Normobaric Hyperoxia Combined With Endovascular Treatment Based on Temporal Gradient: A Dose-Escalation Study

BACKGROUND

Normobaric hyperoxia (NBO) has neuroprotective effects in acute ischemic stroke. Thus, we aimed to identify the optimal NBO treatment duration combined with endovascular treatment.

METHODS

This is a single-center, randomized controlled, open-label, blinded-end point dose-escalation clinical trial. Patients with acute ischemic stroke who had an indication for endovascular treatment at Tianjin Huanhu Hospital were randomly assigned to 4 groups (1:1 ratio) based on NBO therapy duration: (1) control group (1 L/min oxygen for 4 hours); (2) NBO-2h group (10 L/min for 2 hours); (3) NBO-4h group (10 L/min for 4 hours); and (4) NBO-6h group (10 L/min for 6 hours). The primary outcome was cerebral infarction volume at 72 hours after randomization using an intention-to-treat analysis model. The primary safety outcome was the 90-day mortality rate.

RESULTS

Between June 2022 and September 2023, 100 patients were randomly assigned to the following groups: control group (n=25), NBO-2h group (n=25), NBO-4h group (n=25), and NBO-6h group (n=25). The 72-hour cerebral infarct volumes were 39.4±34.3 mL, 30.6±30.1 mL, 19.7±15.4 mL, and 22.6±22.4 mL, respectively (P=0.013). The NBO-4h and NBO-6h groups both showed statistically significant differences (adjusted P values: 0.011 and 0.027, respectively) compared with the control group. Compared with the control group, both the NBO-4h and NBO-6h groups showed significant differences (P<0.05) in the National Institutes of Health Stroke Scale scores at 24 hours, 72 hours, and 7 days, as well as in the change of the National Institutes of Health Stroke Scale scores from baseline to 24 hours. Additionally, there were no significant differences among the 4 groups in terms of 90-day mortality rate, symptomatic intracranial hemorrhage, early neurological deterioration, or severe adverse events.

CONCLUSIONS

The effectiveness of NBO therapy was associated with oxygen administration duration. Among patients with acute ischemic stroke who underwent endovascular treatment, NBO therapy for 4 and 6 hours was found to be more effective. Larger-scale multicenter studies are needed to validate these findings.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT05404373.

Is there a prospective association between psychological distress as measured by the CORE-OM and treatment attendance and treatment duration? A follow-up study at a Norwegian Community Mental Health Centre

BACKGROUND

Feasible and reliable methods for identifying factors associated with treatment duration and treatment attendance in mental health services are needed. This study examined to what degree the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) at the start of treatment is associated with treatment attendance and treatment duration.

METHODS

Outpatients (N = 124) at a community mental health centre in Norway completed the 34-item CORE-OM questionnaire addressing the domains of subjective well-being, problems and symptoms, functioning and risk at the start of treatment. The CORE-OM subscales and the 'all' items total scale were used as predictor variables in regression models, with treatment duration, number of consultations attended, treatment attendance (number of therapy sessions attended divided by number of sessions offered) and termination of treatment (planned versus unplanned) as outcome variables.

RESULTS

Higher CORE-OM subscale scores and the 'all' scale were associated with longer treatment duration. No association was found between CORE-OM scales and number of therapy sessions, treatment attendance (sessions attended/offered) or whether the patients unexpectedly ended treatment.

CONCLUSION

Higher patient-reported psychological distress as measured by the CORE-OM at the start of treatment was prospectively associated with treatment duration but not with treatment attendance or drop-out of treatment. The findings imply that patients with higher initial psychological distress need longer treatment but that treatment attendance may be related to factors other than the severity of distress.

When to Stop Antibiotics in the Critically Ill?

Over the past century, antibiotic usage has skyrocketed in the treatment of critically ill patients. There have been increasing calls to establish guidelines for appropriate treatment and durations of antibiosis. Antibiotic treatment, even when appropriately tailored to the patient and infection, is not without cost. Short term risks-hepatic/renal dysfunction, intermediate effects-concomitant superinfections, and long-term risks-potentiating antimicrobial resistance (AMR), are all possible consequences of antimicrobial administration. These risks are increased by longer periods of treatment and unnecessarily broad treatment courses. Recently, the literature has focused on multiple strategies to determine the appropriate duration of antimicrobial therapy. Further, there is a clinical shift to multi-modal approaches to determine the most suitable timepoint at which to end an antibiotic course. An approach utilising biomarker assays and an inter-disciplinary team of pharmacists, nurses, physicians, and microbiologists appears to be the way forward to develop sound clinical decision-making surrounding antibiotic treatment.

Impact of Opioid Use on Duration of Therapy and Overall Survival for Patients with Advanced Non-Small Cell Lung Cancer Treated with Immune Checkpoint Inhibitors

Immune checkpoint inhibitors (ICI) have significantly improved outcomes in advanced non-small cell lung cancer (NSCLC). We evaluated the effect of opioid use on outcomes in patients receiving ICI either alone or with chemotherapy. We conducted a retrospective review of 209 patients with advanced NSCLC who received an ICI at the University of Virginia between 1 February 2015 and 1 January 2020. We performed univariate and multivariate analyses to evaluate the impact of opioid use on duration of therapy (DOT) and overall survival (OS). Patients with no or low opioid use (n = 172) had a median DOT of 12.2 months (95% CI: 6.9-17.4) compared to 1.9 months (95% CI: 1.8-2.0) for those with high opioid use (n = 37, HR 0.26 95% CI: 0.17-0.40, p < 0.001). Patients with no or low opioid use had a median OS of 22.6 months (95% CI: 14.8-30.4) compared to 3.8 months (95% CI: 2.7-4.9) for those with high opioid use (HR 0.26 95% CI: 0.17-0.40 p < 0.001). High opioid use was associated with a shorter DOT and worse OS. This difference remained significant when accounting for possible confounding variables. These data warrant investigation of possible mechanistic interactions between opioids, tumor progression, and ICIs, as well as prospective evaluation of opioid-sparing pain management strategies, where possible.

Diabetic foot wound ulcers management by vacuum sealing drainage: A meta-analysis

The meta-analysis aimed to assess and compare diabetic foot wound ulcer management by vacuum sealing drainage. Using dichotomous or contentious random- or fixed-effects models, the outcomes of this meta-analysis were examined, and the odds ratio (OR) and the mean difference (MD) with 95% confidence intervals (CIs) were computed. Twenty-three examinations from 2000 to 2023 were enrolled for the present meta-analysis, including 1928 individuals with diabetic foot ulcers. Vacuum sealing drainage had significantly lower wound healing (OR, 2.35; 95% CI, 1.79-3.08, p < 0.001), lower duration of therapy (MD, -6.19; 95% CI, -10.06 to -2.32, p = 0.002), higher wound size reduction (MD, 4.22; 95% CI, 0.87-7.56, p = 0.01) and lower complication (OR, 0.32; 95% CI, 0.13-0.80, p = 0.01) compared with standard therapy in patients with diabetic foot ulcers. The examined data revealed that vacuum sealing drainage had significantly lower wound healing, duration of therapy and complication rates, as well as higher wound size reduction, compared with standard therapy in patients with diabetic foot ulcers. Yet, attention should be paid to its values since most of the selected examinations had a low sample size.

Vancomycin associated acute kidney injury in patients with infectious endocarditis: a large retrospective cohort study

Background: Vancomycin remains the cornerstone antibiotic for the treatment of infective endocarditis (IE). Vancomycin has been associated with significant nephrotoxicity. However, vancomycin associated acute kidney injury (AKI) has not been evaluated in patients with IE. We conducted this large retrospective cohort study to reveal the incidence, risk factors, and prognosis of vancomycin-associated acute kidney injury (VA-AKI) in patients with IE. Methods: Adult patients diagnosed with IE and receiving vancomycin were included. The primary outcome was VA-AKI. Results: In total, 435 of the 600 patients were enrolled. Of these, 73.6% were male, and the median age was 52 years. The incidence of VA-AKI was 17.01% (74). Only 37.2% (162) of the patients received therapeutic monitoring of vancomycin, and 30 (18.5%) patients had reached the target vancomycin trough concentration. Multiple logistic regression analysis revealed that body mass index [odds ratio (OR) 1.088, 95% CI 1.004, 1.179], duration of vancomycin therapy (OR 1.030, 95% CI 1.003, 1.058), preexisting chronic kidney disease (OR 2.291, 95% CI 1.018, 5.516), admission to the intensive care unit (OR 2.291, 95% CI 1.289, 3.963) and concomitant radiocontrast agents (OR 2.085, 95% CI 1.093, 3.978) were independent risk factors for VA-AKI. Vancomycin variety (Lai Kexin vs. Wen Kexin, OR 0.498, 95% CI 0.281, 0.885) were determined to be an independent protective factor for VI-AKI. Receiver operator characteristic curve analysis revealed that duration of therapy longer than 10.75 days was associated with a significantly increased risk of VA-AKI (HR 1.927). Kidney function was fully or partially recovered in 73.0% (54) of patients with VA-AKI. Conclusion: The incidence of VA-AKI in patients with IE was slightly higher than in general adult patients. Concomitant contrast agents were the most alarmingly nephrotoxic in patients with IE, adding a 2-fold risk of VA-AKI. In patients with IE, a course of vancomycin therapy longer than 10.75 days was associated with a significantly increased risk of AKI. Thus, closer monitoring of kidney function and vancomycin trough concentrations was recommended in patients with concurrent contrast or courses of vancomycin longer than 10.75 days.

Real-world treatment outcomes and safety of natalizumab in Finnish multiple sclerosis patients

Objectives

The primary objective was to evaluate long-term treatment persistence and safety of natalizumab in Finnish multiple sclerosis patients. The secondary objectives were to assess patient characteristics, use of natalizumab-related safety protocol, and treatment persistence in patients with different anti-John Cunningham virus antibody statuses (John Cunningham virus status).

Materials & Methods

All adult multiple sclerosis patients in the Finnish multiple sclerosis register who started natalizumab between 1/2006 and 12/2018 were included in this study and followed retrospectively until treatment discontinuation or end of follow-up (12/2019).

Results

In total, 850 patients were included. Median duration of natalizumab treatment was 7.8 years in John Cunningham virus negative (n = 229) and 2.1 years in John Cunningham virus positive patients (n = 115; p < 0.001). The most common cause for treatment discontinuation was John Cunningham virus positivity. After natalizumab discontinuation, patients who had a washout duration of less than 6 weeks had fewer relapses during the first 6 months (p = 0.012) and 12 months (p = 0.005) compared with patients who had a washout duration of over 6 weeks. During the median follow-up of 3.6 years, 76% of patients remained stable or improved on their Expanded Disability Status Scale.

Conclusions

Treatment persistence was very high among John Cunningham virus negative patients. The study supports long-term effectiveness of natalizumab and a washout duration of less than 6 weeks after discontinuation.

Real-World Data about Commonly Used Antibiotics in Long-Term Care Homes in Australia from 2016 to 2019

In this study, we use real-world data to explore trends in antibiotic use in a dynamic cohort of long-term care (LTC) residents. A cross-sectional retrospective analysis of pharmacy medication supply records of 3459 LTC residents was conducted from 31 May 2016 to 31 May 2019. The primary outcome was the monthly prevalence of residents with an antibiotic episode. Secondary outcomes were the type of antibiotic used and duration of use. Over the three-year study period, residents were supplied 10460 antibiotics. On average, 18.9% of residents received an antibiotic monthly. Antibiotic use decreased slightly over time with a mean of 168/1000 (95% CI 146-177) residents using at least one antibiotic per month in June 2016 to 148/1000 (95% CI 127-156) in May 2019. The total number of antibiotic days per 100 resident days remained relatively constant over the study period: 8.8 days in 2016-2017, 8.4 in 2017-2018 and 6.4 in 2018-2019. Prolonged durations exceeding 100 days were seen for a small percentage of residents. We found extensive antibiotic use, which is a recognized contributor to antimicrobial resistance development, underscoring the necessity for quality treatment guidelines in this vulnerable population.

Evaluation of duration of antibiotic therapy across hospitals in Scotland including the impact of COVID-19 pandemic: a segmented interrupted time series analysis

BACKGROUND

Little is known about the duration of antibiotic use in hospital settings. We evaluated the duration of hospital antibiotic therapy for four commonly prescribed antibiotics (amoxicillin, co-amoxiclav, doxycycline, and flucloxacillin) including the assessment of COVID-19 impact.

METHODS

A repeated, cross-sectional study using the Hospital Electronic Prescribing and Medicines Administration system (January/2019-March/2022). Monthly median duration of therapy/duration categories was calculated, stratified by routes of administration, age, and sex. The impact of COVID-19 was assessed using segmented time-series analysis.

RESULTS

There were significant variations in the median duration of therapy across routes of administration (P < 0.05), with the highest value among those antibiotic courses composed of both oral and IV antibiotics ('Both' group). Significantly higher proportions of prescriptions within the 'Both' group had a duration of >7 days compared to oral or IV. The duration of therapy differed significantly by age. Some small statistically significant changes in the level/trends of duration of therapy were observed in the post-COVID-19 period.

CONCLUSIONS

No evidence for prolonged duration of therapy were observed, even during COVID-19 pandemic. The duration of IV therapy was relatively short, suggesting timely clinical review and consideration of IV to oral switch. Longer duration of therapy was observed among older patients.

Using change in predicted adult height during GnRH agonist treatment for individualized treatment decisions in girls with central precocious puberty

OBJECTIVES

It is important to understand what variables influence change in predicted adult height (PAH) throughout GnRHa treatment for central precocious puberty (CPP) to individualize treatment decisions and optimize care.

METHODS

Changes in PAH, chronological age (CA), bone age (BA), BA/CA, and height velocity (HV) were evaluated in girls with CPP throughout treatment with leuprolide acetate (n=77). A second analysis focused on changes in the 3 years preceding the first observed BA of ≥12 years. Relationships were characterized using plot inspection and linear mixed-effects analyses. Association between treatment duration and last assessed PAH was examined using multiple linear regression models.

RESULTS

BA/CA and HV showed a nonlinear change during treatment, with the largest changes and improvement in PAH observed in the first 6-18 months. Rate of BA advancement tended to decrease more slowly in girls initiating treatment at a younger BA. On-treatment change in PAH was predicted by concurrent BA/CA change, HV, and BA, as well as CA at treatment initiation. Last assessed PAH was positively associated with longer treatment durations (primary/exploratory models cut-offs of ≥33/≥55 months).

CONCLUSIONS

These findings support individualized monitoring during GnRHa treatment. Initial response should be interpreted with caution until 6-18 months after treatment initiation and failure should not be assumed based on continued bone maturation in girls starting therapy at a younger age. Treatment cessation should not be automatically based on a diminishing change in PAH or HV, as ongoing treatment may result in continued increase or maintenance of PAH.

Risk of Treatment Failure for Prosthetic Joint Infections: Retrospective Chart Review in an Outpatient Parenteral Antimicrobial Therapy Program

Background

Prosthetic joint infections (PJIs) are a major complication of total joint replacement surgeries. Treatment includes surgical intervention with prolonged courses of IV antibiotics in outpatient parenteral antimicrobial therapy (OPAT) programs. The risk of PJI treatment failure is high and may be associated with various clinical factors.

Objectives

To determine the rate of PJI treatment failure and to identify potential risk factors for failure in patients admitted to an OPAT program.

Methods

A retrospective chart review was conducted for adult patients with PJI admitted to an OPAT program between July 1, 2013, and July 1, 2019. Treatment courses were deemed to have failed according to predetermined criteria. χ² tests and multiple linear regression were used to examine associations of comorbidities, pathogens, and antimicrobial regimens with treatment failure.

Results

In total, 100 patients associated with 137 PJI treatment courses in the OPAT program were included. Of these, 28 patients accounted for 65 of the treatment courses. Methicillin-susceptible Staphylococcus aureus was the most frequently isolated pathogen (31/137 or 22.6% of treatment courses). Patient comorbidities included body mass index of at least 30 kg/m² (58% of patients) and diabetes (41% of patients). The overall rate of treatment failure was 56.2% (77/137 treatment courses). Selected risk factors associated with treatment failure or success were diabetes (50.9% versus 29.8%; odds ratio [OR] 4.03, 95% confidence interval [CI] 1.38-12.88, p = 0.013) and depression (32.1% versus 14.9%; OR 5.02, 95% CI 1.30-22.89, p = 0.025).

Conclusions

The overall rate of PJI treatment failure in the study population was high. Patients with diabetes and depression experienced higher incidences of failure. Future investigations of comprehensive PJI management should be considered to ensure successful treatment and to minimize excessive use of health care resources.

Progress on Denosumab Use in Giant Cell Tumor of Bone: Dose and Duration of Therapy

Giant cell tumor of bone (GCTB) is an aggressive non-cancerous bone tumor associated with risks of sarcoma and metastasis. Once malignancy occurs, the prognosis is generally poor. Surgery remains the main treatment for GCTB. Multidisciplinary management is a feasible option for patients wherein surgical resection is not an option or for those with serious surgery-related complications. Denosumab is an anti-nuclear factor kappa B ligand approved for the treatment of postmenopausal women with osteoporosis, bone metastases, and advanced or inoperable GCTB. However, the guidelines for treating GCTB are unclear; its short-term efficacy and safety in inoperable patients have been demonstrated. Lengthier therapies (high cumulative doses) or pre-operative adjuvant therapy may be associated with severe complications and high local recurrence rates. Short-term administration helps attain satisfactory local control and functionality. As a result, lately, the impact of different doses and lengths of treatment on the efficacy of denosumab in GCTB treatment, the incidence of complications, and recurrence rates have gained attention. The efficacy and safety of denosumab against GCTB, its impact on imaging assessment, related complications, and recurrence of GCTB were previously reviewed. For further research direction, this paper reviews the progress of studies evaluating the impact of the dose and duration of denosumab therapy for GCTB.

Efficacy and Safety of 3 Versus 6 Months of Dual-Antiplatelet Therapy in Patients Implanted With a Coroflex ISAR Stents: A Prospective, Multicenter, Randomized Clinical Trial

BACKGROUND

The optimal duration of dual-antiplatelet therapy (DAPT) after implantation of a drug-eluting stent (DES), especially recently developed polymer-free DESs, is unknown. This study examined the efficacy and safety of 3- versus 6-month DAPT in patients implanted with Coroflex ISAR polymer-free DESs.

METHODS

Between May 2015 and August 2020, 488 patients who underwent Coroflex ISAR stent implantation were enrolled in the study and randomly assigned to the 3-month (n=244) or 6-month (n=244) DAPT group.

RESULTS

At 1 year, the primary endpoint (composite of cardiovascular death, myocardial infarction, target vessel revascularization, and Bleeding Academic Research Consortium [BARC] type 2-5 bleeding) occurred in 9 (3.7%) patients in the 3-month DAPT group and in 7 (2.9%) patients in the 6-month DAPT group (hazard ratio 1.31; P=.60). There was no difference between the 3- and 6-month DAPT groups in either BARC type 2-5 bleeding (1.6% vs 0.8%; hazard ratio 2.00; P=.42) or any bleeding (2.9% vs 3.3%; hazard ratio 0.87; P=.80).

CONCLUSION

Compared with 6 months of DAPT, 3 months of DAPT did not increase the risk of primary endpoint 1 year after Coroflex ISAR stent implantation, although it should be noted that the trial has limited power to see differences due to low event rate and low recruitment rate.

Venetoclax and Hypomethylating Agents as First-line Treatment in Newly Diagnosed Patients with AML in a Predominately Community Setting in the US

BACKGROUND

Treatment with venetoclax + hypomethylating agents (HMAs) is standard-of-care for newly diagnosed (ND) patients with acute myeloid leukemia (AML) aged ≥75 years, or with comorbidities precluding intensive chemotherapy. We describe real-world venetoclax + HMA treatment practices and outcomes in patients with ND AML in the US.

PATIENTS AND METHODS

This retrospective cohort study used an electronic health record-derived, US nationwide, de-identified database, and included adults with ND AML, initiating venetoclax + HMA treatment ≤30 days from diagnosis (June 1, 2018-January 31, 2020). Venetoclax treatment variables included dosing information, schedule modifications, and drug-drug interactions. The median venetoclax + HMA treatment duration and overall survival (OS) from venetoclax initiation to discontinuation, death, or end of follow-up (August 31, 2020) were examined by Kaplan-Meier analyses.

RESULTS

Overall, 169 patients were included. The median age at diagnosis was 77 years; 85.2% of patients were treated in community practice. Ninety-five of 169 patients (56.2%) had evaluable bone marrow response data following the start of treatment; 53.7% were assessed approximately at the end of cycle 1. Following the first treatment cycle, treatment schedule modifications were recorded in 101 patients and dose changes in 56, primarily due to toxicity. The median treatment duration was 5.2 months; the median OS was 8.6 months (median follow-up was 7.2 months). Venetoclax dose changes did not modify efficacy outcomes, but longer median OS was associated with venetoclax treatment schedule modifications (P = .02).

CONCLUSIONS

This study reflects early real-world experience with venetoclax + HMAs in a predominantly community setting and emphasizes the importance of appropriate venetoclax management in optimizing patient outcomes.

Discontinuation of pembrolizumab for advanced urothelial carcinoma without disease progression: Nationwide cohort study

Pembrolizumab, an anti-programmed death 1 monoclonal antibody, has revolutionized the treatment of metastatic urothelial carcinoma. However, the optimal treatment duration for treatment responders has not been established. To address this, we retrospectively assess the treatment outcomes and duration of pembrolizumab for patients whose best response was complete response (CR) or partial response (PR) in a Japanese nationwide cohort of platinum-refractory metastatic urothelial carcinoma. Of 203 patients whose best response was CR or PR, 83 patients discontinued pembrolizumab before progression. The median pembrolizumab treatment duration was 6.9 months. The 2-year relapse-free survival (RFS), treatment-free survival, and OS rates after discontinuation were 49.0%, 57.4%, and 74.5%, respectively. CR, higher hemoglobin levels, and a better Eastern Cooperative Oncology Group performance status at the time of discontinuation were associated with significantly better RFS. Pembrolizumab was re-administered to 12 patients. Pembrolizumab re-challenge resulted in CR, PR, stable disease, and progressive disease in six, three, two, and one patient, respectively. Propensity score-matched landmark analysis revealed no significant OS difference between patients who continued or discontinued pembrolizumab at 6, 12, and 18 months (p = 0.91, 0.99, and 0.25, respectively). Our findings demonstrated that patients with objective responses had favorable survival outcomes and suggested that pembrolizumab could be discontinued safely in this population. This study should drive further efforts to optimize the treatment duration for pembrolizumab responders.

Noninferiority Margin Size and Acceptance of Trial Results: Contingent Valuation Survey of Clinician Preferences for Noninferior Mortality

Objectives

We used modified contingent valuation methodology to determine how noninferiority margin sizes influence clinicians’ willingness to accept clinical trial results that compare mortality in critically ill children.

Methods

We surveyed pediatric infectious diseases and critical care clinicians in Canada, Australia, and New Zealand and randomized respondents to review 1 of 9 mock abstracts describing a noninferiority trial of bacteremic critically ill children assigned to 7 or 14 d of antibiotics. Each scenario showed higher mortality in the 7-d group but met noninferiority criterion. We explored how noninferiority margins and baseline mortality rates influenced respondent acceptance of results.

Results

There were 106 survey respondents: 65 (61%) critical care clinicians, 28 (26%) infectious diseases physicians, and 13 (12%) pharmacists. When noninferiority margins were 5% and 10%, 73% (24/33) and 79% (27/33) respondents would accept shorter treatment, compared with 44% (17/39) when the margin was 20% (P = 0.003). Logistic regression adjusted for baseline mortality showed 5% and 10% noninferiority margins were more likely to be associated with acceptance of shorter treatment compared with 20% margins (odds ratio [OR] 3.5, 95% confidence interval [CI]: 1.3–9.6, P = 0.013; OR 5.1, 95% CI: 1.8–14.6, P = 0.002). Baseline mortality was not a significant predictor of acceptance of shorter treatment.

Conclusions

Clinicians are more likely to accept shorter treatment when noninferiority margins are ≤10%. However, nearly half of respondents who reviewed abstracts with 20% margins were still willing to accept shorter treatment. This is a novel application of contingent valuation methodology to elicit acceptance of research results among end users of the medical literature.

Highlights

Epidemiology and Management of Orbital Cellulitis in Children

BACKGROUND

The epidemiology of orbital cellulitis likely has evolved due to the emergence of methicillin-resistant Staphylococcus aureus (MRSA) and the adoption of pneumococcal conjugate vaccination. In the absence of published guidelines, management is highly variable. We characterized epidemiology and management over an 11-year period.

METHODS

A retrospective cohort study of children 0 to 21 years of age with orbital cellulitis +/- subperiosteal orbital abscess hospitalized at a large quaternary children's hospital from January 2008 to June 2018. We reviewed charts for demographic characteristics, clinical features, management, and outcomes. Using multivariable logistic regression, we evaluated predictors of surgical intervention and assessed whether corticosteroid use or antibiotic duration was related to clinical outcomes.

RESULTS

Among 220 patients, methicillin-susceptible S. aureus was the most common organism (26.3%), with MRSA found in only 5.0%. Rates of vancomycin use fluctuated annually from 40.9% to 84.6%. Surgery was performed in 39.5% of the patients. Corticosteroids, used in 70 patients (32.1%), were unrelated to treatment failure (n = 9), defined as persistent signs and symptoms or initial clinical improvement followed by worsening (P = .137). The median antibiotic duration was 17 days (interquartile range 14-26). After controlling for age, gender, proptosis, eye pain with movement, eyelid swelling, neutrophil count, and corticosteroid use, treatment failure was not significantly associated with receipt of ≥ 3 weeks of antibiotic therapy (8/84, 9.5%) compared with > 2 but < 3 weeks (0/51, 0.0%) or ≤ 2 weeks (1/85, 1.2%) (adjusted odds ratio = 5.83 for ≥ 3 vs ≤2 weeks; 95% confidence interval: 0.58, 59.0).

CONCLUSIONS

Although MRSA was rare, empiric vancomycin use was high. Treatment failure was uncommon in patients who received ≤ 2 weeks of therapy, suggesting that shorter durations are adequate in some patients.

The Influence of Past Metronidazole Exposure on the Outcome of Helicobacter pylori Eradication

Background

Bismuth quadruple therapy (BQT) is recommended as empirical first-line therapy because it is not affected by antibiotic resistance. We examined whether past exposure to metronidazole affected BQT outcomes.

Methods

The records of seven hospitals were searched for patients who received BQT for Helicobacter pylori eradication between 2009 and 2020. The association between past metronidazole exposure and the eradication rate was evaluated.

Results

This study was a multicenter retrospective study. Around 37,602 people tested for H. pylori infection were identified, and 7,233 received BQT. About 2,802 (38.7%) underwent a 13C-urea breath test to confirm eradication. The BQT efficacy was 86.4% among patients without metronidazole exposure and 72.8% among patients with exposure (p < 0.001). The eradication rate of BQT 14 days in patients with past exposure was higher than that of BQT <14 days (85.5 vs. 66.0%, p = 0.009). Multivariate analysis revealed that past metronidazole exposure [odds ratio (OR) 2.6, 95% CI 1.8–3.7; p < 0.001] and BQT <14 days (OR 1.5, 95% CI 1.2–2.0; p = 0.002) were independent risk factors for eradication failure.

Conclusion

Past metronidazole exposure significantly lowered the BQT eradication rate. BQT 14 days should be recommended for patients with suspected metronidazole exposure.

A retrospective real-world study of the current treatment pathways for myelofibrosis in the United Kingdom: the REALISM UK study

Background

Myelofibrosis (MF) is a blood cancer associated with splenomegaly, blood count abnormalities, reduced life expectancy and high prevalence of disease-associated symptoms. Current treatment options for MF are diverse, with limited data on management strategies in real-world practice in the United Kingdom.

Methods

The REALISM UK study was a multi-center, retrospective, non-interventional study, which documented the early management of patients with MF. The primary endpoint was the time from diagnosis to active treatment.

Discussion

Two hundred patients were included (63% [n = 126/200] with primary MF; 37% [n = 74/200] with secondary MF). Symptoms and prognostic scores at diagnosis were poorly documented, with infrequent use of patient reported outcome measures. 'Watch and wait' was the first management strategy for 53.5% (n = 107/200) of patients, while the most commonly used active treatments were hydroxycarbamide and ruxolitinib. Only 5% of patients proceeded to allogeneic transplant. The median (IQR) time to first active treatment was 46 days (0-350); patients with higher risk disease were prescribed active treatment sooner.

Conclusion

These results provide insight into real-world clinical practice for patients with MF in the United Kingdom. Despite the known high prevalence of disease-associated symptoms in MF, symptoms were poorly documented. Most patients were initially observed or received hydroxycarbamide, and ruxolitinib was used as first-line management strategy in only a minority of patients.

Plain Language Summary

Background: Myelofibrosis is a rare blood cancer associated with symptoms that can seriously affect a patient's daily life, such as enlarged spleen and decreased white and red blood cells. Although several treatments are available for patients with myelofibrosis, it is not clear which ones clinicians use most frequently.Methods: We aimed to review which treatments are usually given to patients with myelofibrosis in the UK, by collecting information from the medical records of 200 patients with myelofibrosis treated in different centres across the UK.Results: The results showed that the symptoms patients experienced were not always written down in the medical records. Similarly, clinical scores based on patient characteristics (which clinicians use to try to predict if a patient will respond to treatment well or not) were also missing from the medical records. Clinicians also rarely asked patients to complete questionnaires that try to measure the impact of myelofibrosis and its treatment on their health. The most common approach for patients with myelofibrosis in the UK was 'watch and wait', which over half of patients received. The most common drugs used for treatment were hydroxycarbamide and ruxolitinib; only a very small proportion of patients received a bone marrow transplant. On average, patients waited for 46 days before receiving a treatment, although patients considered to have a more aggressive type of disease received treatment sooner.Conclusion: The results of this study suggest that medical records can be missing key information, which is needed to decide which is the best way to treat a patient with myelofibrosis. They also suggest that clinicians in the UK prefer observation to treatment for a large number of patients with myelofibrosis. This could mean that the approach used for many patients with myelofibrosis does not help them to control symptoms that have an impact on their daily lives.

Diazepam Monotherapy or Diazepam-Ketamine Dual Therapy at Different Time Points Terminates Seizures and Reduces Mortality in a Status Epilepticus Animal Model

BACKGROUND Being refractory to drugs remains an urgent treatment problem in status epilepticus (SE). The fact that γ-aminobutyric acid A receptors (GABAARs) become internalized and inactive, N-methyl-D-aspartate receptors (NMDARs) become externalized and active during SE may explain the refractoriness to benzodiazepine. However, the real-time dynamic efficacy of antiepileptic drugs remains unclear. Therefore, we propose a hypothesis that diazepam monotherapy or diazepam-ketamine dual therapy could terminate seizures and reduce mortality in the SE model at different time points during ongoing SE. MATERIAL AND METHODS An SE model was established in adult Sprague-Dawley rats with lithium and pilocarpine. The GABAAR agonist diazepam was injected at 5, 10, 20, or 30 min when SE continued. In addition, diazepam and the NMDAR antagonist ketamine were injected at 10 to 60 min at 6 different time points. We measured seizure-free rates, seizure duration, degree of behavioral seizure, and mortality. RESULTS Diazepam monotherapy at 5 min and 10 min from the beginning of SE was able to terminate seizures and improved survival rates. Diazepam-ketamine dual therapy at 10 min, 20 min, and 30 min from the beginning of SE terminated seizures and achieved high survival rates. CONCLUSIONS In this parallel randomized controlled trial with a rat model, we found that diazepam monotherapy was an effective antiepileptic strategy at the early stage of SE less than 10 min after SE onset. If SE lasts more than 10 min but less than 30 min, the diazepam-ketamine dual therapy strategy may be an appropriate choice.

Treatment with Ixekizumab Following Secukinumab Failure in Patients with Psoriatic Arthritis: Real-Life Experience from a Resistant Population

Objective

To assess the clinical response to ixekizumab following secukinumab failure in patients with psoriatic arthritis.

Methods

A retrospective multi-center observational study included psoriatic arthritis (PsA) patients with a history of treatment with secukinumab, further treated with ixekizumab. Primary endpoint was primary response to treatment (drug survival > 6 months); secondary endpoints were changes in disease activity indices from initiation of ixekizumab to 6 and 12 months later and overall drug survival.

Results

Of 23 PsA patients, 86% (n = 20) received more than two TNF inhibitors (TNFi). Median secukinumab treatment time was 15 months (IQR 10–21.5 months). Subsequently, 19 patients (83%) had a primary response to ixekizumab. Overall treatment duration during follow-up period for primary responders was 14 months (IQR 10–20.5). Reasons for ixekizumab cessation were worsening psoriasis (27%), peripheral arthritis (27%), both (47%), worsening of axial disease (13%), and adverse events (6%). Articular disease indices including Disease Activity Index for Psoriatic Arthritis (DAPSA), tender joints count (TJC) and Simplified Disease Activity Index (SDAI) were significantly lower at 6 and 12 months (DAPSA 1.5–2 levels reduction; p = 0.018 and 1–1.5 levels reduction; p = 0.031, respectively; TJC −2.16 [−4.0, −0.3]; p = 0.025 and −1.69 [−3.09, −0.28]; p = 0.022, respectively; SDAI −10.13 [−16.4, −3.8], p = 0.003 and −12.2 [−17.1, −7.2], p = 0.0002, respectively). PASI75 at 6 and 12 months was achieved by 63% and 57%, respectively, and PASI100 at 6 and 12 months by 31% and 21%, respectively.

Conclusion

Patients with resistant PsA, including inadequate response to secukinumab, demonstrated a good response to ixekizumab, albeit limited on time. Within class switch from secukinumab to ixekizumab may be a plausible therapeutic option in PsA patients following secukinumab failure.

Optimizing the Management of Uncomplicated Gram-Negative Bloodstream Infections: Consensus Guidance Using a Modified Delphi Process

Background

Guidance on the recommended durations of antibiotic therapy, the use of oral antibiotic therapy, and the need for repeat blood cultures remain incomplete for gram-negative bloodstream infections. We convened a panel of infectious diseases specialists to develop a consensus definition of uncomplicated gram-negative bloodstream infections to assist clinicians with management decisions.

Methods

Panelists, who were all blinded to the identity of other members of the panel, used a modified Delphi technique to develop a list of statements describing preferred management approaches for uncomplicated gram-negative bloodstream infections. Panelists provided level of agreement and feedback on consensus statements generated and refined them from the first round of open-ended questions through 3 subsequent rounds.

Results

Thirteen infectious diseases specialists (7 physicians and 6 pharmacists) from across the United States participated in the consensus process. A definition of uncomplicated gram-negative bloodstream infection was developed. Considerations cited by panelists in determining if a bloodstream infection was uncomplicated included host immune status, response to therapy, organism identified, source of the bacteremia, and source control measures. For patients meeting this definition, panelists largely agreed that a duration of therapy of ~7 days, transitioning to oral antibiotic therapy, and forgoing repeat blood cultures, was reasonable.

Conclusions

In the absence of professional guidelines for the management of uncomplicated gram-negative bloodstream infections, the consensus statements developed by a panel of infectious diseases specialists can provide guidance to practitioners for a common clinical scenario.

Retrospective analysis of the efficacy and duration of botulinum toxin A injections in 30 patients with palmar hyperhidrosis

Palmar hyperhidrosis is a common disorder characterised by excessive sweating due to hyperfunction of the sweat glands. It can be classified as primary disease, or secondary to other causes. It has a high morbidity, and a range of treatment options. Botulinum toxin injections inhibit the release of acetylcholine from the presynaptic receptors. It is an effective treatment; however, it is infrequently selected as only axillary hyperhidrosis currently attracts a Medicare subsidy. We conducted a retrospective review of 30 patients at a Sydney dermatology clinic who received botulinum toxin injections for palmar hyperhidrosis within the past 5 years. This study has the largest patient cohort with this condition in Australia. There was evidence for a median reduction in the Hyperhidrosis Disease Severity Scale, a qualitative self-reported score, as well as an increasing duration of efficacy with repeated injections. There were minimal side-effects of weakness and numbness. There is also an association between treatment of palmar disease and improvement in plantar disease, which suggests that treatment of palmar hyperhidrosis should be considered earlier and more frequently.

Second-Line Bismuth-Containing Quadruple Therapy for Helicobacterpylori Infection: A 12-Year Study of Annual Eradication Rates

Background: Bismuth-containing quadruple therapy (BQT) consisting of a proton-pump inhibitor (PPI), bismuth, metronidazole and tetracycline is recommended as a second-line treatment for Helicobacter pylori (H. pylori) infection when PPI-based standard triple therapy (STT) consisting of a PPI, amoxicillin and clarithromycin is unsuccessful. The purpose of this study was to analyze the long-term results of BQT as a second-line therapy to determine its effectiveness. Methods: This study included 643 subjects who failed first-line STT and received 7 or 10–14 days of BQT as a second-line therapy. We retrospectively analyzed the annual H. pylori eradication rates, demographic factors and adverse events. Results: The overall eradication rates by intention-to-treat (ITT) and per-protocol (PP) analyses were 80.7% (519/643) and 93.3% (519/556), respectively. By PP analysis, the eradication rates for 2008–2011, 2012–2015, and 2016–2019 were 93.3%, 91.0%, and 96.4%, respectively (p = 0.145). There were no significant differences between the 7-day group and the 10–14-day group in both the ITT (79.7% vs. 86.0%, p = 0.148) and the PP analyses (92.7% vs. 96.6%, p = 0.187). A multivariate analysis showed that current smoking was associated with eradication failure. Eighty-nine subjects (16.0%) suffered adverse events, mainly gastrointestinal symptoms, but only six cases were severe. Conclusions: BQT as a second-line therapy is an effective treatment for H. pylori. Treatment for 10–14 days showed a higher eradication rate compared with a 7-day regimen, but not significantly.

Up-to-date information on polymyxin B-immobilized fiber column direct hemoperfusion for septic shock

Endotoxin adsorption therapy by polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP) has been used for the treatment of septic shock patients. Endotoxin, an outer membrane component of Gram-negative bacteria, plays an important role in the pathogenesis of septic shock. Endotoxin triggers a signaling cascade for leukocytes, macrophage, and endothelial cells to secrete various mediators including cytokines and nitric oxide, leading to septic shock and multiple organ dysfunction syndrome. PMX-DHP directly adsorbed not only endotoxin but also monocytes and anandamide. It reduced blood levels of inflammatory cytokines such as interleukin (IL)-1, IL-6, tumor necrosis factor-alpha and IL-17A, adhesion molecules, plasminogen activator inhibitor 1, and high mobility group box-1. As a result, PMX-DHP increased blood pressure and reduced the dose of vasoactive-inotropic agents. PMX-DHP improved monocyte human leukocyte antigen-DR expression in patients with severe sepsis and septic shock. A post hoc analysis of EUPHRATES (Evaluating the Use of Polymyxin B Hemoperfusion in Randomized Controlled Trial of Adults Treated for Endotoxemia and Septic Shock) trial has shown that PMX-DHP significantly reduced 28-day mortality compared with the control group in septic shock patients with endotoxin activity assay level between 0.60 and 0.89. Longer duration of PMX-DHP may be another strategy to bring out the beneficial effects of PMX-DHP. Further studies are needed to confirm the efficacy of PMX-DHP treatment for septic shock.

Optimizing the Outcome of Anti-Myeloma Treatment with Daratumumab

A search of the scientific literature for Daratumumab and myeloma gives more than 600 results (January 2021), which reflects the interest and activity around this antibody, an interest that was also reflected by the assignment of breakthrough designation for Daratumumab as a treatment for multiple myeloma by FDA in 2013. The high expectations have been supported and met due to a very active clinical development program, and our insight into Daratumumab's modes of action have been expanded by a concomitant, systematic activity of translational research. The scope of this article is to point to some areas where the outcome of treatment with Daratumumab for multiple myeloma may be improved with a focus on areas such as when to initiate treatment with Daratumumab, the use of supportive treatment, duration of therapy and some general thoughts about anti-myeloma treatment as a two-step process involving initial de-bulking followed by reprogramming of the host's immune system and immune-mediated control of myeloma.

Anticoagulant medication adherence for cancer-associated thrombosis: A comparison of LMWH to DOACs

Essentials It is not clear if patients are less adherent to low molecular weight heparin (LMWH) compared to direct oral anticoagulants (DOACs) for cancer-associated thrombosis (CAT). We evaluated medication adherence among two propensity-matched groups of patients with CAT by comparing the proportion of days covered (PDC). Median treatment persistence on DOACs was more than 80 days longer than LMWH. Medication adherence was high (~95%) and was similar with LMWH compared to DOACs. ABSTRACT: Background Low molecular weight heparin (LMWH) and direct oral anticoagulants (DOACs) are used to treat cancer-associated thrombosis (CAT). It is not clear if patients are less adherent to LMWH compared to DOACs. Objectives To compare medication persistence and adherence between LMWH and DOACs. Patients/Methods We analyzed Optum's de-identified Clinformatics® Data Mart Database of privately insured adults with cancer diagnosed between January 2009 and October 2015 who were undergoing chemotherapy, immunotherapy, targeted or hormonal therapies; developed CAT; and were treated with an outpatient anticoagulant. The proportion of days covered (PDC) was calculated from the date of anticoagulant prescription until the anticoagulant was switched, stopped, or the study end. Medication adherence was defined as PDC ≥ 80%, ≥95%, and by comparing the mean PDC. Results Two propensity-matched groups of 1128 patients were identified. Patient persistence was higher with DOACs compared to LMWH (median 116 days versus 34 days). With adherence defined as PDC ≥ 80%, we found no significant difference (95.6% versus 94.6% adherence with DOACs versus LMWH, P = .33). The mean difference of PDC between the two groups was also similar. With medication adherence defined as PDC ≥ 95%, adherence was evident in 73% of DOAC users and 81% of patients on LMWH (P < .001). Prescription copayments were higher on average for LMWH compared to DOACs (mean $153.61 versus 40.67; standard deviation $306.74 versus $33.11). Conclusion Patients remain on DOACs longer than LMWH, but medication adherence is similar with LMWH.

Duration of FOLFOX Adjuvant Chemotherapy in High-Risk Stage II and Stage III Colon Cancer With Deficient Mismatch Repair

Background

We evaluated the impact of 3 months of mFOLFOX6 adjuvant chemotherapy or surgery alone in comparison with 6 months of mFOLFOX6 on disease-free survival (DFS) in deficient mismatch repair (dMMR) colon cancer (CC) patients.

Methods

This retrospective study identified a cohort of patients with high-risk stage II and III dMMR CC who underwent curative surgery between May 2011 and July 2019. DFS was compared using the Kaplan-Meier survival methods and Cox proportional hazards models. Propensity-score matching was performed to reduce imbalance in baseline characteristics.

Results

A total of 242 dMMR CC patients were identified; 66 patients received 6 months of mFOLFOX6, 87 patients received 3 months of mFOLFOX6, and 89 patients were treated with surgery alone. The 3-year DFS rate was 72.8% in 3-month therapy group and 86.1% in 6-month therapy group, with a hazard ratio (HR) of 2.78 (95CI%, 1.18 to 6.47; P= 0.019). The difference in DFS between surgery alone group and 6-month therapy group was also observed but was nonsignificant (HR= 2.30, 95%CI, 0.99 to 5.38; P=0.054). The benefit of 6-month therapy in DFS compared with 3-month therapy group was pronounced for patients with stage III (HR=2.81, 95%CI, 1.03 to 7.67; P=0.044) but not for high-risk stage II patients. Propensity score matched analysis confirmed a DFS benefit in the 6-month therapy group.

Conclusion

This study suggested that a 6-month duration of mFOLFOX6 adjuvant chemotherapy in dMMR CC patients may be associated with improved DFS compared with 3-month therapy, particularly in patients with stage III. The observational nature of the study implies caution should be taken in the interpretation of these results.

Real-World Outcomes and Value of First-Line Therapy for Metastatic Non-Small Cell Lung Cancer†

Although physicians rely on clinical trial data to guide cancer treatment decisions, patient characteristics and outcomes often differ between real-world and clinical trial populations. We analyzed retrospective clinical data collected from a prior authorization (PA) tool linked with payer claims data to describe outcomes of first-line treatment for metastatic non-small cell lung cancer among 2,108 patients. Duration of therapy was shorter than observed in clinical trials. Healthcare costs and hospitalizations varied substantially by regimen. PA clinical data linked with administrative claims enable head-to-head comparisons of contemporary cancer treatments used in routine clinical practice, which are not available from clinical trials.

The Association of Antibiotic Duration With Successful Treatment of Community-Acquired Pneumonia in Children

BACKGROUND

National guidelines recommend 10 days of antibiotics for children with community-acquired pneumonia (CAP), acknowledging that the outcomes of children hospitalized with CAP who receive shorter durations of therapy have not been evaluated.

METHODS

We conducted a comparative effectiveness study of children aged ≥6 months hospitalized at The Johns Hopkins Hospital who received short-course (5-7 days) vs prolonged-course (8-14 days) antibiotic therapy for uncomplicated CAP between 2012 and 2018 using an inverse probability of treatment weighted propensity score analysis. Inclusion was limited to children with clinical and radiographic criteria consistent with CAP, as adjudicated by 2 infectious diseases physicians. Children with tracheostomies; healthcare-associated, hospital-acquired, or ventilator-associated pneumonia; loculated or moderate to large pleural effusion or pulmonary abscess; intensive care unit stay >48 hours; cystic fibrosis/bronchiectasis; severe immunosuppression; or unusual pathogens were excluded. The primary outcome was treatment failure, a composite of unanticipated emergency department visits, outpatient visits, hospital readmissions, or death (all determined to be likely attributable to bacterial pneumonia) within 30 days after completing antibiotic therapy.

RESULTS

Four hundred and thirty-nine patients met eligibility criteria; 168 (38%) patients received short-course therapy (median, 6 days) and 271 (62%) received prolonged-course therapy (median, 10 days). Four percent of children experienced treatment failure, with no differences observed between patients who received short-course vs prolonged-course antibiotic therapy (odds ratio, 0.48; 95% confidence interval, .18-1.30).

CONCLUSIONS

A short course of antibiotic therapy (approximately 5 days) does not increase the odds of 30-day treatment failure compared with longer courses for hospitalized children with uncomplicated CAP.

Is fixed short-course antimicrobial therapy justified for patients who are critically ill with intra-abdominal infections?

A long-course antibiotic therapy increases the risk of antibiotic resistance. A 7- to 14-day duration of therapy has been traditionally adopted in patients with intra-abdominal infections (IAIs). Prophylactic antibiotic use is warranted in uncomplicated IAIs, in which the infection involves a single organ, and the source of the infection is completely eradicated by a surgical procedure. A large, randomized clinical trial of the treatment of complicated IAIs recently demonstrated that a fixed 4-day course of antibiotic therapy was as effective as a long-course therapy in patients who underwent adequate source control. Considering the poor prognosis and lack of clear evidence available for shortening the duration of antibiotic therapy in patients who are critically ill or those with ongoing signs of sepsis, the duration of therapy for complicated IAIs should be individually determined according to the clinical course. Limiting therapy to no more than 7 days seems to be warranted in patients who are critically ill with a good clinical response.

Impact of an antimicrobial stewardship program on outcomes in patients with community-acquired pneumonia admitted to a tertiary community hospital

PURPOSE

Results of a study evaluating the impact of an antimicrobial stewardship program (ASP) on clinical outcomes in patients hospitalized for community-acquired pneumonia (CAP) are reported.

METHODS

A retrospective records review was conducted at a 400-bed hospital to identify patients admitted over 3 years with CAP documented as a primary or secondary diagnosis. Clinical and medication-use outcomes during a 1-year baseline period and in the first and second years after ASP implementation (post-ASP years 1 and 2) were analyzed. A local CAP guideline was implemented around the beginning of post-ASP year 2.

RESULTS

The mean hospital length of stay declined from 7.24 days in the baseline period to 5.71 days in post-ASP year 1 (p = 0.011) and 5.52 days in post-ASP year 2 (p = 0.008). Mean inpatient antimicrobial days of therapy (DOT) declined from 5.68 days in the baseline period to 5.08 days (p = 0.045) and 4.99 days (p = 0.030) in post-ASP years 1 and 2, respectively. Mean DOT per 100 total days of antimicrobial therapy declined from 9.69 days in the baseline period to 8.85 days in post-ASP year 1 (p = 0.019) and 8.38 days in post-ASP year 2 (p = 0.001).

CONCLUSION

ASP implementation was associated with specific clinical benefits in patients with CAP, including decreased length of stay, decreased durations of antimicrobial therapy, and a shift in utilization to a primary regimen shown to produce superior clinical outcomes.

Rethinking non-inferiority: a practical trial design for optimising treatment duration

Background

Trials to identify the minimal effective treatment duration are needed in different therapeutic areas, including bacterial infections, tuberculosis and hepatitis C. However, standard non-inferiority designs have several limitations, including arbitrariness of non-inferiority margins, choice of research arms and very large sample sizes.

Methods

We recast the problem of finding an appropriate non-inferior treatment duration in terms of modelling the entire duration–response curve within a pre-specified range. We propose a multi-arm randomised trial design, allocating patients to different treatment durations. We use fractional polynomials and spline-based methods to flexibly model the duration–response curve. We call this a ‘Durations design’. We compare different methods in terms of a scaled version of the area between true and estimated prediction curves. We evaluate sensitivity to key design parameters, including sample size, number and position of arms.

Results

A total sample size of ~ 500 patients divided into a moderate number of equidistant arms (5–7) is sufficient to estimate the duration–response curve within a 5% error margin in 95% of the simulations. Fractional polynomials provide similar or better results than spline-based methods in most scenarios.

Conclusion

Our proposed practical randomised trial ‘Durations design’ shows promising performance in the estimation of the duration–response curve; subject to a pending careful investigation of its inferential properties, it provides a potential alternative to standard non-inferiority designs, avoiding many of their limitations, and yet being fairly robust to different possible duration–response curves. The trial outcome is the whole duration–response curve, which may be used by clinicians and policymakers to make informed decisions, facilitating a move away from a forced binary hypothesis testing paradigm.

Top Questions in Uncomplicated, Non-Staphylococcus aureus Bacteremia

The Infectious Diseases Society of America infection-specific guidelines provide limited guidance on the management of focal infections complicated by secondary bacteremias. We address the following 3 commonly encountered questions and management considerations regarding uncomplicated bacteremia not due to Staphylococcus aureus: the role and choice of oral antibiotics focusing on oral beta-lactams, the shortest effective duration of therapy, and the role of repeat blood cultures.

Impact of an antimicrobial stewardship intervention on appropriateness of prescribing for community-acquired pneumonia in an Australian regional hospital

Community-acquired pneumonia (CAP) is the second commonest indication for antibiotic use in Australian hospitals and is therefore a frequent target for antimicrobial stewardship. A single-centre prospective study was conducted in a regional referral hospital comparing management of adult patients with CAP before and after an educational intervention. We demonstrated a reduction in duration of therapy and reduced inappropriate use of ceftriaxone-based regimens for non-severe CAP.

Comparing the Outcomes of Adults With Enterobacteriaceae Bacteremia Receiving Short-Course Versus Prolonged-Course Antibiotic Therapy in a Multicenter, Propensity Score-Matched Cohort

Background

The recommended duration of antibiotic treatment for Enterobacteriaceae bloodstream infections is 7-14 days. We compared the outcomes of patients receiving short-course (6-10 days) vs prolonged-course (11-16 days) antibiotic therapy for Enterobacteriaceae bacteremia.

Methods

A retrospective cohort study was conducted at 3 medical centers and included patients with monomicrobial Enterobacteriaceae bacteremia treated with in vitro active therapy in the range of 6-16 days between 2008 and 2014. 1:1 nearest neighbor propensity score matching without replacement was performed prior to regression analysis to estimate the risk of all-cause mortality within 30 days after the end of antibiotic treatment comparing patients in the 2 treatment groups. Secondary outcomes included recurrent bloodstream infections, Clostridium difficile infections (CDI), and the emergence of multidrug-resistant gram-negative (MDRGN) bacteria, all within 30 days after the end of antibiotic therapy.

Results

There were 385 well-balanced matched pairs. The median duration of therapy in the short-course group and prolonged-course group was 8 days (interquartile range [IQR], 7-9 days) and 15 days (IQR, 13-15 days), respectively. No difference in mortality between the treatment groups was observed (adjusted hazard ratio [aHR], 1.00; 95% confidence interval [CI], .62-1.63). The odds of recurrent bloodstream infections and CDI were also similar. There was a trend toward a protective effect of short-course antibiotic therapy on the emergence of MDRGN bacteria (odds ratio, 0.59; 95% CI, .32-1.09; P = .09).

Conclusions

Short courses of antibiotic therapy yield similar clinical outcomes as prolonged courses of antibiotic therapy for Enterobacteriaceae bacteremia, and may protect against subsequent MDRGN bacteria.

The efficacy and duration of treatment with propranolol in children with cyclic vomiting syndrome in southern Iran

INTRODUCTION

Cyclic vomiting syndrome is a functional disorder characterised by repeated episodes of nausea and vomiting with symptom-free intervals between the attacks. Cyclic vomiting syndrome is a migraine equivalent; therefore, anti-migraine medications are effective for cyclic vomiting syndrome prophylaxis, but duration of treatment is not clear.

AIM

To determine the efficacy and duration of drug therapy in cyclic vomiting syndrome.

MATERIAL AND METHODS

This study was conducted on 206 cases of cyclic vomiting syndrome, who were treated with propranolol as prophylaxis. After they were symptom-free for at least 9 months, propranolol was tapered and discontinued and then they were followed for at least 6 months after drug withdrawal for evaluation of recurrence.

RESULTS

The study subjects included 127 boys and 79 girls. The mean age of symptom onset was 3.4 years (range: 3 months to 14.5 years) and the mean age at the time of diagnosis was 5.7 years (range: 8.4 months to 18 years). Among the 206 patients in whom propranolol was discontinued, only 16 (7.8%) subjects developed recurrence of symptoms in the 6-month follow-up period.

CONCLUSIONS

There is no need to continue prophylaxis of cyclic vomiting syndrome for a long time. It is also possible to make the duration of drug therapy shorter, which is useful for the convenience of the patients and prevention of drug side effects.

Impact of an Antimicrobial Stewardship Program on Antibiotic Use at a Nonfreestanding Children's Hospital

BACKGROUND

Pediatric stewardship programs have been successful at reducing unnecessary antibiotic use. Data from nonfreestanding children's hospitals are currently limited. This study is an analysis of antibiotic use after implementation of an antimicrobial stewardship program at a community nonfreestanding children's hospital.

METHODS

In April 2013, an antimicrobial stewardship program that consisted of physician-group engagement and pharmacist prospective auditing and feedback was initiated. We compared antibiotic use in the preintervention period (April 2012 to March 2013) with that in the postintervention period (April 2013 to March 2015) in all units except the neonatal intensive care unit and the emergency department. In addition, drug-acquisition costs, antibiotic-specific use, death, length of stay, and case-mix index were examined.

RESULTS

Antibiotic use decreased by 16.8% (95% confidence interval, 18.0% to -9.2%; P < .001) in the postintervention period. Vancomycin use decreased by 38% (P = .001), whereas antipseudomonal β-lactam use was unaltered. Drug-acquisition cost savings were estimated to be $67 000/year over the 2-year postintervention period. Lengths of stay and mortality rates were unchanged in the postintervention period after adjusting for case-mix index.

CONCLUSIONS

Implementation of a simple stewardship initiative with limited resources at a community nonfreestanding children's hospital effectively reduced antibiotic use without an overt negative impact on overall clinical outcomes. The results of this study suggest that nonfreestanding children's hospitals can achieve substantial reductions in antibiotic use despite limited resources.

Switching between endocrine therapies for primary breast cancer: Frequency and timing in Australian clinical practice

AIMS

To determine the frequency, timing and patterns of endocrine therapy switching in Australian practice for postmenopausal women with primary breast cancer.

METHODS

We identified postmenopausal women in a population-based cohort commencing endocrine therapy for invasive primary breast cancer between December 2005 and December 2008 (n = 645). Individual-level administrative health records and self-report data were used to determine women's demographic and clinical characteristics, including preexisting and newly-treated comorbidities, and switches in endocrine therapy. Time to therapy switching was calculated. Chi-square tests compared the characteristics of women who did and did not switch, and those switching within 2 years or after 2 years of commencing therapy.

RESULTS

Twenty-eight percent of women switched from their initial endocrine therapy, most commonly from tamoxifen to anastrozole, or the converse. A small number of anastrozole-to-exemestane and letrozole-to-exemestane switches were observed (n = 19). Most women (>80%) who switched therapies did not have newly-treated comorbidities. Few women (<5%) switched before completing 2 years of therapy, but these women were significantly more likely to have preexisting antidepressant use than women switching later (43% vs 23%, P = 0.048) and remained on the subsequent therapy for less time (6 months vs 2.7 years, P < 0.001).

CONCLUSIONS

Approximately one-quarter of postmenopausal women with primary breast cancer switched endocrine therapies. The findings suggest that the majority of switching in Australian practice was planned; occurring after 2-3 years of, not precipitated by comorbidity, and in a sequence supported by trial evidence. Early switching, however, was associated with preexisting depression and appeared to be a marker of poor persistence.

The Pattern of Antibiotic Prescribing by Dental Practitioners in Zagreb, Croatia

BACKGROUND

Bacterial resistance is considered a consequence of misuse or overuse of antibiotics. Dentistry significantly contributes to this increasing public health problem. The aim of this cross-sectional study was to examine the pattern of antibiotics prescribed by Croatian dentists in Zagreb area.

METHODS

Out of 220 Doctors of Dental Medicine (DMDs) from Zagreb 110 responded to survey. Prior to the research an ethical approval was obtained. Participants were directly contacted. The questionnaire consisted of two parts: general data on DMDs and the part concerning indications, duration, type and dosage of antibiotic therapy. Data were processed using MS Excel and SPSS for Windows, Version 17.0. Statistical significance was tested by Fisher's exact test, chi-square test, Mann-Whitney U test and Spearman's rank correlation at the level of statistical significance p<0.05.

RESULTS

During the period of two months, the doctors prescribed antibiotics to 1,500 patients, 690 (46%) were men and 810 (54%) women. The most often prescribed antibiotics were penicillin (72.5% of patients), represented mostly by amoxicillin in combination with clavulanic acid (57.6%). The most common indication for the prescribed antibiotics was periapical or periodontal abscess (44%). Definite clinical indication (71.2%) was stated as the most common reason for antibiotic prescription. Antibiotic therapy usually lasted 7 days (62.9%). The doctors prescribed daily doses of antibiotics according to the instructions for the use of specific drugs.

CONCLUSION

The examined subjects prescribe antibiotics according to the curriculum taught at the School of Dental Medicine for majority of types, doses and duration of the treatments, although antibiotics over-prescription in cases without medical indication was observed. The national guidelines on antibiotic regimens are required in order to reduce unnecessary antibiotic use.

Effects of a Syndrome-Specific Antibiotic Stewardship Intervention for Inpatient Community-Acquired Pneumonia

A syndrome-specific intervention to improve the management of community-acquired pneumonia in non-intensive care settings was associated with shorter treatment durations, less fluoroquinolone use, and a reduction in use of low-yield diagnostic tests.

Background. Syndrome-specific interventions are a recommended approach to antibiotic stewardship, but additional data are needed to understand their potential impact. We implemented an intervention to improve the management of inpatient community-acquired pneumonia (CAP) and evaluated its effects on antibiotic and resource utilization.

Methods. A stakeholder group developed and implemented a clinical practice guideline and order set for inpatient, non-intensive care unit CAP recommending a short course (5 days) of a fluoroquinolone-sparing antibiotic regimen in uncomplicated cases. Unless there was suspicion for complications or resistant pathogens, chest computed tomography (CT) and sputum cultures were discouraged. This was a retrospective preintervention postintervention study of patients hospitalized for CAP before (April 15, 2008–May 31, 2009) and after (July 1, 2011–July 31, 2012) implementation of the guideline. The primary comparison was the difference in duration of therapy during the baseline and intervention periods. Secondary outcomes included changes in use of levofloxacin, CT scans, and sputum culture.

Results. One hundred sixty-six and 84 cases during the baseline and intervention periods, respectively, were included. From the baseline to intervention period, the median duration of therapy decreased from 10 to 7 days (P < .0001). Prescription of levofloxacin at discharge decreased from 60% to 27% of cases (P < .0001). Use of chest CT and sputum culture decreased from 47% to 32% of cases (P = .02) and 51% to 31% of cases (P = .03), respectively. The frequency of clinical failure between the 2 periods was similar.

Conclusions. A syndrome-specific intervention for inpatient CAP was associated with shorter treatment durations and reductions in use of fluoroquinolones and low-yield diagnostic tests.

Multiple myeloma: patient outcomes in real-world practice

With increasing number of therapies available for the treatment of multiple myeloma, it is timely to examine the course of patients' journeys. We investigated patient characteristics, treatment durations and outcomes, and symptom burden across the treatment pathway in Belgium, France, Germany, Italy, Spain, Switzerland and the UK. In total, 435 physicians retrospectively reviewed 4997 patient charts. Profiles of patients diagnosed with multiple myeloma during the last 12 months were similar across countries; bone pain was the most common presentation. Median duration of first‐line therapy was 6 months, followed by a median treatment‐free interval of 10 months; both these decreased with increasing lines of therapy, as did time to progression. Depth of response, as assessed by the treating physician, also decreased with each additional line of therapy: 74% of patients achieved at least a very good partial response at first line, compared with only 11% at fifth line. Deeper responses were associated with longer time to progression, although these were physician‐judged. Toxicities and co‐morbidities increased with later treatment lines, and were more likely to have led to discontinuation of treatment. These real‐world data provide an insight into patient outcomes and treatment decisions being made in clinical practice.

Real-world treatment patterns and associated progression-free survival in relapsed/refractory multiple myeloma among US community oncology practices

BACKGROUND

Evidence supporting optimal treatment sequencing in relapsed/refractory multiple myeloma (RRMM) patients requiring multiple therapy lines is lacking.

METHODS

Using retrospective chart data, this study describes real-world RRMM treatment patterns and related progression-free survival (PFS) in US community oncology clinics.

RESULTS

Bortezomib ± a non-immunomodulatory drug (IMiD), lenalidomide ± a non-proteasome inhibitor (PI), bortezomib + an IMiD were the most commonly used regimens in early lines of therapy. Median PFS was similar in 1(st) (11.1 months) and 2(nd) line (10.5) and decreased in lines 3 through 5 (3(rd): 7.9; 4(th): 7.2, 5(th): 5.4). Longest PFS (12.5 months) in first line was with bortezomib + ImiD; longest PFS in second line was with lenalidomide ± a non-PI was (13.2 months).

CONCLUSIONS

Re-treatment with bortezomib was common; novel agents were reserved for later therapy lines. Overall, the observed PFS associated with real-world treatment sequences were shorter than those reported in clinical trials.

Pilot trial of paclitaxel-trastuzumab adjuvant therapy for early stage breast cancer: a trial of the ECOG-ACRIN cancer research group (E2198)

BACKGROUND

Blockade of human epidermal growth factor receptor type 2 (HER2) has dramatically improved outcome for patients with HER2-positive breast cancer. Trastuzumab, an anti-HER2 monoclonal antibody, has previously demonstrated improvement in overall survival (OS) in patients with metastatic and early stage HER2-positive breast cancer. However, trastuzumab can cause congestive heart failure (CHF) with an increased frequency for patients who have also received an anthracycline. The current trial was designed to evaluate the impact of the duration of trastuzumab on CHF.

METHODS

E2198 included 227 eligible women with histologically confirmed stage II or IIIA HER2-positive breast cancer. The patients were randomised to receive 12 weeks of paclitaxel and trastuzumab followed by four cycles of doxorubicin and cyclophosphamide (abbreviated Arm) or the aforementioned treatment with additional 1 year of trastuzumab (conventional Arm). The primary end point was to evaluate the safety of this variable duration of trastuzumab therapy, particularly cardiac toxicity defined as CHF or left ventricular ejection fraction decrease >10%. Secondary end points included disease-free survival (DFS) and OS.

RESULTS

Compared with 12-week treatment with trastuzumab, 1 year of trastuzumab-based therapy did not increase the frequency or severity of cardiac toxicity: three patients on the abbreviated Arm and four on the conventional Arm experienced CHF. The 5-year DFS was 76% and 73% for the abbreviated and conventional Arms, respectively, with a hazard ratio (HR) of 1.3 (95% CI: 0.8-2.1; P=0.3). There was also no statistically significance difference in OS (HR, 1.4; P=0.3).

CONCLUSIONS

Compared with 12 weeks of treatment, 1 year of treatment with trastuzumab did not significantly increase the risk of cardiac toxicity. Although not powered for efficacy comparisons, the longer duration of trastuzumab therapy did not demonstrate a signal for marked superiority.

Should HRT be duration limited?

Hormone Replacement Therapy (HRT) has received consistently bad press, despite re-analysis of previous data new studies and supporting Consensus Statements from leading national and international societies. Many women have been convinced by women's journals and the media not to even consider HRT as an option and, General Practitioners, still limit duration to 5 years or, will, arbitrarily, discontinue prescriptions in the early 50s. This article seeks to make sense of our current position. Previous and new evidence on the safety of HRT is reviewed. New data on the long-term consequences of non-treatment of women with Premature Ovarian Insufficiency (POI) is presented and the dichotomy of the older female workforce is explored. From this, a logical plan of management emerges.

New proposal for response-guided peg-interferon-plus-ribavirin combination therapy for chronic hepatitis C virus genotype 2 infection

This study aimed to determine the most suitable duration of pegylated-interferon (Peg-IFN)-plus-ribavirin combination therapy in patients infected with hepatitis C virus (HCV) genotype 2 who had not achieved rapid virological response (serum HCV RNA disappearance after 4 weeks of therapy). HCV genotype 2 patients (n = 182) with a high viral load received >80% of the standard Peg-IFN-plus-ribavirin dose for at least 24 weeks, and their final virological responses were studied. Patients were classified into "rapid virological response" and "non-rapid virological response" groups. The non-rapid virological response group was further divided into a "virological response at 8 weeks" (serum HCV RNA disappearance after 8 weeks of therapy) and a "non-virological response at 8 weeks" group. Factors related to rapid virological response and optimal therapy duration in the non-rapid virological response group were evaluated. Multivariate logistic regression analysis showed that subtype HCV genotype 2a (P = 0.0015) and low concentration of pretreatment serum HCV RNA (P = 0.0058) were independent factors in a rapid virological response. In the virological response at 8 weeks group, the sustained virological response rate after 24 weeks of therapy was significantly lower than after 36 weeks (P = 0.044) or after 48 weeks (P = 0.006), and was similar for 36- and 48-weeks. The cost for achieving (CAS) one sustained virological response was lowest with 36-week therapy. Prolongation of Peg-IFN-plus-ribavirin combination therapy to 36 weeks is suitable for achieving virological response at 8 weeks, given the high, sustained virological response rate and cost benefit.

Extended adjuvant temozolomide with cis-retinoic acid for adult glioblastoma

OBJECTIVE

To determine the toxicity and effectiveness of 24 months of adjuvant temozolomide (tmz) with cis-retinoic acid (cra) for patients with glioblastoma.

METHODS

This retrospective population-based review considered the charts of all patients diagnosed with glioblastoma in Manitoba and referred to a provincial cancer centre during 2002-2008. Consecutive patients came from a population-based referral centre and provincial cancer registry. All patients were treated according to the local standard of care with surgical resection followed by concurrent radiotherapy and tmz 75 mg/m(2) daily, followed by tmz 150-200 mg/m(2) for days 1-5, repeated every 28 days for up to 24 cycles, and cra 50 mg/m(2) twice daily for days 1-21, repeated every 28 days. The main outcome measures were safety, tolerability, and effectiveness of long-term tmz and cra.

RESULTS

Of 247 patients diagnosed with glioblastoma in Manitoba during the study period, 116 started concurrent chemoradiotherapy, and 80 received adjuvant tmz. Of the patients who started concurrent chemoradiotherapy, 80 began adjuvant chemotherapy. Patients completed a median of 5.5 cycles of tmz and 3 cycles of cra. Grade 3 or 4 hematologic toxicity was noted in 16% of patients. Median overall survival was 15.1 months, and 26.7% of patients remained alive at 2 years.

CONCLUSIONS

Extended adjuvant tmz and cra is well tolerated. However, the population-based effectiveness of this regimen is similar to the clinical trial efficacy of 6 months of adjuvant tmz. Future studies in glioblastoma should incorporate duration of adjuvant chemotherapy into the study design.