A multicentre study of capecitabine, oxaliplatin plus bevacizumab as perioperative treatment of patients with poor-risk colorectal liver-only metastases not selected for upfront resection

BACKGROUND

Perioperative chemotherapy improves outcome in resectable colorectal liver-only metastasis (CLM). This study aimed to evaluate perioperative CAPOX (capecitabine-oxaliplatin) plus bevacizumab in patients with poor-risk CLM not selected for upfront resection.

PATIENTS AND METHODS

Poor-risk CLM was defined as follows: more than four metastases, diameter >5 cm, R0 resection unlikely, inadequate viable liver function if undergoing upfront resection, inability to retain liver vascular supply, or synchronous colorectal primary presentation. Patients underwent baseline computed tomography, magnetic resonance imaging, and/or positron emission tomography (PET) for staging and received neoadjuvant CAPOX plus bevacizumab, with resectability assessed every four cycles. Primary end point was radiological objective response rate (ORR).

RESULTS

Forty-six patients were recruited, of which 91% underwent PET to ensure metastases confined to liver. Following neoadjuvant CAPOX plus bevacizumab, the ORR was 78% (95% confidence interval 63% to 89%). This allowed 12 of 30 (40%) patients with initial nonsynchronous unresectable CLM to be converted to resectability. In addition, 10 of 15 (67%) patients with synchronous resectable CLM underwent liver resection, with four additional patients being observed alone due to excellent response to neoadjuvant therapy. No grade 3-4 perioperative complications were seen.

CONCLUSION

Neoadjuvant CAPOX plus bevacizumab resulted in a high response rate for patients with CLMs with poor-risk features not selected for upfront resection and converted 40% of patients to resectability.

Cardiac arrest in private locations: different strategies are needed to improve outcome

BACKGROUND

A tremendous amount of public resources are focused on improving cardiac arrest (OHCA) survival in public places, yet most OHCAs occur in private residences.

METHODS AND RESULTS

A prospective, observational study of patients transported to seven urban and suburban hospitals and the individuals who called 911 at the time of a cardiac arrest (bystander) was performed. Bystanders (N=543) were interviewed via telephone beginning 2 weeks after the incident to obtain data regarding patient and bystander demographics, including cardiopulmonary resuscitation (CPR) training. Of all arrests 80.2% were in homes. Patients who arrested in public places were significantly younger (63.2 vs. 67.2, P<0.02), more often had an initial rhythm of VF (63.0 vs. 37.7%, P<0.001), were seen or heard to have collapsed by a bystander (74.8 vs. 48.1%, P<0.001), received bystander CPR (60.2 vs. 28.6%, P<0.001), and survived to DC (17.5 vs. 5.5%, P<0.001). Patients who arrested at home were older and had an older bystander (55.4 vs. 41.3, P<0.001). The bystander was less likely to be CPR trained (65.0 vs. 47.4%, P<0.001), less likely to be trained within the last 5 years (49.2 vs. 17.9, P<0.001), and less likely to perform CPR if trained (64.2 vs. 30.0%, P<0.001). Collapse to shock intervals for public versus home VF patients were not different.

CONCLUSIONS

Many important characteristics of cardiac arrest patients and the bystander differ in public versus private locations. Fundamentally different strategies are needed to improve survival from these events.

Expert Consensus on the Management of Adverse Events from EGFR Tyrosine Kinase Inhibitors in the UK

Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) such as gefitinib, erlotinib, and afatinib are standard-of-care for first-line treatment of EGFR-mutant advanced non-small cell lung cancer (NSCLC). These drugs have a proven benefit in terms of higher response rate, delaying progression and improvement of quality of life over palliative platinum-based chemotherapy. The most common adverse events (AEs) are gastrointestinal (GI) (diarrhoea and stomatitis/mucositis) and cutaneous (rash, dry skin and paronychia). These are usually mild, but if they become moderate or severe, they can have a negative impact on the patient’s quality of life (QOL) and lead to dose modifications or drug discontinuation. Appropriate management of AEs, including prophylactic measures, supportive medications, treatment delays and dose reductions, is essential. A consensus meeting of a UK-based multidisciplinary panel composed of medical and clinical oncologists with a special interest in lung cancer, dermatologists, gastroenterologists, lung cancer nurse specialists and oncology pharmacists was held to develop guidelines on prevention and management of cutaneous (rash, dry skin and paronychia) and GI (diarrhoea, stomatitis and mucositis) AEs associated with the administration of EGFR-TKIs. These guidelines detail supportive measures, treatment delays and dose reductions for EGFR-TKIs. Although the focus of the guidelines is to support healthcare professionals in UK clinical practice, it is anticipated that the management strategies proposed will also be applicable in non-UK settings.

Effect of a paraprofessional home-visiting intervention on American Indian teen mothers’ and infants’ behavioral risks: a randomized controlled trial

OBJECTIVE

The authors sought to examine the effectiveness of Family Spirit, a paraprofessional-delivered, home-visiting pregnancy and early childhood intervention,in improving American Indian teen mothers’ parenting outcomes and mothers’and children’s emotional and behavioral functioning 12 months postpartum.

METHOD

Pregnant American Indian teens(N=322) from four southwestern tribal reservation communities were randomlyassigned in equal numbers to the Family Spirit intervention plus optimized standard care or to optimized standard care alone. Parent and child emotional and behavioral outcome data were collected at baseline and at 2, 6, and 12 months postpartum using self-reports, interviews,and observational measures.

RESULTS

At 12 months postpartum, mothers in the intervention group had significantly greater parenting knowledge parenting self-efficacy, and home safety attitudes and fewer externalizing behaviors,and their children had fewer externalizing problems. In a subsample of mothers with any lifetime substance use at baseline (N=285; 88.5%), children in the intervention group had fewer externalizing and dysregulation problems than those in the standard care group, and fewer scored in the clinically “at risk” range ($10th percentile) for externalizing and internalizing problems. No between-group differences were observed for outcomes measured by the Home Observation for Measurement of the Environment scale.

CONCLUSIONS

Outcomes 12 months postpartum suggest that the Family Spirit intervention improves parenting and infant outcomes that predict lower lifetime behavioral and drug use risk for participating teen mothers and children.

Prognostic value of a normal or nonspecific initial electrocardiogram in acute myocardial infarction

CONTEXT

Although previous studies have suggested that normal and nonspecific initial electrocardiograms (ECGs) are associated with a favorable prognosis for patients with acute myocardial infarction (AMI), their independent predictive value for mortality has not been examined.

OBJECTIVE

To compare in-hospital mortality among patients with AMI who have normal or nonspecific initial ECGs with that of patients who have diagnostic ECGs.

DESIGN, SETTING, AND PATIENTS

Multihospital observational study in which 391 208 patients with AMI met the study criteria between June 1994 and June 2000 and had ECGs that were normal (n = 30 759), nonspecific (n = 137 574), or diagnostic (n = 222 875; defined as ST-segment elevation or depression and/or left bundle-branch block). A logistic regression model was constructed using a propensity score for ECG findings and data on demographics, medical history, diagnostic procedures, and therapy to determine the independent prognostic value of a normal or nonspecific initial ECG.

MAIN OUTCOME MEASURES

In-hospital mortality; composite outcome of in-hospital death and life-threatening adverse events.

RESULTS

In-hospital mortality rates were 5.7%, 8.7%, and 11.5% while the rates of the composite of mortality and life-threatening adverse events were 19.2%, 27.5%, and 34.9% for the normal, nonspecific, and diagnostic ECG groups, respectively. After adjusting for other predictor variables, the odds of mortality for the normal ECG group was 0.59 (95% confidence interval [CI], 0.56-0.63; P<.001) and for the nonspecific group was 0.70 (95% CI, 0.68-0.72; P<.001), compared with the diagnostic ECG group.

CONCLUSION

In this large cohort of patients with AMI, patients presenting with normal or nonspecific ECGs did have lower in-hospital mortality rates than those of patients with diagnostic ECGs, yet the absolute rates were still unexpectedly high.

Maximizing use of the emergency department observation unit: a novel hybrid design

STUDY OBJECTIVE

We sought to determine whether sharing an observation unit with scheduled procedure patients would maintain a more consistent unit census and patient/nurse ratio. A secondary objective was to determine the effect of this model on patient length of stay and discharge rates.

METHODS

This retrospective, descriptive study was conducted in a high-volume suburban teaching hospital, using a "before-and-after" study design. A "pure" postprocedure unit became a "hybrid" observation postprocedure unit by displacing specific postprocedure patients to inpatient locations. Subsequently, the displaced patients were returned to the unit. On weekends, the unit operated as a pure observation unit. Hourly unit occupancy and census data were prospectively collected, and hourly patient/nurse ratios were calculated. Patient length of stay and discharge data were collected and compared in different settings.

RESULTS

The 2 services showed a complementary census pattern that allowed the hybrid unit to maintain an average hourly patient/nurse ratio of 3.7 compared with the ratio of 2.5 for a pure observation unit. There was no difference in observation patient length of stay (14.8 hours versus 14.7 hours) or discharge rate (20.4% versus 18.1%) between weekdays and weekends. However, scheduled procedure patients experienced significantly shorter lengths of stay in the hybrid unit setting (4.3 hours) than in alternative inpatient locations (9.4 hours).

CONCLUSION

The hybrid model showed better hourly census and nurse resource use rates, with no adverse effect on observation patients. However, scheduled procedure patient length of stay was shorter in this setting.

Successful pediatric stenting of a nonthrombotic coronary occlusion as a complication of radiofrequency catheter ablation

This is a case of a right coronary artery occlusion complicating a RF catheter ablation of a posteroseptal accessory connection in an 8-year-old boy. After multiple balloon angioplasty attempts in the occluded vessel, only transient patency was achieved. The occlusion was successfully treated with placement of an intracoronary stent.

Emergency medicine resident well-being: stress and satisfaction

BACKGROUND

Emergency medicine (EM) residents are exposed to many work-related stressors, which affect them both physically and emotionally. It is unknown, however, how EM residents perceive the effect of these stressors on their well-being and how often they use unhealthy coping mechanisms to manage stress.

AIMS

To evaluate EM residents' perceptions of stressors related to their overall well-being and the prevalence of various coping mechanisms.

METHODS

An online survey instrument was developed to gauge resident stress, satisfaction with current lifestyle, stress coping mechanisms and demographics. A stratified random sample of EM residents from three postgraduate years (PGY-I, PGY-II and PGY-III) was obtained. Descriptive statistics and one-way analysis of variance were used to compare residents across PGY level.

RESULTS

There were 120 potential participants in each of the three PGYs. The overall response rate was 30% (109) with mean age of 30 and 61% were male. On a 0-4 scale (0 = completely dissatisfied), respondents in PGY-I reported significantly less satisfaction with lifestyle than those in PGY-II and III (mean rating: 1.29, 1.66 and 1.70, respectively; P < 0.001). There were no significant differences in mean ratings between PGYs on each of the other stress categories: work relationships (1.37), work environment (1.10) and response to patients (1.08). Residents reported exercise (94%), hobbies (89%) and use of alcohol (71%) as coping methods.

CONCLUSIONS

Residents reported low satisfaction with current lifestyle. This dissatisfaction was unrelated to perceived work-related stress. Some undesirable coping methods were prevalent, suggesting that training programs could focus on promotion of healthy group activities.

Methodological quality and descriptive characteristics of prosthodontic-related systematic reviews

Ideally, healthcare systematic reviews (SRs) should be beneficial to practicing professionals in making evidence-based clinical decisions. However, the conclusions drawn from SRs are directly related to the quality of the SR and of the included studies. The aim was to investigate the methodological quality and key descriptive characteristics of SRs published in prosthodontics. Methodological quality was analysed using the Assessment of Multiple Reviews (AMSTAR) tool. Several electronic resources (MEDLINE, EMBASE, Web of Science and American Dental Association's Evidence-based Dentistry website) were searched. In total 106 SRs were located. Key descriptive characteristics and methodological quality features were gathered and assessed, and descriptive and inferential statistical testing performed. Most SRs in this sample originated from the European continent followed by North America. Two to five authors conducted most SRs; the majority was affiliated with academic institutions and had prior experience publishing SRs. The majority of SRs were published in specialty dentistry journals, with implant or implant-related topics, the primary topics of interest for most. According to AMSTAR, most quality aspects were adequately fulfilled by less than half of the reviews. Publication bias and grey literature searches were the most poorly adhered components. Overall, the methodological quality of the prosthodontic-related systematic was deemed limited. Future recommendations would include authors to have prior training in conducting SRs and for journals to include a universal checklist that should be adhered to address all key characteristics of an unbiased SR process.

Virus Size Analysis by Gas-Phase Mobility Measurements: Resolution Limits

Electrospraying (ES) dissolved viral particles, followed by charge reduction and size analysis with a differential mobility analyzer (DMA), offers a flexible size-analysis tool for small particles in solution. The technique relies on pioneering work by Kaufman and colleagues, commercialized by TSI, and often referred to as GEMMA. However, viral studies with TSI's GEMMA have suffered from limited resolving power, possibly because of imperfections in either the instrument (DMA or charge reduction) or the sample solution preparation. Here, we explore the limits of the resolution achievable by GEMMA, taking advantage of (i) cleaner charge reduction methods and (ii) DMAs of higher resolving power. Analysis of the literature provides indications that mobility peak widths (fwhm) of 2% or less may be achieved by combining careful sample preparation with improved instrumentation. Working with purified PP7 bacteriophage particles small enough to be classifiable by existing high-resolution DMAs, we confirm that fairly narrow viral mobility peaks may be obtained (relative full width at half-maximum fwhm <5%). Comparison of spectra of a given apian virus sample obtained with TSI's GEMMA and our improved instrumentation confirms that one critical limitation is the DMA. This is further verified by narrow peaks from murine parvovirus, norovirus, and encephalomyelitis virus samples, obtained in our improved GEMMA with little sample preparation, directly from infected cell cultures. Classification of purified large (60 nm) coliphage PR772 particles leads to broad peaks, due to both viral degradation and limited intrinsic resolution of the DMAs used to cover the range of such large particles. We conclude that improved DMAs suitable for high-resolution analysis of particles larger than 30 nm need to be developed to determine the intrinsic mobility width of viral particles.

Pretest probability assessment for selective rest sestamibi scans in stable chest pain patients

The objective of this study was to determine whether pretest probability assessments permit more selective testing of chest pain patients with technetium-99m sestamibi scanning. Pretest probabilities of cardiac ischemia were measured both objectively (Acute Cardiac Ischemia Time-Insensitive Predictive Instrument [ACI-TIPI]) and subjectively (physician's estimate of the probability of unstable angina). Two groups were defined: patients whose postsestamibi scan led to a "downgrade" of the intensity of monitoring and those that resulted in no change in monitoring intensity. Sixty-five patients met study criteria; 25 had a disposition downgrade and 40 had no change. Pretest ACI-TIPI scores were similar in the two groups (29% +/- 18% versus 27% +/- 11%, mean +/- standard deviation; P = .95) as were the physician's assessment of unstable angina (39% +/- 22% versus 40% +/- 24%; P = .75). Objective or subjective pretest probabilities are not significantly different in patients who are likely to have their disposition altered by sestamibi scanning.

A geophysical shock and air blast simulator at the National Ignition Facility

The energy partitioning energy coupling experiments at the National Ignition Facility (NIF) have been designed to measure simultaneously the coupling of energy from a laser-driven target into both ground shock and air blast overpressure to nearby media. The source target for the experiment is positioned at a known height above the ground-surface simulant and is heated by four beams from the NIF. The resulting target energy density and specific energy are equal to those of a low-yield nuclear device. The ground-shock stress waves and atmospheric overpressure waveforms that result in our test system are hydrodynamically scaled analogs of full-scale seismic and air blast phenomena. This report summarizes the development of the platform, the simulations, and calculations that underpin the physics measurements that are being made, and finally the data that were measured. Agreement between the data and simulation of the order of a factor of two to three is seen for air blast quantities such as peak overpressure. Historical underground test data for seismic phenomena measured sensor displacements; we measure the stresses generated in our ground-surrogate medium. We find factors-of-a-few agreement between our measured peak stresses and predictions with modern geophysical computer codes.

Transcriptional programming mediated by the histone demethylase KDM5C regulates dendritic cell population heterogeneity and function

Functional and phenotypic heterogeneity of dendritic cells (DCs) play crucial roles in facilitating the development of diverse immune responses essential for host protection. Here, we report that KDM5C, a histone lysine demethylase, regulates conventional or classical DC (cDC) and plasmacytoid DC (pDC) population heterogeneity and function. Mice deficient in KDM5C in DCs have increased proportions of cDC2Bs and cDC1s, which is partly dependent on type I interferon (IFN) and pDCs. Loss of KDM5C results in an increase in Ly6C- pDCs, which, compared to Ly6C+ pDCs, have limited ability to produce type I IFN and more efficiently stimulate antigen-specific CD8 T cells. KDM5C-deficient DCs have increased expression of inflammatory genes, altered expression of lineage-specific genes, and decreased function. In response to Listeria infection, KDM5C-deficient mice mount reduced CD8 T cell responses due to decreased antigen presentation by cDC1s. Thus, KDM5C is a key regulator of DC heterogeneity and critical driver of the functional properties of DCs.