Comparison of 8-vs-12 weeks, adapted dialectical behavioral therapy (DBT) for borderline personality disorder in routine psychiatric inpatient treatment-A naturalistic study

Dialectical behavior therapy (DBT) is widely acknowledged as an effective treatment for individuals with borderline personality disorder (BPD). However, the optimal treatment duration within DBT remains a topic of investigation. This retrospective, naturalistic non-randomized study aimed to compare the efficacy of 8 week and 12 week DBT interventions with equivalent content, focusing on the change of BPD-specific symptomatology as the primary outcome and depressive symptoms as the secondary outcome. Overall, 175 patients who participated in DBT and received either 8 week or 12 week intervention were included in the analysis. Routine inpatient treatment was adapted from standard DBT with the modules: skill training, interpersonal skills, dealing with feelings, and mindfulness. Measurements were taken at baseline, mid-point, and endpoint. The borderline symptom list-23 (BSL-23) was used for the assessment of borderline-specific symptoms, while the Beck depression inventory-II (BDI-II) was used for the assessment of depressive symptoms. Statistical analysis was conducted using linear mixed models. Effect sizes were calculated for both measures. The results of the analysis indicated an improvement in both groups over time. Effect sizes were d = 1.29 for BSL-23 and d = 1.79 for BDI-II in the 8 week group, and d = 1.16 for BSL-23 and d = 1.58 for BDI-II in the 12 week group. However, there were no differences in the change of BPD-specific symptoms or the severity of depressive symptoms between the 8 week and 12 week treatment duration groups. Based on these findings, shorter treatment durations, like 8 weeks, could be a viable alternative, offering comparable therapeutic benefits, potential cost reduction, and improved accessibility. However, further research is needed to explore factors influencing treatment outcomes and evaluate the long-term effects of different treatment durations in DBT for BPD.Trial registration: drks.de (DRKS00030939) registered 19/12/2022.

The second molar dilemma in orthodontics: to bond or not to bond?

OBJECTIVES

To compare orthodontic treatment (OT) outcome in adolescents undergoing nonextraction fixed OT with or without bonding of second molars using the score of the American Board of Orthodontics Cast Radiograph Evaluation (C-R-Eval).

MATERIALS AND METHODS

This study included healthy adolescents with skeletal Class I or mild Class II/Class III malocclusion, normal or deep overbite (OB), and mild-to-moderate dental crowding (<5 mm) who underwent nonextraction fixed OT with ("bonded" group) or without ("not-bonded" group) bonding of second molars. Patient treatment records, pre- and posttreatment digital models, lateral cephalograms, and orthopantomograms were assessed. The evaluated outcomes included leveling of the curve of Spee (COS), OB, control of incisor mandibular plane angle (IMPA), number of emergency visits (related to poking wires and/or bracket failure of the terminal molar tubes), treatment duration, and C-R-Eval. Treatment variables were compared across time points and among groups.

RESULTS

The sample included 30 patients (mean age 16.07 ± 1.80 years) in the bonded group and 32 patients (mean age 15.69 ± 1.86 years) in the not-bonded group. The mean overall C-R-Eval score was significantly higher (P < .001) in the not-bonded group (25.25 ± 3.98) than in the bonded group (17.70 ± 2.97). There were no significant differences in mean changes of COS, OB, IMPA, or treatment duration among groups. The mean number of emergency visits was significantly higher in the bonded (3.3 ± 0.6) than the not-bonded group (1.9 ± 0.4) (P < .001).

CONCLUSIONS

Bonding of second molars enhances the outcome of nonextraction fixed OT as demonstrated by the C-R-Eval without increasing treatment duration, irrespective of more emergency visits.

Real-World Clinical Profile of Patients Prescribed Evolocumab in Japan

BACKGROUND

Real-world utilization data for evolocumab, the first proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor to be introduced in Japan in 2016, to date are limited. This study aimed to clarify the current real-world patient user profiles of evolocumab based on large-scale health claims data.Methods and Results: This retrospective database study examined patients from a health administrative database (MDV database) who initiated evolocumab between April 2016 (baseline) and November 2021. Characteristics and clinical profiles of this patient population are described. In all, 4,022 patients were included in the final analysis. Most evolocumab prescriptions occurred in the outpatient setting (3,170; 78.82%), and 940 patients (23.37%) had a recent diagnosis of familial hypercholesterolemia. Common recent atherosclerotic cardiovascular disease events at baseline included myocardial infarction (1,633; 40.60%), unstable angina (561; 13.95%), and ischemic stroke (408; 10.14%). Comorbidity diseases included hypertension (2,504; 62.26%), heart failure (1,750; 43.51%), diabetes (1,199; 29.81%), and chronic kidney disease (297; 7.38%). Among the lipid-lowering regimens concomitant with evolocumab, ezetimibe+statin was used most frequently (1,281; 31.85%), followed by no concomitant lipid-lowering regimen (1,190; 29.59%), statin (950; 23.62%), and ezetimibe (601; 14.94%). The median evolocumab treatment duration for all patients was 260 days (interquartile range 57-575 days).

CONCLUSIONS

This study provides real-world insights into evolocumab utilization in Japan for optimizing patient care and adherence to guideline-based therapies to better address hypercholesterolemia in Japan.

Duration of osteoporosis treatment to reduce the risk of subsequent osteoporotic fracture and all-cause mortality in elderly hip fracture patients in a Korean real-world study

This study aimed to evaluate the association between treatment duration of osteoporosis medications and clinical outcomes of patients with hip fracture. We found that the risk of subsequent osteoporotic fractures and all-cause mortality showed a decreasing trend as the treatment duration of osteoporosis medications increased.

PURPOSE

To assess the risk of subsequent osteoporotic fracture (SOF) and all-cause mortality (ACM) in elderly patients with hip fracture in South Korea and to evaluate the potential reduction in the risk of SOF and ACM with varying durations of osteoporosis treatment.

METHODS

Newly diagnosed patients with hip fracture (age ≥ 60 years) who initiated osteoporosis medication within 3 months after the hip fracture from 2003-2014 were identified from the National Health Insurance Service-Senior cohort. The risk of SOF and ACM was estimated after the 1-year exposure-measurement period. Adjusted hazard ratios (aHRs) were calculated for treatment duration of osteoporosis medications categorized as short-term treatment (ST, < 3 months), early discontinuation (ED, ≥ 3- < 6 months), late discontinuation (LD, ≥ 6- < 12 months), and treatment continuation (TC, ≥ 12 months).

RESULTS

A total of 4,421 patients were included in the analysis. The 3-year cumulative incidence of SOF was 22.4%, 22.0%, 23.9%, and 21.6%, and that of 3-year ACM was 29.8%, 27.0%, 19.7%, and 18.9% in the ST, ED, LD, and TC groups, respectively. Compared with the ST group, the risk of SOF showed a decreasing trend in the TC group (aHR [95% CI], 0.77 [0.58-1.00]). The risk of ACM was significantly reduced in the LD (aHR 0.68 [0.57-0.82]) and TC (aHR 0.65 [0.50-0.84]) groups.

CONCLUSION

These findings underscore the importance of early and continuous osteoporosis treatment for elderly patients with hip fracture to improve health outcomes. The benefits of long-term osteoporosis treatment should be discussed in clinical practice to improve overall health outcomes.

Prognosis of prosthetic valve infective endocarditis due to Streptococcus spp., a retrospective multi-site study to assess the impact of antibiotic treatment duration

PURPOSE

The duration of antibiotic treatment for prosthetic valve endocarditis caused by Streptococcus spp. is largely based on clinical observations and expert opinion rather than empirical studies. Here we assess the impact of a shorter antibiotic duration.

OBJECTIVES

To assess the impact of antibiotic treatment duration for streptococcal prosthetic valve endocarditis on 12-month mortality as well as subsequent morbidity resulting in additional cardiac surgical interventions, and rates of relapse and reinfection.

METHODS

This retrospective multisite (N= 3) study examines two decades of data on patients with streptococcal prosthetic valve endocarditis receiving either 4 or 6 weeks of antibiotics. Overall mortality, relapse, and reinfection rates were also assessed for the entire available follow-up period.

RESULTS

The sample includes 121 patients (median age 72 years, IQR [53; 81]). The majority (74%, 89/121) received a ß-lactam antibiotic combined with aminoglycoside in 74% (89/121, median bi-therapy 5 days [1; 14]). Twenty-eight patients underwent surgery guided by ESC-guidelines (23%). The 12-month mortality rate was not significantly affected by antibiotic duration (4/40, 10% in the 4-week group vs 3/81, 3.7% in the 6-week group, p=0.34) or aminoglycoside usage (p=0.1). Similarly, there were no significant differences between the 2 treatment groups for secondary surgical procedures (7/40 vs 21/81, p=0.42), relapse or reinfection (1/40 vs 2/81 and 2/40 vs 5/81 respectively).

CONCLUSIONS

Our study found no increased adverse outcomes associated with a 4-week antibiotic duration compared to the recommended 6-week regimen. Further randomized trials are needed to ascertain the optimal duration of treatment for streptococcal endocarditis.

Comparison of efficacy between MBT preadjusted edgewise appliance and clear aligner therapy among class I crowding cases: A randomized controlled trial

Background

To compare the efficacy of McLaughlin Bennett Trevisi (MBT) appliance and Clear Aligner Therapy (CAT) among nonextraction Class I crowding cases.

Methods

The study sample (60 patients) was allotted into two equal groups (30 patients each) using block randomization wherein Group 1: treated with 0.018" MBT appliance and Group 2: treated with CAT for correction of malocclusion. At the end of treatment (T1), treatment duration, chairside time, laboratory time, number, and type of appointments were noted from treatment record cards. For comparing the acceptability among patients treated with both modalities at T1, the patients were interviewed regarding the comfort and ease of using an appliance with a questionnaire-based survey.

Results

The median number of nonscheduled/emergency and finishing stage appointments was significantly higher in Group 1 compared to Group 2 (P-value <0.001). The median duration of treatment at the scheduled, finishing, and overall appointments, was significantly higher in Group 1 compared to Group 2 (P-value <0.001). The median chairside time of all appointments was significantly higher in Group 1 compared to Group 2 (P-value <0.001). The experience with treatment and overall acceptability was significantly higher in Group 2 compared to Group 1 (P-value <0.001). However, mean laboratory time per aligner fabrication in Group 2 was 30.26 ± 3.45 min against no laboratory time consumed in Group 1.

Conclusions

CAT significantly reduces treatment duration, chairside time, number of nonscheduled/emergency, and finishing stage appointments in nonextraction Class I crowding cases. Prospective studies with 3D aligner systems are recommended to add further evidence in this regard.

Clinical Trials Registry-India Registration No

CTRI/2018/04/013301.

The incidence of tuberculosis recurrence: Impacts of treatment duration of and adherence to standard anti-tuberculous therapy

BACKGROUND

We investigated the impacts of the standard treatment durations of and adherence to standard anti-tuberculous therapy (ATT) on recurrence after the successful completion of tuberculosis (TB) treatment.

METHODS

We recruited patients with TB who had received treatment for six or nine months from the 2008-2017 databases of the Taiwanese National Health Insurance Research Database. Treatment duration and adherence to standard ATT were analyzed for their impacts on recurrence within two years. Complete adherence to standard ATT was defined as daily use of ethambutol, isoniazid, pyrazinamide, and rifampin for the first two months, and daily use of isoniazid and rifampin for the first six months.

RESULTS

A total of 33,298 TB patients with new-onset TB were identified and classified into two groups by treatment duration: six months (n = 25,849, 77.63%) and nine months (n = 7449). Sex and age distributions varied between the groups. Treatment duration did not affect TB recurrence within two years (adjusted hazard ratio (AHR): 1.18, 95% confidence interval (C.I.) [0.96-1.44], p = 0.1156). Multivariable logistic regression showed that incomplete adherence to standard anti-tuberculous therapy (80-89% and 90-99% standard anti-TB therapy, AHR: 1.57, 95% C.I. [1.26-1.95], and 1.63, 95% C.I. [1.26-2.06], respectively, p < 0.0001) increased TB recurrence. In addition, male sex, older age, and comorbidity with diabetes mellitus or chronic obstructive pulmonary disease were independent risk factors for TB recurrence within two years.

CONCLUSIONS

TB recurrence was 1.54% within two years under a DOT era. TB treatment durations of six or nine months did not affect TB recurrence within two years after completion of TB treatment, but incomplete adherence to standard anti-tuberculous therapy might increase the TB recurrence rate.

Diagnostic delay, treatment duration and outcomes since the implementation of integrated model of tuberculosis control and their associated factors in a county in East China

OBJECTIVE

This study assesses the diagnostic delay, treatment duration and treatment outcomes of tuberculosis (TB) patients since the implementation of the integrated model of TB control in a county in eastern China. It further identifies factors associated with diagnostic delay and treatment duration in the integrated model.

METHODS

We collected data through the Chinese Tuberculosis Information Management System (TBIMS) for Cangnan County in Zhejiang Province. Chi-square and Mann-Whitney tests were adopted to identify factors associated with duration of treatment and treatment delay for TB patients within the integrated model. Multiple regression analysis was subsequently performed to confirm the identified factors.

RESULTS

In the integrated model from 2012 to 2018, the median health system delay was maintained at 1 day, and the median patient delay decreased from 14 to 9 days and the median total delay decreased from 15 to 11 days. In addition, the proportion of patients who experienced patient delay > 14 days and total delay > 28 days decreased from 49% to 35% and from 32% to 29% respectively. However, the proportion of patients who had health system delay > 14 days increased from 0.2% to 13% from 2012 to 2018. The median treatment duration increased from 199 to 366 days and the number of TB patients lost to follow-up showed an overall upward trend from 2012 to 2018. The multivariable regression analysis indicated that migrant TB patients and TB patients initially diagnosed in hospitals at the prefectural level and above tended to experience total delay > 28 days (p < 0.001). Linear regression analysis confirmed that new TB patients>60 years tended to have longer treatment duration (p < 0.05).

CONCLUSIONS

While our study may suggest the potential of the integrated model in early detection and diagnosis of TB, it also suggests the importance of strengthening supervision and management of designated hospitals to optimize the treatment duration and improve retention of patients in TB care. Enhancing health education for TB patients, especially amongst migrant patients, and training in TB identification and referral for non-TB doctors are also key for early TB detection and diagnosis in the integrated model.

Drug adherence and treatment duration for denosumab and mortality risk among hip fracture patients

This study aimed to assess the impact of drug adherence and treatment duration for denosumab on mortality risk after hip fracture surgery. Lower all-cause mortality risk was associated with drug intervals of 7 months or less and longer treatment duration. The study highlights the importance of proper denosumab administration.

PURPOSE

Prescription of anti-osteoporotic medications (AOMs) after osteoporotic hip fracture may increase bone mineral density (BMD) and decrease mortality risk. However, few studies have been conducted on drug adherence and treatment duration for denosumab, a popular choice among AOMs. This study aimed to assess the impact of denosumab adherence and treatment duration on the mortality risk of hip fracture patients after surgery.

METHODS

We conducted a cohort study using nationwide population data from National Health Insurance Research Database (NHIRD) in Taiwan. Patients newly diagnosed with osteoporosis and hip fracture between 2008 and 2019 who used denosumab after surgery were included. We assessed drug adherence, treatment duration, and other parameters associated with patient outcomes.

RESULTS

A total of 21,316 patients diagnosed with osteoporotic hip fractures were included. Compared with a > 7-month drug interval for denosumab, an interval of ≤ 7 months led to lower all-cause mortality risk (hazard ratio (HR): 0.60, 95% confidence interval (CI): 0.57 ~ 0.64). Patients with denosumab treatment for over 1, 2, and 3 years had lower all-cause mortality risk (HR&CI: 0.68 (0.64 ~ 0.73), 0.48 (0.43 ~ 0.53), 0.29 (0.26 ~ 0.33)) than those with treatment duration < 1 year. Analysis after excluding short-term death yielded similar results. Analysis of causes of death also showed that good adherence and longer duration were associated with reduced mortality due to cancer and cardiovascular disease.

CONCLUSION

Better drug adherence and longer duration of denosumab treatment are associated with lower all-cause mortality risk among hip fracture patients after surgery. Our study highlights the benefits of a proper time interval of denosumab administration. These findings provide important insight into management of osteoporotic hip fractures and may inform clinical practice and development of guidelines.

Dosing transcranial magnetic stimulation in major depressive disorder: Relations between number of treatment sessions and effectiveness in a large patient registry

BACKGROUND

The number of sessions in an acute TMS course for major depressive disorder (MDD) is greater than in the earlier randomized controlled trials.

OBJECTIVE

To compare clinical outcomes in groups that received differing numbers of TMS sessions.

METHODS

From a registry sample (N = 13,732), data were extracted for 7215 patients treated for MDD with PHQ-9 assessments before and after their TMS course. Groups were defined by number of acute course treatment sessions: 1-19 (N = 658), 20-29 (N = 616), 30-35 (N = 1375), 36 (N = 3591), 37-41 (N = 626), or >41 (N = 349) and compared in clinical outcomes at endpoint and at fixed intervals (after 10, 20, 30, and 36 sessions). The impact of additional treatments beyond 36 sessions was also examined.

RESULTS

Groups that received fewer than 30 sessions had inferior endpoint outcomes than all other groups. PHQ-9 symptom reduction was greatest in the group that ended treatment at 36 sessions. The extended treatment groups (>36 sessions) differed from all other groups by manifesting less antidepressant response early in the course and had a slower but steady rate of improvement over time. Extending treatment beyond 36 sessions was associated with further improvement without evidence of a plateau.

CONCLUSIONS

In real-world practice, there are strong relations between the number of TMS sessions in a course and the magnitude of symptom reduction. Courses with less than 30 sessions are associated with diminished benefit. Patients with longer than standard courses typically show less initial improvement and a more gradual trajectory, but meaningful benefit accrues with treatment beyond 36 sessions.

Use of phytosterol-fortified foods to improve LDL cholesterol levels: A systematic review and meta-analysis

AIMS

The main objective was to assess if foods fortified with phytosterols (PS), including plant sterols and plant stanols, reduce low-density lipoprotein cholesterol (LDL-C) concentrations. The secondary objective was to determine the impact of different factors related to PS administration.

DATA SYNTHESIS

The search was carried out in MEDLINE, EMBASE, Web of Science, Scopus and The Cochrane Central Register of Controlled Trials (CENTRAL) databases up to March 2023. The meta-analysis was registered in the PROSPERO database (CRD42021236952). From a total of 223 studies, 125 were included. On average, PS lowered LDL-C 0.55 mmol/L [95% confidence interval (CI) = 10.82-12.67], and this decrease was significantly maintained for all analysed subgroups. A greater reduction in LDL-C levels was detected in relation to a higher daily PS dosage. The food format "Bread, biscuits, cereals", conditioned a lower decrease of 0.14 mmol/L (95%CI -8.71 to -2.16) in LDL-C levels, compared to the predominant food format group of "butter, margarine, spreads". No significant differences were detected with the other subgroups (treatment duration, intake pattern, number of daily intakes and concomitant statin treatment).

CONCLUSION

The present meta-analysis supported that the use of PS-fortified foods had a beneficial effect on LDL-C lowering. In addition, it was observed that the factors that influence a decline LDL-C levels were PS dose as well as the food format in which they were consumed.

Factors that may increase the risk of external apical root resorption during orthodontic treatment : Retrospective clinical investigation

PURPOSE

To determine the correlation between external apical root resorption and malocclusion-related variables in patients treated with fixed orthodontic appliances.

METHODS

In all, 103 patients aged 12-15 years and treated with edge-wise appliances either without extractions or with four premolar extractions were included in this retrospective cohort study. External apical root resorption was assessed in the pre- and posttreatment panoramic radiographs of these patients for incisors, canines, premolars, and first molars. A total of 2332 teeth were evaluated in 206 panoramic radiographs obtained from 103 patients. The gender of the patients, duration of orthodontic treatments, presence of premolar extractions, Angle classification, overbite, overjet and amount of crowding were assessed. Wilcoxon signed-rank test, Mann-Whitney U test, and Kruskal-Wallis test were used for statistical analysis of the data.

RESULTS

Statistically significant (p < 0.001) root resorption occurred in all examined teeth during orthodontic treatment. The degree of root resorption observed in the premolars was significantly greater in premolar extraction cases than in nonextraction cases. Statistically significant negative correlations were found between the degree of root resorption of the maxillary lateral teeth and between the maxillary first premolar teeth and the amount of maxillary crowding.

CONCLUSIONS

The orthodontic treatment protocols and the amount of tooth movements achieved were shown to be dependent on the severity of dental malocclusions and they have an influence on the amount of external apical root resorption that occurs during the course of orthodontic treatment.

Short vs long-course antibiotic therapy in adults with acute cholangitis: A systematic review, meta-analysis, and evidence quality assessment

BACKGROUND

Acute cholangitis (AC) constitutes an infection with increased mortality rates in the past. Due to new diagnostic tools and therapeutic methods, the mortality of AC has been significantly reduced nowadays. The initial antibiotic treatment of AC has been oriented to the most common pathogens connected to this infection. However, the optimal duration of the antibiotic treatment of AC is still debatable.

AIM

To investigate if shorter-course antibiotic treatments could be similarly effective to long-course treatments in adults with AC.

METHODS

This study constitutes a systematic review and meta-analysis of the existing literature concerning the duration of antibiotic therapy of AC and an assessment of the quality of the evidence. The study was conducted in accordance with the recommendations of the Preferred Reporting Items for Systematic Review and Meta-Analyses. Fifteen studies were included in the systematic review, and eight were eligible for meta-analysis. Due to heterogeneous duration cutoffs, three study-analysis groups were formed, with a cutoff of 2-3, 6-7, and 14 d.

RESULTS

A total of 2763 patients were included in the systematic review, and 1313 were accounted for the meta-analysis. The mean age was 73.66 ± 14.67 years, and the male and female ratio was 1:08. No significant differences were observed in the mortality rates of antibiotic treatment of 2-3 d, compared to longer treatments (odds ratio = 0.78, 95% confidence interval: 0.23-2.67, I² = 9%) and the recurrence rates and hospitalization length were also not different in all study groups.

CONCLUSION

Short- and long-course antibiotic treatments may be similarly effective concerning the mortality and recurrence rates of AC. Safe conclusions cannot be extracted concerning the hospitalization duration.

Antimicrobial treatment of patients with a periprosthetic joint infection: basic principles

The antibiotic treatment of periprosthetic joint infections (PJI) is complicated by the presence of biofilm produced by bacteria on the abiotic surface of the implant. Bacteria within the deeper layers of the biofilm become metabolically less active, resulting in antibiotic tolerance due to several mechanisms. This review describes the basic principles of antibiotic treatment in PJI in relation to the behavior of bacteria within the biofilm. The concept of biofilm-active antibiotics will be explained from an in vitro as well as in vivo perspective. Evidence from clinical studies on biofilm-active antibiotics in PJI will be highlighted, mainly focusing on the role of rifampicin for Gram-positive microorganisms and fluoroquinolones for Gram-negative microorganisms. The optimal treatment duration will be discussed as the timing of switching to oral antibiotic therapy.

Treatment patterns in older patients with myelodysplastic syndromes: A population-based analysis reflecting the real world

INTRODUCTION

Treatment for myelodysplastic syndromes (MDS) is complex, options are limited, and insight into consecutive treatments is lacking. We performed this study to assess the outcomes in a real-world cohort of patients with MDS.

MATERIALS AND METHODS

An observational population-based study was performed using the HemoBase registry. Treatment patterns and overall survival (OS) were analyzed with Kaplan-Meier analyses.

RESULTS

In 144 of 280 (51.4%) patients with MDS >50 years, first-line treatment was initiated. The median age was 75.1 years (range: 52.6-92.0); the majority were male (72.2%). Hypomethylating agents (HMA), intensive chemotherapy, lenalidomide, and erythropoiesis-stimulating agents (ESA) were given as first-line treatment to 31.1% (n = 45), 12.5% (n = 18), 2.8% (n = 4), and 53.5% (n = 77) of the population, respectively. The median treatment duration was 5.8 months (95% Confidence Interval [CI]: 1.1-10.4) for HMA, 1.7 months (95%CI: 0.9-2.6) for intensive chemotherapy, 10.8 months (95%CI: 4.7-17.0) for lenalidomide, and 14.8 months (95%CI: 11.4-18.1) for ESA. Consecutive treatments were given to 27.2% of patients. The main reasons for first-line treatment discontinuation were treatment failure (45.8%), toxicity (6.9%), or death (20.1%). Median OS after termination of the initial, second, and third treatment was 5.8 months (95%CI: 3.2-8.5), 9.3 months (95%CI: 0.0-19.6), and 1.0 months (95%CI: 0.0-5.1), respectively.

DISCUSSION

This study shows the treatment outcomes in a real-world population of older patients with MDS. Treatment duration and median OS after treatment discontinuation were relatively limited. There is still an urgent need for new treatment options, strategies to further optimize duration of existing treatments, and communication of realistic treatment goals and expectations, especially for older, higher-risk patients with MDS with a poor prognosis.

Observational versus randomized controlled trials to inform antibiotic treatment durations: a narrative review

BACKGROUND

Studies comparing shorter and longer antibiotic treatment durations are increasingly common. Randomized controlled trials (RCTs) are an ideal methodological approach to study antibiotic treatment durations; however, these trials can be logistically and financially challenging to conduct.

OBJECTIVES

In this narrative review, we sought to compare the strengths and limitations of observational study data with those of RCT data in evaluating antibiotic treatment durations. We used uncomplicated Gram-negative bacteraemia as an illustrative case example because several published RCTs and observational studies have been conducted in similar patient populations.

SOURCES

We searched MEDLINE for articles comparing treatment durations for gram-negative bacteremia from inception to June 9th, 2022. We included studies reporting on all-cause mortality and/or relapse at day 28-30. Data comparing short- versus long-course therapy were pooled by Bayesian random effects meta-analyses to assess the odds ratios (OR) of all-cause mortality and relapse at 30 days, stratified by study design. Parameters were summarized with median and 95% highest-density credible intervals (CrI). Posterior probabilities of OR > 1.0 were estimated. Observational studies were further examined to determine if and how they addressed potential sources of bias.

CONTENT

We identified 1671 unique records and included 10 studies (seven observational and three RCTs). With respect to 30-day mortality, the Bayesian posterior probability that a longer course of therapy was better (i.e. OR >1.0) was 42% in RCTs (OR, 0.94; 95% CrI, 0.51-1.68) and 91% in observational studies (OR, 1.25; 95% CrI, 0.88-1.73). No observational study fully addressed all potential sources of bias.

IMPLICATIONS

On the basis of our findings, we discuss future directions for antibiotic treatment duration trials, including approaches to limit sources of bias in observation data and novel trial designs.

Duration of antibiotic treatment for Gram-negative bacteremia - Systematic review and individual participant data (IPD) meta-analysis

BACKGROUND

We aim to compare the effect of short versus long treatment duration in Gram-negative bacteremia on all-cause mortality in pre-specified sub-groups.

METHODS

Individual participant data meta-analysis of randomized controlled trials (RCTs) comparing short (≤7) versus longer (>7 days) antibiotic treatment for Gram-negative bacteremia. Participants were adults (≥18 years), with Gram-negative bacteremia during hospital stay. We searched PubMed, Cochrane Central Register of Controlled Trials, and Web of Science to identify trials conducted up to May 2022. Primary outcome was 90-day all-cause mortality. Secondary outcomes were 30-day mortality, relapse of bacteremia, length of hospital stay, readmission, local or distant infection complications, adverse events, and resistance emergence.Outcomes were assessed in pre-specified subgroups: women vs men; non-urinary vs urinary source; presence vs absence of hypotension on initial presentation; immunocompromised patients versus non-immunocompromised patients, and age (above/below 65). Fixed-effect meta-analysis model was used to estimate pooled odds ratio (OR) and 95% confidence interval (CI). All three trials had low risk of bias for allocation generation and concealment.

FINDINGS

Three RCTs (1186 patients) were included; 1121 with enterobacterales bacteremia. No significant difference in mortality was demonstrated between 7- and 14-days treatment (90-day mortality: OR 1.08, 95% CI 0.73-1.58; 30-day mortality: 1.08, 0.62-1.91). Relapse (1.00, 0.50-1.97); length of hospital stay (P = 0.78); readmission (0.96, 0.80-1.22); and infection complications (local: 1.62 0.76-3.47; distant: 2.00, 0.18-22.08), were without significant difference, and so were adverse events or resistance emergence.No significant difference in clinical outcomes between 7 and 14 days of antibiotics was demonstrated in the subgroups of gender, age, hemodynamic status, immune status, and source of infection.

INTERPRETATION

For patients hemodynamically stable and afebrile at 48 h prior to discontinuation, seven days of antibiotic therapy for enterobacterales bacteremia result in similar outcomes as 14 days, in terms of mortality, relapse, length of hospital stay, complications of infection, resistance emergence, and adverse events. These results apply for any adult age group, gender, source of infection, immune status, and hemodynamic status on presentation.

FUNDING

There was no funding source for this study.

Orthodontic brackets debonding: evaluation of the time factor and the tooth type]

Introduction

The aim of the study was to assess the time factor and tooth type during premature debond of orthodontic brackets.

Material and Method

A retrospective epidemiological study was carried out on adolescents who had benefited from a multi-metal vestibular attachment treatment, having all 6 to 6 teeth bonded to the arch on the day of installation.

Results

333 patients were included. The detachment rate decreased as the treatment progresses. The teeth with most orthodontic debonding were the maxillary first molar, mandibular first molar, mandibular second premolar, and maxillary second premolar. Skeletal class II patients tended to take off more than class I patients. Detachments were significantly more frequent in the mandibular arch in deepbite compared to normalbite patterns, the mandibular second premolar being the tooth at risk. There seems to be a correlation between the quality of oral hygiene and the rate of detachment, regardless of the time of treatment.

Discussion

The type of orthodontic movement, the quality of the bonding, the failure to observe the precautions by the patient may affect the date of the detachment. The low coronary height, hygiene, the biting force, the divergence seems to intervene on the type of attachment debonded.

Conclusion

The brackets are more particularly debonded at the start of treatment and on the posterior teeth. Anteroposterior and especially vertical dysmorphosis could have an implication in debonding.

Trastuzumab therapy duration in HER2-positive de novo metastatic breast cancer: 1999-2018

PURPOSE

The optimal duration of first-line trastuzumab (T) treatment for de novo stage IV HER2-positive metastatic breast cancer (MBC) patients after complete response (CR) is not known.

METHODS

A retrospective cohort study of de novo stage IV HER2-positive MBC patients who had trastuzumab included in their initial treatment (n = 69), 1999-2018, was conducted with follow-up for CR, progressive disease (PD), vital status, and disease-specific survival (DSS). Statistics included Kaplan-Meier plots and Cox proportional hazards models.

RESULTS

Mean trastuzumab treatment time was 4.1 years (range 0.1-15). 54% of patients experienced CR at average time 9 months on treatment (n = 37). Eight CR patients discontinued T treatment after 18 months average post-CR time (range 0-86) and twenty-nine stayed on T treatment post CR [average 65 months (range 10-170)]. Average follow-up was 6 years, range 1-15 years. 5-year DSS was 92% for CR on T patients (N = 29); 88% CR off T (n = 8); 73% No CR on T (n = 14); and 29% No CR off T (n = 18) (p < 0.001). In forward Cox proportional hazards modeling, CR = yes [HzR = 0.31, (95% CI 0.14, 0.73), p = 0.007], continuous T treatment > 2 years [HzR = 0.24, (95% CI 0.10, 0.62), p = 0.003], and age < 65 [HzR = 0.29, (95% CI 0.11, 0.81), p = 0.018] were significantly associated with better DSS.

CONCLUSION

Maximum trastuzumab treatment time to CR was 27 months with 2 or more years trastuzumab treatment independently associated with better survival. Survival comparisons and hazard modeling both indicate as good or better survival associated with continuous trastuzumab treatment regardless of CR status. Word count (n = 250).

De-escalating adjuvant durvalumab treatment duration in stage III non-small cell lung cancer

BACKGROUND

One year of adjuvant durvalumab following concurrent chemoradiotherapy significantly improves progression-free survival (PFS) and overall survival (OS) for patients with stage III non-small cell lung cancer (NSCLC). However, the optimal length of adjuvant therapy has not been determined.

METHODS

We identified patients with stage III NSCLC treated with definitive chemoradiation and adjuvant durvalumab from November 2017 to April 2021 from the United States Veterans Affairs system. Predictors of early durvalumab discontinuation were evaluated with Cox proportional hazards regression. The effect of differing durations of durvalumab treatment (up to 6, 9, and 12 months) on PFS and OS were compared with a marginal structural model and time-dependent Cox modelling.

RESULTS

We included 1006 patients with stage III non-small cell lung cancer who received concurrent chemoradiotherapy and at least one dose of adjuvant durvalumab. The median duration of durvalumab treatment was 7 months (interquartile range 2.8-11.5) and 31% completed the intended durvalumab course. The most common reasons for early discontinuation were tumour progression (22%), immune-related adverse events (15%), and non-immune-related toxicity (6.0%), Marginal structural models suggested similar PFS for 9 months versus 12 months of durvalumab treatment and inferior PFS for 6 months versus 12 months.

CONCLUSIONS

A substantial proportion of patients undergoing adjuvant durvalumab discontinue therapy early due to toxicity, and shorter durvalumab treatment durations may provide similar disease control to 12 months of therapy. Prospective randomised controlled studies are needed to characterise the optimal durvalumab treatment duration in locally advanced NSCLC patients.

Cost-Effectiveness of Shortening Treatment Duration Based on Interim PET Outcome in Patients With Diffuse Large B-cell Lymphoma

BACKGROUND

Guideline recommendations for diffuse large-B-cell lymphoma (DLBCL) treatment are shifting from long to short treatment duration, although it is still unclear whether shortening treatment duration does not cause any harm. As interim PET (I-PET) has high negative predictive value for progression, we evaluated the cost-effectiveness of shortening treatment duration dependent on I-PET result.

MATERIALS AND METHODS

We developed a Markov cohort model using the PET Re-Analysis (PETRA) database to evaluate a long treatment duration (LTD) strategy, ie 8x R-CHOP or 6x R-CHOP plus 2 R, and a short treatment duration (STD) strategy, ie 6x R-CHOP. Strategies were evaluated separately in I-PET2 positive and I-PET2 negative patients. Outcomes included total costs and quality-adjusted life-years (QALYs) per patient (pp) from a societal perspective. Net monetary benefit (NMB) per strategy was calculated using a willingness-to-pay threshold of €50,000/QALY. Robustness of model predictions was assessed in sensitivity analyses.

RESULTS

In I-PET2 positive patients, shortening treatment duration led to 50.4 additional deaths per 1000 patients. The STD strategy was less effective (-0.161 [95%CI: -0.343;0.028] QALYs pp) and less costly (-€2768 [95%CI: -€8420;€1105] pp). Shortening treatment duration was not cost-effective (incremental NMB -€5281). In I-PET2 negative patients, shortening treatment duration led to 5.0 additional deaths per 1000 patients and a minor difference in effectiveness (-0.007 [95%CI: -0.136;0.140] QALY pp). The STD strategy was less costly (-€5807 [95%CI: -€10,724;-€2685] pp) and led to an incremental NMB of €5449, indicating that it is cost-effective to shorten treatment duration. Robustness of these findings was underpinned by deterministic and probabilistic sensitivity analyses.

CONCLUSION

Treatment duration should not be shortened in I-PET2 positive patients whereas it is cost-effective to shorten treatment duration in I-PET2 negative patients.

[Cholecystectomy in acute cholecystitis-a surgical emergency or elective in the next day's program?]

BACKGROUND

The treatment of acute cholecystitis is based on the German S3 guidelines on "Prophylaxis, diagnosis and treatment of gallstones", which was updated in 2018. If the patient has no contraindications for surgery, early laparoscopic cholecystectomy is the treatment of choice.

OBJECTIVE

Current meta-analyses and studies confirm that for most patients the optimal period of time for surgical treatment is the first 24 h after hospitalization; however, there is an ongoing controversial discussion on how strictly the 24 h rule should be adhered to and under which circumstances it may be valid to deviate from it.

MATERIAL AND METHOD

A systematic analysis of the current literature and a clinical evaluation were carried out.

RESULTS

For the diagnosis of an acute cholecystitis, laparoscopic cholecystectomy should be carried out within the first 24 h after hospitalization regardless of the age and comorbidities of the patient as well as the severity of inflammation. If there is no special emergency situation, under certain circumstances surgery can be performed in the next day's program.

DISCUSSION

This recommendation for early surgery for high-risk patients has so far been controversially discussed; however, current studies confirm that the advantages of early surgery outweigh the disadvantages also for this group of patients. The surgical risk should be individually assessed and be included in the treatment decision.

A randomized factorial trial of internet-delivered cognitive behavioural therapy: An 8-week program with or without extended support and booster lesson

While internet-delivered cognitive behavioural therapy (ICBT) is effective, some patients suggest extended support post-treatment could improve care. In this randomized factorial trial, we examined the benefits of an 8-week therapist-assisted ICBT program offered with or without an optional 4-week extension of support (Factor 1) and with or without an optional booster lesson (Factor 2). Patients screened for ICBT for depression and/or anxiety were randomly assigned to the conditions (N = 434) and we examined the use of the extension and booster, differences between those who did or did not use extension or booster, and the impact of the extension or booster on outcomes, engagement, and satisfaction at 26-weeks post-enrollment. Therapists recorded time and observations with offering support during the extension and booster. In the extension group, 54.4% (n = 56) requested the extension, while in the booster group 50.9% (n = 56) accessed the booster, and in the combined group, 41.6% (n = 47) requested the extension and 51.3% (n = 58) accessed the booster. Those who requested the extension were older, and more likely to report medication and mental health service use and severe mental health-related disability at pre-treatment; they also reported putting less effort into ICBT and finding skills more difficult. The booster was more often used among those with lower symptom severity, and those who put more effort into and had more positive experiences with ICBT. As expected, those assigned to extension sent more messages to their therapist, and those assigned to booster logged in more often. Therapists also took more time to deliver ICBT with an extension (>18 min) or booster (>13 min) compared to the 8-week program, and perceived extension and booster as beneficial for some, but not all patients. Treatment satisfaction was high across conditions, and effect sizes were large from pre-treatment to 26-week follow-up on most measures. No significant group differences were found in this study. Lack of group differences, however, could reflect low use of the extension and booster. Results provide helpful information about the demand for extensions and boosters, and provide directions for future research.

Treatment Patterns in US Patients Receiving First-Line and Second-Line Therapy for Metastatic Pancreatic Ductal Adenocarcinoma in the Real World

INTRODUCTION

Metastatic pancreatic ductal adenocarcinoma (mPDAC) is a common cancer with poor survival outcomes. Although treatment options are limited, real-world treatment patterns and outcomes are not well understood, particularly beyond first-line treatment. This study described real-world treatment patterns and outcomes for mPDAC in the USA.

METHODS

This retrospective analysis used electronic health record-derived de-identified data of patients with mPDAC diagnosed between January 1, 2014 and June 30, 2021. Treatments were classified into six groups: (1) standard combination chemotherapy; (2) nonstandard combination chemotherapy; (3) single-agent chemotherapy; (4) targeted therapy; (5) clinical study drugs; and (6) off-label therapies. Analyses were descriptive in nature. Treatment utilization and switching, and time on treatment and time to discontinuation, were described by first-line (1LOT) and second-line (2LOT) treatment groups. Median overall survival (mOS) from 1LOT and 2LOT was stratified by treatment group, and for 1LOT on the basis of whether patients received further treatment.

RESULTS

1LOT included 6979 patients, 3241 (46%) of whom received further 2LOT. Standard combination chemotherapy was the most common 1LOT (70%) and 2LOT (46%). Nonstandard combination chemotherapy was used more as 2LOT (35%) than 1LOT (11%). First-line time on treatment was generally higher than second-line time on treatment, and time to discontinuation was lower than time on treatment. mOS in days (months) from 1LOT was 271 (8.9), 252 (8.3), 219 (7.2), 170 (5.6), 280 (9.2), and 182 (6.0), and mOS from 2LOT was 202 (6.6), 193 (6.3), 186 (6.1), 193 (6.3), 179 (5.9), and 97 (3.2), for groups 1-6, respectively. Within group 1, mOS from 1LOT was 318 days (10.4 months) for FOLFIRINOX and 241 days (7.9 months) for gemcitabine and nab-paclitaxel.

CONCLUSION

Most patients with mPDAC received 1LOT in line with clinical practice guidelines, yet mOS remains poor. This study highlights the need for novel therapies to demonstrate improved patient survival compared with therapies in current clinical practice guidelines.

The issue with claiming "non-inferiority" to the control group with poor outcomes

We wrote a commentary for the article by Molina et al. 1. Molina J, Montero-Mateos E, Praena-Segovia J, León-Jiménez E, Natera C, López-Cortés LE, et al. Seven-versus 14-day course of antibiotics for the treatment of bloodstream infections by Enterobacterales: a randomized, controlled trial. Clin Microbiol Infect. 2021 Sep. epub ahead of print.

Real-world effectiveness and rheumatologist satisfaction with secukinumab in the treatment of patients with axial spondyloarthritis

OBJECTIVES

To assess the effectiveness of secukinumab in patients with axSpA treated in routine clinical settings in 5 European countries.

METHODS

Retrospective analysis of a cross-sectional survey to assess real-world effectiveness of secukinumab in the management of axSpA and rheumatologist satisfaction with treatment in France, Germany, Italy, Spain and the UK from March to December 2018. Outcomes collected included patient demographics, clinical characteristics and rheumatologist- and patient-reported satisfaction with secukinumab treatment.

RESULTS

Five hundred thirty-five patients receiving secukinumab for more than 4 months were assessed, 359 of whom were diagnosed with AS and 178 with nr-axSpA. Rheumatologist assessment of disease status at treatment initiation indicated that 39 (7.3%) had stable/improving disease. Secukinumab treatment for 4 months or longer resulted in 515 (95.9%) patients judged as stable/improving. Treatment was associated with benefits from initiation to assessment in terms of BASDAI (6.2 vs 2.8), 44-joint count score (9.7 vs 6.6), rheumatologist global VAS score (56.9 vs 23.0) and patient global VAS scores (64.4 vs 25.5). These benefits for key clinical outcomes were sustained for periods of 12 months or longer. Patient-reported outcomes on health status using EQ-5D, global functioning using the ASAS health index and overall work impairment via WPAI were sustained over the treatment period, while patient and rheumatologist satisfaction with secukinumab treatment remained very high at 80.2 and 91.2%, respectively.

CONCLUSION

Consistent benefits across multiple clinical and patient-reported outcomes were seen with secukinumab treatment in patients with AS and nr-axSpA treated in routine clinical settings across five European countries. Key Points • In routine clinical settings across five European countries, secukinumab treatment resulted in improvements in a wide range of clinical outcomes including physician-reported disease severity, disease status, pain, BASDAI, 44-joint count score and global VAS scores. • Key clinical and patient reported outcomes were sustained for a 12-month period or longer with secukinumab treatment. • Rheumatologist- and patient-reported treatment satisfaction was high with secukinumab.

Seven-versus 14-day course of antibiotics for the treatment of bloodstream infections by Enterobacterales: a randomized, controlled trial

OBJECTIVE

To prove that 7-day courses of antibiotics for bloodstream infections caused by members of the Enterobacterales (eBSIs) allow a reduction in patients' exposure to antibiotics while achieving clinical outcomes similar to those of 14-day schemes.

METHODS

A randomized trial was performed. Adult patients developing eBSI with appropriate source control were assigned to 7 or 14 days of treatment, and followed 28 days after treatment cessation; treatments could be resumed whenever necessary. The primary endpoint was days of treatment at the end of follow-up. Clinical outcomes included clinical cure, relapse of eBSI and relapse of fever. A superiority margin of 3 days was set for the primary endpoint, and a non-inferiority margin of 10% was set for clinical outcomes. Efficacy and safety were assessed together with a DOOR/RADAR (desirability of outcome ranking and response adjusted for duration of antibiotic risk) analysis.

RESULTS

248 patients were assigned to 7 (n = 119) or 14 (n = 129) days of treatment. In the intention-to-treat analysis, median days of treatment at the end of follow-up were 7 and 14 days (difference 7, 95%CI 7-7). The non-inferiority margin was also met for clinical outcomes, except for relapse of fever (-0.2%, 95%CI -10.4 to 10.1). The DOOR/RADAR showed that 7-day schemes had a 77.7% probability of achieving better results than 14-day treatments.

CONCLUSIONS

7-day schemes allowed a reduction in antibiotic exposure of patients with eBSI while achieving outcomes similar to those of 14-day schemes. The possibility of relapsing fever in a limited number of patients, without relevance to final outcomes, may not be excluded, but was overcome by the benefits of shortening treatments.

Effects of antibiotic duration on the intestinal microbiota and resistome: The PIRATE RESISTANCE project, a cohort study nested within a randomized trial

Background

Shortening antibiotic-treatment durations is a key recommendation of antibiotic-stewardship programmes, yet it is based on weak evidence. We investigated whether halving antibiotic courses would reduce antibiotic-resistance genes (ARG) in the intestinal microbiomes of patients treated for gram-negative bacteraemia.

Methods

This nested prospective cohort study included adult patients hospitalized at Geneva University Hospitals (Switzerland) participating in the PIRATE randomized trial assessing non-inferiority of shorter antibiotic courses (7 versus 14 days) for gram-negative bacteraemia (‘cases’) and, simultaneously, hospitalized patients with similar demography and comorbidity yet no antibiotic therapy (‘controls’). Stool was collected from case and control patients on days 7, 14, 30 and 90 after antibiotic initiation (day 1) and days 7 and 14 after admission, respectively, and analysed by whole-metagenome shotgun sequencing. The primary outcome was ARG abundance at day 30; secondary outcomes included microbiota-species composition and clustering over time.

Findings

Forty-five patients and 11 controls were included and evaluable; ARG analyses were conducted on the 29 per-protocol patients receiving 7 (±2) days or 14 (±3) days of antibiotic therapy. At day 30, ARGs were not detected at similar abundance in patients receiving 7 and 14 days (median counts/million [mCPM]: 96 versus [vs] 71; p=.38). By day 30, total ARG content between both groups was not significantly different from that of controls at D7 (362 and 370 mCPM vs 314 mCPM, p=.24 and 0.19). There were no significant differences amongst antibiotic-treated patients at any timepoint in bacterial diversity or clustering, but Shannon species diversity was significantly reduced compared to controls through day 14 (median 3.12 and 3.24 in the 7-day and 14-day groups vs 3.61 [controls]; p=.04 and 0.012). Patients treated for 14 days had reduced faecal phage content during and after therapy compared to other patient groups.

Interpretation

Reducing antibiotic durations by half did not result in decreased abundance of ARGs in patients treated for gram-negative bacteraemia, nor did it improve microbiota species diversity.

Funding

The study was funded by the University of Geneva's Louis-Jeantet Foundation (grant no. S04_12) and the Swiss National Science Foundation (NRP Smarter Healthcare, grant no. 407,440_167359).

Real-World Treatment Patterns and Overall Survival of Patients with Metastatic Castration-Resistant Prostate Cancer in the US Prior to PARP Inhibitors

Introduction

Therapeutic options for metastatic castration-resistant prostate cancer (mCRPC) patients are continuously advancing. We described mCRPC treatment patterns in the US from 2013 to 2019.

Methods

Patients with a confirmed mCRPC diagnosis and adenocarcinoma histology were included in the US Flatiron Health Electronic Health Record-derived de-identified database. Treatment patterns [including treatment per lines of therapies (LOTs), LOT sequences, and time on treatment] and overall survival (OS) have been described in mCRPC settings.

Results

Of 5213 patients (mean age: 72.6 years), 4374 (83.9%) were treated with ≥ 1 LOT post-mCRPC diagnosis (among those with ≥ 1 LOT, 55.3%, 29.5%, 14.7%, and 6.7% had ≥ 2, 3, 4, and 5 LOTs, respectively). In first line (1L), the main treatment class was next-generation hormonal agents (NHA; 62.5% of patients with ≥ 1 LOT), while the shortest and longest time on 1L were observed for chemotherapy (median 2.8 months) and NHA (median 5.1 months), respectively. The most common LOT sequences were NHA → NHA (29.4% of patients with ≥ 2 LOTs) and NHA → NHA → chemotherapy (16.7% of patients with ≥ 3 LOTs). In Kaplan–Meier analyses, the median OS was 19.4, 14.6, and 11.1 months post-1L, 2L, and 3L start, respectively. Patients who moved rapidly through LOTs had an increased risk of death.

Conclusions

NHA were widely used as 1L therapy in mCRPC patients from 2013 to 2019, but time on 1L NHA treatment was on average < 6 months. While NHA → NHA was the most observed 1L → 2L LOT sequence, a plethora of other LOT sequences were observed. OS was poor, highlighting an unmet need for life-prolonging treatments.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-01823-6.

Impact of Extended Duration of Polymyxin B-Immobilized Fiber Column Direct Hemoperfusion on Hemodynamics, Vasoactive Substance Requirement, and Pulmonary Oxygenation in Patients with Sepsis: An Observational Study

INTRODUCTION

Polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP) is used for patients with septic shock, and the recommended hemoperfusion period is 2 h. However, it remains unclear whether the optimal duration is 2 h or longer. The purpose of this study was to compare the effects of PMX-DHP between conventional and longer duration of PMX-DHP.

METHODS

We retrospectively investigated 103 patients with sepsis who underwent PMX-DHP. The demographic data, routine biochemistry, microbiological data, and primary infection site were reviewed in the medical chart. The acute physiology and chronic health evaluation (APACHE) II score, sequential organ failure assessment (SOFA) score, heart rate, mean arterial pressure (MAP), vasoactive-inotropic score (VIS), and PaO2/FiO2, at baseline and day 3, were compared between the standard group (2 h of PMX-DHP) and the extended group (>2 h of PMX-DHP).

RESULTS

Median MAP was significantly lower and median VIS was significantly higher in the extended group at baseline (p < 0.05, 0.01, respectively) There were no significant differences in APACHE II score, SOFA score, and PaO2/FiO2 at baseline between the 2 groups. The increase of MAP and the decrease in VIS from baseline to day 3 were significantly greater in the extended group (p < 0.01, respectively). In the extended group, increase in PaO2/FiO2 was significantly larger in the patients who underwent ≥8 h duration than that in patients who underwent <8 h duration (p < 0.01). The ventilator-free days, the incidence of continuous renal replacement therapy, and the 28-day mortality were not different between the groups.

DISCUSSION/CONCLUSIONS

Longer duration of PMX-DHP was associated with the improved MAP and decreased volume of vasoactive-inotropic agents compared with the conventional duration. Eight and longer hours duration of PMX-DHP was associated with the improvement in the pulmonary oxygenation. Further studies are needed to confirm the efficacy of longer duration of PMX-DHP in patients with septic shock.

Quality of care indicators in the MAnageMent of BlOOdstream infections caused by Enterobacteriaceae (MAMBOO-E study): state of the art and research agenda

OBJECTIVES

The impact on outcome of five interventions was reviewed in order to investigate the state of the art for management of Enterobacteriaceae bloodstream infection (E-BSI).

METHODS

We searched for randomised controlled trials (RCTs) and observational studies published from January 2008 to March 2019 in PubMed, EMBASE and Cochrane Library. Populations consisted of patients with E-BSI. Interventions were as follows: (i) performance of imaging to assess BSI source and/or complications; (ii) follow-up blood cultures (FU-BCs); (iii) use of loading dose followed by extended/continuous infusion (E/CI) of β-lactams; (iv) duration of treatment (short- versus long-term); and (v) infectious diseases (ID) consultation. Patients without intervention were considered as controls. The main outcome was 30-day mortality. RoB 2.0 and ROBINS-I tools were used for bias assessment.

RESULTS

No study was eligible for interventions i, iii and v. For FU-BCs, one observational study including 901 patients with E-BSI was considered. Intervention consisted of repeating BCs within 2-7 days after index BCs. All-cause 30-day mortality was 14.2% (35/247) in the intervention group versus 14.7% (96/654) in the control group. For short treatment duration, two RCTs and six observational studies were included comprising 4473 patients with E-BSI. All-cause mortality was similar in the short and long treatment groups (OR = 1.10, 95% CI 0.83-1.44).

CONCLUSION

Of the assessed interventions, only short treatment duration in non-immunocompromised patients with E-BSI is supported by current data. Studies investigating the use of systematic imaging, FU-BCs, E/CI β-lactams and ID consultation in patients with E-BSI are needed.

Addressing HCV Elimination Barriers in Italy: Healthcare Resource Utilization and Cost Impact Using 8 Weeks' Glecaprevir/Pibrentasvir Therapy

Introduction

In Italy, hepatitis C virus (HCV) elimination is achievable; however, barriers remain to achieving the World Health Organization’s elimination targets, and have become more pronounced with the spread of COVID-19. Glecaprevir/pibrentasvir (G/P) is a direct-acting antiviral therapy for HCV, approved for 8-week treatment in patients without cirrhosis, and with compensated cirrhosis (CC). Previously, 12 weeks of therapy was recommended for patients with CC. Shortened treatment may reduce the burden on healthcare resources, allowing more patients to be treated. This study presents the benefits that 8-week vs 12-week treatment with G/P may have in Italy.

Methods

A multicohort Markov model was used to assess the collective number of healthcare visits and time on treatment with 8-week vs 12-week G/P in the HCV-infected population of Italy from 2019 to 2030, using healthcare resource data from post-marketing observational studies of G/P. Increased treatment capacity and downstream clinical and economic benefits were also assessed assuming the reallocation of saved healthcare visits to treat more patients.

Results

Modeled outcomes showed that by 2030, 8-week treatment saved 27,006 years on therapy compared with 12-week treatment, with 21,065 fewer hepatologist visits. Reallocating these resources to treat more patients could increase capacity to treat 5064 (1.4%) more patients with 8 weeks of G/P, all with CC. This increased treatment capacity would further avoid 2257 cases of end-stage liver disease, 893 liver-related deaths, and provide net savings to the healthcare system of nearly €70 million.

Conclusion

The modeled comparisons between 8- and 12-week treatment with G/P show that shorter treatment duration can lead to greater time and resource savings, both in terms of healthcare visits and downstream costs. These benefits have the potential to enable the treatment of more patients to overcome elimination barriers in Italy through programs aimed to engage and treat targeted HCV populations.

Real world duration of curative intent breast, colorectal, non-small cell lung, and prostate cancer treatment

Background

Advances in curative treatment for breast, colorectal, NSCLC and prostate cancer have led to improvements in cancer survival. Cancer treatment and recovery time can vary depending on the recommended modalities and intensity of therapy. Our objective was to determine the current real world duration of curative treatments for the four common cancers.

Methods

A retrospective review was completed of patients referred to BC Cancer from 2010 to 2016, ≤ 65 years old, newly diagnosed with stage I-III breast, colorectal, NSCLC or prostate cancer who received curative intent treatment. Information was collected on baseline characteristics, date of diagnosis, surgery, type, duration and intent of both radiotherapy and chemotherapy.

Results

In total, 22,275 patients were included: 55.7% breast, 22.4% colorectal, 9.2% NSCLC, 12.7% prostate cancer. Stage I/II/III at diagnosis: breast 47.2/38.7/14.1%, colorectal 26.5/30.1/43.5%, NSCLC 46.5/18.1/35.4%, prostate 7.7/62.9/29.4%. Patients treated with definitive surgery only: breast 35.9%, colorectal 58%, NSCLC 52.2%, prostate 40.1%. The median duration of multimodality treatment was breast 24.6 weeks, colorectal 26.7 weeks, NSCLC 9.1 weeks, and prostate 6.0 weeks.

Conclusions

Approximately half of patients who undergo curative cancer treatment require definitive radiotherapy or multimodality treatment. The median duration of therapy for the most commonly treated cancers ranged from 6.0–26.7 weeks. Multimodality curative treatment can be prolonged for selected cancers when accounting for the duration of adjuvant chemotherapy and radiotherapy and recovery time between modalities.

Factors influencing treatment efficiency

OBJECTIVES

The purpose of this cohort study was to evaluate the effect of self-ligating brackets (SB) and other related factors that influence orthodontic treatment time.

MATERIALS AND METHODS

This was a two-armed prospective study. Consecutively treated patients who were recruited from a private practice were enrolled and asked to choose between SB and conventional brackets (CB). If the patient did not have a preference, that patient was randomly allocated. An identical archwire sequence was used, and all patients were treated by a single orthodontist. Treatment duration, number of bracket failures, poor oral hygiene, poor elastic wear, whether or not to orthodontic mini-implants (OMI) were used, OMI failure, extraction, American Board of Orthodontics Discrepancy Index, and arch length discrepancy were measured and statistically analyzed using t-tests, correlation analysis, and analysis of covariance (ANCOVA). Stepwise regression analysis was conducted to generate an equation to predict treatment duration.

RESULTS

A total of 134 patients with an average age of 22.73 years were included. The average treatment duration was 28.63 months. ANCOVA showed no significant difference in treatment duration between CB and SB. Stepwise regression analysis could explain 64.6% of the variance in treatment duration using five variables.

CONCLUSIONS

SB did not exhibit a significant reduction in treatment time as compared with CB. Patient cooperation, extractions, and malocclusion severity had a significant impact on treatment duration.

Occlusal outcome after orthodontic treatment with preadjusted straight-wire and standard edgewise appliances : A retrospective cohort study

PURPOSE

Orthodontic fixed appliances have been proven to be effective in treating a wide variety of malocclusions, and different types of appliances have emerged during recent decades. However, the comparative effects of different appliances have not been adequately assessed. Thus, the aim was to assess the occlusal outcome of orthodontic treatment with preadjusted straight-wire (SWIRE) and standard edgewise (SEDGE) appliances.

METHODS

In all, 56 patients (mean age: 13.5 years; 45% male) receiving extraction-based treatment with either SWIRE or SEDGE appliances were included. Between-group differences in the occlusal outcome assessed with the American Board of Orthodontists Objective Grading System (ABO-OGS) and treatment duration were analyzed statistically at the 5% level.

RESULTS

The average ABO-OGS score was 31.3 ± 7.2 points and 34.0 ± 10.4 points in the SWIRE and SEDGE groups with no statistically significant difference between groups (P = 0.26). Treatment duration was significantly shorter in the SWIRE group compared to the SEDGE group, with an average difference of -6.8 months (95% confidence interval [95% CI] = -9.6 to -4.0 months; P < 0.001). Likewise, fewer visits were needed with SWIRE compared to SEDGE appliances with an average difference of -7.2 visits (95% CI = -10.3 to -4.2 visits; P < 0.001). Adjusting for the influence of any potential confounders did not considerably impact the results.

CONCLUSION

Similar treatment outcomes were observed after premolar extraction treatment with SWIRE and SEDGE appliances. On the other hand, SEDGE appliances were associated with prolonged treatment duration and more visits needed to complete treatment compared to SWIRE appliances.

Optimal duration of endocrine therapy with extended aromatase inhibitors for postmenopausal patients with hormone receptor-positive breast cancer: a meta-analysis

BACKGROUND

The optimal duration of endocrine therapy for patients with hormone receptor-positive (HR-positive) breast cancer is still unclear. This meta-analysis aims to determine the optimal duration of endocrine therapy with extended aromatase inhibitors (AI) for postmenopausal patients with HR-positive early breast cancer who have finished 5 years of endocrine therapy.

METHODS

Eligible randomized controlled trials were classified into three categories according to the whole duration of endocrine therapy (10 years versus 5 years, 7-8 years versus 5 years, and 10 years versus 7-8 years). For each category, hazard ratio (HR) for disease-free survival (DFS) and overall survival (OS), and risk ratio (RR) for the incidence of adverse events were pooled.

RESULTS

Altogether 9 RCTs enrolling a total of 22,313 postmenopausal women with HR-positive breast cancer were included. Pooled data showed an improvement in DFS when extending endocrine therapy from 5 to 7-8 years (HR = 0.79 [0.69, 0.91]), specifically among those who had been treated with only tamoxifen (HR = 0.40 [0.22, 0.73]) or sequential tamoxifen followed by AI (HR = 0.82 [0.71, 0.95]), with tumors that were node-positive (HR = 0.72 [0.56, 0.93]), estrogen receptor (ER) and progesterone receptor (PR) positive (HR = 0.61 [0.47, 0.78]), or ≥ 2 cm in size (HR = 0.72 [0.51, 0.98]). However, no improvement in DFS was obtained when extending from 7-8 to 10 years (HR = 0.98 [0.87, 1.11]). In addition, the extension of endocrine therapy was not associated with an improvement in OS, but was associated with an increased risk of bone fracture and osteopenia/osteoporosis.

CONCLUSION

Patients who have been treated with AI for 5 years, with tumors that are node-negative, ER+/PR- or ER-/PR+, and < 2 cm in size do not need to receive extended AI therapy. For those who have been treated with only tamoxifen or sequential tamoxifen followed by an AI for a total of 5 years, with tumors that are node-positive, ER+/PR+ or ≥ 2 cm in size, 2-3 years of extended AI is necessary and maybe enough.

[How long should treatment with tocilizumab be carried out for giant cell arteritis and how should it be ended (discontinue/taper off)?]

The revised S2 guidelines for treatment of giant cell arteritis have recently been published. Glucocorticosteroids remain the standard first line treatment. For severe or relapsing courses of the disease, the IL‑6 antagonist tocilizumab, a potent antibody, is now available as a therapeutic option; however, how long this treatment should be continued after having achieved a stable remission remains a matter of discussion. For patients with a complicated course and a high risk of relapse, a continuous treatment would be the safest way; however, with a milder course of disease for approximately half of the patients, treatment without relapse can be discontinued again.

Frontline treatment patterns and attrition rates by subsequent lines of therapy in patients with newly diagnosed multiple myeloma

BACKGROUND

For patients with multiple myeloma (MM), each additional line of therapy (LOT) is associated with lower response rates, shorter treatment duration and treatment-free intervals, and increased rates of toxicities and comorbidities. Here, we examine frontline treatment patterns, and attrition rates by LOT among newly diagnosed MM (NDMM) patients in the United States who were eligible or ineligible for autologous stem cell transplant (ASCT).

METHODS

Data were identified from three US patient-level databases collectively covering the period January 2000 to September 2018. Patients had an index diagnosis of MM on or after January 1, 2007, medical and prescription insurance coverage at diagnosis, a 1-year look-back period prior to the index diagnosis, no prior malignancies in the 1-year period before index diagnosis, and had received ≥1 LOT.

RESULTS

Among patients who did not receive ASCT (non-transplant; n = 22,062), 12,557 (57%) received only 1 LOT and 9505 (43%) received > 1 LOT. Patients receiving only 1 LOT were significantly older, had higher mean Charlson Comorbidity Index (CCI) scores, and higher incidences of comorbidities. Among the 2763 patients receiving ASCT, 2184 received > 1 LOT, and 579 (21%) received only 1 LOT (ie, ASCT was the last treatment). 1682 (61%) patients received induction therapy as frontline treatment, of whom 187 (11%) also received consolidation therapy. The latter group was younger than those who received only induction therapy, had lower mean CCI scores, and comparable or lower incidences of selected comorbidities. The most common frontline therapy for non-transplant and transplant-eligible patients was bortezomib/dexamethasone and bortezomib/lenalidomide/dexamethasone, respectively. Attrition rates across all LOTs were high for non-transplant patients (range, 43-57%) and transplant patients (range, 21-37%). Treatment duration decreased by LOT for non-transplant patients and was consistent across LOTs for transplant patients.

CONCLUSIONS

In this analysis, a substantial proportion of patients with NDMM who received frontline therapy did not appear to receive a subsequent LOT. These high attrition rates underscore the need to use the most optimal treatment regimens upfront rather than reserving them for later LOTs in which the clinical benefit may decrease.

Does a 5-day course of antibiotics in elderly patients with community-acquired pneumonia achieve the established criteria of clinical stability?

OBJECTIVE

We aimed to determine the proportion of elderly patients hospitalised for community-acquired pneumonia (CAP) in whom a 5-day antibiotic therapy would achieve clinical stability according to American Thoracic Society (ATS) criteria.

METHODS

Patients aged≥75 years, hospitalised for CAP between November 2018 and August 2019, were analysed retrospectively. The American Thoracic Society (ATS) clinical stability criteria (temperature≤37°C, heart rate≤100/min, respiratory rate≤24/min, systolic blood pressure≥90mmHg, oxygen saturation≥90% in room air) were assessed after five days of antibiotic therapy.

RESULTS

Seventy-five patients (mean age 88 years, 49% requiring oxygen therapy) were included. Six died, and at day 5, 36/69 (52%) fulfilled 4/5 stability criteria. The median duration of treatment was 9 days. In 28 patients (41%), it was ≤7 days.

CONCLUSION

In 52% of elderly patients with CAP, a 5-day treatment regimen resulted in clinical stability.

Duration of orthodontic treatment with fixed appliances in adolescents and adults: a systematic review with meta-analysis

OBJECTIVES

Adults with fixed orthodontic appliances are increasing nowadays. Compared with adolescents, adults present biological differences that might influence treatment duration. Therefore, the aim of the study was to compare duration of treatment with fixed appliances between adults and adolescents.

MATERIALS AND METHODS

Eight databases were searched up to September 2019 for randomized and non-randomized clinical studies comparing treatment duration with fixed appliances in adolescents and adult patients. After duplicate study selection, data extraction, and risk of bias assessment with the Cochrane ROBINS-I tool, random effects meta-analyses of mean differences (MD) and their 95% confidence intervals (CIs) were performed, followed by assessment of the quality of evidence with GRADE.

RESULTS

A total of 11 unique studies (one prospective and 10 retrospective non-randomized) with 2969 adolescents and 1380 adult patients were finally included. Meta-analysis of 7 studies found no significant difference in the duration of comprehensive treatment with fixed appliances (MD = - 0.8 month; 95% CI = - 4.2 to 2.6 months; P = 0.65; I2 = 92%) between adults and adolescents. Similarly, both distalization of upper first molars with skeletal anchorage for class II correction and the retraction of canines into the premolar extraction spaces lasted similarly long among adults and adolescents. On the other hand, alignment of palatally displaced canines lasted considerably longer in adults compared to adolescents (1 study; MD = 3.8 months; 95% CI = 1.4 to 6.2 months; P = 0.002). The quality of evidence for the meta-analysis was low due to the inclusion of non-randomized studies with considerable risk of bias.

CONCLUSIONS

While existing evidence does not indicate a difference in the overall duration of treatment with fixed appliances between adults and adolescents, the alignment of palatally displaced canines lasted significantly longer in adults. However, our confidence in these estimates is low due to the risk of bias in the included studies.

TRIAL REGISTRATION

PROSPERO: ( CRD42019148169 ).

Correlation between initial tumour volume and treatment duration on Dabrafenib: observation study of subjects with BRAF mutant melanoma on the BRF112680 trial

BACKGROUND

Planar-based measurements of lesions in metastatic melanoma have limitations in estimating tumor burden of a patient and in predicting response to treatment. Volumetric imaging might add predictive value to Response criteria in Solid Tumor (RECIST)-measurement. Based on clinical observations, we explored the association between baseline tumor volume (TV) and duration of treatment with dabrafenib in patients with metastatic melanoma. We have also explored the prognostic value of TV for overall survival (OS) and progression free survival (PFS).

METHODS

This is a retrospective, chart-review of primary source documents and medical imaging of a cohort of patients participating in the BRF112680 phase 1 clinical trial at the Prince of Wales Hospital. TV was quantified by contouring all the measurable baseline target lesions in the standard manner for radiation planning using Voxxar™ software. We used Cox regression models to analyse associations between TV and duration of treatment with dabrafenib and between TV, PFS and OS.

RESULTS

Among 13 patients of BRAF 112680 trial, 10 were included in the retrospective analysis. Target lesion sum volume ranged from 0.3 to 1065.5 cm³ (cc), with a median of 27.5 cc. The median PFS and OS were 420 days (range 109-1765) and 1680 days (range 390-2940), respectively. The initial TV was inversely correlated with duration of treatment with dabrafenib (rho - 0.6; P 0.03). In multivariate analysis, TV was a predictor for OS (HR 2.81 CI 1.06-6.19) and PFS (8.76 (CI 1.05-43.58). Patients with tumour volume above the median had significantly lower OS of 6-months compared to 56-months survival for patients with smaller volumes; P = 0.019.

CONCLUSIONS

TV is a predictor for treatment duration and is prognostic of OS and PFS in patients with metastatic melanoma. These findings need to be validated prospectively in clinical trials.

[Practical update of total dose compensation in case of temporary interruption of external radiotherapy in the COVID-19 pandemic context]

L’étalement est un facteur important de récidive locale et indirectement d’évolution à distance, notamment, en cas de durée de traitement allongée. La pandémie actuelle a un impact sur les patients en cours de radiothérapie qui doivent interrompre leur traitement de manière parfois prolongée du fait de la nécessité de soins respiratoires induits par le COVID-19. Les modèles utilisés de compensation de la dose totale en cas d’interruption prolongée de la radiothérapie sont connus, mais il nous a semblé important de synthétiser afin que chaque oncologue radiothérapeute puisse proposer un traitement le plus optimal possible tant en termes de risque de récidive locale que de protection des tissus sains. L’objectif de ce type de recommandation est d’homogénéiser les pratiques de l’ensemble de la discipline.

Time to CA19-9 nadir: a clue for defining optimal treatment duration in patients with resectable pancreatic ductal adenocarcinoma

BACKGROUND

Defining optimal treatment duration in patients with resectable pancreatic ductal adenocarcinoma (PDAC) receiving primary chemotherapy is an unmet need. The role of time to CA19-9 nadir and of nadir magnitude was explored in this study.

PATIENTS AND METHODS

The databases of our institution's prospective trials were queried to speculate on the time to maximum chemotherapy response. Patients with pathologically proven, metastatic (N = 356) or non-metastatic non-resected (N = 163) PDAC and elevated baseline (> 34 UI/mL) CA19-9 were analyzed. Survival curves were estimated using the Kaplan-Meier method and compared by means of the log-rank test for analyses including at least 45 patients. Multivariable Cox proportional hazards model was used to estimate clinical features for their association with OS. All probability values were from two-sided tests.

RESULTS

Time to CA19-9 nadir was ≥ 4 months in 184 of 346 (53%) metastatic and 121 of 163 (74%) non-metastatic patients (p = 0.002). The likelihood of a later nadir was higher with taxane-based chemotherapy as compared to taxane-free combinations (73% versus 56%; p = 0.02). Both metastatic and non-metastatic patients had significantly longer survival when nadir occurred later. Patients with a larger CA19-9 nadir magnitude had significantly longer survival. Metastatic patients with CA19-9 reduced by < 50%, 50-89%, or > 89% and had a median survival of 7.4, 9.8, and 14.7 months, respectively (p ≤ 0.001 for all comparisons). The corresponding figures for non-metastatic patients were 10.6; 17.0; and 18.7 months, respectively (p ≤ 0.02 for < 50% versus 50-89% or > 89%; p = 0.14 for 50-89% versus > 89%). Multivariable analyses showed that time to CA19-9 nadir but not CA19-9 nadir magnitude was independently predictive of survival.

CONCLUSION

The present study suggests that a 4-6 months program might be a more suitable candidate for prospective assessment in comparison to shorter pre-defined period in patients who are candidates to surgery after primary chemotherapy.

Extracorporeal membrane oxygenation support for postcardiotomy cardiogenic shock in adult patients: predictors of in-hospital mortality and failure to be weaned from extracorporeal membrane oxygenation

Postcardiotomy cardiogenic shock (PCCS) is a rare clinical entity associated with substantial morbidity and mortality. It is characterized by heart failure that results in an inability to be weaned from cardiopulmonary bypass (CPB). The aim of this study was to analyze the outcomes of extracorporeal membrane oxygenation (ECMO) in patients with PCCS and to identify predictors of in-hospital mortality and failure to be weaned from ECMO. From January 2002 to August 2016, 3248 patients underwent cardiac surgery in our hospital. Of these, 29 patients (0.89%) required ECMO because of an inability to be weaned from cardiopulmonary bypass. The median duration of ECMO support was 144 h (340-52 h) (range 17-818 h). Sixteen patients (55.2%) were weaned from ECMO, and 6 (20.7%) survived to hospital discharge. The multivariate analysis revealed that reoperation [odds ratio (OR): 13.667, 95% confidence interval (CI): 0.999-187.056, p = 0.05] and ECMO support duration > 130 h (OR: 17.688, 95% CI: 1.324-236.233, p = 0.03) were independent predictors of failure to be weaned from ECMO. Temporarily being weaned from CPB > 15 min (OR: 0.027, 95% CI: 0.001-0.586, p = 0.02) was found to be a protective factor. The multivariate analysis revealed that CPB time > 270 min (OR: 12.503, 95% CI: 1.058-147.718, p = 0.05) and ECMO support duration > 60 h (OR: 12.503, 95% CI: 1.058-147.718, p = 0.05) were independent predictors of in-hospital mortality. ECMO is an acceptable technique for treating PCCS in patients undergoing cardiac surgery. Our data suggest a reevaluation of therapeutic strategies after 60 h and again after 130 h of ECMO support.

Methods for constructing treatment episodes and impact on exposure-outcome associations

PURPOSE

To assess the impact on exposure time and outcome misclassifications, and consequent impact on exposure-outcome associations from treatment episode construction. We investigated the dosage assumptions of 1 unit per day, and 1 DDD per day, versus actual prescribed dosage under different handling of gaps and overlaps of prescriptions.

METHODS

Data on mirtazapine and citalopram exposure (years 2006-2014) from the Swedish Prescribed Drug register were used. Via a within individuals design we compared method A, based on actual dosage, with methods B and C based on 1 unit of drug per day and 1 DDD per day assumptions, respectively, including consideration of gaps and overlaps. Four outcomes were used, hospitalizations and outpatient visits for all and for psychiatric causes.

RESULTS

Relative to method A, both alternative methods lead to misclassification of exposure time. With regard to outcome misclassifications, method B overestimates the effect of the exposure on the outcome in 77% and 100% of exposure definition comparisons for mirtazapine and citalopram respectively, while 23% of the comparisons for mirtazapine results in underestimation of exposure-outcome associations. Conversely, treatment episodes based on DDD (method C) result in underestimation of the exposure-outcome association in 100% and 87.5% of exposure definition comparisons for mirtazapine and citalopram respectively, while 12.5% of the comparisons for citalopram results in overestimation of the exposure-outcome associations.

CONCLUSIONS

The study provides results that have consistent clinical relevance. We have showed that a non-accurate construction of exposure time may lead to errors on outcome detection during exposed time, and consequently affect conclusions on safety or efficacy profile of a treatment.

Rational Approaches to Treatment Duration with Immunotherapy in Metastatic Renal Cell Carcinoma

Immune checkpoint inhibitors (ICIs) have revolutionized the treatment paradigm for metastatic renal cell carcinoma. The appropriate duration for ICI treatment is not clear, however. Analyses of landmark trials reveal that some patients exhibit sustained durable responses to ICIs even after treatment discontinuation, resulting in prolonged treatment-free intervals that can mitigate potential toxicities and the considerable financial burden associated with treatment. Adaptive approaches with PD1 monotherapy and combination immunotherapy tailored to tumor response are ongoing. More efforts will be needed to clarify the ideal ICI dosing regimen to maximize oncological benefit while minimizing treatment-related adverse effects and costs. PATIENT SUMMARY: We reviewed considerations surrounding treatment strategies when using immunotherapy to treat patients with kidney cancer. It is clear that some patients can experience prolonged cancer control when discontinuing immunotherapy. However, individualized approaches will be necessary to strike a balance between optimizing patient outcomes and reducing unnecessary side effects and cost.

[Anal channel cancer: customization of dose, volume and breaching]

The conservative treatment of squamous cell carcinoma of anal canal by irradiation is recommended as first indication. Despite its rarity, significant improvements were obtained by retrospective or prospective clinical studies these 20 past years, evaluating concomitant chemotherapy and IMRT. Nevertheless, the individualisation of the treatment, over dose distribution, has poor data available. Fractionation remains classic (1.8-2.0Gy/Fr), but the optimal dose level remains under discussion. The strategy concerning the volumes and doses for the prophylactic volumes remains under discussion. This paper will describe the data published, and the recommendations of working Groups, and the main options under evaluation. To conclude, today only the absence of gap is recommended, the benefit of a one-step schedule reducing the treatment time, then increasing local control and survival, but personalised schedules remain under investigation.

Effect of chlorhexidine bathing on colonization or infection with Acinetobacter baumannii: a systematic review and meta-analysis

Healthcare-associated infections (HAIs) caused by multi-drug-resistant Gram-negative bacteria (MDRGNB) have increased prevalence in intensive care units (ICUs). A common strategy to prevent HAIs is bathing patients with chlorhexidine gluconate (CHG). However, the effectiveness of CHG bathing against multidrug-resistant Acinetobacter baumannii (MDRAB) is still controversial. The aim of this study was to perform a systematic review and meta-analysis of the effectiveness of CHG bathing on Acinetobacter baumannii colonization and infection in the ICU setting. A systematic literature search of PubMed, EMBASE, Web of Science and CINAHL was performed from inception through to June 2018. Randomized controlled trials (RCTs), pre-post studies, or interrupted time series (ITS) studies were included. The numbers of patients with/without colonization or infection of A. baumannii in the experimental or control groups were extracted from each study. Quality assessment was performed by the related instruments of National Institute of Health. Pooled risk ratios (RRs) were calculated using the random-effects model. One RCT and 12 pre-post or ITS studies comprising 18,217 patients were included, of which 8069 were in the CHG bathing arm and 9051 in the control arm. CHG bathing was associated with a reduced colonization of A. baumannii (RR, 0.66; 95% confidence interval: 0.57-0.77; P<0.001). Chlorhexidine at 4% showed a better effect than 2% chlorhexidine (meta-regression P=0.044). CHG bathing was associated with a non-significant reduction of infection (pooled RR 0.41, 95% CI: 0.13-1.25). This study suggests that CHG bathing significantly reduces colonization of A. baumannii in the ICU setting. However, more trials are needed to confirm whether CHG bathing can reduce infections with A. baumannii.

Optimal duration of first-line chemotherapy for advanced gastric cancer: data from the AGAMENON registry

BACKGROUND

The optimal duration of first-line chemotherapy for patients with advanced gastric cancer is unknown. Diverse clinical trials have proposed different strategies including limited treatment, maintenance of some drugs, or treatment until progression.

METHOD

The sample comprises patients from the AGAMENON multicenter registry without progression after second evaluation of response. The objective was to explore the optimal duration of first-line chemotherapy. A frailty multi-state model was conducted.

RESULTS

415 patients were divided into three strata: discontinuation of platinum and maintenance with fluoropyrimidine until progression (30%, n = 123), complete treatment withdrawal prior to progression (52%, n = 216), and full treatment until progression (18%, n = 76). The hazard of tumor progression decreased by 19% per month with the full treatment regimen. However, we found no evidence that fluoropyrimidine maintenance (hazard ratio [HR] 1.07, confidence interval [CI] 95%, 0.69-1.65) worsened progression-free survival (PFS) with respect to treatment until progression. Predictive factors for PFS were ECOG performance status, ≥ 3 metastatic sites, prior tumor response, and bone metastases. Toxicity grade 3/4 was more common in those who continued the full treatment until progression vs fluoropyrimidine maintenance (16% vs 6%).

CONCLUSION

The longer duration of the full initial regimen exerted a protective effect on the patients of this registry. Platinum discontinuation followed by fluoropyrimidine maintenance yields comparable efficacy to treatment up to PD, with a lower rate of serious adverse events.