in Norway will commence in July 2018. Characteristics of the OPTIMA main participants recruited to 31st May 2018 are shown in the table.

Main study patient characteristicsCharacteristic %Median age in years (range)57 (40-80) Menopause statusPre34 Post66 Male1Tumour size<30mm58 >=30mm42Node statuspN04 pN1mi(sn)7 pN1(sn)20 pN155 pN214Historic grade16 258 336

Conclusion: OPTIMA is one of two large scale prospective trials validating the use of test-guided chemotherapy decisions in node-positive early breast cancer. It is expected to have a global impact on breast cancer treatment. Experience from the preliminary study and close engagement with centres will aid trial success.

Funding: OPTIMA is funded by the UK NIHR HTA Programme (10/34/501). Views expressed are those of the authors and not those of the HTA Programme, NIHR, NHS or the DoH.

Citation Format: Stein RC, Hughes-Davies L, Makris A, Macpherson IR, Conefrey C, Rooshenas L, Pinder SE, Thomas J, Hall PS, Cameron DA, Earl HM, Naume B, Poole CJ, Rea DW, MacIntosh SA, Harmer V, Morgan A, Hulme C, McCabe C, Stallard N, Higgins H, Donovan JL, Bartlett JM, Marshall A, Dunn JA. OPTIMA: A prospective randomized trial to validate the clinical utility and cost-effectiveness of gene expression test-directed chemotherapy decisions in high clinical risk early breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT1-05-02.

Abstract OT1-06-01: OPTIMA: A prospective randomized trial to validate the predictive utility and cost-effectiveness of gene expression test-directed chemotherapy decisions in early breast cancer

Background: Multi-parameter gene expression assays (MPAs) are widely used to estimate individual patient residual risk in hormone-sensitive HER2-negative node-negative early breast cancer, allowing patients with low risk to safely avoid chemotherapy. Evidence for MPA use in node-positive breast cancer is limited. OPTIMA (Optimal Personalised Treatment of early breast cancer usIng Multi-parameter Analysis) aims to validate MPA's as predictors of chemotherapy sensitivity in a largely node-positive breast cancer population.

Methods: OPTIMA is a partially blinded multi-center, phase 3 randomized controlled trial with an adaptive two-stage design. The main eligibility criteria are women or men aged 40 or older with resected ER-positive, HER2-negative breast cancer and up to 9 involved axillary lymph nodes. Randomization is to standard management (chemotherapy and endocrine therapy) or to MPA-directed treatment. Those with a “high risk” tumor MPA score receive standard management whilst those at “low risk” are treated with endocrine therapy alone. The preliminary phase (OPTIMA prelim) evaluated the performance of several MPAs to select a test to be used in the main efficacy trial based on economic analysis, and assessed the feasibility and acceptability of a large UK trial. OPTIMA prelim used Oncotype DX as the primary discriminator; the main trial will use Prosigna (PAM50) with Prosigna Score ≤60 defined as “low-risk”. The co-primary outcomes are (1) Invasive Disease Free Survival (IDFS) and (2) cost-effectiveness of test-directed therapy. Secondary outcomes include IDFS in “low-risk” patients, quality of life and additional survival measures. An integrated qualitative recruitment study will identify and address challenges to recruitment and informed consent. Tumor blocks from all consenting participants will be banked allowing the performance of alternative MPA technologies to be evaluated. Recruitment of 4500 patients will permit demonstration of 3% non-inferiority of test-directed treatment, with 5% significance and 85% power, assuming 3 years follow-up and a control arm 5-year IDFS of at least 85%. The addition of patients from OPTIMA prelim will allow non-inferiority to be assessed with 2.5% significance.

Results: OPTIMA-prelim recruited 412 patients in 23 months from 35 sites with a 47% acceptance rate. The main study opened in January 2017. Early progress indicates that the recruitment target is achievable in the intended 46-month timescale through the participation of >100 sites

Conclusion: OPTIMA, as one of two large scale prospective trials validating the use of test-guided chemotherapy decisions in node-positive early breast cancer, is expected to have a global impact on breast cancer treatment. Experience from OPTIMA prelim showed that patient advocate support and close engagement with sites will aid trial success.

Funding: The project is funded in the UK by the NIHR HTA Programme (10/34/501). Views expressed are those of the authors and not those of the HTA Programme, NIHR, NHS or the DoH.

Citation Format: Stein RC, Makris A, Hughes-Davies L, Macpherson IR, Hall PS, Cameron DA, Earl HM, Pinder SE, Poole CJ, Rea DW, McIntosh S, Harmer V, Morgan A, Rooshenas L, Conefrey C, Donovan JL, Hulme C, McCabe C, Stallard N, Campbell A, Higgins H, Bartlett JMS, Marshall A, Dunn JA. OPTIMA: A prospective randomized trial to validate the predictive utility and cost-effectiveness of gene expression test-directed chemotherapy decisions in early breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT1-06-01.

Selecting breast cancer patients for chemotherapy: the opening of the UK OPTIMA trial

The mortality from breast cancer has improved steadily over the past two decades, in part because of the increased use of more effective adjuvant therapies. Thousands of women are routinely treated with intensive chemotherapy, which can be unpleasant, is expensive and is occasionally hazardous. Oncologists have long known that some of these women may not need treatment, either because they have a low risk of relapse or because they have tumour biology that makes them less sensitive to chemotherapy and more suitable for early adjuvant endocrine therapy. There is an urgent need to improve patient selection so that chemotherapy is restricted to those patients who will benefit from it. Here we review the emerging technologies that are available for improving patient selection for chemotherapy. We describe the OPTIMA trial, which has just opened to recruitment in the UK, is the latest addition to trials in this area, and is the first to focus on the relative cost-effectiveness of alternate predictive assays.

OT1-02-08: The PERSEPHONE Trial: Duration of Trastuzumab with Chemotherapy in Women with HER2 Positive Early Breast Cancer. Changing the Randomisation Point To Address Potential Barriers to Recruitment

Background

Persephone is a phase III randomised controlled trial comparing six months of trastuzumab (9 doses) to the standard 12 month duration (18 doses) in patients with HER2 positive early breast cancer in respect of disease free survival, safety and cost-effectiveness. The trial opened to recruitment in October 2007 but soon showed that meeting recruitment targets was challenging, reaching only 20–30 patients per month. A key issue seemed to be the mandatory requirement to randomise before patients started trastuzumab treatment. Successful accrual of patients in the PHARE trial, a Persephone sister study, run by the National Institute for Cancer, Paris had not incorporated this criteria.

Method: In September 2009, following accrual of 316 patients, this potential barrier to recruitment was addressed by a major protocol amendment which relaxed the eligibility criteria to allow randomisation of patients who had received up to 9 doses of trastuzumab.

Results: To date, 1334 patients have been randomised into PERSEPHONE. After the amendment, monthly recruitment increased to 40–50 patients and, more recently, to 60–70 patients. Of the 1018 patients recruited since September 2009, 450 (44%) patients had received at least 1 dose of trastuzumab pre-randomisation (see Table).

RFA for Liver Tumors: Does It Really Work?

The use of radiofrequency ablation (RFA) is increasing in the treatment of both primary and metastatic hepatic tumors. However, the role of RFA has yet to be clearly defined in patients who are still considered amenable to surgical intervention. Future prospective studies are needed to define whether RFA can be used as an alternative to surgery in certain patient populations. In the interim, radiofrequency ablation technology will continue to advance and serve as both a palliative and potentially curative intervention for individuals with hepatic tumors.

Papillary lesions of the breast: evaluation with stereotactic directional vacuum-assisted biopsy

PURPOSE

To evaluate the use of stereotactic directional vacuum-assisted biopsy (SDVAB) in diagnosing and managing papillary lesions of the breast.

MATERIALS AND METHODS

The authors retrospectively reviewed the mammographic and histopathologic findings of 26 cases in which papillary lesions were diagnosed at SDVAB. In all cases, subsequent surgical excision (n = 20) or long-term imaging follow-up (n = 6) was performed and correlated with findings at SDVAB.

RESULTS

SDVAB of 26 lesions yielded tissue that was classified as benign in 12, atypical in six, and malignant in eight. Of the 12 lesions that were diagnosed as histologically benign at SDVAB, six were surgically excised. Of these six lesions, five yielded benign correlative results. The sixth lesion was thought to be discordant with the imaging findings, and was surgically excised and determined to be malignant. Of the six benign lesions that were not surgically sampled for biopsy, five decreased in size and one was not seen at radiographic follow-up. Of the six lesions diagnosed as atypical at SDVAB that were surgically excised, one was benign and five were atypical. None proved to be malignant. Of the eight lesions diagnosed as malignant at SDVAB, surgical excision demonstrated ductal carcinoma in situ in all eight; two also had foci of invasive carcinoma.

CONCLUSION

Benign and malignant papillary lesions of the breast can be reliably diagnosed at SDVAB when the SDVAB results correlate with the imaging findings. However, the extent of malignant papillary disease may be underestimated at SDVAB; in our study, invasive carcinoma was later discovered in 25% of patients with this diagnosis.

Factors influencing smoking cessation in patients with coronary artery disease

The purpose of this paper is to review the sociodemographic, clinical, and psychological characteristics suggested as being predictors of difficulty with smoking cessation in patients with coronary artery disease. These characteristics include age, gender, socioeconomic status, social support, intensity of smoking, severity of coronary artery disease, anxiety, depression, hostility/anger/aggression, and health locus of control. In addition, nicotine addiction is discussed as a factor which may further compound this problem. Consideration of these factors in relation to the patient with coronary artery disease may assist in the delivery of an optimal and individualized intervention program to facilitate sustained smoking cessation. A brief overview of intervention strategies is provided.

Breast biopsy and guidance for occult lesions

Biopsy and histological examination is the only way of determining with absolute accuracy whether a lesion is benign or malignant, as well as its exact nature and whether it shows any evidence of precancerous changes. Occult malignant lesions, not clinically detectable, may be found by the study of surrounding tissue in the course of the excision of a benign lesion. However, they are most often found by breast x-rays (mammography or xerography) which are done for: the survey of high-risk asymptomatic women; contralateral breast studies; symptomatic breasts without palpable findings; nipple discharge; large pendulous breasts; and multinodular breasts. Biopsies for occult lesions, based on radiographic findings, are recommended for: suspicious calcifications; stellate-shaped masses; breast masses with ill-defined borders or nodular contours; dominant masses; and areas of increased density or distorted breast architecture. In general, biopsy for these lesions is best done under general anesthesia, as an in-patient and as a two-step type of procedure, i.e., the biopsy should be studied by permanent histologic sections before making a final diagnosis. Preoperative localization can be done by measurements, markers, radio-opaque dye injections or by needle localization which we feel is the preferred technique because it is simple and accurate and allows for removal of only a small amount of tissue with better cosmetic results. The advantages and disadvantages of various types of needle localization are discussed and figures are given for 387 needle localizations in which 148 cancers were found (38.2%). Of these cancers, 54.1% were invasive and 45.9% were noninvasive.(ABSTRACT TRUNCATED AT 250 WORDS)

The True Capsule of the Knee-Joint

Images